Radical Debridement Research Articles

Clinical study of drug-loaded calcium sulfate in the treatment of hematogenous osteomyelitis in children

BackgroundAt present, good results have been obtained in the treatment of hematogenous osteomyelitis(HO) in children by the use of drug-loaded calcium sulfate, but there are few clinical studies reported. The aim of this study was to investigate the clinical efficacy of radical debridement combined with drug-laden calcium sulphate antibiotics in paediatric haematogenous osteomyelitis.MethodsIn this study, we retrospectively analyzed the clinical data of 15 cases of pediatric hematogenous osteomyelitis admitted to our hospital in recent years. A total of 15 pediatric patients with HO treated in our hospital from January 2018 to February 2022 were included for evaluation.ResultsAll 15 patients were treated with drug-laden calcium sulfate, and the antibiotic of choice was vancomycin in 14 cases and vancomycin combined with gentamicin in 1 case. The follow-up period ranged from 12 to 36 months, with a mean follow-up time of 24.73 months, and all children were treated with drug-laden calcium sulfate with satisfactory clinical outcomes. The results of serological examination showed that the preoperative white blood cell count level, C-reactive protein and erythrocyte sedimentation rate were higher than the postoperative ones, and the differences were statistically significant (P < 0.05).After the operation, referring to the treatment standard of McKee’s osteomyelitis, 15 cases were cured without recurrence; According to the Lower Extremities Functional Scale, 12 cases were excellent, 2 cases were good and 1 case was moderate, with an excellent rate of 93.33%. Children with lower limb involvement could walk with full weight bearing, and gait was basically normal.ConclusionDrug-loaded calcium sulfate is a good therapeutic method for the treatment of hematogenous osteomyelitis in children, with a effect of reducing complications and reducing recurrence.

Restoring Quality of Life: Assessing the Impact of Free Flap Reconstruction in Coronavirus Disease 2019-Associated Rhino-Orbital Mucormycosis Patients.

Background In India, between May 5 and July 2021, 41,512 cases and 3,554 deaths due to mucormycosis were reported in coronavirus disease 2019 (COVID-19)-infected patients or COVID-19-recovered patients. COVID-19-associated rhino-orbital mucormycosis (CAROM) has been associated with adverse effects that can affect oral health, vision, and physical as well as emotional functioning. After the radical debridement of CAROM and antifungal therapy, reconstructive surgery should be employed to restore function and aesthetics; however, limited clinical data exist on its potential effect on the quality of life (QOL) of these patients. Objective Our objective was to assess the QOL among CAROM patients reconstructed with free flap surgery. Materials and Methods This analysis studied 19 patients of CAROM who had maxillectomy and/or orbital exenteration defects reconstructed with free flaps at a tertiary care center. All these patients were free from any residual disease, as confirmed by tissue biopsy taken from the affected area. The QoL of these patients was assessed 1 week preoperatively and 4 to 6 months postoperatively using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC QLQ-HN43) questionnaire module. Results There was a statistically significant improvement in 10 out of the total 19 parameters ( p < 0.05) which include pain in the mouth, problems opening mouth, speech, swallowing, weight loss, dry mouth and sticky saliva, body image, fear of progression, social contact, and social eating. Conclusion The EORTC QLQ-HN43 questionnaire module presented a statistically significant improvement in the functional as well as psychological status of the CAROM patients undergoing reconstruction by free flap surgery.

Multidrug-resistant bacterial colonisation in Ukrainian war injuries: a need for multimodal therapy

This case report describes the interdisciplinary treatment of a complex shrapnel injury to the right femur of an 18-year-old Ukrainian soldier. This open multifragmentary fractur of the femur with a large bone defect, soft tissue damage and osteomyelitis was complicated by several multidrug-resistant bacteria, including Acinetobacter baumanii, which could not be eradicated by antibiotic treatment. Sterility was only achieved by multiple radical debridement and by negative pressure wound therapy with instillation (NPWTi) using hypochlorous acid. The femur was then reconstructed with a chimeric double-barrel fibula free flap. This report highlights the importance of multimodal antimicrobial wound treatments in an era of increasing antibiotic resistance to enable a successful und functional reconstruction of complex and infected fractures.

