Surgical management of chronic osteomyelitis:Organisms,recurrence and treatment outcome

Purpose:The study aimed to identify the risk factors of recurrence in chronic osteomyelitis(COM)and to document the microbiological patterns pre-and intra-operatively and at recurrence,if any.Methods:We performed retrospective review on COM patients treated with surgical debridement and a 6-week course of antibiotics.The patients with symptoms of osteomyelitis for at least 6 weeks,present or past episodes of discharging sinus,documentation of bone sequestration in operative notes or preop-erative images were included in the study.Patients with symptoms of osteomyelitis<6 weeks,lack of history of discharging sinus or lack of evidence of sequestration in preoperative images or intraoperative notes were excluded.Logistic regression models were used to assess the impact of risk factors of recurrence.Cohen-Kappa scores were derived to see the concordance between pre-operative and intra-operative isolates and at recurrence.Results:Totally,147 COM patients(115 males and 32 females,mean age(33±19)years)were included in this study.Recurrence was noted in 28 patients(19.0%).Polymicrobial growth and extended spectrum beta-lactamase producing Enterobacteriaceae increased the chance of recurrence.Cierny-Mader stage-1,hematogenous aetiology and negative intraoperative culture reduced the chance of recurrence.Concordance between pre-operative and intra-operative cultures was 59.85%(Kappa score 0.526,p<0.001)and between index surgery and at recurrence was 23.81%(Kappa score 0.155,p<0.001).Lack of knowledge of causative organism preoperatively did not affect outcome.At mean follow-up(42±15)months,all patients were apparently infection free for at least 1 year.Conclusion:Polymicrobial growth and multi-drug resistant organisms increase the risk of recurrence in COM.Patients'age,gender,diabetes mellitus,previous failed treatment,duration of symptoms,hae-moglobin,white cell count,C-reactive protein and erythrocyte sedimentation rate at presentation did not have any impact on the recurrence of infection.Pre-operative isolation of organism is of questionable value.Recurrences of infections do occur and are more of re-infections than relapses.Diligent isolation of organism must be attempted even in re-debridements.Even patients with recurrences do well with appropriate debridement and antibiotic therapy.

Outcome of complex tibial plateau fractures with Ilizarov external fixation with or without minimal internal fixation

Purpose: To evaluate the clinico-radiological outcome of complex tibial plateau fractures treated with Ilizarov external fixation with or without minimal internal fixation. Methods: This retrospective review was conducted on all the cases of Schatzker types V and VI tibial plateau fractures treated by Ilizarov external fixation between July 2006 and December 2015 with the minimum follow-up duration of one year. There were 30 patients: 24 males and 6 females, mean age 43.33 years, and mean follow-up 3.6 years. Three of them were open fractures;15 cases were Schatzkertype V fractures and the other 15 type VI. According to AO/OTA classification, there were 11 type C1, 12 C2 and 7 type C3 fractures. Outcome assessment was made with American Knee Society Score (AKSS) and Rasmussen's Radiological Score (RRS) at final follow-up. Results: Out of the 30 cases, mini-open reduction was performed in 7, bone graft in 4, minimal internal fixation in 10 and knee temporary immobilisation in 11 patients. Mean duration of external fixation was 11.8 weeks. All fractures united. Pin tract infections in 7 and common peroneal neuropathy in 2 patients were self-limiting. Two patients had axial misalignment of less than 10°. At final follow-up, the mean knee range of motion was 114.7, mean AKSS 81.5 and mean RRS 16.7. On statistical analysis, Schatzker type of fractures, use of minimal internal fixation and knee-spanning did not influence the final outcome. Conclusion: Ilizarov external fixator with or without minimal internal fixation provides acceptable outcome for complex tibial plateau fractures. Care must be taken to look for minor loss of alignment, especially in Type VI Schatzker fractures after removal of the fixator. However small sample size precludes firm conclusions.