Tuberculous arthritis of native joints - a systematic review and European Bone and Joint Infection Society workgroup report.

Introduction: The aim of this systematic review was to assess the existing published data on the diagnosis and management of tuberculosis (TB) arthritis involving native joints in adults aged 18 years and older. Methods: This study was performed in accordance with the guidelines provided in the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). Results: The systematic review of the literature yielded 20 data sources involving 573 patients from nine countries. There was considerable variation amongst the studies in terms of the approach to diagnosis and management. The diagnosis was mostly made by microbiological tissue culture. Medical management involved a median of 12 months of anti-tubercular treatment (interquartile range, IQR, of 8-16; range of 4-18 months). The duration of preoperative treatment ranged from 2 to 12 weeks. Surgery was performed on 87 % of patients and varied from arthroscopic debridement to complete synovectomies combined with total joint arthroplasty. The mean follow-up time of all studies was 26 months (range of 3-112 months). Recurrence rates were reported in most studies, with an overall average recurrence rate of approximately 7.4 % (35 of 475 cases). Conclusions: The current literature on TB arthritis highlights the need for the establishment of standardized guidelines for the confirmation of the diagnosis. Further research is needed to define the optimal approach to medical and surgical treatment. The role of early debridement in active TB arthritis needs to be explored further. Specifically, comparative studies are required to address questions around the use of medical treatment alone vs. in combination with surgical intervention.

Guideline for management of septic arthritis in native joints (SANJO).

This clinical guideline is intended for use by orthopedic surgeons and physicians who care for patients with possible or documented septic arthritis of a native joint (SANJO). It includes evidence and opinion-based recommendations for the diagnosis and management of patients with SANJO.

Second Ray Amputation in Diabetic Foot - Functionally Better than Proximal Foot Amputations, but Beware of Charcot Arthropathy: A Case Report and Review of Literature.

Introduction: Lower limb amputations secondary to diabetic foot infection/osteomyelitis (OM) are the most common cause for non-traumatic amputations of the lower extremity. Hind/midfoot amputations are commonly done for metatarsal (MT) OM. They are, however, associated with higher complication and revision rates and often lead to below knee amputation. In comparison, distal/forefoot toe disarticulation/ray amputation (R amp) have lesser revision rates/complications and give better functional outcome. Here, we report a case of 2nd R amp with an uncommon complication. Case Report: A 42-year-old male with uncontrolled diabetes and bilateral diabetic neuropathy presented with discharging sinus over plantar aspect of the left foot since 1 week. There was no evidence of underlying OM on MRI. Wound healed with soft-tissue debridement and empirical antibiotics (culture negative) for 2 weeks. Re-debridement was done for a wound gape 6 weeks later. Infection resolved with targeted antibiotics (oral ciprofloxacin and doxycycline) for Enterobacter cloacae given for 1 month. Six months later, he developed pain and swelling in the left foot following prolonged barefoot walking and possible injury with a stone. There was local redness, swelling, and a plantar sinus. MRI revealed septic arthritis of the left 2nd metatarsophalangeal (MTP) joint, OM of the 2nd MT head, and an encapsulated soft-tissue abscess. Aggressive debridement with 2nd R amp and careful separation of encapsulated abscess was done leaving behind base of 2nd MT to maintain stability of the Lisfranc joint. Wound healed primarily. Targeted antibiotics for Methicillin Susceptible Staphylococcus aureus were given for 6 weeks. Good diabetic control and avoiding bare foot walking were advised and he is infection free, fully functional, and asymptomatic at 36 months. However, he was noted to have developed valgus deformity of the midfoot secondary to Charcot osteoarthropathy of the Lisfranc joints at 36 months follow-up, involving 1st, 3rd, and 4th TMT joints. The other foot did not show any evidence of Charcot arthropathy. Conclusion: Recurrent wound infections with subsequent OM are a common feature of diabetic foot. R amps have better functional outcomes with preserved foot stability, shorter length of hospitalization, and associated costs as compared to hind/midfoot amputations. They may, however, develop Charcot osteoarthropathy due to the void between adjoining MTs resulting in altered forces across the Lisfranc joints. Surgeons must beware of this complication, especially following R amps and monitor these patients with serial clinical and radiographic examination.