A 270° Retention of Spinal Structure in the Treatment of Thoracic and Lumbar Tuberculosis via Posterior-Only Approach

Objective The necessity of radical debridement in the treatment of thoracic and lumbar tuberculosis is increasingly challenged. We introduce the 1-stage surgical treatment with 270° retention of the spinal structure via a posterior-only approach and investigate the clinical efficacy and feasibility of this method in treating thoracic and lumbar spinal tuberculosis. Summary of Background Data In former research articles, many potential disadvantages are found in the treatment of thoracic and lumbar tuberculosis after radical debridement, such as prolonged operative time, increased the surgical trauma, unsatisfactory bony fusion, instability of the spine, and too much blood loss. Methods Twenty-one patients who had thoracic and lumbar tuberculosis were admitted to our hospital between January 2013 and September 2014. All of them were treated with 1-stage surgical treatment by internal fixation, focal debridement, and fusion via the posterior-only approach. Then, the clinical efficacy was evaluated, with the Cobb angle reflecting spinal kyphotic angles, erythrocyte sedimentation rate (ESR), Frankel Grade scores, and imaging examination preoperatively and postoperatively. Results Patients were followed up for 24 to 40 months (mean, 29.95 months), Fusion occurred at 4 to 9 months (mean, 5.86 months). There were significant differences between groups regarding the Cobb angle, ESR, and Frankel Grade scores. Delayed wound healing affected 1 patient because of diabetes. No complications regarding the internal fixation and no tuberculosis recurrence were observed during follow-up. Conclusions Combined with anti-tuberculosis chemotherapy, the method, characterized by 270° retention of the spinal structure, can be an effective and feasible method in treating thoracic and lumbar spinal tuberculosis.

Delayed Reconstruction of the Perforator Pedicle Propeller Flap after the Induced Membrane Technique for Gustilo IIIB Open Distal Tibial Fracture.

This study aimed to evaluate the safety and efficacy of delayed reconstruction of the perforator pedicle propeller flap after the induced membrane technique in the treatment of Gustilo IIIB open distal tibial fracture, and to evaluate the clinical outcome and complications of two different perforator pedicle propeller flaps.Thirty-four patients with Gustilo IIIB open distal tibial fractures treated by the induced membrane technique and delayed reconstruction of two different perforator pedicle propeller flaps from May 2017 to March 2022 were retrospectively analyzed. Patients were divided into two groups according to the different kinds of perforator pedicle propeller flaps covered. The operation required two stages. The Radiographic Union Score for Tibial fractures (RUST) was used to evaluate the healing of the tibial bone defect. The American Orthopaedic Foot and Ankle Society (AOFAS) score was used to evaluate ankle function. The complications associated with the technique were recorded.The number of serial debridements, excluding those performed during emergency and final operations, was a mean of 2.28±0.83 in the PAPF group. The PAPF group had a mean bone defect length of 6.76 ± 0.69 cm, the median healing time of 13.11 ± 0.96 months, RUST score 12.68 ± 1.63, and AOFAS score of 84.12 ± 6.38. On the other hand the PTAPF group's mean bone defect length was 6.73 ± 0.95 cm, the median healing time 12.63 ± 1.46 months, RUST score 13.73 ± 1.53 and AOFAS score 82.79 ± 5.49. There were no observed significant differences the two groups in the number of serial debridements, bone defect length, bone union time, RUST score, or AOFAS score (p>0.05). Flap size ranged from 9×6cm2 to 14×7cm2 in the PAPF group and from 9×6cm2 to 13×7cm2 in the PTAPF group. There were no severe complications such as flap-related complications or amputation. The differences in complications in the two groups were not statistically significant.In cases of severe open tibial fracture, the reconstructive method is important. When delayed reconstruction is inevitable, surgeons should first perform radical debridement, followed by vacuum sealing drainage as a bridging therapy; both PAPF and PTAPF can be considered for definitive soft tissue coverage.

Interdisciplinary aspects of abdominal and plastic surgery- what does the (abdominal) surgeon need to know?

