Session 18: Infection
Fredag d. 26. oktober
13:00-14:30
Lokale: Stockholm/Copenhagen
Chairmen: Christen Ravn og Per Hviid Gundtoft
Mats Bue, Pelle Hanberg, Janne Koch, Louise Kruse, Martin Lundorff, Bent Aalbæk, Henrik Elvang Jensen, Kjeld Søballe, Mikkel Tøttrup
Department of Orthopaedic Surgery, Horsens Regional Hospital; Department of Orthopaedic Surgery, Horsens Regional Hospital; Department of Experimental Medicine, University of Copenhagen; Department of Veterinary Disease Biology, University of Copenhagen; Department of Orthopaedic Surgery, Horsens Regional Hospital; Department of Veterinary Disease Biology, University of Copenhagen; Department of Veterinary Disease Biology, University of Copenhagen; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Randers Regional Hospital
Background: The increasing incidence of orthopaedic methicillin- resistant Staphylococcus aureus (MRSA) infections represents a significant therapeutic challenge. Being effective against MRSA, the role of vancomycin may become more important in the orthopaedic setting in the years to come.
Purpose / Aim of Study: To evaluate the effect of implant-associated osteomyelitis on vancomycin bone penetration.
Materials and Methods: In eight pigs, implant-associated osteomyelitis was induced on day 0, using a Staphylococcus aureus strain. Following administration of 1,000 mg of vancomycin on day 5, vancomycin concentrations were obtained with microdialysis for 8 hours in the implant bone cavity, in cancellous bone adjacent to the implant cavity, in subcutaneous adipose tissue (SCT) adjacent to the implant cavity, and in healthy cancellous bone and healthy SCT in the contralateral leg. Venous blood samples were also obtained. The extent of infection and inflammation was evaluated by post-mortem computed tomography scans and a histological evaluation of the peri-implant pathological bone area (PIBA).
Findings / Results: In relation to all the implant cavities, bone destruction was found. Ranging from 0.20 to 0.74, tissue penetration, was incomplete for all compartments except for healthy SCT. The lowest tissue penetration was found in the implant cavity. By a PIBA width of 3 mm, the vancomycin penetration decreased dramatically.
Conclusions: Staphylococcus aureus implant-associated osteomyelitis was found to reduce vancomycin bone penetration, especially in the implant cavity. A strong negative correlation between PIBA width and vancomycin penetration were found. These findings suggest that it may be unsafe to rely solely on vancomycin therapy when treating acute osteomyelitis. Particularly when metaphyseal cavities are present, surgical debridement seems necessary.
Department of Orthopaedic Surgery, Horsens Regional Hospital; Department of Orthopaedic Surgery, Horsens Regional Hospital; Department of Experimental Medicine, University of Copenhagen; Department of Veterinary Disease Biology, University of Copenhagen; Department of Orthopaedic Surgery, Horsens Regional Hospital; Department of Veterinary Disease Biology, University of Copenhagen; Department of Veterinary Disease Biology, University of Copenhagen; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Randers Regional Hospital
Background: The increasing incidence of orthopaedic methicillin- resistant Staphylococcus aureus (MRSA) infections represents a significant therapeutic challenge. Being effective against MRSA, the role of vancomycin may become more important in the orthopaedic setting in the years to come.
Purpose / Aim of Study: To evaluate the effect of implant-associated osteomyelitis on vancomycin bone penetration.
Materials and Methods: In eight pigs, implant-associated osteomyelitis was induced on day 0, using a Staphylococcus aureus strain. Following administration of 1,000 mg of vancomycin on day 5, vancomycin concentrations were obtained with microdialysis for 8 hours in the implant bone cavity, in cancellous bone adjacent to the implant cavity, in subcutaneous adipose tissue (SCT) adjacent to the implant cavity, and in healthy cancellous bone and healthy SCT in the contralateral leg. Venous blood samples were also obtained. The extent of infection and inflammation was evaluated by post-mortem computed tomography scans and a histological evaluation of the peri-implant pathological bone area (PIBA).
Findings / Results: In relation to all the implant cavities, bone destruction was found. Ranging from 0.20 to 0.74, tissue penetration, was incomplete for all compartments except for healthy SCT. The lowest tissue penetration was found in the implant cavity. By a PIBA width of 3 mm, the vancomycin penetration decreased dramatically.