Salvaging lives in carbapenem-resistant Gram-negative osteoarticular and soft tissue infections: early compromises save lives.

PURPOSE: Incidence of carbapenem-resistant Gram-negative infections has risen alarmingly all across the globe, both in developed and developing countries alike. The purpose of this study was to assess whether challenges of life-threatening infections with very high resistance pattern can be successfully addressed by a modified approach. METHODS: This is a retrospective study of 26 patients with osteoarticular and soft tissue infections with carbapenem-resistant Gram-negative bacilli treated between 2001 and 2017 with at least two year follow-up after stopping antibiotics. All were treated by a multispecialty team approach with primary aim of "source control at the earliest and avoiding recurrence at all cost". The protocol involved opting for early compromises especially in at "risk individuals", such as resorting to early amputations, especially if salvage meant multiple bony and soft tissue reconstructive procedures, explanation of prosthesis than staged revision, avoiding internal fixations, opting for shortest possible time in external fixators with reshaping and telescoping bone ends to get bony stability and increase surface area even if it meant compromising length. RESULTS: There were five amputations, two excision arthroplasty of hip, many minor but acceptable malunions and shortening. However, lives of 24/26 patients could be salvaged, much better than most of the published data. The two patients who died had peri-prosthetic joint infection after total hip arthroplasty and presented very late in sepsis and died within days of explantation. Infection remission could be achieved in remaining patients. CONCLUSION: These "risk to life" cases can be successfully treated by lowering the aims and expectations from "excellent function to salvage of life and infection remission". Therein lies the "success" in these complex high-risk cases.

Rare Case of Non-tuberculous Mycobacterial Infection following Repair of Pectoralis Major Avulsion: Case Report and Review of Literature.

Introduction: Non-tuberculous mycobacteria (NTM) infections of the musculoskeletal system are commonly missed due to their rarity and the absence of systemic symptoms. Here, we present a rare case of NTM infection following repair of an avulsed pectoralis major tendon in an immunocompetent host managed by a multi-disciplinary team specializing in musculoskeletal infections. Case Report: A 23-year-old male patient presented with discharging sinus in the right axilla for 6 months. He sustained the right pectoralis major muscle avulsion following an accident which was surgically repaired using FiberWire® and endo buttons. He developed a discharging sinus 4-month post-surgery. He presented with persistent infection in spite of empirical antibiotics elsewhere. Radiographs and MRI sonogram showed intra-medullar endo buttons in the proximal humerus with marginal pus collection in the axillary region with minimal medial extension into pectoralis major and minor muscles along the superior aspect. A detailed plan was made with inputs from a multidisciplinary bone infection team. Wound was radically debrided, implants and sutures removed, humerus scraped, and tissues sent for microbiology and histopathology. Extended incubation of deep tissue culture as suggested by ID specialists grew Rapidly growing mycobacteria, a type of NTM 3 weeks after surgery. Patient was started on intravenous amikacin along with oral clarithromycin and linezolid based on antibiotic susceptibility. Wound discharge persisted for almost 5-week post-surgery and stopped 2 weeks after initiation of appropriate antibiotics. Amikacin was given for 1 month and oral antibiotics were continued for 6 months. The pectoralis major function was unaffected after surgery and patient returned to normal activities 3 months after debridement. Patient has an infection free follow-up of 4 years. Conclusion: This case outlines the importance of having a high degree of suspicion for the diagnosing orthopedic NTM infections. In addition, it showcases the advantages of having good communication between surgeons, infectious disease specialist, and microbiologist for achieving good functional outcomes.

Hierarchical Machine Learning for High-Fidelity 3D Printed Biopolymers.