The aim was to reflect the established interdisciplinary aspects of general/abdominal and plastic surgery by means of a narrative review. Methods: (i) With specific references out of the medical literature and (ii) own clinical and perioperative as well as operating technical and tactical management experiences obtained in surgical daily practice, we present a choice of options for interdisciplinary cooperation that could be food of thought for other surgeons. - Decubital ulcers require pressure relieve, debridement and plastic surgery coverage, e.g., by a rotation flap plasty, V-Y flap or"tensor-fascia-lata"(TFL) flap depending on localization (sacral/gluteal defects, ischiadic tuber).-Coverage of soft tissue defects, e.g., after lymph node dissection, tumor lesions or disturbance of wound healing can be managed with fasciocutaneous or muscle flaps.-Bariatric surgery: Surgical interventions such as butt lift, tummy tuck should be explained and demonstrated in advance and performed commonly after reduction of the body weight.-Abdominoperineal rectum extirpation (APE): Holm's procedure with greater circumferential extent of resection at the mesorectum and the insertion site of the levator muscle at the anal sphicter muscle resulting in a substantial defect is covered by myocutaneous flap plasty.-Hernia surgery: Complicated/recurrent hernias or abdominal wall defect can be covered by flap plasty to achieve functional reconstruction, e.g., using innervated muscle. Thus, abdominal wall can respond better onto changes of pressure and tension.-Necrotising fasciitis: Even in case of suspicious fasciitis, an immediate radical debridement must be performed, followed by intensive care with calculated antibiotic treatment; after appropriate stabilization tissue defects can be covered by mesh graft of flap plasty.-Soft tissue tumor lesions cannot be resected with primary closure to achieve appropriate as intended R0 resection status by means of local radical resection all the time-plastic surgery expertise has to be included into interdisciplinary tumor concepts.-Liposuction/-filling: Liposuction can be used with aesthetic intention after bariatric surgery or for lipedema. Lipofilling is possible for reconstruction and for aesthetic purpose.-Reconstruction of lymphatic vessels: Lymphedema after tumor operations interrupting or blocking lymphatic drainage can be treated with microsurgical reconstructions (such as lympho-venous anastomoses, lympho-lymphatic anastomoses or free microvascular lymph node transfer).-Microsurgery: It is substantial part of modern reconstructive plastic surgery, i.e.,surgery of peripheral nerves belongs to this field. For visceral surgery, it can become important for reconstruction of the recurrent laryngeal nerve.-Sternum osteomyelitis: Radical debridement (eventually, complete sternal resection) with conditioning of the wound by vacuum-assisted closure followed byplastic surgery coveragecan prevent chronification, threatening mediastinitis, persisting infectious risk, long-term suffering or limited quality of life. The presented selection of single topics can only be an excerpt of all the options for surgical cooperation in daily clinical and surgical practice. An interdisciplinary approach of abdominal and plastic surgery is characterized bya highly developed cooperationin common surgical interventions including various techniques and tactics highlighting the specifics of the two fields.

Surgical debridement in long bone chronic osteomyelitis: is wide tumour-like resection necessary?

The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit. We analyzed the retrospective record review from 2014 to 2020 of patients with long bone COM. All were managed by multidisciplinary infection team (MDT) protocol. Adequate debridement was employed for all cases, and no case of wide resection was included. A total of 53 patients (54 bones) with median age of 45.5 years (interquartile range 31 to 55) and mean follow-up of 29 months (12 to 59) were included. In all, ten bones were Cierny-Mader type I, 39 were type III, and five were type IV. All patients were treated with single-staged management, except for one (planned two-stage stabilization). Positive microbial cultures grew in 75%. Overall, 46 cases (85%) had resolution of COM after index procedure, and 49 (90.7%) had resolution on last follow-up. Four patients (7%) underwent second surgical procedure and six patients (11%) had complications. We challenge the need for wide tumour-like resection in all cases of COM. Through detailed preoperative evaluation and planning with MDT approach, adequate debridement and local delivery of high concentration of antibiotic appears to provide comparable outcomes versus radical debridement.

Rapid and effective treatment of chronic osteomyelitis by conductive network-like MoS2/CNTs through multiple reflection and scattering enhanced synergistic therapy

Staphylococcus aureus (S. aureus)-infected chronic osteomyelitis (COM) is one of the most devastating infectious diseases with a high recurrence rate, often leading to amputation and even death. It is incurable by all the current strategies involving the clinical use of radical debridement and systemic intravenous antibiotics. Here, we reported on a microwave (MW)-assisted therapy for COM by constructing a heterojunction formed by flake nanoflower-shaped molybdenum disulfide (MoS2) and tubular carbon nanotubes (CNTs). This composite could achieve a combination of MW thermal therapy (MTT) and MW dynamic therapy (MDT) to accurately and rapidly treat COM with deep tissue infection. In vitro and in vivo experiments showed that MoS2/CNTs were effective in non-invasively treating S. aureus-induced COM due to the heat and reactive oxygen species (ROS) produced under MW irradiation. The mechanism of heat and ROS generation was explained by MW network vector analysis, density of states (DOS), oxygen adsorption energy, differential charge and finite element (FEM) under MW irradiation. Since the Fermi layer was mainly contributed by the Mo-4d and C–2P orbitals, MoS2/CNTs could store a large amount of charge and easily release more electrons. In addition, charge accumulation and dissipation motion were strong on the surface of and inside MoS2/CNTs because of electromagnetic hot spots, resulting in the spilling out of a great deal of high-energy electrons. Due to the low oxygen adsorption energy of MoS2/CNTs-O2, these high-energy electrons combined further with the adsorbed oxygen to produce ROS.

