[Postoperative implant-associated osteomyelitis of the shoulder: Hardware-retaining revision concept using temporary drainage]. / Postoperative implantatassoziierte Osteitis am Schultergürtel: Materialerhaltendes Revisionskonzept mit Einlage einer Dauerdrainage.

BACKGROUND: Posttraumatic and postoperative osteomyelitis (PPO) is a subgroup of bone infections with increasing importance. However, to date no standardized reoperation concept exists particularly for patients with PPO of the shoulder region. Therefore the purpose of this study was to evaluate a revision concept including débridement, irrigation, and insertion of temporary drainage with hardware retention until healing. PATIENTS AND METHODS: A total of 31 patients with PPO were included with a proximal humerus fracture (n = 14), clavicle fracture (n = 10), or AC-joint separation (n = 7). In all, 27 of these patients could be followed for > 1 year. RESULTS: Hardware retention until fracture or ligament healing could be achieved in > 83%. Six patients required follow-up débridement due to recurrent infections, but then were unremarkable. Clinical outcome showed excellent Constant scores (91.6 ± 2.8). CONCLUSION: A cost-efficient, simple, and successful revision concept for patients with PPO of the shoulder region is described.

High complication rate after septic orthopaedic implant removal of the lower leg.

INTRODUCTION: The aim of the study was to determine predictive risk factors for revision surgery in patients with septic orthopaedic implant removal of the lower leg. MATERIALS AND METHODS: A total of 196 patients with septic removal of orthopaedic implants after primary trauma of the lower leg between 2008 and 2012 were evaluated. Patients with endoprosthesis infection were excluded from this study. RESULTS: Thirteen patients (22.4 %) had infectious complications with revision surgery. We found 14 patients with soft tissue infections, 10 patients with osteomyelitis, 19 patients with wound-healing problems, 10 patients with pin track infections and two patients with fistulas. High complication rates were associated with severity of the initial trauma, localisation, and the state of union or non-union. Patients with peripheral arterial disease, anaemia and smoking showed a significantly higher risk for revision surgery; whereas patients with diabetes and arterial hypertension did not. A total of 22.6 % had open fractures as an initial trauma. In 76 %, bacteria could be detected. The complication rate was 41.2 % after initial open fractures and 19.6 % after initial closed fractures. A higher grade of soft tissue damage showed no increasing complication rate (p > 0.05). CONCLUSIONS: In this study, complications after septic implant removal of the lower leg were evaluated and risk factors were determined. The awareness of the risks for complications after septic orthopaedic implant removal can lead to a better treatment for patients. Decision-making can be based on scientific results to prevent patients suffering from further severe disease progression.

[Flaps for soft tissue defect closure in the distal lower leg]. / Lappenplastiken zur Defektdeckung am distalen Unterschenkel.

Soft tissue defects in the distal lower leg region are challenging to treat, especially in trauma cases. To achieve early closure of the defect, pediculated adipofascial or muscle flaps can be used as well as free flaps. The pediculated adipofascial suralis flap has a reliable blood supply and a broad radius so this flap can be used for almost every defect location on the distal lower leg except for defects larger than 10 × 10 cm. The donor site defect does not lead to major problems and is well tolerated. The soleus flap can cover defects in the middle third and proximal distal third of the lower leg with its muscle. The donor site defect is occasionally associated with reduced calf functioning but is tolerated well most of the time. Because of these advantages, the pediculated adipofacial suralis flap and the soleus muscle flap can be used instead a microvascular free flap for the closure of defects in the distal lower leg region.

[Infected knee prostheses. Part 1: early infection or acute hematogenous infection]. / Die infizierte knieprothese. Teil 1: frühinfekt oder akuter hämatogener Infekt.

