Early prophylactic bone grafting of high-energy tibial fractures

Fifty-three high-energy tibial fractures treated with early prophylactic posterolateral bone grafting were retrospectively reviewed. The bone-grafting procedures were performed at a mean of ten weeks following injury and at a mean of eight weeks following soft-tissue coverage. Ninety-six percent of the fractures had associated injuries with a mean injury severity score of 20.9. Seventy-nine percent of the fractures were classified as Grade III open fractures, and 40% had bone loss greater than 50% of the cortical circumference. Ninety-six percent of the fractures healed at a mean time of 43 weeks after injury. Segmental bone loss and soft-tissue injury requiring flap coverage were the best predictors of prolonged time to union. Comparison with a matched historical control group of tibial fractures not receiving early bone grafts revealed a mean reduction in time to union of 11.7 weeks (p = 0.03). The incidence of chronic osteomyelitis was 1.9%. These results are attributed to early and repeated aggressive debridement, immediate rigid external fixation, early soft-tissue coverage, and early posterolateral bone grafting. Recommendations include posterolateral cancellous bone grafting two weeks following wound closure by delayed primary closure, split-thickness skin graft, or local rotational myoplasty. A six-week delay following freely vascularized soft-tissue coverage prior to bone grafting is suggested.     

Treatment of chronic osteomyelitis complicating nonunion and segmental defects of the tibia with open cancellous bone graft, posterolateral bone graft, and soft-tissue transfer

Forty-two consecutive patients with chronic osteomyelitis complicating persistent tibial nonunion and chronic osteomyelitis complicating tibial fracture with segmental bone loss were treated from January 1979 through December 1986 using a protocol including either open cancellous bone grafting (Friedlaender-Papineau technique), posterolateral bone grafting (Harmon technique), or local or microvascular soft-tissue transfer before cancellous bone grafting. Each patient had undergone surgical debridement and intravenous antibiotic therapy before inclusion in this study. Patients were classified using a staging system which included consideration of anatomic location of the infection within the bone; extent of bone involvement; quality of soft-tissue envelope and vascular integrity; and generalized host status. The overall success rate for arresting the osteomyelitis and healing the nonunion was 62% (26/42). If the six patients who refused additional bone graft surgery, the one patient who represented poor patient selection, and the patient who refused ankle arthrodesis are eliminated, the success rate for healing of the nonunion and resolving the osteomyelitis in this difficult patient population is: open bone cell graft, 66% (12/18); soft-tissue transfer 87.5%, (7/8); and posterolateral bone grafting, 87.5% (7/8). Use of a standardized classification system allows comparison of treatment results. Adequate debridement is crucial in treating osteomyelitis complicating established long bone fractures and nonunions. Determining the extent of debridement has proven to be the single most difficult aspect technically. Patient selection and pretreatment education are crucial. Caring for these patients is not only labor intensive and demanding of personnel and hospital resources, but demanding of the patients as well.     

The treatment of chronic hematogenous osteomyelitis

Eighty-five patients with a total of 103 foci of chronic hematogenous osteomyelitis were treated in the period from 1965-1982. Only patients who had been followed for two or more years of treatment were included in the series for evaluation. All foci were treated surgically with thorough debridement. According to the management of the wounds, patients were divided into three groups: wound healing by secondary intention in cases where skin closure was impossible; primary closure of wound with or without pedicle muscle transfer in cases of a small debrided cavity or in cases where a nearby skeletal muscle is available; and closed irrigation and suction drainage of the wound cavity. After a long-term follow-up period, satisfactory results to varying degrees were obtained in each group. Closed intermittent irrigation and suction drainage with high concentrations of antibiotic solutions gave the best results. In instances of failure, the causes may be due to inadequate removal of infected sclerotic bone and sequestra, obstruction of drainage tubes, resistance to antibiotics, or inadequate systemic antibiotic treatment. The use of myocutaneous flap transference to close the postoperative wound of chronic osteomyelitis was introduced, and preliminary results are encouraging.     