Conclusions: Staphylococcus aureus implant-associated osteomyelitis was found to reduce vancomycin bone penetration, especially in the implant cavity. A strong negative correlation between PIBA width and vancomycin penetration were found. These findings suggest that it may be unsafe to rely solely on vancomycin therapy when treating acute osteomyelitis. Particularly when metaphyseal cavities are present, surgical debridement seems necessary.
Pelle Hanberg, Andrea Lund, Kjeld Søballe, Mats Bue
Department of Orthopaedic Surgery, Horsens Regional Hospital; Orthopaedic Research Unit, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Horsens Regional Hospital
Background: Bone infections are difficult to treat, which may partly be explained by an incomplete and heterogeneous tissue distribution of antimicrobials. In the specific cases of open tibial fractures and chronic osteomyelitis, literature have been inconclusive regarding choice of antimicrobial treatment. Recent studies suggest the use of meropenem for patients with open tibial fractures or chronic osteomyelitis.
Purpose / Aim of Study: The objective of this study was to describe the meropenem pharmacokinetics in plasma, subcutaneous adipose tissue (SCT) and cancellous bone using microdialysis in a porcine model.
Materials and Methods: Six female pigs were assigned to receive 1 g of meropenem intravenously over 5 min. Measurements of meropenem were obtained from plasma, SCT and cancellous bone of the tibial condyle for 8 hours thereafter. Microdialysis was applied for sampling in solid tissues. The meropenem concentration was determined using UHPLC.
Findings / Results: Tissue penetration of meropenem from plasma to cancellous bone was incomplete and delayed. Comparing cancellous bone with both plasma and SCT, the elimination rate and maximal concentration of meropenem was prolonged and lower, respectively. The T>MIC, for a MIC of 0.5 μg/mL, was shorter for the cancellous bone compared with both plasma and SCT. For MICs above 0.5 μg/mL T>MIC in cancellous bone was only shorter than SCT. Considering a MIC of 4 μg/mL, reflecting a worst-case scenario, no animals achieved the target of 40% T>MIC in plasma and cancellous bone, while only 17% achieved it in the SCT.
Conclusions: The main finding of this study was short T>MIC in cancellous bone after intravenous administration of 1 g meropenem. Consequently, our data suggest that higher doses or other ways of applying meropenem, should be considered in the cases of open tibial fractures and chronic osteomyelitis.
Department of Orthopaedic Surgery, Horsens Regional Hospital; Orthopaedic Research Unit, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Horsens Regional Hospital
Background: Bone infections are difficult to treat, which may partly be explained by an incomplete and heterogeneous tissue distribution of antimicrobials. In the specific cases of open tibial fractures and chronic osteomyelitis, literature have been inconclusive regarding choice of antimicrobial treatment. Recent studies suggest the use of meropenem for patients with open tibial fractures or chronic osteomyelitis.
Purpose / Aim of Study: The objective of this study was to describe the meropenem pharmacokinetics in plasma, subcutaneous adipose tissue (SCT) and cancellous bone using microdialysis in a porcine model.
Materials and Methods: Six female pigs were assigned to receive 1 g of meropenem intravenously over 5 min. Measurements of meropenem were obtained from plasma, SCT and cancellous bone of the tibial condyle for 8 hours thereafter. Microdialysis was applied for sampling in solid tissues. The meropenem concentration was determined using UHPLC.
Findings / Results: Tissue penetration of meropenem from plasma to cancellous bone was incomplete and delayed. Comparing cancellous bone with both plasma and SCT, the elimination rate and maximal concentration of meropenem was prolonged and lower, respectively. The T>MIC, for a MIC of 0.5 μg/mL, was shorter for the cancellous bone compared with both plasma and SCT. For MICs above 0.5 μg/mL T>MIC in cancellous bone was only shorter than SCT. Considering a MIC of 4 μg/mL, reflecting a worst-case scenario, no animals achieved the target of 40% T>MIC in plasma and cancellous bone, while only 17% achieved it in the SCT.
Conclusions: The main finding of this study was short T>MIC in cancellous bone after intravenous administration of 1 g meropenem. Consequently, our data suggest that higher doses or other ways of applying meropenem, should be considered in the cases of open tibial fractures and chronic osteomyelitis.
