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Background. Combat is associated with high-energy explosive injuries, often resulting in open tibial fractures complicated by nonunion and infection. We characterize the infections seen in conjunction with combat-associated type III tibial fractures. Methods. We performed a retrospective medical records review to identify US military service members wounded in Iraq or Afghanistan with open diaphyseal tibial fractures who were admitted to our facility (Brooke Army Medical Center, Fort Sam Houston, Texas) between March 2003 and September 2006. Results. Of the 62 patients with open tibial fractures who were identified in our initial search, 40 had fractures that met our inclusion criteria as type III diaphyseal tibial fractures. Three patients were excluded because their fractures were managed with early limb amputation, and 2 were excluded because of incomplete follow-up records. Twenty-seven of these 35 patients had at least 1 organism present in initial deep-wound cultures that were performed at admission to the hospital. The pathogens that were identified most frequently were Acinetobacter, Enterobacter species, and Pseudomonas aeruginosa. Thirteen of the 35 patients had union times of >9 months that appeared to be associated with infection. None of the gram-negative bacteria identified in the initial wound cultures were recovered again at the time of a second operation; however, all patients had at least 1 staphylococcal organism. One patient had an organism present during initial culture and in the nonunion wound; this organisim was a methicillin-resistant Staphylococcus aureus strain that was inadvertently not treated. Five of 35 patients ultimately required limb amputation, with infectious complications cited as the reason for amputation in 4 of these cases. Conclusions. Combat-associated type III tibial fractures are predominantly associated with infections due to gram-negative organisms, and these infections are generally successfully treated. Recurrent infections are predominantly due to staphylococci.

Purpose. To review outcomes of 24 patients who underwent Ilizarov ring fixation for infected non-union of the tibia. Methods. Medical records of 21 men and 3 women aged 13 to 74 (mean, 38) years who underwent Ilizarov ring fixation for infected non-union of the tibia were reviewed. The mean bone defect was 3.3 (range, 2–5) cm. The mean time from injury to presentation was 11.9 (range, 1–36) months. The mean number of previous surgeries was 2 (range, 0–14). A local flap was used in 2 patients and a free flap was used in one patient. Nine of the patients underwent Ilizarov ring fixation without soft tissue and bony resection, as inadequate stability was the reason for non-union. Patients were assessed using the Association for the Study and Application of the Method of Ilizarov criteria. Results. Patients were followed up for a mean of 11 (range, 8–46) months. Functional outcome was excellent in 8 patients, good in 12, fair in 2, and failure in one, whereas bone union outcome was excellent in 6 patients, good in 14, fair in one, and poor in 2. The mean time to union was 8 (range, 3–31) months. The mean external fixation index was 4.2 (range, 1.5–15.7) cm/month. Complications encountered were pin tract infection (n=5), re-fracture (n=2), soft tissue impingement by Ilizarov rings (n=2), recurrence of wound infection (n=1), mal-union (n=1), and mortality (n=1). Conclusion. Ilizarov ring fixation is a viable option for infected non-union of the tibia. Adequate assessment of bone union is crucial before removal of fixator to prevent re-fracture.

Background Biofilms cause chronic infections including those associated with orthopaedic hardware. The only methods that are Food and Drug Administration-approved for detecting and identifying bacterial infections are cultures and selected DNA-based polymerase chain reaction methods that detect only specific pathogens (eg, methicillin-resistant Staphylococcus aureus). New DNA-based technologies enable the detection and identification of all bacteria present in a sample and to determine the antibiotic sensitivities of the organisms. Case Description A 34-year-old man sustained an open tibia fracture. He experienced 3 years of delayed healing and episodic pain. In addition to his initial treatment, he underwent three additional surgeries to achieve fracture healing. During the last two procedures, cultures were taken and samples were tested with the IBIS T5000 and fluorescence in situ hybridization (FISH). In both cases, the cultures were negative, but the IBIS and FISH confirmed the presence of a biofilm within the tibial canal. Literature Review Examinations of tissues from biofilm infections, by DNA-based molecular methods and by direct microscopy, have often found bacteria present despite negative cultures. Infections associated with orthopaedic hardware may be caused by bacteria living in biofilms, and these biofilm organisms are particularly difficult to detect by routine culture methods. Purposes and Clinical Relevance Rapid DNA-based detection methods represent a potentially clinically useful tool in the detection of bacterial biofilms. The sensitivity and clinical impact of the technology has yet to be established.