A hierarchical machine learning (HML) framework is presented that uses a small dataset to learn and predict the dominant build parameters necessary to print high-fidelity 3D features of alginate hydrogels. We examine the 3D printing of soft hydrogel forms printed with the freeform reversible embedding of suspended hydrogel method based on a CAD file that isolated the single-strand diameter and shape fidelity of printed alginate. Combinations of system variables ranging from print speed, flow rate, ink concentration to nozzle diameter were systematically varied to generate a small dataset of 48 prints. Prints were imaged and scored according to their dimensional similarity to the CAD file, and high print fidelity was defined as prints with less than 10% error from the CAD file. As a part of the HML framework, statistical inference was performed, using the least absolute shrinkage and selection operator to find the dominant variables that drive the error in the final prints. Model fit between the system parameters and print score was elucidated and improved by a parameterized middle layer of variable relationships which showed good performance between the predicted and observed data (R2 = 0.643). Optimization allowed for the prediction of build parameters that gave rise to high-fidelity prints of the measured features. A trade-off was identified when optimizing for the fidelity of different features printed within the same construct, showing the need for complex predictive design tools. A combination of known and discovered relationships was used to generate process maps for the 3D bioprinting designer that show error minimums based on the chosen input variables. Our approach offers a promising pathway toward scaling 3D bioprinting by optimizing print fidelity via learned build parameters that reduce the need for iterative testing.

Analgesic effectiveness of Local Infiltrative Analgesia alone versus combined single dose adductor canal block with Local Infiltrative Analgesia: A single centre case control study.

BACKGROUND: Both adductor canal block (ACB) and of Local Infiltrative Analgesia (LIA) have been shown to reduce pain after total knee arthroplasty (TKA). The efficacy of combining ACB and LIA remains controversial. The objective of this study is to analyse the effect of LIA + single dose ACB compared to LIA alone on early post-operative pain and mobilization in TKA. METHODS: This Cohort Prospective study analyses the Visual Analogue Score (VAS) pain scores and rehabilitation milestones at 24 h between LIA alone and LIA + single dose ACB in unilateral TKA operated by a single surgeon between August 2014 and February 2019. RESULTS: VAS at rest and on movement were significantly better in the combined LIA + ACB group (n = 151) compared to LIA (n = 120) alone at 24 h. All patients were able to achieve the desired milestones of sitting, standing by the bedside and walking with the help of a walker within 24 h of the surgery. CONCLUSION: Though the VAS scores were statistically significant, the actual scores at rest and on movement in both groups were significantly better than preoperative scores with excellent pain relief. All patients in both groups were able to ambulate within 24 h. LIA alone significantly improved the pain scores and enabled early mobilization. Addition of single dose ACB to LIA did not significantly alter the milestones.

Fungal osteomyelitis and soft tissue infections: Simple solutions to uncommon scenarios.

INTRODUCTION: Fungal osteoarticular/soft tissue infections (FOaSI) are an uncommon entity with protracted course due to variability in clinical picture, slow progression; resulting in misdiagnosis with empirical therapy. Recent studies have shown an alarming emergence of FOaSI in immunocompetent individuals with high mortality rates. This study recommends a protocol for managing these complex and confusing scenarios. METHODOLOGY: We have retrospectively analysed patients with FOaSI between January 2014 and December 2016, with a minimum 12 months follow up. RESULTS: 8 cases (6 male, 2 female) with a mean age of 42.88 years (26-53) presented to us 45 days (3-365) after initial symptoms. They underwent mean 3 procedures before being diagnosed with a fungal infection. Deep tissue cultures grew 9 fungi and 6 bacteria, commonest fungus being Candida sp (n = 4), treated with appropriate antifungals and antibiotics. Infection remission was achieved in 7/8 (87.5%) cases at 27.1 months (19-45) follow-up with 1 mortality. Excellent functional results as per our criteria were seen in 5 cases (62.5%) with 1 talus excision, 1 ray amputation and 1 mortality. CONCLUSIONS: This study highlights the significance of implementing a simple rule such as obtaining fungal cultures in every case of bone and soft tissue infections. Standardisation of treatment may not be the ideal solution, since different fungi have different growth patterns and invasiveness. A simple protocol of customising the medico- surgical treatment with an open ended discussion between the surgeons, microbiologists, pathologists and infectious disease specialists forms the cornerstone to success.