Anne Brun Hesselvig, Anders Odgaard, Magnus Arpi, Thomas Bjarnsholt, Frank Madsen
Ortopædkirurgisk Afdeling, Gentofte Hospital; Ortopædkirurgisk Afdeling, Gentofte Hospital; Klinisk Mikrobiologisk Afdeling, Herlev Hospital; Costerton Biofilm Center, Panum Instituttet; Ortopædkirurgisk Afdeling, Aarhus Universitetshospital
Background: Infection following joint replacement surgery is a catastrophic complication. Many prophylactic procedures have been implemented to prevent peri-prosthetic infection but dispite this the infection rate is steady at 1-2%. The hypotheses for the present research project are 1) that the patient’s skin is the main source for intraoperative microbial contamination and 2) that intraoperative contamination can be reduced by using an iodine impregnated incisional drape.
Purpose / Aim of Study: The purpose of the project is to gain insight into the etiology of postoperative infection following joint replacement surgery with intraoperative contamination as our focal point. Specifically, we want to examine whether iodine impregnated incisional drape prevents intraoperative contamination and consequently averts infection.
Materials and Methods: To examine whether Ioban diminishes the risk of intraoperative contamination, a transregional, prospective, two arm study of 1200 patients undergoing knee arthroplasty surgery was performed. All patients were swabbed during surgery and the surgeons’ glove was also examined for bacteria.
Findings / Results: 1135 operated patients for either TKA or UKA were eligible for analysis, 299 patients from Region Midt and 837 in Region H, respectively. The overall contamination rate was 12,5 %. 56/570 (9,82%) were contaminated in the Ioban group and 86/565 (15,22%) in the control group (chi-square test) (P=0,006).
Conclusions: Ioban is a useable preventative measure for intra operative contamination.
Ortopædkirurgisk Afdeling, Gentofte Hospital; Ortopædkirurgisk Afdeling, Gentofte Hospital; Klinisk Mikrobiologisk Afdeling, Herlev Hospital; Costerton Biofilm Center, Panum Instituttet; Ortopædkirurgisk Afdeling, Aarhus Universitetshospital
Background: Infection following joint replacement surgery is a catastrophic complication. Many prophylactic procedures have been implemented to prevent peri-prosthetic infection but dispite this the infection rate is steady at 1-2%. The hypotheses for the present research project are 1) that the patient’s skin is the main source for intraoperative microbial contamination and 2) that intraoperative contamination can be reduced by using an iodine impregnated incisional drape.
Purpose / Aim of Study: The purpose of the project is to gain insight into the etiology of postoperative infection following joint replacement surgery with intraoperative contamination as our focal point. Specifically, we want to examine whether iodine impregnated incisional drape prevents intraoperative contamination and consequently averts infection.
Materials and Methods: To examine whether Ioban diminishes the risk of intraoperative contamination, a transregional, prospective, two arm study of 1200 patients undergoing knee arthroplasty surgery was performed. All patients were swabbed during surgery and the surgeons’ glove was also examined for bacteria.
Findings / Results: 1135 operated patients for either TKA or UKA were eligible for analysis, 299 patients from Region Midt and 837 in Region H, respectively. The overall contamination rate was 12,5 %. 56/570 (9,82%) were contaminated in the Ioban group and 86/565 (15,22%) in the control group (chi-square test) (P=0,006).
Conclusions: Ioban is a useable preventative measure for intra operative contamination.
Charlotte Packroff Stenqvist, Camilla Toft Nielsen, Bo Madvig Larsen, Mitchell James Flies, Ditte Brander, Per Pallesen
Orthopedic Surgery, Nykøbing Falster Hospital; Orthopedic Surgery, Nykøbing Falster Hospital; Orthopedic Surgery, Nykøbing Falster Hospital; Orthopedic Surgery, Nykøbing Falster Hospital; Orthopedic Surgery, Nykøbing Falster Hospital; Orthopedic Surgery, Nykøbing Falster Hospital
Background: Closed incision negative pressure wound therapy(ciNPWT) has been shown clinically effective in wound treatment of high-risk wounds after severe skeletal trauma and in arthroplasty revision surgery but still there are no specific indications for ciNPWT.
Purpose / Aim of Study: The purpose of this study was to identify if the use of ciNPWT with “Prevena” reduces wound revision surgery in major lower (above ankle) atraumatic amputations.
Materials and Methods: This is a retrospective cohort quality study at Nykøbing Falster Hospital, Region Sjaelland identifying al major amputations from 2010-2017. Patients amputated due to tumours were excluded. CiNPWT with "Prevena" was implemented on 1. June 2014 and defines the transition between the control group (2010-2013) and the intervention group (2015-2017). Differences between the groups were analysed using the Chi-Squared test and unpaired parametric t-test with Welch correction. Statistical significance level was chosen to p <0.05.
