Chronic Osteomyelitis Of Tibia Research Articles

Shock wave assisted intracellular delivery of antibiotics against bone infection with Staphylococcus aureus via P2X7 receptors

BackgroundTreatment of chronic osteomyelitis (bone infection) remains a clinical challenge; in particular, it requires enhanced delivery of antibiotic drugs for the treatment of intracellular Staphylococcus aureus (S. aureus), which prevents infection recurrence and resistance. Previous studies have found that noninvasive shock waves used to treat musculoskeletal diseases can alter cell permeability, however, it is unclear whether shock waves alter cell membrane permeability in chronic osteomyelitis. Furthermore, it remains unknown whether such changes in permeability promote the entry of antibiotics into osteoblasts to exert antibacterial effects. MethodsIn our study, trypan blue staining was used to determine the shock wave parameters that had no obvious damage to the osteoblast model; the effect of shocks waves on the cell membrane permeability of osteoblast model was detected by BODIPY®FL vancomycin; high performance liquid chromatography-mass spectrometry (HLPC-MS) was used to detect the effect of shock wave on the entry of antibiotics into the osteoblast model; plate colony counting method was used to detect the clearance effect of shock wave assisted antibiotics on S. aureus in the osteoblast model. To explore the mechanism, the effect of different pulses of shock waves on S. aureus was examined by plate colony counting method, besides, P2X7 receptor in osteoblast was detected by immunofluorescence and the extracellular ATP levels was detected. Furthermore, the effect of P2X7 receptor antagonists KN-62 or A740003 on the intracellular antibacterial activity of shock-assisted antibiotics was observed. Then, we used S. aureus to establish a rat model of chronic tibial osteomyelitis and investigated the efficacy and safety of shock-wave assisted antibiotics in the treatment of chronic osteomyelitis in rats. ResultsThe viability of the osteoblast models of intracellular S. aureus infection was not significantly affected by the application of up to 400 shock wave pulses at 0.21 mJ/mm2. Surprisingly, the delivery of BODIPY®FL vancomycin to osteoblast model cells was markedly enhanced by this shock wave treatment. Furthermore, the shock wave therapy increased the delivery of hydrophilic antibiotics (vancomycin and cefuroxime sodium), but not lipophilic antibiotics (rifampicin and levofloxacin), which improved the intracellular antibacterial effect. Afterwards, we discovered that shock wave treatment increased the extracellular concentration of ATP (the P2X7 receptor activator)， while KN-62 or A740003, a P2X7 receptor inhibitor, decreased intracellular antibacterial activity. We then found that 0.1 mL of 1 × 1011 CFU/mL ATCC25923 S. aureus was suitable for modeling chronic osteomyelitis in rats. Besides, the shock wave-assisted vancomycin treatment with the strongest antibacterial and osteogenic effects among the tested treatments was confirmed in vivo by imaging examination, microbiological cultures, and histopathology, with favorable safety. ConclusionsOur results suggest that shock waves can promote the entry of antibiotics into osteoblasts for antibacteria by changing the cell membrane permeability in a P2X7 receptor-dependent manner. Besides, considering antibacterial and osteogenic efficiency and a high degree of safety in rat osteomyelitis model, shock wave-assisted vancomycin treatment may thus represent a possible adjuvant therapy for chronic osteomyelitis.

First report of successful treatment of chronic pediatric tibial osteomyelitis and fracture using autologous platelet-rich plasma

Osteomyelitis is a refractory disease caused by microbial invasion of the bone, leading to destruction of the bone tissue. It is more common in children. Osteomyelitis requires long treatment at high cost and is associated with high rates of recurrence and disability. It can also be complicated by sepsis that, if not treated in time, can result in death. Here, we report the first case of a 10-year-old patient who presented with chronic tibial osteomyelitis complicated with fracture. The patient had received traditional treatment for osteomyelitis for over 14 months without success. However, after 4 months of treatment with autologous platelet-rich plasma, the fracture, infection, and osteomyelitis resolved completely. These clinical observations demonstrate the potential for using autologous platelet-rich plasma as a novel treatment for chronic pediatric osteomyelitis.