Diagnosis and Management of Osteoarticular Tuberculosis: A Drastic Change in Mind Set Needed-It is Not Enough to Simply Diagnose TB.

BACKGROUND: In the era of increasing drug resistance in pulmonary tuberculosis (TB), it is prudent to assess causes of poor response to anti tubercular therapy (ATT) and drug sensitivity pattern (DSP) in osteoarticular TB. MATERIALS AND METHODS: As a part of Bombay Orthopaedic society's research project, members were asked to refer non responders to ATT to our institute. Cases were enrolled from October 2010 to March 2014. Deep tissue samples were obtained in all but five cases and subjected to a battery of tests including histopathology (HPE) and TB culture and sensitivity. The DSP was compared with the study performed by the principle author from 2004 to 2007 and published in 2009. RESULTS: 39 male and 50 female patients with a mean age of 24.85 years (2-66) were included and classified in four groups after results. (1) Culture and HPE positive-36. 24 had MDR and three XDR TB. Primary resistance to even second line drugs and deterioration of DSP since last study was noted, (2) culture negative and HPE positive-21. The cause of poor response was surgical in more than half cases, (3) non representative samples or lost to follow-up-15, (4) TB mimics-16. CONCLUSION: There is increasing incidence of primary resistance to second line drugs, primary resistance in children and worsening of resistance patterns as compared to older studies. ATT initiation is a fateful decision and every attempt should be made to rule out TB mimics and establish DSP before initiation.

Safety and efficacy of sequential simultaneous bilateral total knee arthroplasty: A single centre retrospective cohort study.

BACKGROUND: Simultaneous bilateral total knee arthroplasty (TKA) is a promising option for patients with bilateral arthritis of the knee because of the requirement of a single hospitalization and anesthetic regimen, reduced overall hospital stay, lower overall costs, and quicker recovery compared to staged bilateral TKA. However, there are conflicting reports on the safety of the procedure, with little data available in the Indian setting. Herein, we compared the efficacy and safety of sequential simultaneous bilateral TKA (SSBTKA) with those of unilateral TKA (UTKA). METHODS: This retrospective analysis included cases of SSBTKA (n = 380, 760 knees) and UTKA (n = 754) performed by the same surgeon and followed up for a minimum duration of 1 year. The functional outcomes (postoperative changes in Oxford Knee Score [OKS] and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), length of hospital stay (LOS), complications, and rates of revision and mortality were compared between the two groups. RESULTS: The mean follow-up durations were 40.59 and 36.69 months for the UTKA and SSBTKA groups, respectively. The LOS was significantly longer in the SSBTKA group than in the UTKA group (Median [Interquartile range]: 4[1] vs. 3[0], p < 0.001). The OKS and WOMAC scores increased with time in both groups. The improvements in each of these scores at 3, 6, and 12 months postoperatively were either statistically similar between the two groups or, if statistically different, the differences were too small to be clinically meaningful. Blood transfusions (4% [SSBTKA] vs.0.3% [UTKA], p < 0.001), cardiac complications (1.6% vs. 0.4%, p = 0.034), urine retention (3.7% vs. 1.2%, p = 0.005), and deep infection (0.8% vs. 0%, p = 0.015) were significantly more frequent in the SSBTKA group. None of the patients in the UTKA group had to undergo revision surgery, whereas in the SSBTKA group, 2 (0.6%) patients underwent revision TKA. The overall mortality rates were low in both groups (0.8% [SSBTKA] and 0.3% [UTKA]), with no significant between-group difference (p = 0.209). CONCLUSION: The functional outcomes and mortality rates associated with SSBTKA are comparable to those associated with UTKA. The risk of complications and the need for revision, although higher with SSBTKA, the actual numbers are low enough to justify its use. Although the LOS in SSBTKA is longer than that in UTKA, it is likely to be shorter than the cumulative LOS for two UTKA procedures (i.e. a staged bilateral TKA). Thus, SSBTKA appears to be a safe and effective choice for appropriately selected patients.

Twisted Plating - A Method of Distal Fibula Fixation.