OBJECTIVE: Treatment of an early total knee arthroplasty (TKA) infection with the goal of salvaging the implant. INDICATIONS: Early postoperative infections within the first 4 weeks. The acute hemtogenous infection of the knee joint with TKA and duration of symptoms for a maximum of 4 weeks. CONTRAINDICATIONS: Unsuitable for anesthesia, high acute infection with sepsis and risk for bacteremia with danger to life, large soft tissue damage where plastic surgery coverage is not possible. SURGICAL TECHNIQUE: Arthrotomy, synovectomy, inlay removal, jet lavage, instillation of polyhexanide, new inlay, drainage and infusion-aspiration-drainage if necessary, wound closure with plastic surgery if necessary. POSTOPERATIVE MANAGEMENT: Infusion-aspiration-drainage with polyhexanide for 3 days or drainage for 3 days. Continuous passive motion (CPM) with increasing range of motion (ROM) 0-0-30°. Removal of the drain after 5 days and mobilization with increasing ROM and full weight-bearing. RESULTS: The success rate for the salvage procedure is about 70%.

[Infected knee prostheses. Part 2: chronic late infections]. / Die infizierte knieprothese. Teil 2: der chronische spätinfekt.

OBJECTIVE: Treatment of late and chronic infections, which require the replacement of all the infected implant material. INDICATIONS: All infections lasting more than 4 weeks that have been proven to be bacterial and/or obvious signs of infection. CONTRAINDICATIONS: Unsuitable for anesthesia, high acute infection with sepsis and risk for bacteremia with danger to life, large soft tissue damage where plastic surgery coverage is not possible. SURGICAL TECHNIQUE: Arthrotomy, synovectomy, removal of all foreign bodies including all residue of polymethylmethacrylate (PMMA), jet lavage, spacer, drainage, wound closure or temporary closure using vacuum sealing. POSTOPERATIVE MANAGEMENT: Bed rest with a leg brace and drainage until daily drainage volume is <50 ml, then mobilization with no weight-bearing in an orthesis, 4 weeks systemic antibiotics, after 2 weeks without antibiotics aspiration of the joint, when no bacteria are found reimplantation of a revision TKA (total knee arthroplasty) and with plastic surgery for coverage (gastrognemius flap) if necessary, when bacteria are found again revision with exchange of the spacer. RESULTS: In the literature, the success rate for both the one-stage or the two-stage procedure is about 80-95%. In our very nonhomogeneous collective the overall rate of success is about 81%.

[Soft tissue healing in infected arthroplasty]. / Weichteilsanierung bei infizierter endoprothetik.

OBJECTIVE: Soft-tissue defect coverage with well vascularized tissue (musculocutaneous or fasciocutaneous) in the arthroplasty setting. Where arthroplasty has been removed due to infection, as a muscle flap to close infected cavities. INDICATIONS: Soft tissue defects, wound-edge necrosis in arthroplasty, and persistent infection in Girdlestone patients. CONTRAINDICATIONS: Moribund patients. SURGICAL TECHNIQUE: Pedicled flap: as far as possible, lift the flap as an island flap to increase coverage. Then suture the flap into the defect (split skin graft where appropriate). Free flap: lift the flap and prepare a vascular pedicle for anastomosis. Suture the flap into the site and create arterial and vascular micro-anastomoses (split skin graft where appropriate). POSTOPERATIVE MANAGEMENT: Position the extremity according to the flap type used. Use 500 ml HES (hydroxyethyl starch) 6% for 5 days. Avoid compression of the pedicle or anastomosis area. Flaps are generally autonomous after 3 weeks. RESULTS: The survival rate for both flap types, free and pedicled, is >90%. The flap survival rate should not be confused with the healing rate for infected arthroplasty.

[Definition of the Diagnosis Osteomyelitis-Osteomyelitis Diagnosis Score (ODS)]. / Zur Definition der Diagnose Osteomyelitis - Osteomyelitis-Diagnose-Score (ODS).