Histology can help diagnose infection, and PMN infiltration is a classical criterion for prosthetic joint infection, osteomyelitis and FRI; it is defined as >5 neutrophils per high-power field in 5 high-power fields on histological analysis of periprosthetic tissue at 400× magnification.2 However, this criterion lacks sensitivity, especially in chronic infection.3 Plasma cells are mainly present in chronic inflammatory reactions, such as inflammatory rheumatism caused by autoimmune disease, and rheumatoid arthritis in particular. Lyon Bone and Joint Infection Study Group: Coordinator: TF; Infectious Diseases Specialists—TF, Florent Valour, Thomas Perpoint, Patrick Miailhes, Florence Ader, Sandrine Roux, Agathe Becker, Claire Triffault-Fillit, Anne Conrad, Cécile Pouderoux, Marie-Elodie Langlois, Marielle Perry, Fatiha Daoud, Johanna Lippman, Evelyne Braun, Christian Chidiac; Surgeons—Sébastien Lustig, Elvire Servien, Cécile Batailler, Romain Gaillard, Stanislas Gunst, Julien Roger, Charles Fiquet, Michel Henri Fessy, Anthony Viste, Philippe Chaudier, Jean Luc Besse, Lucie Louboutin, Gaël Gaudin, Tanguy Ledru, Adrien Van Haecke, Quentin Ode, Marcelle Mercier, Florie Alech-Tournier, Sébastien Martres, Franck Trouillet, Cédric Barrey, Emmanuel Jouanneau, Timothée Jacquesson, Ali Mojallal, Sophie Brosset, Fabien Boucher, Hristo Shipkov, Joseph Chateau, Philippe Céruse, Carine Fuchsmann, Arnaud Gleizal; Anesthesiologists—Frédéric Aubrun, Mikhail Dziadzko, Caroline Macabéo; Microbiologists—Frederic Laurent, Laetitia Beraut, Céline Dupieux, Camille Kolenda, Jérôme Josse, Claude-Alexandre Gustave; Imaging—Fabien Craighero, Loic Boussel, Jean-Baptiste Pialat; Nuclear Medicine—Isabelle Morelec, Marc Janier, Francesco Giammarile; PK/PD specialists—Michel Tod, Marie-Claude Gagnieu, Sylvain Goutelle; Clinical research assistant and database manager—Eugénie Mabrut. Contributors TF and CB participated to the patient care.

Background Non-union continues to be one of the orthopedist’s greatest challenges. Despite effective culture methods, the detection of low-grade infection in patients with non-union following tibial fracture still presents a challenge. We investigated whether “aseptic” tibial non-union can be the result of an unrecognized infection. Methods A total of 23 patients with non-union following tibial shaft fractures without clinical signs of infection were investigated. Intraoperative biopsy samples obtained from the non-union site were examined by means of routine culture methods and by polymerase chain reaction (PCR) for the detection of 16 S ribosomal RNA (rRNA). Control subjects included 12 patients with tibial shaft fractures. Results 23 patients (8 women and 15 men; mean age: 47.4 years) were included into this study. Preoperative C-reactive protein levels (mean: 20.8 mg/l) and WBC counts (mean: 8,359/μl) in the study group were not significantly higher than in the control group. None of the samples of non-union routine cultures yielded microorganism growth. Bacterial isolates were found by conventional culturing methods in only 1 case of an open fracture from the control group. In this case, PCR yielded negative results. 16 S rRNA was detected in tissue specimens from 2 patients (8.7%) with non-union. The analysis of these variable species-specific sequences enabled the identification of specific microorganisms (1x Methylobacterium species, 1x Staphylococcus species). Both PCR-positive patients were culture-negative. Conclusions The combination of microbiological culture and broad-range PCR seems to substantially add to the number of microbiological diagnoses obtained and may improve the clinican’s ability to tailor therapy to the individual patient’s needs.