Findings / Results: We found 161 patients in the intervention group and 179 patients in the control group. Patients in the intervention group were significantly younger (73.2 ± 9.6) compared to the control group (77.9 ± 11.6), p<0.001. Both groups were comparable in terms of gender as well as the presence of diabetes and complicated wounds. We found 24 patients who needed revision in the intervention group (14.8%) and 29 (15.8%) in the control group in the immediate postoperative period of 2 months (p=0.79).
Conclusions: We didn’t find any reduced rate of revision surgery in our study in patients treated with ciNPWT in the immediate postoperative days, but patients receiving ciNPWT tend to go through fewer operative procedures. More research in ciNPWT in this field of use is needed.
Orthopedic Surgery, Nykøbing Falster Hospital; Orthopedic Surgery, Nykøbing Falster Hospital; Orthopedic Surgery, Nykøbing Falster Hospital; Orthopedic Surgery, Nykøbing Falster Hospital; Orthopedic Surgery, Nykøbing Falster Hospital; Orthopedic Surgery, Nykøbing Falster Hospital
Background: Closed incision negative pressure wound therapy(ciNPWT) has been shown clinically effective in wound treatment of high-risk wounds after severe skeletal trauma and in arthroplasty revision surgery but still there are no specific indications for ciNPWT.
Purpose / Aim of Study: The purpose of this study was to identify if the use of ciNPWT with “Prevena” reduces wound revision surgery in major lower (above ankle) atraumatic amputations.
Materials and Methods: This is a retrospective cohort quality study at Nykøbing Falster Hospital, Region Sjaelland identifying al major amputations from 2010-2017. Patients amputated due to tumours were excluded. CiNPWT with "Prevena" was implemented on 1. June 2014 and defines the transition between the control group (2010-2013) and the intervention group (2015-2017). Differences between the groups were analysed using the Chi-Squared test and unpaired parametric t-test with Welch correction. Statistical significance level was chosen to p <0.05.
Findings / Results: We found 161 patients in the intervention group and 179 patients in the control group. Patients in the intervention group were significantly younger (73.2 ± 9.6) compared to the control group (77.9 ± 11.6), p<0.001. Both groups were comparable in terms of gender as well as the presence of diabetes and complicated wounds. We found 24 patients who needed revision in the intervention group (14.8%) and 29 (15.8%) in the control group in the immediate postoperative period of 2 months (p=0.79).
Conclusions: We didn’t find any reduced rate of revision surgery in our study in patients treated with ciNPWT in the immediate postoperative days, but patients receiving ciNPWT tend to go through fewer operative procedures. More research in ciNPWT in this field of use is needed.
Nikolaj Milandt, Per Hviid Gundtoft, Søren Overgaard
The Orthopaedic Research Unit, Odense University Hospital, Denmark; Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, Kolding, Denmark; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Denmark
Background: The diagnostic and prognostic value of unexpected positive intraoperative cultures remains unclear in diagnosing prosthetic joint infection (PJI) in total hip arthroplasty (THA) revisions.
Purpose / Aim of Study: To study whether first-time aseptic revision of THA with unexpected bacterial growth in cultures of intraoperatively obtained biopsies has increased risk for re-revision due to all causes and due to PJI.
Materials and Methods: Cases reported to the Danish Hip Arthroplasty Register (DHR) as first-time aseptic loosening revisions performed during 2010 to 2016, were included. DHR data were merged with that of the Danish Microbiology Database, which contains data from all intraoperatively obtained cultures in Denmark. Revisions were grouped based on the number of unexpected positive cultures growing the same bacterial genus: ≥2, 1, and 0 cultures. Positive cultures in presumed aseptic revision cases were defined as unexpected. The revisions were followed until re-revision, death, or end of the 1-year follow- up period. The relative risk for re-revision due to all causes and PJI was estimated.
Findings / Results: We included 2,305 first-time aseptic revisions. Unexpected growth was found in 282 cases (12%), of which 170 (60%) grew the same bacteria in only 1 culture. Coagulase-negative staphylococcus accounted for 121 cases (71%). Re-revision was performed in 163 cases (7%), with PJI being the indication for revision in 43 cases (26%). The relative risk of re-revision was significantly higher for cases with 1 positive culture growing the same bacteria compared to culture-negative cases with both all-cause revision: 1.73 (95% CI 1.07; 2.80) and PJI revision: 2.63 (95% CI 1.16; 5.96).