AIM: The disease "osteomyelitis" is characterised by different symptoms and parameters. Decisive roles in the development of the disease are played by the causative bacteria, the route of infection and the individual defense mechanisms of the host. The diagnosis is based on different symptoms and findings from the clinical history, clinical symptoms, laboratory results, diagnostic imaging, microbiological and histopathological analyses. While different osteomyelitis classifications have been published, there is to the best of our knowledge no score that gives information how sure the diagnosis "osteomyelitis" is in general. METHOD: For any scientific study of a disease a valid definition is essential. We have developed a special osteomyelitis diagnosis score for the reliable classification of clinical, laboratory and technical findings. The score is based on five diagnostic procedures: 1) clinical history and risk factors, 2) clinical examination and laboratory results, 3) diagnostic imaging (ultrasound, radiology, CT, MRI, nuclear medicine and hybrid methods), 4) microbiology, and 5) histopathology. RESULTS: Each diagnostic procedure is related to many individual findings, which are weighted by a score system, in order to achieve a relevant value for each assessment. If the sum of the five diagnostic criteria is 18 or more points, the diagnosis of osteomyelitis can be viewed as "safe" (diagnosis class A). Between 8-17 points the diagnosis is "probable" (diagnosis class B). Less than 8 points means that the diagnosis is "possible, but unlikely" (class C diagnosis). Since each parameter can score six points at a maximum, a reliable diagnosis can only be achieved if at least 3 parameters are scored with 6 points. CONCLUSION: The osteomyelitis diagnosis score should help to avoid the false description of a clinical presentation as "osteomyelitis". A safe diagnosis is essential for the aetiology, treatment and outcome studies of osteomyelitis.

Vastus lateralis muscle flap for infected hips after resection arthroplasty.

We evaluated the potential of a vastus lateralis muscle flap in controlling infection after resection arthroplasty of the hip. We retrospectively reviewed 119 patients with 120 chronic infections after resection arthroplasty treated with this procedure. The flap was fixed with Mitek anchors in the acetabular cavity. The mean duration of infection after resection before the muscle flap procedure was 6.5 months (2 to 13). The patients had previously undergone a mean of 4.9 operations (2 to 25). In all patients the infected cavity was the origin of the persistent infection. The mean follow-up was for 2.6 years (1.0 to 4.7). No patient had recurrent infection post-operatively and all had an improvement in the pain and better quality of life.

[Arthrodesis of the elbow joint. Indications, surgical technique and clinical results]. / Ellenbogengelenkarthrodese. Indikation, Operationsverfahren und klinische Ergebnisse.

Arthrodesis of the elbow joint (EA) is a rare salvage procedure which is disliked by both surgeons and patients. The aim of this study was to analyze the indications, the operation techniques and the outcome of EA in patients treated at our clinic. Between January 1997 and December 2005 a total of 20 patients with a mean age of 55 years (range 27-85 years) were treated with EA at our clinic. In 18 patients a compression plate was used as surgical technique. In 18 out of the 20 patients the operation was performed post-traumatically after infection, bone and tissue defects and painful loss of motion. Of these patients, 16 could be followed up for an average time of 66 months. The outcome was evaluated based on the degree of pain, range of motion, radiographic findings and grip strength measured with the Jamar dynamometer. All patients had a solid and fused EA, the average angle was 89 degrees (range 80-110 degrees) and the grip strength was reduced by 27% compared to the unaffected side. The patients achieved 56 points in the Morrey score, 38.29 points in the DASH (disabilities of the arm, shoulder and hand) score and 80 points in the Constant-Murley score. The indication of EA depends on several factors, therefore it is essential to take the patients' functional requirements into consideration and the best arthrodesis angle should be validated pre-operatively. In these cases the patients can regain good grip strength and a high level of stability within defined functional limitations.

[Chronic osteitis of the lower extremities. An interdisciplinary treatment concept]. / Chronische Osteitis der unteren Extremität. Interdisziplinäre Behandlungskonzepte.

INTRODUCTION: The purpose of this investigation was the retrospective analysis of patients with delayed infections, chronic posttraumatic osteitis of the lower extremities and free-flap coverage after radical debridement of bone and soft tissue. METHODS: From the time period 1994-2003 a total of 22 patients including 4 females and 18 males were investigated. In 16 patients treatment was carried out on the lower leg and in 6 patients the foot was treated with subsequent free-flap coverage. In 14 cases the latissimus dorsi muscle was used, in 5 cases the gracilis muscle, in 2 cases parascapula flaps were used and in 1 case the serratus anterior muscle. The average age of the patients was 43 years (range 17-63 years) and grouping was according to the HOST classification. Functional outcome was evaluated by a standardized questionnaire (Funktionsfragebogen Hannover FFbH-OA 2,0), quality of life and social reintegration by non-standardized questionnaires. RESULTS: In the cases investigated the following results could be achieved: full leg activity 55%, leg pain while walking 73%, special footwear 68%, normal gait 55%, positive quality of life and social reintegration 55%, port activities 36% and reemployment 45%. CONCLUSION: According to the results of this study the quality of life of patients with chronic osteitis of the lower leg is in general satisfying. In order to improve quality management and cost reduction in public health an interdisciplinary treatment concept of plastic and orthopedic surgeons should be established for complex fracture management as this is the most effective tool in treating chronic osteitis.