Chronic Tibial Osteomyelitis - Use of Biactive Glass as an Alternative of Treatment: Report of a Case

<i>Background:</i> Chronic osteomyelitis is a disease usually of infectious origin. The main cause is post-traumatic, it affects the bone tissue and surrounding tissue, the most frequent causative agent is Staphylococcus aureus. The most affected bone is the tibia. <i>Case description:</i> A 42-year-old male with a diagnosis of chronic tibia osteomyelitis, with sequelae of previous surgical interventions, multiple antibiotic treatments, and type IV B classification by Cierny-Mader. <i>Methods:</i> Two-stage surgical management was chosen. Firstly, extensive bone and soft tissue debridement, placement of cement beads medicated with amikacin in the medullary cavity and osteoclast system for irrigation with vancomycin. In the second stage, free fibular bone grafting, fixation and stabilization with screws, bioactive glass placement in areas of interface between stabilized fibula and posterior tibial cortex. <i>Results:</i> Before a multitratada chronic osteomyelitis it is necessary to individualize and evaluate treatment alternatives, in this case the surgical management in two time, the use of medication beads, bone graft and the use of bioactive glass, achieved a complete eradication of the infection and favorable clinical evolution with optimal functional recovery of affected limb.

Evaluating physiological progression of chronic tibial osteomyelitis using infrared thermography

PurposeMedical infrared thermography (IRT) was used as a complementary means for the clinical evaluation of musculoskeletal trauma and progression of chronic tibial osteomyelitis.MethodsTwenty-two adult patients with a medical diagnosis of chronic tibial osteomyelitis were followed up by IRT performed along with standard radiography. Thermal data of the affected limb were compared with those of the healthy contralateral limb based on the thermal profile of the lower limbs as per the medical thermography guideline (32 °C). Data were acquired in the following regions of the lower limb: proximal tibia, diaphysis, and distal tibia, using a FLIR infrared camera, and data were processed using MATLAB®.ResultsFor patients with active infections, an increase in the average temperature of the affected limb above + 1.0 °C was observed when compared with the temperature of the contralateral. The wound region of the patients showed an increased temperature (32.3 °C) compared with the temperature of the contralateral (31.4 °C). In contrast, in latent infections, the thermal differences were small, generally below 0.3 °C, and thus were within the threshold of normality. In contrast, in areas diagnosed with reduced blood supply, the affected limb showed an average temperature up to − 5.7 °C below normal. Additionally, the initial temperature range (26.5 to 34.5 °C) decreased during the treatment to 29.8 to 34.1 °C, indicating a convergence toward normality.ConclusionIRT has significant potential as a complementary imaging modality in the follow-up of patients with bone lesions with a diagnosis of osteomyelitis as it does not use ionizing radiation, thus allowing repetitive use as desired. Thermal images show important physiological information related to vascularization necessary for bone repair, as well as provide a good indication of the boundary of the infected area, adjacent to the trauma, which is useful for positioning the radiography equipment. However, it should be noted that IRT cannot replace other medical imaging techniques, as it provides information about the skin and cannot directly evaluate the interior of the body.

Efficacy of apolipoprotein 2-Jifusheng in the treatment of osteomyelitis in rabbits

To evaluate the effect of one-stage treatment of bone morphogenetic protein 2 combined with Jifusheng in the experimental model of osteomyelitis in rabbits. The model of chronic osteomyelitis of tibia was established in 30 3-month-old male New Zealand white rabbits with a body weight of (2.0±0.5) kg, and the model was verified 4 weeks after operation. Thirty rabbits with osteomyelitis were randomly divided into 3 groups with 10 rabbits in each group (n= 10). The model group did not do any treatment after focal debridement, treatment group A was implanted with musculosheng at the site of focal debridement and bone defect, and treatment group B was implanted with apolipoprotein 2-Jifusheng at the site of focal debridement and bone defect. The therapeuticeffect was evaluated by blood biochemical, microbiological, imaging, pathological and immunohistochemical examination 8 weeks after operation. At 4 weeks after operation, 30 rabbits with osteomyelitis were successfully validated. The results of serological examination showed that the hypersensitive C-reactive protein (CRP) and white blood cell count(WBC)in the model group were significantly higher than those in the blank group at 2 and 4 weeks after operation. Eight weeks after treatment, the detection of blood indexes showed that the white blood cell count (WBC)and hypersensitive C reactive protein (CRP)in treatment group A and treatment group B were significantly lower than those in the model group (P<0.05), but there was no significant difference between treatment group An and treatment group B (P>0.05). Eight weeks after treatment, the bone defect area was measured. The bone volume/total volume (BV/TV) and bone mineral density (BMD)in treatment group A and B were significantly higher than those in the model group (P<0.05), and the bone volume/total volume (BV/TV) and bone mineral density(BMD)in treatment group B were significantly higher than those in treatment group A (P<0.05), the repair of bone defect was almost complete, and the bone volume and bone mineral density increased significantly. At 8 weeks after treatment, the number of osteoblasts/bone tissue area (N.Ob/T.Ar) and the number of osteoblasts/bone tissue perimeter (N.Ob/B.Pm) in treatment group A and B were significantly higher than those in model group, and the N.Ob/T.Ar and N.Ob/B.Pm in treatment group B were significantly higher than those in treatment group A. The immunohistochemical staining of TNF- α and IL-6 around bone tissue in treatment group A and treatment group B was significantly less than that in model group, but there was no significant difference between treatment group B and treatment group A. The combined application of apolipoprotein 2-Jifusheng can promote bone repair and reduce the inflammation of the focus. it can treat rabbits with osteomyelitis in one stage, provide objective basis for the formulation of clinical treatment strategy of osteomyelitis and further promote clinical research.

