Surgical treatment for infected long bone defects after limb-threatening trauma: application of locked plate and autogenous cancellous bone graft

Background: Treatment strategies for bone defects include free bone grafting, distraction osteogenesis, and vascularized bone grafting. Because bone defect morphology is often irregular, selecting treatment strategies may be difficult. With the Masquelet technique, a fracture site is bridged and fixed with a locking plate after treating deep infection with antibiotic-containing cement, and a free cancellous bone-graft is concomitantly placed into the defects. This procedure avoids excessive bone resection. Methods: We studied 6 patients who underwent surgical treatment for deep infection occurring after extremity trauma (2004 through 2009). Ages at surgery ranged from 29 to 59 years (largest age group: 30 s). Mean follow-up was 50.7 months (minimum/maximum: 36/72 months). One patient had complete amputation of the upper extremity, 3 open forearm fractures, 1 closed supracondylar femur fracture, and 1 open tibia fracture. In all patients, bone defects were filled with antibiotic-containing cement beads after infected site debridement. If bacterial culture of infected sites during curettage was positive, surgery was repeated to refill bone defects with antibiotic-containing cement beads. After confirmation of negative bacterial culture, osteosynthesis was performed, in which bone defects were bridged and fixed with locking plates. Concomitantly, crushed cancellous bone grafts harvested from the autogenous ilium was placed in the bone defects. Results: Time from bone grafting and plate fixation to bone union was at least 3 and at most 6 months, 4 months on average. Infection relapsed in one patient with methicillin-resistant Staphylococcus aureus, necessitating vascularized fibular grafting which achieved bone union. No patients showed implant loosening or breakage or infection relapse after the last surgery during follow-up. Conclusion: The advantage of cancellous bone grafting include applicability to relatively large bone defects, simple surgical procedure, bone graft adjustability to bone defect morphology, rapid bone graft revascularization resulting in high resistance to infection, and excellent osteogenesis

Long-term follow-up of free vascularized fibular head graft for reconstruction of the proximal humerus after wide resection for bone sarcoma

Purpose: This study investigated the shape of bone grafts and associations with upper limb function over the long term after free vascularized fibular head graft (FVFHG) for reconstruction of the proximal humerus after wide resection for bone sarcoma. Methods: Patients comprised 3 women who had undergone FVFHG at least 5 years previously. Age at surgery was 12 years in 2 cases and 76 years in one. The mean follow-up periods were 10 years 4 months. Evaluated parameters comprised: 1) graft hypertrophy, and 2) shape of the fibular head as changes in shape of the bone graft; and 3) ISOLS score, and 4) DASH score as indicators of upper limb function. Results: Rates of graft hypertrophy of the fibular shaft were -14%, -17%, and -20%, respectively, with transverse diameter decreasing in all cases. In terms of changes in shape of the grafted fibular head, transverse diameter had diminished in 2 patients (-5 mm and -2 mm), and the head had been completely resorbed in the remaining patient. Both patients in whom the fibular head remained were young, and both had good ISOLS scores >80% and good DASH scores of 5.0 and 8.3. The patient in whom the fibular head had been resorbed was elderly, with ISOLS and DASH scores of 73.3% and 34.2, respectively; comparatively poor compared with the other two. A comparison of ISOLS and DASH scores before and after fibular head resorption, however, showed no deterioration in either score. Conclusions: Long-term follow-up of humerus reconstruction by FVFHG showed no deterioration in upper limb function despite the risk of fibular head resorption. FVFHG of the proximal humerus is a reconstruction technique that can provide good long-term upper limb function

Short-term results of endoscopic (okutsu method) versus palmar incision open carpal tunnel release: a prospective randomized controlled trial

Purpose:The surgical techniques widely used in Japan for idiopathic carpal tunnel syndrome (CTS) are the Okutsu method of endoscopic carpal tunnel release (ECTR) and palmar incision for open carpal tunnel release (OCTR). However, no prospective randomized controlled trials (RCTs) have compared treatment outcomes between these two procedures. This RCT compared short-term outcomes between ECTR and OCTR for CTS. Materials and Methods:Subjects were 101 hands (79 patients) treated in the department. ECTR was performed on 51 hands (40 patients), and OCTR was performed on 50 hands (39 patients). For assessment items, the following patient-based outcomes were evaluated: 1) changes in subjective symptoms; and 2) impairment in activities of daily living. The following items were also evaluated by physicians: 3) abductor pollicis brevis-distal latency (APB-DL); 4) sensation; and 5) muscle strength. All these assessments were made in postoperative weeks 4 and 12. Results: Recovery of muscle strength at postoperative week 4 was significantly better with ECTR (p< 0.05), but no significant differences were identified between groups in any of the other items. The ECTR group showed transient postoperative exacerbation of subjective symptoms in two hands (4%) and of APB-DL in three hands (6%). Comparison of hands with improved and exacerbated postoperative APB-DL in the ECTR group revealed significantly greater preoperative electrophysiological severity in exacerbated hands (p< 0.05). The cause of postoperative exacerbation with ECTR was considered to be transient nerve dysfunction resulting from the unique aspects of the ECTR procedure. Conclusions: Compared with OCTR, ECTR offers superior recovery of muscle strength in the early postoperative period. At the same time, ECTR may carry a risk of transient nerve dysfunction in the early postoperative period. Caution must therefore be exercised when using ECTR for patients with severe electrophysiological findings

Surgical treatment options for septic non-union of the tibia: two staged operation, Flow-through anastomosis of FVFG, and continuous local intraarterial infusion of heparin

Background : The treatment of septic non-union of the tibia is a challenging area. The objective of this clinical study was to improve the treatment outcomes in patients with a highly active infection by the three strategies consisting of a two-staged operation, a flow-through technique for vascular anastomosis of a free vascularized fibular graft (FVFG), and continuous local intra-arterial infusion of heparin. Patients & Method : Five patients with septic non-union of the tibia who were treated with an FVFG (mean age: 52.8 years) were enrolled. The mean postoperative follow-up period was 47.2 months, and the mean length of the bone defect was 111 mm. A two-staged operation, in which polymethylmethacrylate (PMMA) beads containing antibiotics were inserted into a bone defect followed by bone reconstruction performed with an FVFG later. Vascular anastomosis was performed with the flow-through technique in all patients. Immediately after FVFG, heparin was continuously infused through a femoral arterial catheter for 1 week. Result : Bone union was confirmed an average of 18.8 weeks after-surgery in all patients without reoperation for thrombus. Conclusion : Our attempt to apply the strategies appears to be a viable treatment option for septic non-union of the tibia