[Implant-associated post-traumatic osteomyelitis. Bacterial biofilms and the immune defence as protagonists of the local inflammatory process]. / Die implantatassoziierte posttraumatische Osteitis. Bakterielle Biofilme und Infektabwehr als Protagonisten der lokalen Entzündungsreaktion.

BACKGROUND: Formation of bacterial biofilms on implants is a severe complication following orthopaedic surgery. In the present study we addressed the role of the immune response, particularly with regard to the pathogenesis of the disease. METHODS: In a prospective study comprising 74 patients with implant-associated post-traumatic osteomyelitis, peripheral blood cells as well as cells recovered from the infected site during surgery were characterised phenotypically and functionally. RESULTS: We found massive infiltration of polymorphonuclear neutrophils (PMN), which were highly activated, particularly regarding their bactericidal potential, such as increased production of superoxides and upregulation of activation-associated surface receptors. CONCLUSION: PMN are activated in response to the implant-associated osteomyelitis; they also infiltrate the infected tissue, but cannot control the infection. By release of their cytotoxic entities they could contribute to tissue destruction and eventually to osteolysis.

Cellular inflammatory response to persistent localized Staphylococcus aureus infection: phenotypical and functional characterization of polymorphonuclear neutrophils (PMN).

Persistent, localized Staphylococcus aureus infections, refractory to antibiotic treatment, can result in massive tissue destruction and surgical intervention is often the only therapeutic option. In that context, we investigated patients with S. aureus-induced infection at various sites, apparent as either olecranon bursitis, empyema of the knee joint or soft tissue abscess formation. As expected, a prominent leucocyte infiltrate was found, consisting predominantly of polymorphonuclear neutrophils (PMN) (up to 75%) and to a lesser extent of T lymphocytes and natural killer (NK) cells. In line with their bactericidal capacity, PMN expressed the high-affinity receptor for IgG, CD64 and the lipopolysaccharide (LPS) receptor CD14; moreover, the oxygen radical production in response to the bacterial peptide f-MLP was enhanced, while chemotactic activity was greatly reduced. The more intriguing finding, however, was that a portion of PMN had acquired major histocompatibility complex (MHC) class II antigens and CD83, indicative of a transdifferentiation of PMN to cells with dendritic-like characteristics. Of note is that a similar transdifferentiation can be induced in PMN in vitro, e.g. by gamma interferon or by tumour necrosis factor alpha. Co-cultivation of transdifferentiated PMN with autologous T lymphocytes resulted in prominent T cell proliferation, provided that S. aureus enterotoxin A was added. Taken together, persistent S. aureus infection induces PMN to acquire characteristics of dendritic cells, which in turn might promote the local immune response.

[Postoperative and bacterial osteitis. New possibilities for therapy]. / Postoperative und bakterielle Osteitis. Neue Therapieansätze.

Current therapy concepts for post-trauma osteitis include radical debridement, stabilization of bone and soft tissue care using early flap transfers. With this more radical approach, the long term results are improved, however, total treatment time still is very long. In addition to the physical, mental and social consequences for the patient, treatment costs are also very high. Antibiotic therapy as an adjuvant is still standard and effective although the development of worldwide antibiotic resistance has increased treatment difficulties. One of the main aims of research is to reduce these problems or to prevent the development of osteitis entirely. However, research has not yet elucidated the complex immunologic changes involved. In addition, most results are obtained from animal studies and clinical investigations are required.

