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.

Treatment of Infected Nonunions With Bone Defects Using Autologous Bone Graft and Absorbable Antibiotic-Loaded Calcium Sulfate-Hydroxyapatite Paste.

BACKGROUND: Revision surgery in the presence of infection carries high risks. We describe our results using a new technique to treat these challenging problems. We treated infected nonunions with cavitary voids with adjuvant antibiotic loaded calcium sulfate-hydroxyapatite paste composite and autologous bone graft (ABG) layer technique coupled with stable fixation. METHODS: Thirty consecutive patients who underwent revision foot and ankle surgery for an infected nonunion were prospectively studied. Following multidisciplinary team workup, surgical debridement and biopsies were undertaken. Bone voids were measured and classified according to containment and size. ABG was mixed and layered with an adjuvant antibiotic-loaded calcium sulfate-hydroxyapatite paste followed by surgical reconstruction including arthrodesis and fixation. Empirical and pathogen-specific antibiotics were instituted until intraoperative sample-specific antibiotics were identified and used. Patients were prospectively followed up for a minimum of 1 year. RESULTS: The male-female ratio was 16:14, mean age was 51.3 years, and 23.3% smoked at definitive surgery. Void volume was <1 cm3 (n=9), 1-2 cm3 (n = 13), and >2 cm3 (n=8). No patients either were lost to follow-up or had a further infective episode at a mean of 38.3 months; 86.7% united with fusion on imaging. Four patients had radiographic evidence of nonunion; 3 were asymptomatic and 1 required revision surgery (void >2 cm3). Independent ambulation was achieved at an average of 12 weeks, at 1 year mean American Orthopaedic Foot & Ankle Society score was 77.7 (SD 9.59), and the Manchester-Oxford Foot Questionnaire reached an effect size >0.5 in all domains at 1 year following surgery. The union rate was independent of smoking status and vitamin D deficiency (P = .94). CONCLUSION: Layered autologous bone grafting with adjuvant antibiotic-loaded calcium sulfate-hydroxyapatite paste has been shown to be effective and safe in revision arthrodesis, with low comorbidities in void gaps without infection recurrence.

BILATERAL NEUROARTHROPATHY 11 YEARS AFTER SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANT FOR TYPE 1 DIABETES MELLITUS.

OBJECTIVE: To report a case of a man who developed bilateral Charcot arthropathic feet 11 years after a simultaneous pancreas-kidney transplant (SPKT) for type 1 diabetes mellitus (DM). The patient had remained normoglycemic after surgery. METHODS: We present a retrospective review of the case notes and serial imaging. RESULTS: The patient developed dense peripheral diabetic neuropathy due to poor glycemic control. His biochemical markers of DM all normalized following SPKT, and he was discharged by his primary and secondary care diabetes services. Eleven years later, he developed Charcot arthropathy in one foot and, within a month, the other foot as well. CONCLUSION: Individuals with DM who had preoperative end organ diabetes-related damage who went into biochemical remission after SPKT may be at risk for future complications. They should not be discharged from specialist diabetes services, and they need continued education about foot care.

A rare anatomical variant: transosseous supraclavicular nerve identified during clavicle fracture fixation.

We describe a rare case of an anatomical variant of the supraclavicular nerve in the intra-operative setting of clavicle fixation for a fracture. Intra-operatively it was noted that one of the supraclavicular nerves was passing through a foramen in the clavicle shaft. A 60-year-old gentleman presented with a displaced multifragmentary fracture of the left clavicle after a fall. Plate fixation with a pre-contoured locking plate was performed under general anaesthesia. The clavicle was exposed through an infraclavicular transverse incision. It was necessary to divide this transosseous nerve branch to permit appropriate plate positioning. Post-operatively the patient was left with some incisional chest numbness. Surgeons should aim to preserve the branches of the supraclavicular nerve although this may not always be possible as we have demonstrated. The patient should be warned about potential deficit.

Retrograde nailing for distal femur fractures in the elderly.

INTRODUCTION: We report the results of treating a series of 56 fractures in 54 elderly patients with a distal femur fracture with a retrograde femoral nail. METHODS: Fifty-four of the nails were inserted percutaneously with a closed reduction. After surgery all patients were allowed to weight bear as tolerated. Four fractures were supported in a temporary external splint. RESULTS: The mean age of patients was 80.6 years (range 51-103 years), 52/54 (96%) were females. There were no cases of nail related complications and no re-operations were required. One patient was lost to follow up. The 30-day mortality was 5/54 (9.3%) and the one year mortality was 17/54 (31.5%). CONCLUSIONS: Distal femoral nail fixation provides a good method of fixation allowing immediate mobilisation for this group of patients.

Impact of intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.

BACKGROUND: There is emerging evidence indicating that distractions in the operating room (OR) are prevalent. Studies have shown a negative impact of distractions, but they have been conducted mostly with residents in simulated environments. We tested the hypothesis that intraoperative distractions are associated with deterioration in patient safety checks in the OR. METHODS: We assessed 24 elective urologic procedures. Blinded trained assessors (two surgeons, one psychologist) used validated instruments to prospectively assess in vivo frequency and severity of distractions (related to communication, phones/pagers, equipment/provisions, OR environment, other hospital departments, or a member of the OR team) and completion of safety-related tasks (related to the patient, equipment, and communication). Descriptive and correlational analyses were conducted. RESULTS: Mean case duration was 70 min (mean intraoperative time 31 min). A mean of 4.0 communication distractions (range 0-9) and 2.48 other distractions (range 0-5) were recorded per case (distraction rate of one per 10 min). Distractions from external visitors (addressed to the entire team or the surgeon) and distractions due to lack of coordination between hospital departments were most disruptive. Regarding safety checks, patient tasks were completed most often (85-100 %) followed by equipment tasks (75-100 %) and communication tasks (55-90 %). Correlational analyses showed that more frequent/severe communication distractions were linked to lower completion of patient checks intraoperatively (median rho -0.56, p < 0.05). CONCLUSIONS: Distractions are prevalent in ORs and in this study were linked to deterioration in intraoperative patient safety checks. Surgeons should be mindful of their tolerance to distractions. Surgical leadership can help control distractions and reduce their potential impact on patient safety and performance.