Purpose Ilizarov pioneered bone transport using a circular external fixator. Papineau described a staged technique for the treatment for infected pseudarthrosis of the long bones. This article presents a single-stage Papineau technique and Ilizarov bone transport, and postoperative negative-pressure wound dressing changes for septic bone defects of the tibia. Materials and methods We studied the files of seven patients (mean age, 32 years) with septic bone defects of the tibia treated with a Papineau technique and Ilizarov bone transport in a single stage, followed by postoperative negative-pressure wound dressing changes. All patients had septic pseudarthrosis and skin necrosis of the tibia. The technique included a single-stage extensive surgical debridement of necrotic bone, open bone grafting with cancellous bone autograft and bone transport, and postoperative negative-pressure wound dressing changes for wound closure. The mean time from the initial injury was 6 months (range, 4–8 months). The mean follow-up was 14 months (range, 10–17 months). Results All patients experienced successful wound healing at a mean of 29 days. Six patients experienced successful bone regeneration and union at the docking side at a mean of 6 months. One patient experienced delayed union at the docking site, which was treated with autologous cancellous bone grafting. Two patients experienced pin track infection, which was successfully treated with antibiotics and pin site dressing changes. All patients were able to return to their work and previous levels of activity, except one patient who had a stiff ankle joint and had to change his job. No patient experienced recurrence of infection, or fracture of the regenerated or transported bone segment until the period of this study. Conclusion The combined Papineau and Ilizarov bone transport technique with negative-pressure wound closure provides for successful eradication of the infection, reconstruction of the bone defect, and soft-tissue closure. A single-stage surgical treatment is feasible, without any complications.

Background It is important to predict the occurrence of deep infection in open fractures when treating such fractures. We tried to develop a new scoring system for predicting the occurrence of deep infection in open upper and lower extremity fractures on the basis of the Hannover Fracture Scale’98 (HFS-98). Methods A total of 394 open upper and lower extremity fractures (351 patients) were retrospectively reviewed in the initial analysis. The relationship between Gustilo’s grade and the eight items on HFS-98 in the open extremity fractures was first investigated by multivariate analysis. By this analysis, we selected significant items that correlated with Gustilo’s grade. Among these cases, 318 patients with 352 open extremity fractures (humerus = 27, forearm = 62, femur = 76, tibia = 187) were used for the following infection analyses. The relationships between the incidence of deep infection and sex (male or female), age (<30, 30–50, <50 years), grade of polytrauma (ISS < 18, 18 ≤ ISS ≤ 30, ISS > 30), site of fracture (humerus, forearm, femur, tibia), existence of fracture line around joint (+ or −) or some significant items in the above initial analysis were further analyzed by multivariate analysis after univariate analysis. We devised a new scoring system of open extremity fractures based on P values in the above analysis. The discrimination of the newly devised scoring system was evaluated with receiver operating characteristic (ROC) curves. Results The following factors: muscle injury (MI, P  = 0.0001); wound contamination (WC, P  = 0.0001); and local circulation (LC, P  = 0.0001) were significant factors affecting the occurrence of deep infection on multivariate analysis. We devised a new scoring system for open extremity fractures (MI: 0–20 points, WC: 0–20 points, and LC: 0–20 points). The cut-off point for occurrence of deep infection in these fractures was 35 by ROC analysis. Conclusions This new scoring system was thought to be useful for predicting the occurrence of deep infection in open extremity fractures. However, further prospective study or multicenter study would be needed to clarify the validity of this scale.

This study of 10 patients presents the early results of a protocol of debridement, antibiotic bead placement, and use of the Ilizarov method with a circular external fixator for treatment of infected nonunions of the tibia in a military population. The nonunions resulted from high-energy fractures in nine cases and an osteotomy in one. The Ilizarov techniques used were transport (five cases), shortening and secondary lengthening (two cases), minimal resection with compression (one case), and resection with bone grafting (two cases). Flap coverage was required for five patients. There were two recurrences of infection (20%) among patients with the most compromised soft tissue. Only 50% of patients were able to perform limited duties while wearing the external fixator. Only four patients returned to active duty; however, three patients from special operations units were able to return to jump status. Six patients underwent medical retirement because of insufficient function, resulting from decreased ankle or knee range of motion and arthrosis or muscle weakness.