[Vastus lateralis flap--an ideal procedure for definitive surgery of infected cavities of the hip]. / Vastus-lateralis-Lappen--Ein ideales Verfahren zur definitiven Sanierung von Infekthöhlen an der Hüfte.

Between January 1994 and August 1998, 12 patients with 13 chronic infections after resection arthroplasty were treated successfully with vastus lateralis muscleflap. One patient was suffering from chronic infection on both sides. In all cases we found the infected cavity to be the origin of the persistent infection. The average duration of infection was 8.3 months. The patients had undergone an average of 3.8 operations. Up to now there was no recurrent infection, controlled by clinical investigation, ultrasound and laboratory findings in all 13 cases. Follow up investigation occurred 2.5 years (1.5-4.7) after flap transfer. The flap is easy to harvest. He has a very constant pattern of vascular pedicle and a wide arc of rotation. The functional deficits of donor side morbidity are minimal. That vastus lateralis flap seems to be an ideal procedure to stop draining infections due to infected cavities in the hip region.

[Treatment of soft tissue damage--definitive management]. / Behandlung des Weichteilschadens--Definitivversorgung.

Fractures of the extremities combined with soft tissue damage are still a big challenge for the orthopaedic surgeon. Medical mismanagement leads very often to osteomyelitis and high treatment costs. Radical débridement is the key to therapy success. Closure of soft tissue lesions has to be done within 1 week. Methods of choice are vacuum sealing, meshgraft, flap transfer and the Ilisarov procedure. The chosen tool has to be harmonized with the fracture classification. Only individual decisions are possible. For the best results, orthopaedic surgeons should have a good knowledge of the reconstructive possibilities.

[The determinants of the quality of life after a type-III open tibial fracture. The results of a multicenter study]. / Determinanten der Lebensqualität nach offenem Unterschenkelbruch Typ III. Ergebnisse einer Multicenterstudie.

This study investigated to what extent quality of life four years or more after the fracture is determined by initial staging (Gustilo subclassification, time from injury to arrival at hospital), by the therapeutic course (length of hospital stay, number of operations), by complications (amputation, infection) and by demographic factors (gender, age). A total of 197 patients after type III open tibial shaft fractures (type IIIA 70, type IIIB 85, type IIIC 42) from nine centers volunteered to participate in this study. During patients' follow-up appointments (mean duration of follow-up 50 months), therapeutic course, pre-surgical staging and demographic data were recorded by the surgeon. Patients were asked to rate quality of life on the Nottingham Health Profile and on a visual analogue scale. Multiple regression analysis (stepwise) identified two predictors for reducing overall quality of life (F-test: P = 0.007): number of operations (adjusted beta: -0.21) and age (adjusted beta: -0.17). Other factors showed no significant relationship with overall quality of life or with subscales of the Nottingham Health Profile. These findings indicate a dilemma between two therapeutic goals: good functional outcome, which often requires repeated operations, and quality of life, which suffers under prolonged surgical treatment.

[Necrosis of the rectus abdominis muscle. Complication after ilioinguinal approach]. / Musculus-rectus-abdominis-Nekrose. Komplikation nach ilioinguinalem Zugang.

After a car accident, a 19-year-old man had to undergo laparotomy in a local hospital due to intra-abdominal bleeding. A right-sided transrectal incision was chosen, and to improve exposure the rectus muscle was cut horizontally at the cranial end of the incision. Ten days after the accident the patient was transferred to our hospital for stabilization of the pelvic and acetabular fracture on the right side. An ilioinguinal approach was chosen. Two days later the abdominal cavity was opened due to necrosis of the cranial part of the rectus abdominis muscle. Following a 10-day period without pathological symptoms, suddenly sepsis developed. Ultrasound showed a lot of fluid in the rectus sheath; no muscle structure could be identified. The operation showed total necrosis of the rectus muscle due to thrombotic occlusion of the inferior epigastric artery. The standardized tourniquets around the vessels used during the ilioinguinal approach seemed to be responsible for the rectus muscle necrosis. Therefore, if a combined intraabdominal and pelvic approach has to be used, median laparotomy is the better choice, because no risk is posed to the blood supply of the rectus muscle, in contrast to the ilioinguinal approach. The problem is discussed in detail.