1238 Surgical Management of Chronic Osteomyelitis of the Femur and Tibia: A Scoping Review

Abstract Aim This scoping review aims to map and summarise the literature on treatment of chronic femoral and tibial osteomyelitis, in order to enhance the reader’s understanding of potential treatment options, whilst also identifying areas of future research Method This scoping review was guided by the methodological framework of the Joanna Briggs institute. A computer-based search was conducted in PubMed, EMBASE, MEDLINE, Emcare and CINAHL, for articles reporting treatment of chronic tibial/femoral osteomyelitis. Title/abstract and full text screening was performed independently by two reviewers according to pre-defined criteria. Results A total of 1223 articles were identified, with 40 studies, involving 2,489 patients being finally included. A range of treatments are reported, with the key reported principles being removal of infected tissue, dead-space management and antibiotic therapy. The majority (76.2%) of patients presented with stage III or IV disease according to the Cierny-Mader classification and the most commonly cultured pathogen was Staphylococcus aureus. The proportion of patients achieving remission with no recurrence during follow up varies from 72.0% - 100.0%. Conclusions The majority of studies report excellent outcomes in terms of infection remission and lack of recurrence. However, using the current literature to identify specific patient and treatment related factors which may affect treatment results is challenging due to a number of potential confounding factors. Further high-level research such as randomized control trials and comparative studies are required to achieve this.

Modified induced membrane technique and pedicled skin (myocutaneous) flap for chronic tibial osteomyelitis in patients with diabetes

To investigate the effectiveness of modified induced membrane technique and pedicled skin (myocutaneous) flap for chronic tibial osteomyelitis in patients with diabetes. A clinical data of 22 diabetic patients with chronic tibial osteomyelitis between January 2017 and March 2019 was retrospectively analyzed. There were 15 males and 7 females with an average age of 52 years (range, 44-65 years). The course of diabetes was 3-12 years (mean, 6.1 years). The course of chronic osteomyelitis was 4 months to 7 years (mean, 3.3 years). The chronic osteomyelitis was rated as type Ⅲ in 9 cases and as type Ⅳ in 13 cases according to the Cierny-Mader classification criteria. Bacterial culture showed 21 cases of single bacterial infection and 1 case of mixed bacterial infection. Preoperative color Doppler ultrasound and CT angiography confirmed that the anterior and posterior tibial arteries were unobstructed. In the first stage of treatment, the bone and soft tissue defects were filled with antibiotic bone cement after the lesion was thoroughly debrided; the length of bone defect was 4-9 cm (mean, 5.6 cm), and the size of soft tissue defect was 5 cm×2 cm to 10 cm×7 cm. After 7-10 days, the bone cement was removed and a new antibiotic bone cement was filled into the bone defect. Meanwhile, the pedicled skin (myocutaneous) flap was performed to repair the wound. After 7-12 weeks, the inflammatory indexes returned to normal, autogenous iliac bone or combined with artificial bone was used to repair the bone defect in the second stage of treatment. The wound healing, bone defect healing, complications, and the number of successful treatments were recorded. The satisfaction of the skin flap efficacy and the function of the affected limb were evaluated. Local necrosis of the skin flap occurred in 3 cases after operation, leading to delayed healing of the wound; the other 19 flaps survived successfully, leading to primary healing of the wound. The skin grafts survived completely and the incisions healed by first intention. All cases were followed up 13-28 months with an average of 20 months. The infection recurred in 2 cases within 12 months after operation, and the bone defects healed after treated by modified induced membrane technique. The bone defect healing rate was 100%; the bone healing time was 6-10 months, with an average of 8.9 months; the infection control rate and successful treatment rate were 90.9% (20/22) and 90.9% (20/22), respectively. At 12 months after operation, according to the satisfaction evaluation standard of skin flap efficacy formulated by ZHANG Hao et al., all were satisfied. According to Johner-Wruhs adjacent joint function method, the limb function recovery was excellent in 13 cases, good in 7 cases, and fair in 2 cases, with an excellent and good rate of 90.9%. For the treatment of chronic tibial osteomyelitis in patients with diabetes without vascular occlusion, the modified induced membrane technique and pedicled skin (myocutaneous) flap can repair bone and soft tissue defects, and control the infection at the same time, the short- and medium-term effectiveness are good.

