New bone formation using antibiotic-loaded calcium sulfate beads in bone transports for the treatment of long-bone osteomyelitis.

PURPOSE: Bone transport is one of the most frequently used techniques for critical-sized bone defects due to trauma or infection. To fill the defect area and avoid the collapse of soft tissues during transport, some authors have described the use of polymethylmethacrylate or absorbable antibiotic carriers in the form of cylindrical blocks. METHODS: In this article, we present our experience in the treatment of post-traumatic osteomyelitis of the lower and upper limbs, using a bone transport technique with antibiotic-loaded calcium sulfate in the form of beads. Results With the progressive absorption of calcium sulfate, we observed the formation of a bone-like tissue envelope at the periphery of the defect area. Histological analysis and direct visualization during open revision surgery of the docking site in all patients confirmed the presence of newly formed bone tissue with a high presence of osteoblasts and few osteoclasts; no areas of necrosis or signs of infection were observed. This bone envelope maintained the mechanical protective function of the transport path and docking site, and also provided a biological stimulus to avoid the development of necrotic areas and optimize the consolidation phase. Conclusion Bone transport with calcium sulfate beads improves biological and mechanical support and reduces the number of surgeries required.

Treatment of Infected Tibial Non-Unions with Ilizarov Technique: A Case Series.

BACKGROUND: The Ilizarov external fixation technique has been widely used for the treatment of long-bone infected non-unions. After surgical infected bone resection, to allow filling of the remaining bone gap, biomaterials with antibacterial properties could be used. The aim of this study was to report outcomes of infected tibial non-unions treated using the Ilizarov technique and antibacterial bioactive glass. METHODS: Between April 2009 and December 2014, 26 patients with infected tibial non-unions were treated with the Ilizarov technique and possible use of the bioactive glass, S53P4. The Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria, a clinical and radiographic evaluating tool, was used for assessing the sample. RESULTS: The average age at the start of treatment was 51 years. The mean follow-up time was 113 weeks. According to the ASAMI Functional Scoring System, 10 excellent (38.5%) cases and 12 good (46.1%) values were recorded. According to the ASAMI Radiological System, they were excellent in 16 (61.5%) cases and good in nine (34.6%). CONCLUSIONS: Treatment of infected tibial non-unions using the Ilizarov technique was effective in bone segment regeneration. To fill the remaining bone gap, additional bioactive glass S53P4 could be used, allowing a decrease in re-interventions and minimizing complications.

Definitive Treatment of Femoral Shaft Fractures: Comparison between Anterograde Intramedullary Nailing and Monoaxial External Fixation.

BACKGROUND: Femoral shaft fractures result from high-energy trauma. Despite intramedullary nailing (IMN) representing the gold standard option of treatment, external fixation (EF) can be used temporarily for damage control or definitively. The purpose of this study is to compare two different options, anterograde IMN and monoaxial EF, for the treatment of femoral shaft fractures. METHODS: Between January 2005 and December 2014, patients with femoral shaft fractures operated on in two centers were retrospectively evaluated and divided into two groups: the IMN group (n = 74), and the EF group (n = 73). For each group, sex; laterality; age; and AO classification type mean follow-up, mean union time, and complications were reported. RESULTS: Both groups were found to have no statistical differences (p > 0.05) in sex, laterality, age, and AO classification types. In the IMN group the average surgery duration was 79.7 minutes (range 45-130). The average time for bone union was 26.9 weeks. Major complications occurred in 4 (5.4%) patients. In the EF group the average follow-up duration was 59.8 months (range 28-160). The average time for bone union was 24.0 weeks. Major complications occurred in 16 (21.9%) patients. CONCLUSIONS: IMN is the gold standard for definitive treatment of femoral shaft fractures. In patients with severe associated injuries, EF should be a good alternative.

External Fixation as a Definitive Treatment for Humeral Shaft Fractures: Radiographic and Functional Results With Analysis of Outcome Predictors.

OBJECTIVES: To evaluate the results obtained using unilateral external fixation as a definitive treatment for humeral shaft fractures and to identify possible predictors of radiographic and functional outcomes. DESIGN: Retrospective study. SETTING: One large metropolitan hospital. PATIENTS: A consecutive cohort of 107 patients who underwent external fixation for 109 humeral shaft fractures. MAIN OUTCOME MEASURES: Union rate, time to fracture healing, and functional assessment with disabilities of the arm, shoulder, and hand questionnaire, Constant score, Mayo Elbow Performance Index, and return to prefracture sports activity at a minimum of 2 years after surgery. Comorbidities were evaluated using the Cumulative Illness Rating Scale. Multiple linear regression analysis was used to determine whether any explanatory variables were significantly associated with the outcomes. RESULTS: The union rate in 109 humeral shaft fractures was 97.2% (106/109) at a mean of 99.2 days. Two patients (1.8%) had delayed union, and 1 patient (0.9%) did not achieve union. At the latest follow-up, the mean Constant score, Mayo Elbow Performance Index, and disabilities of the arm, shoulder and hand questionnaire score was 85.6, 97.4, and 7.4 points, respectively. All patients engaged in sports activities before fracture resumed a sport activity. At the multiple linear regression analysis, obesity was directly related to a delayed healing of fracture (P = 0.010) and comorbidity was the most important determinant of the functional outcomes at follow-up (P < 0.001). CONCLUSIONS: These data support the use of unilateral external fixation as an effective therapeutic option in patients with humeral shaft fracture. Comorbidity as assessed by Cumulative Illness Rating Scale score is the most important determinant of functional outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Can Clinical and Surgical Parameters Be Combined to Predict How Long It Will Take a Tibia Fracture to Heal? A Prospective Multicentre Observational Study: The FRACTING Study.

BACKGROUND: Healing of tibia fractures occurs over a wide time range of months, with a number of risk factors contributing to prolonged healing. In this prospective, multicentre, observational study, we investigated the capability of FRACTING (tibia FRACTure prediction healING days) score, calculated soon after tibia fracture treatment, to predict healing time. METHODS: The study included 363 patients. Information on patient health, fracture morphology, and surgical treatment adopted were combined to calculate the FRACTING score. Fractures were considered healed when the patient was able to fully weight-bear without pain. RESULTS: 319 fractures (88%) healed within 12 months from treatment. Forty-four fractures healed after 12 months or underwent a second surgery. FRACTING score positively correlated with days to healing: r = 0.63 (p < 0.0001). Average score value was 7.3 ± 2.5; ROC analysis showed strong reliability of the score in separating patients healing before versus after 6 months: AUC = 0.823. CONCLUSIONS: This study shows that the FRACTING score can be employed both to predict months needed for fracture healing and to identify immediately after treatment patients at risk of prolonged healing. In patients with high score values, new pharmacological and nonpharmacological treatments to enhance osteogenesis could be tested selectively, which may finally result in reduced disability time and health cost savings.