Conclusions: First-time aseptic THA revisions with unexpected growth in only 1 biopsy culture had an increased risk for re-revision, due to both all causes and PJI.
The Orthopaedic Research Unit, Odense University Hospital, Denmark; Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, Kolding, Denmark; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Denmark
Background: The diagnostic and prognostic value of unexpected positive intraoperative cultures remains unclear in diagnosing prosthetic joint infection (PJI) in total hip arthroplasty (THA) revisions.
Purpose / Aim of Study: To study whether first-time aseptic revision of THA with unexpected bacterial growth in cultures of intraoperatively obtained biopsies has increased risk for re-revision due to all causes and due to PJI.
Materials and Methods: Cases reported to the Danish Hip Arthroplasty Register (DHR) as first-time aseptic loosening revisions performed during 2010 to 2016, were included. DHR data were merged with that of the Danish Microbiology Database, which contains data from all intraoperatively obtained cultures in Denmark. Revisions were grouped based on the number of unexpected positive cultures growing the same bacterial genus: ≥2, 1, and 0 cultures. Positive cultures in presumed aseptic revision cases were defined as unexpected. The revisions were followed until re-revision, death, or end of the 1-year follow- up period. The relative risk for re-revision due to all causes and PJI was estimated.
Findings / Results: We included 2,305 first-time aseptic revisions. Unexpected growth was found in 282 cases (12%), of which 170 (60%) grew the same bacteria in only 1 culture. Coagulase-negative staphylococcus accounted for 121 cases (71%). Re-revision was performed in 163 cases (7%), with PJI being the indication for revision in 43 cases (26%). The relative risk of re-revision was significantly higher for cases with 1 positive culture growing the same bacteria compared to culture-negative cases with both all-cause revision: 1.73 (95% CI 1.07; 2.80) and PJI revision: 2.63 (95% CI 1.16; 5.96).
Conclusions: First-time aseptic THA revisions with unexpected growth in only 1 biopsy culture had an increased risk for re-revision, due to both all causes and PJI.
Nikolaj Odderskær, Kajsa Lindberg, Daniel Haaning Kristensen, Morten Tange Kristensen
Risskov, Bandagist-Centret; Copenhagen, Sundhed og Genoptræning - Vanløse-Brønshøj-Husum; Aarhus, DemensCentrum; Departments of Physiotherapy and Orthopedic Surgery, Amager-Hvidovre Hospital
Background: Currently, there is no national clinical guideline for the rehabilitation offered to patients with lower limb amputations (LLA) in Danish municipalities. Thus, with the ambition of evidence-based healthcare practice, a potential heterogeneity in rehabilitation approaches seem problematic.
Purpose / Aim of Study: To evaluate the functional effect of a consensus and evidence-based rehabilitation program on a cohort of LLA patients, using three well-known outcome measures.
Materials and Methods: We studied a cohort of 44 newly amputated, dysvascular LLA patients (25 below knee amputations (BKA) and 19 above knee amputations (AKA), 33 men and 11 women, mean (SD) age of 67 (9.3) years). All participants completed a one-hour supervised exercise program twice a week for a mean of 17.5 (8.8) weeks. Baseline data was collected the second time walking with a prosthesis out of parallel bars or when considered safe by physiotherapist while the final test was collected following completion of the program. Functional levels were measured using three standardized tests: 10 Meter Walk (10MWT), Timed Up&Go (TUG) and 2 Minute Walk (2MWT).
Findings / Results: Performances improved significantly (p<0.001) in all three outcome measures from baseline to completion of program; the 10MWT from a mean of 0.44 (0.25) meter/seconds to 0.74 (0.44) meter/seconds, (Effect Size [ES]=1.06), the TUG from 34.3 (20.7) seconds to 20.3 (12.9) seconds, (ES=1.04), and the 2MWT from 56.07 (27.19) meters to 82.57 (38.04) meters, (ES=0.99).
Conclusions: Large improvements were seen in walking speed, functional mobility, and endurance for a cohort of LLA patients who followed a consensus and evidence-based rehabilitation program. Still, performances were below thresholds for non- amputated people. Further, long-term intervention studies seem needed to evaluate if further progress can be achieved.