Modern papineau technique with vacuum-assisted closure

We describe a contemporary modification of the Papineau technique by implementing a vacuum-assisted closure (V.A.C.(R)) device in lieu of wet-to-dry dressing changes. The method makes use of a protocol similar to that of Papineau and others for the treatment of chronic osteomyelitis. This protocol includes aggressive excisional debridement of infected or necrotic bone, open bone grafting with cancellous autograft, vacuum-assisted wound closure by secondary intent, and eradication of chronic infection with concomitant parenteral antibiotics. A representative case report is included to illustrate the technique.     

Treatment of 2d and 3d degree complicated tibial shaft fractures with the PMMA bead pouch technic

In a consecutive series of 222 compound fractures treated at the University of Louisville Level I Trauma Center from November 1984 to January 1987, 21 severe compound tibia shaft fractures in 20 patients were managed with the antibiotic bead pouch technique. There were 5 tibia shaft fractures and 16 tib-fib fractures. There were 9 type II and 12 type III (4 III A and 8 III B) open tibias. The patients' ages ranged from 16 to 50 years; the mean age was 29 years. There were 19 men and 1 woman. The Injury Severity Score (I.S.S.) ranged from 9 to 34; the mean I.S.S. was 14.4. Porous plastic film (Opsite) is placed over the soft tissue defect to establish a "closed" bead - hematoma - fracture environment containing high local levels of antibiotic at the fracture site. All patients had external skeletal fixation, serial wound débridement, and parenteral systemic antibiotics (cefazolin, penicillin, tobramycin). An aggregate of 46 bead pouch changes were performed in the 21 tibia fractures. During these changes, 86 cultures were taken, 5 of which were positive. One patient developed a wound infection, which was caused by tobramycin-resistant Pseudomonas and Enterococcus. No cases of osteomyelitis were observed at the fracture site. Wound closure was obtained in 9 fractures with delayed primary closure, and in 12 fractures with flap coverage and/or split thickness skin grafting. All patients underwent autogenous cancellous bone grafting after wound closure was established. The mean follow-up was 26 months (range 13-43 months). At final follow-up, 4 results were rated excellent, 11 good, 3 fair and 3 poor.(ABSTRACT TRUNCATED AT 250 WORDS)     

Muscle flaps in the treatment of osteomyelitis of the lower extremity

Thirty three consecutive patients with chronic osteomyelitis and deficient soft tissue coverage treated with a muscle flap from 1991-1998 were reviewed retrospectively. Osteomyelitis was diagnosed by positive bone cultures and radiographic changes consistent with osteomyelitis. Osteomyelitis was divided into localized <50% diameter: 24 patients and diffuse >50% diameter or infected nonunion: 9 patients. The average age was 38 (18-74). The cause of the osteomyelitis was open fracture 23, closed fracture and open reduction internal fixation 5, gunshot wound 3, burn 1, and chronic venous stasis ulcer 1. Localized osteomyelitis was treated with saucerization and coverage with a free or rotational muscle flap. Pandiaphyseal osteomyelitis was treated with a complete diaphysectomy in 3, and wide saucerization in 2. Twenty three patients were treated with a free flap and 10 with a rotational flap.A reconstructive success was considered a limb that allowed full weight bearing with a stable wound, no drainage and no recurrence of infection. Patients were evaluated for risk factors: malnutrition, renal or liver failure, alcohol abuse, immune deficiency, chronic hypoxia, malignancy, diabetes, age over 70, steroid therapy, tobacco abuse, or drug abuse.Patients were followed an average of 34 months (12-58) after surgery. A reconstructive success was achieved in 91% (20/22) of patients with local osteomyelitis and in 56% (5/9) of patients with diffuse osteomyelitis (p < 0.05). A reconstructive success was achieved in 88% (7/8) patients with no risk factors and in 78% (18/23) of patients with one or more risk factors (not significant p = 0.05).     

Coverage of the infected wound.