Who needs their descending thoracic aorta anyway? Extra-anatomic bypass for aorto-bronchial fistula after TEVAR

BackgroundAortobronchial fistula after TEVAR remains a vexing clinical problem associated with high mortality. Although a combination of endovascular and open surgical strategies have been reported in managing this pathology, there is as yet no definitive treatment algorithm that can be used for all patients. We discuss our approach to an aortobronchial fistula associated with an overtly infected aortic endograft.Case presentationA 49-year-old female sustained a traumatic aortic transection 14 years prior, managed by an endovascular stent-graft. Due to persistent endoleak, she underwent open replacement of her descending thoracic aorta 4 years later. Ten years after her open aortic surgery, the patient presented with hemoptysis, and a pseudoaneurysm at her distal aortic suture line was identified on computed tomography, whereupon she underwent placement of an endograft. Eight weeks later, she presented with dyspnea, recurrent hemoptysis, malaise and fever, with clinical and radiographic evidence of an aortobronchial communication and an infected aortic stent-graft. The patient underwent management via a two-stage open surgical approach, constituting an extra-anatomic bypass from her ascending aorta to distal descending aorta and subsequent radical excision of her descending aorta with all associated infected prosthetic material and repair of the airway.ConclusionAortobronchial fistula after TEVAR represents a challenging complex clinical scenario. Extra-anatomic aortic bypass followed by radical debridement of all contaminated tissue may provide the best option for durable longer-term outcomes.

Hydroxyapatite: An antibiotic recruiting moiety for local treatment and prevention of bone infections.

Treatment of chronic osteomyelitis by radical debridement and filling of the dead space with antibiotic containing calcium sulfate/hydroxyapatite (CaS/HA) bone substitute has shown excellent long-term outcomes. However, in extensive infections, sessile bacteria may remain in bone cells or soft tissues protected by biofilm leading to recurrences. The primary aim of this study was to evaluate if systemically administrated tetracycline (TET) could bind to pre-implanted HA particles and impart an antibacterial effect locally. In vitro studies indicated that the binding of TET to nano- and micro-sized HA particles was rapid and plateaued already at 1 h. Since protein passivation of HA after in-vivo implantation could affect HA-TET interaction, we investigated the effect of serum exposure on HA-TET binding in an antibacterial assay. Although, serum exposure reduced the zone of inhibition (ZOI) of Staphylococcus aureus, a significant ZOI could still be observed after pre-incubation of HA with serum. We could in addition show that zoledronic acid (ZA) competes for the same binding sites as TET and that exposure to high doses of ZA led to reduced TET-HA binding. In an in-vivo setting, we then confirmed that systemically administered TET seeks HA particles that were pre-implanted in muscle and subcutaneous pouches in rats and mice respectively, preventing HA particles from being colonized by S. aureus. Clinical Significance: This study describes a new drug delivery method that could prevent bacterial colonization of a HA biomaterial and reduce recurrences in bone infection.

Use of fibular graft in Masquelet technique in osteomyelitis of long bones-a novel modification in the technique

Background: Improper treatment of acute osteomyelitis mostly leads to chronic osteomyelitis. In the year 2000, Alain C. Masquelet described the Induced membrane technique for the first time. In this study, we aimed to determine the clinical efficiency of the Masquelet technique for bone loss due to osteomyelitis in the long bones. Methods: This study was conducted at our tertiary care centre Shri Vasantrao Naik medical college and hospital, Yavatmal between August 2016 and September 2020. Masquelet technique with some modification was performed in all cases. Results: In first stage, the defects were filled with antibiotic-loaded polymethyl methacrylate (PMMA) cement after radical debridement. In second stage after 6 to 8 weeks we used a combination of fibular strut graft with iliac cancellous graft. X-rays were taken before second stage and after 3 months, 6 months and 1 year to see for the union. The study included 10 patients, with 6 males and 4 females with mean age of 34 years (20 to 54). The mean duration of bone infection was 4 months (range: 3-5 months). All patients had an average follow-up period of 16 months (range, 12-24 months). Radiographic evidence of bone union was seen in 6 months (3 to 9 months) infection was not seen in any case. Conclusions: This modified Masquelet is an effective method for the treatment of chronic osteomyelitis of the long bones.