Long term functional outcomes of a permanent antibiotic cement spacer for chronic distal tibial osteomyelitis in a patient with diabetes

A 66-year-old male with chronic right distal tibial osteomyelitis presents with erythema and a draining sinus tract concerning for acute exacerbation. Previously stable on amoxicillin/clavulanate, worsening symptoms for 3–4 months prompted referral. Following evaluation, treatment consisted of debridement, insertion of an antibiotic cement spacer into the partial cortical tibial defect and free flap coverage. At five-year follow up, the antibiotic spacer remains in place without recurrence of osteomyelitis and with preserved function. Further investigation is needed to validate permanent retention of an antibiotic spacer as an alternative to vascularized or non-vascularized bone grafts for management of chronic tibial osteomyelitis in the comorbid diabetic limb salvage population.

Osteomyelitis in Children with Sickle Cell Disease: A Challenging Diagnosis: Case Report from Cameroon

Introduction: Sickle Cell Disease (SCD) is the most prevalent genetic disease in the world predominantly in the African population with Sickle Cell Anaemia (SCA) being its dominant form. One of the most frequent complications of SCD is osteomyelitis. SCA is due to a point mutation in the beta globin chain of haemoglobin. This is responsible for the sickled shape of RBCs under low oxygen tension conditions leading to obstruction in the microcirculation. This leads to vaso-occlusive crises (VOC) which has a similar clinical presentation to that of osteomyelitis, another complication of SCD. Case Presentation: We present the case of a three-year-old girl with SCA who presented with an inability to bear weight in a febrile context. A diagnosis of VOC was initially made, which was later on changed to both a left chronic tibial and right distal femoral osteomyelitis following a series of biological, and imaging investigations. Surgical debridement and drainage were performed, resulting 9 weeks later in the involution of fever and leg pain. Conclusion: Osteomyelitis when associated with SCD is a dreadful and deathly disease in low income countries as it also presents like VOC therefore higher suspicion index is recommended. It is therefore important to take this into consideration at an early stage in patients with homozygous sickle cell disease so as to rapidly initiate multidisciplinary care. Appropriate investigations, appropriate antibiotic therapy, and timely surgical intervention would help to greatly reduce morbidity and mortality.

Does the causative microorganism and etiology of trauma affect the duration of treatment in chronic tibia osteomyelitis?

Does the causative microorganism and etiology of trauma affect the duration of treatment in chronic tibia osteomyelitis?

Single-stage treatment of chronic localized tibial osteomyelitis with local debridement and antibiotic-loaded calcium sulfate implantation: a retrospective study of 42 patients