Myocutaneous versus fasciocutaneous free flap in the treatment of lower leg osteitis.

Preliminary reports have indicated that debridement of all necrotic soft tissue and bone is a highly efficient method in treatment of lower leg osteitis, if combined with free flap transfer. Yet the question, whether fasciocutaneous or musculocutaneous flaps are the better choice, is controversial. To answer that question, we looked at the files of 69 patients who underwent surgical treatment of osteitis of the leg between 1982 and 1989. Those patients underwent an agressive debridement and closure of the soft tissue defect by free flap transfer in a single stage operation. Long term follow up was possible for 50 patients (72%). Out of these patients two groups were formed: Those being treated treated with musculocutaneous (mc) - and those with fasciocutaneous free flap (fc). In mc-group the 30 patients received 33 flaps, 20 patients of fc 21 flaps. We lost 3 Latissimus dorsi and 2 Parascapular flaps. Flap survival rate was 91% in both groups. The rate of early reexploration was much higher in the mc-group. We could demonstrate, that free flap transfer itself is not the final step in the treatment of osteitis. Only 30% of mc-patients were cured after the transfer. The remaining 21 patients needed another 4.09 (mean) operations. The rate in fc with 65% cured patients was significantly higher. The remaining 7 patients required 3.57 (mean) subsequent operations. Relapse of infection after free flap transfer occurred in 33% (10 pat.) in mc. We found a range of 1 to 6 recurrent fistulas. Five patients have been free of drainage for more than 4 years. Two are still suffering from active infections. Amputation as a final solution in that group had to be done in 3 patients (10%). In the fc-group only 10% (2 pat.) showed a relapse of infection. Both had only 1 fistula. One of these patients has been drainage free for more than 4 years now, one is still active. There were no amputations in that group. So taking the 4 year drainage free time as a measure, mc-group showed an overall success rate of 83%. In fc-group it was much higher with 95%. From our clinical experience we cannot agree with the hypothesis of an antiinflammatory effect of muscle flaps, which has been discussed so often in the literature.

The treatment of infected tibial pilon fractures.

A total of 33 patients with infection after pilon fracture were retrospectively reviewed from 1988 to 1992. Twenty patients were transfered from peripheral hospitals with active osteitis, 13 patients were treated primarily in our hospital. Factors inducing infection in this group of patients are discussed critically. All patients underwent radical debridement. Restoration of bone stability was required in 72%. Due to the extent of infection, segmental resection had to be perfomed on 7 patients. Resulting soft tissue defects were closed with free flaps in 11 cases. Infection was controlled in 31 patients (93%), but only 8 could be classified as "cured" (24%). Two patients had amputations after failure of treatment. Despite successful therapy, the functional results are poor. Therefore, avoiding infection, has top priority in the post fracture treatment. The correct form of osteosynthesis adapted to the soft tissue lesion can lower infection rates significantly. Soft tissue defects, resulting from open fractures or after primary treatment, have to be closed by flap transfer within a short period of time. The management of the soft tissue is at least as important as the reconstruction of the bone in the treatment of pilon fractures.

[Posterior aortic wall motion in mitral valve disease (author's transl)]. / Die Bewegung der Aortenwand im präkordialen Echokardiogramm bei Patienten mit Mitralklappenerkrankungen.

The posterior aortic wall motion was studied in 60 patients, 39 patients with mitral valve disease and 21 normals. The motion of the posterior aortic wall was measured by using the amplitude of the posterior aortic wall motion from the beginning of left ventricular contraction to aortic valve closure and an atrial filling and emptying index. The latter two indices were used, because left atrial volume changes were reflected by the motion of the posterior aortic wall. It could be demonstrated that normals differed in their motion pattern of the posterior aortic wall to those with mitral valve disease. Furthermore, patients with mitral stenosis, mitral insufficiency and mixed mitral valve disease could be differentiated from each other in terms of these indices and an atrial filling-emptying ratio. Thus careful inspection of the posterior aortic wall motion by precordial echocardiography can be used as a parameter of mitral valve function.