Fifty-four consecutive patients with chronic wounds were identified by the following criteria: (1) established infection for 6 months, (2) exposure of bone, mediastinum, or other vital structure, (3) mechanical and/or vascular limitations to delayed closure techniques, (4) no response to wound debridement in prolonged antibiotic therapy. These wounds were divided into four groups: osteomyelitis (21), pressure sore (17), soft tissue wound (10), and osteoradionecrosis (6). Wound treatment in all patients included debridement, muscle flap closure, and culture specific antibiotic therapy. These consecutively treated patients over a 4-year period presented with an average duration of chronic infection of 2.9 years. Ninety-three per cent of these patients after treatment have demonstrated stable coverage without recurrent infection with a minimum of 1 year and a maximum of 4.6 years follow-up. The results demonstrate safe, effective coverage (93% of patients) of chronic infected wounds associated with long bone and pelvic osteomyelitis as well as chronic perineal sinuses following proctocolectomy and osteoradionecrosis. Debridement with short-term (average 12 days) antibiotic therapy has been effective when muscle flap coverage is provided.     

Results of treatment of tibial and femoral osteomyelitis in adults

From January 1, 1971, to December 31, 1985, 425 patients with chronic osteomyelitis of the femur or tibia were seen at the authors' institution. The success rate in this recent experience was 84.4% compared with 50.9% in the authors' results published in 1970. A classification of chronic osteomyelitis is as follows: (1) hematogenous osteomyelitis; (2) osteomyelitis in united fractures (fracture with union); (3) osteomyelitis in nonunion (fracture with nonunion); and (4) postoperative or posttraumatic osteomyelitis in which bone was not fractured. For management of the scarring of surrounding soft tissue, there has been a change to excision of the scarred tissue and reliance on muscle flap, free-tissue transfer, or closure of soft tissues without irrigation with antibiotic solution. In recent years, free microvascular osseous grafts have permitted more aggressive resection of the involved osseous tissue. The predominance of gram-negative organisms and penicillin-resistant Staphylococcus aureus and the occurrence of methicillin-resistant S. aureus continue.     

Long-term results of multiple-stage treatment for posttraumatic osteomyelitis of the tibia

BACKGROUND: The treatment of posttraumatic osteomyelitis of the tibia requires meticulous debridement and adequate soft tissue coverage. At our institution, we perform a staged procedure consisting of surgical debridement followed by muscle coverage. If necessary, implantation of a cancellous iliac bone graft was always performed as a three-stage treatment. METHODS: We performed a retrospective analysis of 47 patients treated for posttraumatic osteomyelitis of the tibia between 1987 and 1998. RESULTS: Twenty-two patients originally had a Gustilo grade III fracture, 21 patients had a Gustilo grade I or II or closed fracture, the Gustilo grade was not known for 2 patients, and 2 patients had no fracture. Using the Cierny-Mader classification, most patients had a localized osteomyelitis. To cover the debrided area, 20 pedicled muscle transfers and 28 microvascular free flaps were used; one patient had two localizations of osteomyelitis (both proximal and distal) and received two muscle flaps. Flap failure was 8% and was successfully treated by additional flap coverage in two cases; one was closed by a split skin graft and one was closed by secundum. Twenty-six patients received a cancellous bone graft. During an average follow-up of 94 months, 9% had a recurrence of osteomyelitis for which additional surgical interventions were necessary. Finally, all the infections were eventually cured. CONCLUSION: Our staged surgery proved to be an excellent method of treating osteomyelitis after open or closed fractures of the tibia.     

清创一期植骨及腓肠神经皮瓣治疗跟骨慢性骨髓炎伴软组织缺损

【摘要】 目的 探讨清创、一期植骨联合腓肠神经皮瓣移植治疗跟骨慢性骨髓炎伴软组织缺损的疗效。方法 2008年11月~2011年11月,对 12例合并软组织缺损的跟骨慢性骨髓炎患者采用清创、一期植骨联合腓肠神经皮瓣移植修复创面,观察术后皮瓣成活、骨髓炎治愈及踝关节功能情况。结果 术后随访9~24个月,平均 17个月。9例皮瓣Ⅰ期愈合,3例窦道形成或边缘坏死经处理后愈合;随访期间无骨髓炎复发;根据美国足踝外科协会(AOFAS ) 踝后足功能评分术后(89.4±7.8)较术前(42.8±15.3)明显提高,差异有统计学意义(P<0.05)。结论 跟骨慢性髓炎合并软组织缺损通过彻底清创、一期植骨及腓肠神皮瓣移植取得良好的效果,该方法具有疗效确切、疗程短、简单易行等特点。     