Risskov, Bandagist-Centret; Copenhagen, Sundhed og Genoptræning - Vanløse-Brønshøj-Husum; Aarhus, DemensCentrum; Departments of Physiotherapy and Orthopedic Surgery, Amager-Hvidovre Hospital
Background: Currently, there is no national clinical guideline for the rehabilitation offered to patients with lower limb amputations (LLA) in Danish municipalities. Thus, with the ambition of evidence-based healthcare practice, a potential heterogeneity in rehabilitation approaches seem problematic.
Purpose / Aim of Study: To evaluate the functional effect of a consensus and evidence-based rehabilitation program on a cohort of LLA patients, using three well-known outcome measures.
Materials and Methods: We studied a cohort of 44 newly amputated, dysvascular LLA patients (25 below knee amputations (BKA) and 19 above knee amputations (AKA), 33 men and 11 women, mean (SD) age of 67 (9.3) years). All participants completed a one-hour supervised exercise program twice a week for a mean of 17.5 (8.8) weeks. Baseline data was collected the second time walking with a prosthesis out of parallel bars or when considered safe by physiotherapist while the final test was collected following completion of the program. Functional levels were measured using three standardized tests: 10 Meter Walk (10MWT), Timed Up&Go (TUG) and 2 Minute Walk (2MWT).
Findings / Results: Performances improved significantly (p<0.001) in all three outcome measures from baseline to completion of program; the 10MWT from a mean of 0.44 (0.25) meter/seconds to 0.74 (0.44) meter/seconds, (Effect Size [ES]=1.06), the TUG from 34.3 (20.7) seconds to 20.3 (12.9) seconds, (ES=1.04), and the 2MWT from 56.07 (27.19) meters to 82.57 (38.04) meters, (ES=0.99).
Conclusions: Large improvements were seen in walking speed, functional mobility, and endurance for a cohort of LLA patients who followed a consensus and evidence-based rehabilitation program. Still, performances were below thresholds for non- amputated people. Further, long-term intervention studies seem needed to evaluate if further progress can be achieved.
Signe Muus Steffensen, Birgitte Jul Kiil, Hans Henrik Møller Nielsen, Klaus Kjær Petersen
Plastic surgery, Aarhus University hospital; Plastic surgery, Aarhus; Plastic surgery, Aarhus university hospital; orthopedic surgery, Aarhus University hospital
Background: Treatment of osteomyelitis is a challenge. Coverage of significant soft tissue defects after bone and soft tissue debridement with associated bony dead space was traditionally performed with free muscle flaps (M) and is still the preferred approach by many surgeons. Free fasciocutaneous flaps (FC) can provide the same degree of coverage and bulk.
Purpose / Aim of Study: The aim of this study is comparison of (M) and (FC) according to overall complication rates, donorsite morbidity, post-op mobilization, safety of procedure if later surgery is required due to recurrence of osteomyelitis and the advantage of liposuction of (FC).
Materials and Methods: A retrospective review was conducted of all free flap reconstructions after osteomyelitis debridement in the lower leg from 2004 to 2018 at Aarhus university hospital.
Findings / Results: 16 patients underwent free flap reconstruction after osteomyelitis debridement. (8 (M=Gracilis flaps) and 8 (FC=Anterolateral thigh flaps (ALT)). 15 flaps healed completely, 1 (M) flap was lost due to venous congestions. 7 (M) had minor complications, 8 (FC) with no complications. None experienced recurrence of osteomyelitis. Equal low donorsite morbidity was found in both groups according to sensibility and function. Early post-op full weight-bearing mobilization was experienced in (FC = 1 week) compared to (M = 3 weeks). The advantage of thinning with liposuction of (FC) for refinement of functional and cosmetic outcome was compared to (M).
Conclusions: Conclusion: Fasciocutaeus free faps are superior to muscle free flaps in several aspects in the use of covering defects after osteomyelitis debridement with bony dead space in lower limb reconstructions.
Plastic surgery, Aarhus University hospital; Plastic surgery, Aarhus; Plastic surgery, Aarhus university hospital; orthopedic surgery, Aarhus University hospital
Background: Treatment of osteomyelitis is a challenge. Coverage of significant soft tissue defects after bone and soft tissue debridement with associated bony dead space was traditionally performed with free muscle flaps (M) and is still the preferred approach by many surgeons. Free fasciocutaneous flaps (FC) can provide the same degree of coverage and bulk.