Efficacité de la fixation interne précoce associée à un lambeau libre pour le traitement des fractures ouvertes de l’avant-bras Gustilo IIIB

IntroductionGustilo IIIB open forearm fractures are severe injuries often associated with extensive bone and soft tissue injuries. The treatment of Gustilo IIIB open forearm fractures remains a challenging problem, with a high morbidity rate such as infection, nonunion, even amputation. External fixation is preferred for open lower limb fractures. However, there are significant differences between open bone injuries of the upper and lower extremity in terms of treatment plans. Use of internal fixation methods for open fractures is a controversial issue, as it requires early coverage of skin and soft tissue defects after radical debridement and irrigation. The optimal approach for open forearm fractures remains to be determined. The present study evaluated whether early internal fixation combined with free flap placement is effective for the treatment of Gustilo IIIB open forearm fracture. HypothesisEarly internal fixation combined with the free flap technique in the treatment of Gustilo IIIB open forearm fracture provides good consolidation results. Material and methodsFrom January 2015 to January 2020, 20 patients with Gustilo IIIB open forearm fracture treated with early internal fixation combined with free skin flap placement were retrospectively analyzed. There were 9 males and 11 females, with an average age of 40years. In all cases, the injuries were classified as Gustilo type IIIB. The area of the wounds ranged from 9×3cm to 27×10cm. Fist-stage plate fixation was adopted in 16 cases. Four patients presenting with major contamination received first-stage fixation with Kirschner wires and external fixation, and the second-stage surgery of surgical treatment included flap placement and internal fixation within 10days. The rates of limb salvage and complications were recorded. The Anderson scoring system was utilized to assess limb function. ResultsLimb salvage was successful in all 20 cases. The average length of hospital was 19 days (range, 7–28days). Four patients developed superficial infections. After debridement, the wounds were covered with skin grafts. No deep infections or osteomyelitis occurred. Three patients developed nonunion, and bone grafts achieved bone healing later. The donor skin flaps healed well, with partial pigmentation. No complete necrosis of the flaps occurred. Only the distal part of flaps became necrotic in two cases, which were then successfully treated by debridement and skin grafting. The average follow-up duration was 14.7months (range, 8–24months). According to the Anderson scoring system, 7 cases were graded as excellent, 6 cases as good, 5 cases as fair, and 2 cases as poor. ConclusionFor Gustilo IIIB type injuries, early and thorough debridement along with early internal fixation and skin flap coverage of the wound can achieve satisfactory clinical results, shorten the treatment cycle, and maximize limb function recovery. Level of evidenceIV; retrospective study without control group.

A Rare Case of Complete Sequestration of the Patella: an Unusual Presentation of Patellar Tuberculosis

Abstract Osteoarticular tuberculosis affecting the knee with isolated involvement of the patella is rare, accounting for less than 0.09% to 0.15% of cases. We present a case of 48-year-old man presenting with chronic knee swelling, pain, and stiffness. Radiographs revealed a completely sclerotic patella with erosions and irregular margins. Magnetic resonance imaging revealed chronic synovitis, joint effusion, and bony erosions with full-thickness cartilage defects in the patella. He underwent surgical debridement with extensive synovectomy, and a total patellectomy was performed. Intraoperative samples conclusively diagnosed it as a tubercular infection of the patella and synovium. The patient was started on antitubercular chemotherapy. A 2-year follow-up revealed good knee function with an extensor lag of 100. There has been no recurrence of infection. This report is a rare case of complete patellar sequestration secondary to tuberculosis patella, which was successfully treated with radical debridement and patellectomy.