BackgroundAlthough various methods have been introduced, the management of chronic tibial osteomyelitis remains a challenge. This study aims to assess a combined treatment method, local debridement combined with antibiotic-loaded calcium sulfate implantation, for the management of the local (Cierny-Mader type III) tibial osteomyelitis.MethodsForty-two patients (43 limbs) with type III tibial osteomyelitis, from January 2012 to December 2018, who received the treatment method mentioned above were included in the study. The infection remission rate, recurrence rate, complications rate, and bone healing rate were respectively analyzed.ResultsWith a mean follow-up of 42.8 months, 38 limbs (37 patients) (88.4%, 38/43) achieved infection remission without recurrence. Among those patients pain, limitation of movement, sinus tracts, topical redness, and swelling were generally eliminated. Only 4 patients felt slight pain after a long-distance walk, while another 6 patients showed minor but acceptable discomfort in affected limbs. Five patients (11.6%) suffered from osteomyelitis recurrence that required secondary surgical and medical treatment, but no amputation was necessary to eliminate the infection. Prolonged aseptic drainage was the most frequent complication that was observed in 13 patients (30.0%). They were successfully managed by appropriate wound caring in 10 patients and by surgical intervention, months later, in 3 patients. According to the final X-ray examination, bone losses caused by local debridement were generally repaired, though the shape of the tibia was not well-restored to its initial form in 17 limbs. No fracture was recorded during follow-up.ConclusionLocal debridement combined with antibiotic-loaded calcium sulfate implantation is effective and safe in a single-stage treatment of chronic Cierny-Mader III tibial osteomyelitis.

Osteomyelitis complicating secondarily infected atopic eczema: two case reports and a narrative literature review

BackgroundAtopic eczema is a relapsing, itchy chronic cutaneous inflammatory disease that commonly affects children. The disease is often complicated by cutaneous infections such as eczema herpeticum, eczema vaccinatum and a varied number of bacterial infections – impetigo, cellulitis and erysipelas. However, rare case reports of infective endocarditis, otitis media and osteo-articular infections have been associated with atopic eczema. These associations possibly represent the extracutaneous infectious complications of atopic eczema.Case presentationHere we present two cases of osteomyelitis in HIV negative children with habitual scratching of poorly managed and/or uncontrolled atopic eczema respectively. Both cases presented to the orthopaedic surgeons and were admitted as acute phalangeal osteomyelitis and acute – on – chronic tibial osteomyelitis respectively. The first case was an 8 year old girl who had moderate-severe poorly-controlled atopic eczema and contiguously spread phalangeal osteomyelitis. The second case was an 11 year old pre-pubertal boy who had untreated atopic eczema and tibial osteomyelitis possibly from haematogenously spread Staphylococcus aureus infection. Both were successfully discharged from hospital and currently have well controlled eczema. The 11 year old patient is also being reviewed monthly by the orthopaedic surgeons and is chronic suppressive antibiotics. He may require sequestrectomy, should it be needed.ConclusionsInvasive staphylococcal and streptococcal osteo-articular (OA) infection can arise as an extra-cutaneous infectious complication of poorly controlled atopic eczema. It is more common in the 3 to 15 year age group and especially in boys with a septic arthritis to osteomyelitis ratio of around 29:5. Clinicians should maintain a high index of suspicion in patients with moderate-severe atopic eczema and they ought to promptly manage these OA infections with intravenous antibiotics to avoid further complications.

Chronic Osteomyelitis of the tibia and ankle treated with Limb Salvage Reconstruction.

Introduction: To confirm the success of our limb salvage treatment protocol and determine what factors are predictive of success versus failure in limb salvage techniques for patients with chronic osteomyelitis of the tibia and ankle.Methods: Retrospective case series analyzing factors and outcomes in patients who underwent limb salvage techniques for chronic osteomyelitis of tibia or ankle. Main outcome measurements included infection controlled without the need for amputation or chronic antibiotic suppression and union of infected non-unions.Results: Mean follow-up was 3.9 years. Out of the sixty-seven patients (mean age: 51.4 years) treated for chronic osteomyelitis, fifty-four had an associated non-union. Sixty-one patients (91.0%) had their infection controlled by limb salvage. Five ultimately required amputation and one remained on daily chronic antibiotics. Diabetics complicated with neuropathy and increasing numbers of limb salvage surgeries were associated with a significantly higher failure rate. Forty-eight out of fifty-four patients (88.9%) also had successful healing of their infected non-union. Diabetes and need for more limb salvage surgeries were also found to have a significantly higher failure rate.Conclusions: Limb salvage is a reliable and successful treatment for patients with chronic osteomyelitis and infected non-unions of the lower extremities. Diabetic neuropathy is a risk factor that impedes success.Level of Evidence: Prognostic Level IV.