Purpose / Aim of Study: The aim of this study is comparison of (M) and (FC) according to overall complication rates, donorsite morbidity, post-op mobilization, safety of procedure if later surgery is required due to recurrence of osteomyelitis and the advantage of liposuction of (FC).
Materials and Methods: A retrospective review was conducted of all free flap reconstructions after osteomyelitis debridement in the lower leg from 2004 to 2018 at Aarhus university hospital.
Findings / Results: 16 patients underwent free flap reconstruction after osteomyelitis debridement. (8 (M=Gracilis flaps) and 8 (FC=Anterolateral thigh flaps (ALT)). 15 flaps healed completely, 1 (M) flap was lost due to venous congestions. 7 (M) had minor complications, 8 (FC) with no complications. None experienced recurrence of osteomyelitis. Equal low donorsite morbidity was found in both groups according to sensibility and function. Early post-op full weight-bearing mobilization was experienced in (FC = 1 week) compared to (M = 3 weeks). The advantage of thinning with liposuction of (FC) for refinement of functional and cosmetic outcome was compared to (M).
Conclusions: Conclusion: Fasciocutaeus free faps are superior to muscle free flaps in several aspects in the use of covering defects after osteomyelitis debridement with bony dead space in lower limb reconstructions.
Magnus Petur Bjarnason Obinah, Stig Brorson, Hans Gottlieb
Dept. of Orthopaedic Surgery, Herlev University Hospital; Dept. of Orthopaedic Surgery, Zealand University Hospital, Køge; Dept. of Orthopaedic Surgery, Herlev University Hospital
Background: Chronic osteomyelitis (OM) is usually treated with surgical excision of infected bone and subsequent dead space management.
Purpose / Aim of Study: We report short-term outcome after antibiotic loaded biocomposite (ALB) for management of infected bone defects in a consecutive series of 97 patients with chronic OM treated by a multidisciplinary team at our institution.
Materials and Methods: We applied a single-stage revision protocol including surgical debridement, tissue sampling, dead-space management using ALB, stabilization and empirical antibiotic therapy adjusted based on culturing. Closure was performed directly, with a local flap, a free flap or secondarily. In 41 patients, OM followed an overlying soft- tissue infection, 30 followed surgical management of a closed fracture, 18 followed elective surgical procedures, 5 followed open fractures, 2 were spontaneous and 1 patient had previously diagnosed OM. 71 of the included patients had systemic comorbidities (Cierny-Mader Class B hosts), 38 were diabetics, 23 were active smokers, 25 had a past history of smoking, 14 abused alcohol and 9 had a previous history of alcohol abuse. Patients were followed-up by chart review for a mean of 5.8 months (0 to 25).
Findings / Results: Mean age was 66.2 years (26 to 92). 12 patients required a soft-tissue revision after a mean time of 2.2 months (0 to 12). 11 patients required bone revision after a mean time of 3.4 months (0 to 10) where the ALB was re-applied in nine cases. 6 patients required amputation after a mean time of 3.2 months (0 to 12). 2 patients died after 1 and 5 months respectively. 70 patients (73%) had no adverse advents following surgery.
Conclusions: An acceptable outcome was obtained considering a heterogeneous population with a high systemic comorbidity rate and considerable smoking and alcohol abuse.
Dept. of Orthopaedic Surgery, Herlev University Hospital; Dept. of Orthopaedic Surgery, Zealand University Hospital, Køge; Dept. of Orthopaedic Surgery, Herlev University Hospital
Background: Chronic osteomyelitis (OM) is usually treated with surgical excision of infected bone and subsequent dead space management.
Purpose / Aim of Study: We report short-term outcome after antibiotic loaded biocomposite (ALB) for management of infected bone defects in a consecutive series of 97 patients with chronic OM treated by a multidisciplinary team at our institution.
Materials and Methods: We applied a single-stage revision protocol including surgical debridement, tissue sampling, dead-space management using ALB, stabilization and empirical antibiotic therapy adjusted based on culturing. Closure was performed directly, with a local flap, a free flap or secondarily. In 41 patients, OM followed an overlying soft- tissue infection, 30 followed surgical management of a closed fracture, 18 followed elective surgical procedures, 5 followed open fractures, 2 were spontaneous and 1 patient had previously diagnosed OM. 71 of the included patients had systemic comorbidities (Cierny-Mader Class B hosts), 38 were diabetics, 23 were active smokers, 25 had a past history of smoking, 14 abused alcohol and 9 had a previous history of alcohol abuse. Patients were followed-up by chart review for a mean of 5.8 months (0 to 25).
