Effectiveness of teriparatide combined with the Ilizarov technique in septic tibial non-union.

Aim The septic non-union is a common compliance in bone healing due to bone infection. Bone resection, associated with Ilizarov osteo-distraction technique, is commonly used in these cases. The aim of this study was to analyse clinical and radiological results of teriparatide in combination with the Ilizarov technique and to compare this treatment with the standard treatment. Methods Forty adult patients underwent surgery because of type C of the Association for the Study and Application of Methods of Ilizarov (ASAMI) classification non-union were enrolled. The patients were divided in two groups: those treated with Ilizarov technique (Norm group) and those treated with Ilizarov technique combined with teriparatide injection (Teri group). Surgical duration, complication rate, bone healing status, clinical and functional outcomes were assessed according to the A.S.A.M.I. classification in the mean follow-up of 12 months. The subjective quality of life was assessed by the Short Form Survey (SF)-12. Results Teri group showed less time wearing Ilizarov's frame (p <0.05) than the Norm group and a statistical significance in the inter-rater reliability Cohen's k (p>0.05) respect to Norm according the score between the bone healing and clinical outcome results. There was no statistically significant difference between the two groups in other parameters that were assessed. Conclusion A benefit of teriparatide was found as adjuvant in the treatment of septic non-union.

Bone Defect Management with Vascularized Fibular Grafts in the Treatment of Grade III-IV Osteomyelitis.

PURPOSE: This study is a retrospective analysis of our experience in microsurgical bone transfers for complex limb reconstructions. The aim of this study is to evaluate reliability of the vascularized fibula technique: infection recurrence, hypertrophy, time to bone union, complications, and time to healing in severe osteomyelitis (Cierny-Mader III and IV) cases over a 38 to 93 month follow-up. PATIENTS AND METHODS: From March 2010 until December 2015, 18 patients' limbs (6 females and 1 2 males; mean age 48.7 years) were reconstructed with 10 free fibula flaps, 5 pedicled fibula flaps, 3 peroneus brevis osteomuscular flaps. We reconstructed 2 radiuses, 2 ulnae, 4 femurs, 4 tibiae, 1 acetabulum and 3 fibular malleoli. RESULTS: We considered as successful results all cases where patients had successful functional bone reconstruction with no recurrence of infection during the follow up (mean time 63.6 months). We obtained 14 complete functional reconstructions, 2 limb salvages with impaired function, and 2 failures which underwent major amputations. In only one case there was an infection recurrence. CONCLUSIONS: The bone defect reconstruction with vascularized fibula grafts in severe bone infections is an effective option, but requires a well trained multidisciplinary team to manage the high rate of complications. Complications, in our series, were demonstrated to be significantly associated to patients defined as B-hosts according to Cierny-Mader's classification (P < 0.05), and caliber discrepancy between fibula and reconstructed bones such as Tibia and Femur (P < 0.005). Furthermore, stress fractures in the grafted fibulae were prognostic indicators for overall treatment failure (P < 0.05).

The role of dalbavancin in the multi-disciplinary management of wound infections in orthopaedic surgery.

Antimicrobial resistance is continuously increasing among bacterial clinical isolates (especially methicillin resistance in Staphylococcus aureus, MRSA), negatively impacting on outcomes of patients with Surgical Site Infections (SSIs). A multi-disciplinary team work is essential for SSIs prevention and for the choice of antibiotic therapy of orthopaedic SSIs. In particular, an Antibiotic Stewardship (AS) approach is recommended for preserving the activity of old and new antimicrobials. Dalbavancin is a novel antimicrobial agent, belonging to the lipoglycopeptides family, recently approved by FDA for the treatment of ABSSSIs (Acute Bacterial Skin and Skin Structure Infections) and can be considered as a candidate for the treatment of orthopaedic superficial SSIs. An antimicrobial activity directed against MRSA and other multi-resistant Gram-positive pathogens, a bactericidal effect and an extremely extended half-life are among key features of this drug. Dalbavancin gives to clinicians the option to provide an intravenous antimicrobial agent shown to be as effective as conventional therapies, without requiring prolonged admission into the hospital, drastically reducing the length of hospital stay (without reducing the treatment compliance) and total cost per patient. In this paper, we analyze general, microbiological and pharmacological features of dalbavancin, aiming at supporting clinicians while positioning this drug in the context of orthopaedic SSIs.

The peroneus brevis flap in the treatment of bone infections of the lower limb.

The Peroneus Brevis Flap is a described option for the soft tissue coverage and for small bone gap reconstruction in the lower third of the lower leg, where few other local flaps are available and reliable. We analysed retrospectively a case series of 11 consecutive patients whose age ranged from 31 to 87 years (mean 56), who underwent a reconstruction with a PB flap in the treatment of post-traumatic bone infections from October 2010 to February 2012. In our series, only one patient at a 3 year minimum follow-up showed recurrence of the bone infection and required further surgical treatment. Main complications were partial flap necrosis or overlying skin graft necrosis, but without the need of secondary surgery. In our experience, the PB flap is a reliable option for soft tissue coverage in the treatment of distal leg and ankle osteomyelitis.