MICROFLORA OF SURGICAL WOUNDS AND FISTULAS IN PATIENTS WITH CHRONIC OSTEOMYELITIS OF THE TIBIA BEFORE RECONSTRUCTIVE TREATMENT, IN CASE OF RECURRENCE OF INFECTION

Relevance of microbiological monitoring in chronic osteomyelitis of the tibia developed during treatment of fractures with a plate is associated with a noticeable increase of various kinds of the microflora. A microbiological study was conducted of pathological material taken from wounds, fistulas and from the focus of inflammation in 49 patients with chronic tibial osteomyelitis, developed during treatment of fractures with a plate. The patients underwent sequestrectomy of the tibia and subsequent application of bilocal consecutive compression-distraction osteosynthesis or monolocal compression osteosynthesis. Microbiological study of smears taken before the reconstructive treatment from fistulas and wounds of patients showed that in monoculture there were 30 strains, the remaining 30 - as a part of 14 two - and three-component associations. The frequency of S. aureus strains was 55.3%, followed by coagulase-negative staphylococcus - 13.6% and representatives of the family Enterobacteriacae - 10.2%. There were methicillin-resistant strains of S. aureus in 11.8%, strains of coagulase-negative staphylococcus (MRCoNS) - 6.8%. Recurrence of the disease was observed in 7 patients. The microflora of the discharge from the fistula was represented by monocultures of S. aureus and associations of bacteria in which one of the components was methicillin-resistant strains of S. aureus. We observed differences in the contents of the microflora before reconstructive treatment of patients and in recurrence of infection. In case of recurrence of infection, the qualitative contents of the microflora changed: in 2 patients in the association of microorganisms and in 3 - in monocultures, S. aureus strains acquired resistance to ß-lactam antibiotics, new associations appeared, which were not present in primary cultures before reconstructive treatment. The study showed that the spectrum of micro-organisms in chronic osteomyelitis of the tibia, developed after osteosynthesis with a plate, varied and is subject to change and that dictates the need for microbiological monitoring to detect the etiological structure of pathogens, monitoring of antibiotic resistance of the isolated strains and rational approach to treatment of patients.

Treatment of chronictibial osteomyelitis with irrigation sequential Flow-through type anterolateral thigh chimeric myocutaneous flap

Objective To investigate the clinical effects of irrigation sequential Flow-through type anterolateral thigh chimeric myocutaneous flap in the treatment of chronic tibial osteomyelitis. Methods From January, 2012 to December, 2017, trench grooved sequential Flow-through anterolateral femoral chimeric flaps were used to treat chronic tibial osteomyelitis. On the basis of sensitive antibiotics, bone grooving and VSD grooved sequential Flow-through anterolateral thigh chimeric flaps were used to fill the bone cavity and cover the wound. The patients received the follow-up care in outpatient office and telephone regularly after hospital discharge. Results Among the 18 cases in this group, 2 cases were positive and 16 cases were negative in secondary bacteriological detection. The flaps and donor sites survived in one stage. Fifteen cases healed in one stage, and extravasate occurred in 3 cases after operation. After dressing change, the wounds healed in 25 days, 32 days and 43 days after flap operation, respectively. All the patients were followed-up for 12 to 30 months, with an average of 25 months. Local low toxicity infection symptom occurred again in 1 case with delayed healing 6 months after operation. After 1 week of antibiotic treatment, the symptom subsided. After 1 more week of antibiotic use, the patient was discharged from hospital. And followed-up for 1 year, no recurrence occurred. During the follow-up period, no recurrence of infection and no fracture occurred after primary fracture healing in other 17 cases. One year after the second operation, there was no obvious stenosis in the bridged vessels examined by Doppler ultrasonography and the blood flow velocity was the same as that of the contralateral limbs. Conclusion The application of irrigation and sequential Flow-through type anterolateral thigh chimeric myocutaneous flap for treatment of chronic tibial osteomyelitis can achieve good therapeutic effect and is worth popularizing. Key words: Tibial osteomyelitis; Chimeric myocutaneous flap, anterolateral thigh flap; Flow-through flap; Microsurgical technique

Efficacy of novel nano-hydroxyapatite/polyurethane composite scaffolds with silver phosphate particles in chronic osteomyelitis.