EXPERIENCE IN TREATMENT OF GUNSHOT WOUNDS OF LIMBS IN TRAUMATIC AMPUTATIONS DUE TO EXPLOSIVE TRAUMA

Abstract. Aim. To improve the results of surgical treatment in patients with traumatic limb amputations by developing diagnostic and treatment strategy for managing patients with soft tissue wounds of amputation stumps.&#x0D; Materials and methods. 283 wounded in-patients of Military Medical Clinical Center of the Central Region with gunshot traumatic limb amputations or their segments as a result of explosive injury were retrospectively studied during the period of February 24, 2022 to February 24, 2023.&#x0D; Results and discussion. Being admitted to the third level of medical service, surgical clinic, full-scale medical aid was provided to&#x0D; 283 wounded servicemen including surgical interventions with continuous intensive therapy. If necessary, the strategy of damage control surgery was continued and extended.&#x0D; Diagnostic and treatment strategy consisted of mandatory primary examination of amputation stump in the dressing room, X-ray examination of the limb, ultrasonography and Doppler ultrasound of the extremity (stump) vessels, and spiral computer tomography. 52 patients (18.37 %) underwent emergency operations. In 231 patients (81.63 %) treatment consisted of staged repeated (secondary if indicated) debridement of amputation stump and gunshot wounds of the limbs, and placement of VAC systems using negative pressure therapy. Repeated debridement was carried out every 3-5 days, performing necrectomy and using sanitation with antiseptic solutions. Polyurethane sponges were used to fill wound defect of the stump tissue, followed by 3-4 dermatotension sutures, and then VAC bandage was formed by conventional method.&#x0D; The following early complications occurred: bleeding — in 8 (2.83 %) patients, development of tension hematomas in 7 (2.47 %) and purulent inflammation in the form of suppuration, phlegmon and abscess in 43 (15.19 %) patients, requiring a greater number of repeated and secondary surgical debridements and placement of VAC systems. Late postoperative complications were: "defective stumps" in 17 (6.01 %) patients, ligature fistulas in 11 (3.89 %), formation of osteophytes in 3 (1.06 %), neurinoma — in 2 (0.71 %) and phantom pain syndrome in 11 (3.89 %) patients.&#x0D; Conclusions. To decrease the number of complications associated with purulent inflammation in amputation stump, primary surgical intervention should be carried out in the form of radical primary surgical debridement of gunshot wound, leaving long stump with no sutures. Following clear diagnostic and treatment strategy in managing patients with wound defects of soft tissues of amputation stumps in gunshot traumatic limb amputations leads to decreased number of postoperative complications.

Surgery for mitral annular caseous calcification-related calcified amorphous tumor: a case report

BackgroundA calcified amorphous tumor (a non-neoplastic tumor) with caseous calcification of the mitral annulus is a rare pathology that causes severe embolic events. We present a rare case of mitral valve surgery for a mitral annular caseous calcification-related calcified amorphous tumor found in cerebral infarction.Case presentationA 69-year-old man was diagnosed with a mitral valve calcified amorphous tumor with mitral annular caseous calcification found in cerebral infarction. He was admitted because of acute multiple embolic cerebral infarctions. A search for the embolic source through transesophageal echocardiography revealed a mitral valve tumor raised from the posterior mitral valve leaflet on the side of the left ventricle. Computed tomographic cardiac angiography revealed a calcified mitral valve tumor invading the posterior mitral valve annulus and left ventricular muscle. Intraoperative findings revealed a mitral annular calcification-related calcified amorphous tumor with caseous calcification of the posterior leaflet and annulus, which was suspected. Therefore, we performed radical debridement of the mitral annular calcification and bioprosthetic mitral valve replacement with patch repair of the posterior mitral valve annulus 2 weeks after the onset of cerebral infarction. The patient recovered well post operation, without any embolic events.ConclusionsA calcified amorphous tumor with caseous mitral annulus calcification may be highly associated with embolic events. In this case, mitral valve replacement with annular patch repair may be a favorable procedure for preventing embolic events.

Circumferential Radical Debridement and Omental Free Flap in the Treatment of Severe Chronic Venous Ulcers.