Primary closure for postoperative mediastinitis in children

OBJECTIVES: Mediastinitis affects approximately 1% of children undergoing median sternotomy. Conventional therapy involves debridement followed by open wound care with delayed closure, days to weeks of closed suction or antimicrobial irrigation, and vacuum-assisted closure or muscle flap closure. We hypothesized that primary closure without prolonged suction or irrigation is an effective, less traumatic treatment for mediastinitis in children. METHODS: From January 1986 to July 2002, 6705 procedures involving median sternotomy were performed at the C. S. Mott Children's Hospital, resulting in 57 cases of mediastinitis (0.85%). Cases were divided into 2 groups, with 42 cases treated with primary closure and 15 cases treated with delayed or muscle flap closure. The 42 cases of primary closure comprised the primary study group of this institutional review board-approved, retrospective analysis. Patient demographics, surgical variables, mediastinitis-related parameters, and outcomes were evaluated. RESULTS: One patient had recurrent mediastinitis for an overall infection eradication rate of 97% (40/41). Three patients (7%) required re-exploration for suspected ongoing infection. Of these re-explorations, 1 patient had evidence of continued mediastinitis. The remaining 2 patients with sepsis of unclear cause had no clinical or culture evidence of recurrent infection. One of these patients ultimately died of sepsis without active mediastinitis for a hospital survival of 97% (41/42). No significant differences could be detected between the treatment successes and failures in this small cohort of patients. CONCLUSIONS: Simple primary closure is an effective means to treat selected cases of postoperative mediastinitis in children. The results compare favorably with other more lengthy or debilitating treatments.     

Sternal osteomyelitis: use of vacuum-assisted closure device as an adjunct to definitive closure with sternectomy and muscle flap reconstruction

OBJECTIVES: Sternal osteomyelitis following cardiac surgery often requires debridement and flap coverage. The VAC (vacuum-assisted closure) device has been useful in complex wound coverage. A retrospective review of a single surgeon's experience with sternal reconstruction using the VAC device as an adjunct to debridement and muscle flap reconstruction was performed. METHODS: Thirteen consecutive patients over a 34-month period underwent debridement and reconstruction of sternal wounds. Eleven patients (85%) were males, and two (15%) were females. Mean age was 61 years (range: 43-73 years). Acute purulent sternal infections occurred in seven patients, while chronic sternal osteomyelitis was seen in six patients. Use of the VAC device during the perioperative period was evaluated. RESULTS: Of the 13 patients, the VAC device was used prior to flap closure in six patients, and after flap closure in two patients. Sternal debridement with bilateral pectoralis muscle flaps was used to reconstruct 12 patients, and one patient underwent debridement only with VAC placement. All 13 patients (100%) had complete closure of their complex wounds at an average of follow-up of 14 months. CONCLUSIONS: The VAC device is useful in the treatment of sternal osteomyelitis in three contexts: (1) as a temporary wound care technique preoperatively that minimizes dressing changes and prevents shear stresses of an open sternum, (2) as the sole method of wound closure in specific cases, and (3) as a technique to facilitate healing in postoperative flap reconstruction cases complicated by reinfection.     