Recently, chronic osteomyelitis is still a challenging surgical problem. Unfortunately, the traditional clinical method using bone cement loaded antibiotics is restricted due to its non-biodegradability and limited release of antibiotics. Hydroxyapatite is a good adsorbent with good biocompatibility, an ideal bone repair material, and can avert the requirement for the secondary surgical procedure of removal. In this study, nano-hydroxyapatite combined with a polyurethane containing 3% silver (Ag/n-HA/PU) was synthesized, and investigated for its efficacy of treating chronic bone infection with bone defects. To clarify its silver ions release characteristics, the concentration of the Ag+ in the elution was analyzed every day after in vitro deionized water immersion. A chronic osteomyelitis of tibia in rabbit model was established, and 70 New Zealand rabbits were divided into 4 groups, including the blank control group, nano-hydroxyapatite combined with polyurethane (n-HA/PU) implant group, 3% Ag/n-HA/PU group and 10% Ag/n-HA/PU group after debridement. Routine blood tests, radiography, Micro-CT, and histological staining were conducted at 4 days, 3, 6 and 12 weeks post-treatment. The results showed that the released silver from the 3% Ag/n-HA/PU and 10% Ag/n-HA/PU exhibited an initial burst release and followed by a slow controlled release up to 39 days and 42 days respectively. A good repair of bone defects, an appropriate rate of degradation of scaffolds and no significant toxicity were observed in the 3% Ag/n-HA/PU group, indicating the advantages of this novel synthetic scaffold to be a potential option for the treatment of chronic osteomyelitis. A novel nano-composite, nano-hydroxyapatite combined with a polyurethane containing 3% silver (Ag/n-HA/PU) provide controlled release of Ag+, illustrated by its abilities of biodegradation, antimicrobial activity, and favorable repair of bone defects in the treatment of chronic osteomyelitis.

Autologous lipotransfer for bone defects secondary to osteomyelitis: A report of a novel method and systematic review of the literature.

Autologous bone grafting is the gold standard in patients with bone defects but is associated with significant pain and donor site morbidity. Autologous lipotransfer (fat grafting or lipofilling) has become very popular in the therapy of chronic wounds. Mesenchymal stem cells from adipose tissue are known for their regenerative, reparative, and immunomodulatory effects. This case study and review evaluates the use of autologous lipotransfer for chronic osteomyelitis in a 26-year-old patient. A 26-year-old female suffering from chronic tibial osteomyelitis was initially treated with surgical debridement and antibiotics followed by lipoharvest and autologous lipofilling. MRI and computed tomography scans were performed at 2 and 6 weeks and 6 months postoperatively. A formal systematic review of clinical trials investigating autologous lipotransfer for osteomyelitis was conducted. The patient remained asymptomatic without recurrence, and the bone defect cavity showed vascularised adipose tissue after 6 weeks, with early signs of osteogenesis. The highest foot and ankle disability index was 100. The systematic review identified 266 studies after duplicates were removed. After screening for eligibility, seven manuscripts were further assessed, with none meeting the inclusion criteria. This is the first study to report the successful use of autologous lipotransfer with early signs of osteogenesis in a patient suffering from chronic osteomyelitis. Autologous lipotransfer is relatively simple, safe, and minimally invasive, making it a potential alternative to current treatments. Further research is required to assess the safety, feasibility, and efficacy of autologous fat grafting and the mechanism of osteogenesis.

L-shaped corticotomy with bone flap sliding in the management of chronic tibial osteomyelitis: surgical technique and clinical results

BackgroundWe described the use of the technique of L-shaped corticotomy with bone flap sliding to treat chronic osteomyelitis of the tibia in eight patients and presented the preliminary results.MethodsL-shaped corticotomy with bone flap sliding was performed in eight patients between 2007 and 2014. All patients had chronic tibial osteomyelitis involving the anterior tibial cortex with intact and healthy posterior cortex. The size of bone defects following sequestrectomy and radical debridement was 8.1 cm on average. One patient required a latissimus dorsi flap. The mean follow-up period was 34.1 months. The functional and bone results were evaluated at the time of the latest follow-up.ResultsComplete eradication of infection and union of docking sites were achieved in all patients. Functional results were judged excellent in five patients and good in the rest three patients. Bone results were graded as excellent in all cases. The mean external fixation time was 169.9 days and external fixation index was 21.2 days/cm. Pain was the most common complaint that we faced during lengthening. Pin tract infections were observed in four patients, and mild transient stiffness of ankle joint was observed in three patients.ConclusionsWe have found this technique to be safe and effective, significantly diminishing the external fixation index. The earlier removal of the external fixator may result in increased patient comfort, a reduced complication rate, and a rapid and convenient rehabilitation.