Chronic venous leg ulcers are a significant health care burden with a difficult and unreliable treatment. Free flaps may be needed for wound coverage in severe cases. Incomplete removal of dermatoliposclerosis (DLS) area and/or not addressing the underlying venous dysfunction may contribute to the reported modest long-term results. A series of 5 patients with severe chronic venous ulcers of the leg, resistant to conservative treatment and superficial venous surgery, were treated with radical, circumferential, subfascial resection of the DLS skin and coverage with omental free flaps. Delayed arteriovenous (AV) loops were used as recipients. All patients had previous superficial venous surgery and multiple skin grafts. Mean follow-up was 8 years (4-15 years). One hundred percent of flaps survived completely. No major complications occurred. One patient developed ulceration of the flap at 2 years and healed with basic wound care. At a mean follow-up of 8 years, all patients were ulcer-free. One patient died 15 years after the surgery for unrelated causes. Radical circumferential resection of DLS area in severe chronic venous leg ulcers and coverage with a free omental flap using staged AV loop provided durable coverage in a series of 5 patients. Complete resection of DLS area, addressing the underlying venous pathology, and draining the flap to a healthy competent vein graft (AV loop) may contribute to these favorable results.

Evaluation of Adjuvant Antibiotic Loaded Injectable Bio-Composite Material in Diabetic Foot Osteomyelitis and Charcot Foot Reconstruction.

The management of diabetic foot osteomyelitis (DFO) is extremely challenging with high amputation rates reported alongside a five-year mortality risk of more than fifty percent. We describe our experience in using adjuvant antibiotic-loaded bio-composite material (Cerament) in the surgical management of DFO and infected Charcot foot reconstruction. We undertook a retrospective evaluation of 53 consecutive patients (54 feet) who underwent Gentamicin or Vancomycin-loaded Cerament application during surgery. The feet were categorised into two groups: Group 1, with infected ulcer and DFO, managed with radical debridement only (n = 17), and Group 2, requiring reconstruction surgery for infected and deformed Charcot foot. Group 2 was further subdivided into 2a, with feet previously cleared of infection and undergoing a single-stage reconstruction (n = 19), and 2b, with feet having an active infection managed with a two-stage reconstruction (n = 18). The mean age was 56 years (27-83) and 59% (31/53) were males. The mean BMI was 30.2 kg/m2 (20.8-45.5). Foot ulcers were present in 69% (37/54) feet. At a mean follow-up of 30 months (12-98), there were two patients lost to follow up and the mortality rate was 11% (n = 5). The mean duration of post-operative systemic antibiotic administration was 20 days (4-42). Thirteen out of fifteen feet (87%) in group 1 achieved complete eradication of infection. There was a 100% primary ulcer resolution, 100% limb salvage and 76% bony union rate within Group 2. However, five patients, all in group 2, required reoperations due to problems with bone union. The use of antibiotic-loaded Cerament resulted in a high proportion of patients achieving infection clearance, functional limb salvage and decrease in the duration of postoperative antibiotic therapy. Larger, preferably randomised, studies are required to further validate these observations.

Percutaneous Coronary Intervention-Related Radiation Ulcer: Diagnosis, Management, and Prevention Strategy.

Radiation ulcers after percutaneous coronary intervention (PCI) are increasingly common. However, their diagnosis, treatment, and prevention strategies have not been well studied. To present our experience in the diagnosis, treatment, and prevention of PCI-related radiation ulcers. Patients diagnosed with PCI-related radiation ulcers were collected. Radiation fields of PCI were simulated using the Pinnacle treatment planning system to confirm the diagnosis. Surgical methods and outcomes were reviewed, and a prevention protocol was developed and evaluated for its effectiveness. Seven male patients with ten ulcers were included. Among the patients, the right coronary artery was the most common target vessel of PCI, and the left anterior oblique was the most commonly used PCI view. Nine ulcers had undergone radical debridement and reconstruction: four smaller ones with primary closure or local flaps, and five with thoracodorsal artery perforator flaps. No new cases were identified in a 3-year follow-up period after implementing the prevention protocol. PCI-related ulcer diagnosis is more evident with radiation field simulation. The thoracodorsal artery perforator flap is an ideal option for back or upper arm radiation ulcer reconstruction. The proposed prevention protocol for PCI procedures was effective in lowering the incidence of radiation ulcers.