Findings / Results: Mean age was 66.2 years (26 to 92). 12 patients required a soft-tissue revision after a mean time of 2.2 months (0 to 12). 11 patients required bone revision after a mean time of 3.4 months (0 to 10) where the ALB was re-applied in nine cases. 6 patients required amputation after a mean time of 3.2 months (0 to 12). 2 patients died after 1 and 5 months respectively. 70 patients (73%) had no adverse advents following surgery.
Conclusions: An acceptable outcome was obtained considering a heterogeneous population with a high systemic comorbidity rate and considerable smoking and alcohol abuse.
Tue Smith Jørgensen, Ylva Hellsten, Hans Gottlieb, Stig Brorson
Department of Orthopedic Surgery, Herlev Hospital; Nutrition exercise and sports, Science, University of Copenhagen; Department of Orthopedic Surgery , Herlev Hospital; Department of Orthopedic Surgery, Zealand University Hospital
Background: Diabetic foot ulcers represent a broad range of pathophysiological patterns in a heterogeneous patient population, and standardized treatment recommendations are difficult to establish. Adequate classification and documentation of diabetic foot ulcers is essential to evaluate the wound healing tendency, facilitate communication between clinicians and to help predict which ulcers are likely to heal.
Purpose / Aim of Study: Therefore, the aim of this study was to assess the interobserver agreement of a commonly used classification system for diabetic foot ulcers; the Meggitt-Wagner Classification, and to compare the agreement on classification to the agreement in treatment recommendations.
Materials and Methods: An interobserver study was conducted based on a questionnaire linked to 30 photographs of diabetic foot ulcers. Three groups of observers were tested: 1) experienced orthopedic wound care doctors (n=7), 2) nurses specialized in wound care (n=8) 3) untrained nurses assigned to a diabetic wound care training course (n=23). Krippendorff’s alpha was used for calculating interobserver agreement, and an agreement >0.6 was defined as substantial.
Findings / Results: The Krippendorffs alpha value for interobserver agreement on the Meggitt-Wagner Classification was 0.52 for the doctors. 0.67 for the specialized nurses and 0.61for the untrained nurses. The corresponding values regarding agreement on recommendation of surgical revision of the wound, were 0.35, 0.22 and 0.15.
Conclusions: The inter observer agreement on the Meggitt- Wagner classification was substantial, but the agreement on recommendation of surgical revision was not. Whether Meggitt- Wagners Classification is only applicable in a research purpose and not in a clinical setting is not possible to answer in this study.
Department of Orthopedic Surgery, Herlev Hospital; Nutrition exercise and sports, Science, University of Copenhagen; Department of Orthopedic Surgery , Herlev Hospital; Department of Orthopedic Surgery, Zealand University Hospital
Background: Diabetic foot ulcers represent a broad range of pathophysiological patterns in a heterogeneous patient population, and standardized treatment recommendations are difficult to establish. Adequate classification and documentation of diabetic foot ulcers is essential to evaluate the wound healing tendency, facilitate communication between clinicians and to help predict which ulcers are likely to heal.
Purpose / Aim of Study: Therefore, the aim of this study was to assess the interobserver agreement of a commonly used classification system for diabetic foot ulcers; the Meggitt-Wagner Classification, and to compare the agreement on classification to the agreement in treatment recommendations.
Materials and Methods: An interobserver study was conducted based on a questionnaire linked to 30 photographs of diabetic foot ulcers. Three groups of observers were tested: 1) experienced orthopedic wound care doctors (n=7), 2) nurses specialized in wound care (n=8) 3) untrained nurses assigned to a diabetic wound care training course (n=23). Krippendorff’s alpha was used for calculating interobserver agreement, and an agreement >0.6 was defined as substantial.
Findings / Results: The Krippendorffs alpha value for interobserver agreement on the Meggitt-Wagner Classification was 0.52 for the doctors. 0.67 for the specialized nurses and 0.61for the untrained nurses. The corresponding values regarding agreement on recommendation of surgical revision of the wound, were 0.35, 0.22 and 0.15.
Conclusions: The inter observer agreement on the Meggitt- Wagner classification was substantial, but the agreement on recommendation of surgical revision was not. Whether Meggitt- Wagners Classification is only applicable in a research purpose and not in a clinical setting is not possible to answer in this study.