Accordion technique in the treatment of tibial delayed union or nonunion

Objective To assess the clinical curative effect of accordion technique in the treatment of tibial delayed union or nonunion. Methods From February 2016 to December 2017, data of 11 patients with tibial delayed union (n=8) or non-union (n=3) who had been treated by accordion technique with an Ilizarov ring external fixator were retrospectively analyzed. 10 males and 1 female were included in our study, with an average age of 41.9 years (range, 21-63 years). There were 5 cases of docking site delayed union after Ilizarov transport for chronic tibial osteomyelitis. There were 3 cases of fracture site delayed union after external fixation for open tibia comminuted fracture. There were 3 cases of nonunion after tibia closed fracture, including 2 cases who had hybrid external fixation treatment, and 1 case who had conservative treatment. All the cases received accordion technique using Ilizarov ring external fixators. First, gradual compression at the fracture site was conducted until the bony contact was seen on a radiograph. After bony contact, compression was continued at a rate of 0.85 mm/d for a week, followed by distraction of 0.85 mm/d for 2-3 weeks. Afterward, a second compression was conducted using same rate and time with the distraction procedure. And there was a 7-day latent period between compression and distraction. One or two cycles of compression-distraction were needed before union was present radiographically. Results Bony union was obtained in all 11 patients after a mean time of 5.4 months (from 3 to 9 months). The mean follow-up for the 11 patients was 15.2 months (from 11 to 29 months). The mean duration of the accordion technique treatment was 50.2 d (range, 35-67 d). The accordion technique was used 1 time for 8 patients, and 2 times for 3 patients. The mean duration of bone consolidation was 114.9 d (range, 64-239 d). According to Paley evaluation criteria, osseous results were excellent in 8 cases, good in 3 cases, with a good to excellent rate of 100%(11/11); functional results were excellent in 7 cases, and good in 4 cases, with a good to excellent rate of 100%(11/11). Conclusion The accordion technique is a minimal invasive, safe and reliable treatment program for tibial delayed union or nonunion. Key words: Tibial fractures; Fractures, ununited; External fixators

Repair of the soft tissue defects combined dead space in lower extremities with the descending branch of lateral circumflex femoral artery chimeric perforator flap

Objective To investigate the feasibility and clinical effects of chimeric perforator flap based on the descending branch of lateral circumflex femoral artery(d-LCFA) for reconstructing the three-dimensional tissue defect in lower extremities. Methods From May, 2008 to June, 2017, 79 cases of soft tissue defects with dead space were repaired by using a d-LCFA chimeric perforator flap, in which 33 cases of car accident trauma, 12 cases of chronic tibial osteomyelitis, 10 cases of plowing machine injury, 9 cases of chronic calcaneal osteomyelitis, 6 cases of falling injury, 5 cases of crushing injury, 3 cases of spoke injury, and 1 case of suppurative knee arthritis. These patients were accompany with different degrees of infection and dead space after radical debridement. The dead cavity was filled by muscular flap, and perforator flap covered the superficial wound. Recording the flap’s appearance, color, texture, osteomyelitis recurrence and the patient’s knee extension at 1, 3, 6, 9 and 12 months followed-up. Results Seventy-five flaps survived without complications, and the donor sites were closed directly. All patients had no postoperative hematoma or secondary infection. Vascular crisis occurred in 2 days after the operation in 4 flaps, 1 flap had an arterial crisis on the second-postoperative-day, and the flap was necrotic after surgical exploration. The deep circumflex iliac artery chimeric perforator flap was used for repairing. Three flaps with venous crisis during 48 h after operation, in which 2 flaps survived eventually after surgical exploration, and another flap was necrosis and repaired by skin graft. The followed-up periods ranged from 3 months to 30 months(mean, 9.7 months). All flaps had satisfied with appearance and texture. There were no osteomyelitis recurrence and any ranges of motion limitations in the hip and knee joints of the operated leg. Conclusion The chimeric perforator flap with d-LCFA merely anastomosed 1 group vascular pedicle can make the dead space be filled and cover the superficial wound simultaneously. It is an ideal option for reconstructing the skin defect with dead space in lower extremity, which can improve the quality of restoration of recipient site and reduce the damage of donor site. Key words: Lateral circumflex femoral artery, descending branch; Chimeric flap; Perforator flap; Dead space; Lower limb; Microsurgical technique