Operační léčba tuberkulózní spondylodiscitidy

PURPOSE OF THE STUDY The paper presents a monocentric retrospective study of patients treated surgically for spinal tuberculosis. Clinical and radiological results are analysed, early and late complications are recorded. The study aims to answer the following questions. 1. Can we use instrumentation to restore the stability and alignment in the infected spinal focus? 2. Should we always perform radical anterior resection of TBC lesions? 3. What is the prognosis of surgical treatment of TBC patients with neurological deficit manifestation? MATERIAL AND METHODS Between 2010 and 2020, a total of 12 patients were treated for spinal tuberculosis at our department, of whom 9 patients (5 men, 4 women) with the mean age of 47.3 years (range 29 to 83 years) underwent a surgery. A total of three patients were operated on before the final confirmation of the TBC and treatment with antituberculosis medication, four patients in the initial therapy phase and two patients in the continuous phase. Two patients only underwent a non-instrumented decompression surgery followed by external support fixation. In the other seven patients, always with spinal deformity, instrumentation was used (3 cases of isolated posterior decompression, transpedicular fixation, posterior fusion, 4 cases of anteroposterior instrumented reconstruction). In 2 cases a structural bone graft and in 2 cases an expandable titanium cage were used for anterior column reconstruction. RESULTS Of the total number of patients, altogether eight patients were assessed at 1 year after surgery (one 83-year-old patient died from heart failure 4 months after surgery). Of the remaining eight patients, three patients exhibited a neurological deficit and postoperative regression of the finding. The McCormick score improved from the preoperative mean score of 3.25 to 1.62 at 1 year after surgery (p < 0.001). The clinical VAS score regressed from 5.75 to 1.63 at 1 year after surgery (p < 0.001). Radiographic healing of the anterior fusion was achieved in all patients, both after decompression and instrumented surgery. The initial mean kyphosis of 20.36 degrees of the operated segment measured by the mCobb angle was corrected to 14.6 degrees postoperatively, with a subsequent slight deterioration to 14.86 degrees (p < 0.05). The greatest correction was achieved in patients who had undergone a two-stage surgery with anterior resection and AP reconstruction. DISCUSSION In our cohort, titanium instrumentation was used in seven of nine patients. One patient only manifested persistent tuberculosis with nonspecific bacterial flora superinfection. Revision surgery with anterior radical debridement and subsequent treatment with antituberculotic drugs healed the patient. There were four patients with major preoperative neurological deficit persisting more than 2 weeks before the final treatment with subsequent improvement in all cases. These patients were treated with anteroposterior reconstruction and anterior radical debridement. CONCLUSIONS No increased risk of recurrent infection associated with the use of spinal instrumentation was found in the study. Anterior radical debridement is performed in patients with manifested kyphotic deformity and spinal canal compression, followed by reconstruction with a structural bone graft or a titanium cage. The other patients are treated based on the principle of "optimal" debridement with or without the use of transpedicular instrumentation. If adequate spinal canal decompression and stability are achieved, neurological improvement can be anticipated even in case of a major neurological deficit. Key words: spine tuberculosis, tuberculous spondylitis, Pott's disease, anterior debridement, spine instrumentation.

OUTCOME OF PATHOLOGICAL FRACTURES OF PAEDIATRIC FEMUR FOLLOWING CHRONIC OSTEOMYELITIS TREATED WITH ILIZAROV METHOD

Background: Pathological fracture of the paediatric femur after chronic osteomyelitis presents a challenging situation. It is complicated by the need for radical debridement, often leaving a wide bone gap and instability that is difcult to be managed by the traditional methods. The Ilizarov method due to its versatility is a potential treatment option for this condition. 19 children with pathological femur Materials and methods: fractures following chronic Osteomyelitis were treated with Ilizarov methods. 3 children were excluded, and the nal outcome was measured in 16 children. The mean age of the patients was 6.76±1.93 years, with 12 males (63.15%) and 7 females (36.84%). The Beit cure classication of childhood chronic osteomyelitis was used. The mean follow up after ring removal was 26.06±5.07 months. NEER's criteria was used to assess the radiological and functional outcomes. With a mean union time of 10.94±3.93 weeks, 100% union Results: was achieved in all of the 16 cases. The mean external xator period was 14.25±4.94 weeks. The infection was fully eradicated in all of the cases, except 1 (6.25%) child diagnosed with tubercular osteomyelitis is still having the active infection. According to NEER's functional and anatomical grading, excellent results were found in 6 (37.5%) cases, satisfactory in 8 (50%), and unsatisfactory in 2 (12.5%) cases. Pin tract infection was found in 10 (62.5%) children, axial deformity after ring removal in one (6.25%), and knee stiffness in 2(12.5%) children. In children w Conclusion: ith pathological femur fractures caused by chronic osteomyelitis, the Ilizarov method can be a viable treatment option. It helps to eradicate infection, promotes fracture healing, and produces satisfactory to excellent results.