一期植骨加内固定治疗手部开放性骨缺损

目的探讨应用一期植骨加内固定治疗手部开放性骨缺损的手术疗效。方法2000-2003年治疗手部开放性骨缺损12例；急诊采用彻底清创，自体髂骨植骨加钢板或克氏针内固定术治疗。其中7例因伴有皮肤软组织缺损同时行皮瓣移植术。结果11例创面I期愈合，其中6例皮瓣完全存活；1例皮瓣远端部分坏死，钢板外露，经皮瓣提升覆盖创面处理后愈合。术后随访1-3年，骨折愈合时间为2-6个月，平均3.5个月。手功能按TAM评定，优良率达82%。结论一期植骨加骨固定治疗手部开放性骨缺损能缩短病程，防止指体短缩，有利于手功能的恢复，彻底清创和良好的创面覆盖是手术成功的关键。     

Early prophylactic autogenous bone grafting in type III open tibial fractures

The authors report the results achieved in patients with type III open tibial fractures who underwent primary autogenous bone grafting at the time of debridement and skeletal stabilisation. Twenty patients with a mean age of 35.8 years (range, 24-55) were treated between 1996 and 1999. Eight fractures were type IIIA, 11 were type IIIB, and 1 was type IIIC. At the index procedure, wound debridement, external fixation and autogenous bone grafting with bone coverage were achieved. The mean follow-up period was 46 months (range, 34-55). The mean time to fixator removal was 21 weeks (range, 14-35), and the mean time to union was 28 weeks (range, 19-45). Skin coverage was achieved by a myocutaneous flap in 2 patients, late primary closure in 4, and split skin grafting in 14. One (5%) of the patients experienced delayed union, and 1 (5%) developed infection. In tibial type III open fractures, skin coverage may be delayed, using the surrounding soft tissue to cover any exposed bone after thorough débridement and wound cleansing. Primary prophylactic bone grafting performed at the same time reduces the rate of delayed union, shortens the time to union, and does not increase the infection rate.     

Management of infected tibial intramedullary nailing using an organized treatment protocol

Twenty cases of osteomyelitis following intramedullary nailing of the tibial shaft fracture were managed with a prospective treatment protocol comprising intramedullary reaming debridement, antibiotic-bead depot, external skeletal fixation, microvascular muscle flap and early cancellous bone grafting. The follow-up period ranged from 25 to 48 months (average, 34.3 months). Pseudomonas aeruginosa (37.5%) and staphylococcus aureus (20.8%) were the organisms most commonly involved. There were 8 united and 12 ununited fractures after reaming debridement surgery. Nineteen infections were initially arrested by one debridement. One infection was arrested by two sequential debridements. All 12 ununited fractures were stabilized by Hoffmann unilateral external fixation until the fracture healed. The time spent in external fixation ranged from 3 to 7 months (average, 5.2 months). Early cancellous bone grafting was successfully accomplished for 9 ununited fractures with major debridement bone loss. The average union time of the 9 fractures with bone grafting was 7.2 months (range, from 6 to 8 months). We believe that this treatment protocol gives a predictable and rapid recovery. The complications were infection recurrence in two cases at the old tibial shaft fracture sites, minor pin tract infection of Hoffmann external fixators in two cases, and stiffness in two ankles and one knee.     

Fingertip Injuries: Evaluation and Treatment

The primary goal of treatment of an injury to the fingertip is a painless fingertip with durable and sensate skin. Knowledge of fingertip anatomy and the available techniques of treatment is essential. For injuries with soft-tissue loss and no exposed bone, healing by secondary intention or skin grafting is the method of choice. When bone is exposed and sufficient nail matrix remains to provide a stable and adherent nail plate, coverage with a local advancement flap should be considered. If the angle of amputation does not permit local flap coverage, a regional flap (cross-finger or thenar) may be indicated. If the amputation is more proximal or if the patient is not a candidate for a regional flap because of advanced age, osteoarthritis, or other systemic condition, shortening with primary closure is preferred. Composite reattachment of the amputated tip may be successful in young children. The outcome of nail-bed injuries is most dependent on the severity of injury to the germinal matrix.     

Reconstruction of large infected tibia defects.