Acetabular spacers in 2-stage hip revision: is it worth it? A single-centre retrospective study.

PURPOSE: The aim of this work is to evaluate an acetabular antibiotic loaded bone cement spacer in 2-stage revision surgery as a potential approach able to reduce complications during the inter-stage period (i.e. dislocation, acetabular wear), as well as simplify 2-stage hip revision surgery and improve hip biomechanics. METHODS: We performed a retrospective comparative study and evaluated clinical, radiological and surgical data of 71 patients affected by periprosthetic hip infection who were treated with 2-stage exchange. 31 patients were treated using an acetabular spacer in addition to the femoral (group A) while 40 underwent a standard revision surgery (femoral spacer only, group B). RESULTS: Mean time of surgery for the first stage was 148 ± 59 minutes and 142 ± 45 minutes for group A and B respectively; we noted a statistically significant reduction (26 min, p = 0.015) in the same parameter for the second stage (83 ± 35 minutes for group A and 109 ± 36 minutes for group B). We observed the following interstage complications: 5 femoral spacer dislocations (1 for group A and 4 for group B); 1 spacer fracture (group B), 1 spacer fracture (group A), 2 periprosthetic fractures (group B) and 2 patients with acetabular spacer instability (group B). Additionally, we observed a significant improvement in leg length restoration for group A (p = 0.03). CONCLUSIONS: Our data show that the acetabular spacer technique is able to reduce the interstage complication rate and allow improved hip biomechanics restoration.

Azole-resistant Candida albicans prosthetic joint infection treated with prolonged administration of anidulafungin and two-stage exchange with implant of a mega-prosthesis.

Fungal prosthetic joint infection (PJI) is a rare but severe complication of artroplasty. We report a case of PJI due to azole-resistant Candida albicans successfully treated with combination of prolonged administration of anidulafungin and two-stage joint exchange with insertion of a mega-prosthesis.

[Diagnosis in patients with a painful arthroplasty]. / Diagnosi differenziale in pazienti con protesi ortopedica dolorosa.

The differential diagnosis between asepting loosening or prosthetic joint infection is not always easy. Tc-99m-labelled leucocyte scans, frozen section and histology can help recognise doubtful cases. We report the experience of the Unit for Infectious Diseases and Septic Orthopaedics of the ASL-2 Liguria, Italy, with a Tc-99m-labelled leucocyte scan and intraoperative frozen section to choose the best therapeutic approach: one-stage or two-stage exchange or arthrodesis-arthroplastica. All cases underwent histology and intraoperative cultures to confirm the diagnosis, and the effectiveness of the approach was evaluated at follow up after 18 months. From January 2011 to December 2012, 36 patients were evaluated (21 hip and 15 knee arthroprosthesis). The Tc-99m-labelled leukocyte scan was positive in 31 and negative in 5 patients. Frozen section was negative in 7 patients. Five of them were patients with a negative Tc-99m-labelled leucocyte scan and were treated successfully with one-stage exchange, even if, in one of them, Enterococcus faecalis was isolated at replacement and suppressive antibiotic treatment was needed. The other 31 patients were treated with arthrodesis arthroplasty (3 patients) or a two-stage exchange. In this group the Tc-99m-labelled leucocyte scan was positive in all patients and the frozen section was positive in 29/31 cases with 6% false negative. Histology was positive in 27/31 with 13% of false negative. The sensitivity and specificity value was respectively 90% and 100% in the frozen section, 84% and 100% in histology. Cultures were positive in 23/31 cases. Patients subjected to two-stage exchange were evaluated again during prosthesis replacement but the results of the Tc-99m-labelled leucocyte scan and histology showed unclear results more frequently: the Tc-99m-labelled leucocyte scan was positive in two cases, the frozen section in three and histology in seven in spite of positive culture in three cases and one relapse in a patient with a frozen section and histology positive but negative culture. In the second step sensitivity and specificity were respectively 67% and 96% in the frozen section, 75% and 88% in histology. Finally, our experience suggests the utility of nuclear and histological tests during diagnostic work-up for differential diagnosis of aseptic loosening or prosthetic joint infection. The same tests produce more uncertain data when performed in two-stage exchange during the second step.

Mechanical and biological treatment of long bone non-unions.

Non-union (NU) of bones is a multifactorial phenomenon. Infected non-unions and/or those with bone loss require "biological treatment", such as the excision of the pathological infected non-union site or the "creation" of new bone substance by the use of distraction techniques. The treatment of choice that meets both the biological and mechanical requirements is that of the external fixation, in as much as it has an extremely low septic complication rate and the mechanical environment can be varied automatically or programmed depending on the requirements. The authors report on a total of 287 cases of non-union treated with external fixation, with a 93% success rate.