Twenty-nine patients are reported who underwent free tissue transfer reconstruction of contaminated tibia defects with both soft tissue defects and osteomyelitis. Infection was controlled through the use of a two-stage composite tissue reconstruction. In the first stage, the wounds were closed with the free muscle or skin flap. Bone defects were bridged with vascularized bone grafts within 6 to 12 weeks after soft tissue closure. Twenty patients underwent reconstruction using iliac crest, whereas nine patients were treated with fibular transfer. The follow-up period for 28 patients ranged from 10 months to 6 years until bone union was completed. The bone united smoothly in 22 patients, but union of the other six grafts was delayed and required additional cancellous bone grafting.     

多种技术联用治疗难治性骨髓炎的疗效分析

目的探讨应用Ilizarov骨搬移技术联合抗生素骨水泥片技术、Masquelet技术(膜诱导技术)等技术治疗长骨慢性骨髓炎的临床疗效。 方法回顾性分析2012年6月至2016年10月,新疆军区总医院创伤骨科联合应用病灶清除、Ilizarov技术、抗生素骨水泥片填充技术、膜诱导成骨技术、远端缓慢回缩技术等技术治疗的20例股骨、胫骨慢性骨髓炎和感染性骨不连患者。纳入标准：慢性骨髓炎合并骨不连或骨缺损的患者;经常规治疗效果差的患者;无影响治疗的合并症;病例资料完整的患者。排除标准：不符合疾病的纳入标准;存在活动性结核、肿瘤等疾病的患者;依从性差、不能按照医生要求调整外固定架的患者。记录上述患者是否需行皮瓣转移手术、带外固定架时间、全负重时间及是否出现复发情况。 结果所有患者均得到随访,随访时间平均(29.2±1.8)个月。均获得了良好的骨性愈合,所治疗患者感染均得到一期愈合,创面无需皮瓣转移或植皮均得到良好闭合,骨搬移结合处愈合良好。患者骨搬移长度平均(7.3±1.8)cm。所有患者未出现神经损伤,其中有两例患者术前存在腓总神经损伤,术后在骨搬移过程中出现不同程度的神经功能恢复。 结论应用Ilizarov的骨搬移和骨延长技术能有效治疗彻底清创后的骨缺损或肢体短缩问题,保证彻底清创、促进局部血运改善、不需要皮瓣覆盖也能愈合创面;抗生素骨水泥片起到占位器和膜诱导作用促进成骨;远端缓慢回缩有利于骨端愈合;多种方法联合应用,有效地提高了难治性骨髓炎的治愈率,是一种安全有效的治疗方法。     

Treatment of chronic osteomyelitis by free grafts of cancellous autologous bone tissue. A preliminary report.

Chronic osteomyelitis was treated by free grafts of autologous bone tissue in 13 consecutive patients aged 18 to 81 to years. In all patients the osteomyelitis was located in the leg, and Staphylococcus aureus was the causative organism. Seven had an infected non-union. The duration of the osteomyelitis varied from less than 1 year to 75 years. Surgical debridement and grafting of cancellous and cortical cancellous bone were performed at the one operation. The osteomyelitis healed after a single operation in all patients but one, who needed three operations before the infection was eradicated. In one patient a second bone grafting operation was necessary before weight-bearing could be allowed. Although the number of patients is small, the results agree well with larger series published recently. Grafting of autologous bone tissue seems to be a very valuable method of treatment for chronic osteomyelitis.     

Treatment of Chronic Osteomyelitis by Free Grafts of Cancellous Autologous Bone Tissue: A Preliminary Report

Chronic osteomyelitis was treated by free grafts of autologous bone tissue in 13 consecutive patients aged 18 to 81 years. In all patients the osteomyelitis was located in the leg, and Staphylococcus aureus was the causative organism. Seven had an infected non-union. The duration of the osteomyelitis varied from less than 1 year to 75 years. Surgical debridement and grafting of cancellous and cortical cancellous bone were performed at the one operation. The osteomyelitis healed after a single operation in all patients but one, who needed three operations before the infection was eradicated. In one patient a second bone grafting operation was necessary before weight-bearing could be allowed. Although the number of patients is small, the results agree well with larger series published recently. Grafting of autologous bone tissue seems to be a very valuable method of treatment for chronic osteomyelitis.