Objective The literature entails various intramedullary and extramedullary methods for distal fibula fracture fixation; with no consensus yet over the ideal method of fixation. We have retrospectively analyzed the results of using a twisted and contoured 3.5 mm locking compression plate (LCP) as a posterior buttress plate. Methods Of the 62 cases with ankle fractures managed at our institute by the senior author from 1 st January 2012 to 31 st December 2015, 41 patients met our inclusion criteria (Danis-Weber types B and C). Results All 41 distal fibular fractures healed uneventfully, at a mean of 10.4 weeks (8-14 weeks) (Figs. 6, 7, 8 to 9) with no complications. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 92.6 (86-100) at a mean follow-up of 31.5 months (14-61 months). Conclusions We have achieved excellent clinical and radiological outcomes using a twisted 3.5 mm LCP as a posterior buttress by combining the advantages of posterior antiglide plating and lateral LCP.

Decreasing hospital length of stay and enhancing recovery in Total Knee Arthroplasty.

BACKGROUND: Patients undergoing Total Knee Arthroplasty (TKA) typically have early postoperative pain and decreased mobility, especially so in the first 24 h. Achieving a pain free knee in the immediate postoperative period and reducing complications using multimodal pain and blood management protocols forms a keystone in early mobilization and functional recovery. Enhanced Recovery after Surgery pathways (ERASp) since their inception, have significantly improved perioperative care and functional outcomes, thereby reducing the average length of stay (ALOS), complications and overall healthcare costs. ERASp modified suitably for TKA have had encouraging results. We have retrospectively analyzed the outcomes of the ERASp for TKA at our tertiary care centre with equal emphasis on pre-hospital preparations, in-hospital care, and post-hospital discharge. METHODS: All TKA patients operated by the senior author between July 2016 and January 2018 with a minimum one year follow up were included. The outcomes measured were: Visual Analogue Score (VAS) for pain at rest and on movement, milestones, transfusion requirements, postoperative complications, ALOS and functional scores at one year follow-up. RESULTS: 775 patients (392 unilateral TKA {UTKA} and 383 bilateral {BTKA}) met our inclusion criteria. Both groups were comparable demographically. Mean VAS pain scores at rest were 3.15 ±â€¯2.15 on the day of surgery, 2.5 ±â€¯1.86 on the first postoperative day and 2.08 ±â€¯1.81 on the second day, and 6.2 ±â€¯2.38, 5.77 ±â€¯2.34 and 4.71 ±â€¯2.48 on movement respectively in the UTKA group. In the BTKA group, the mean VAS pain scores at rest were 4.39 ±â€¯2.25 on the day of surgery, 3.98 ±â€¯2.36 on the first postoperative day and 3.05 ±â€¯2.12 on the second day and 6.21 ±â€¯2.38, 5.77 ±â€¯2.34 and 4.71 ±â€¯2.48 on movement respectively. 85.49% of UTKA and 77.22% of BTKA patients walked on the day of surgery. Decrease in haemoglobin and transfusion rates were 1.25 ±â€¯0.41 g% and 0.5%, 1.85 ±â€¯0.62 and 3.9% in the UTKA and BTKA groups respectively.The average length of hospital stay (LOS) was 3.98 days. LOS was 3.17 and 4.78 days with 1.55% and 6.05% major complications in the UTKA and BTKA groups respectively.There was a significant improvement in Oxford Knee and WOMAC scores at 3, 6 and 12 months in both groups. CONCLUSIONS: Pain following TKA is a major deterrent in early mobilization thereby delaying functional recovery and increasing ALOS. We recommend our multimodal interdisciplinary protocol to achieve early mobilization, better pain scores and minimize complications, resulting in overall reduced LOS.

Advantages of clamping and drainage over continuous drainage in a total knee arthroplasty.

INTRODUCTION: The use of closed-suction drainage systems after total knee arthroplasty (TKA) is common practice in India, but with no consensus on its use. In this retrospective study, we compared whether clamped or unclamped drainage has any advantages over the other in unilateral TKA. METHODS: Group-A (n = 351) had an unclamped drain removed at 24 h postoperative, with measurement of total drainage at 24 h between January 2011 and February 2013. Group B (n = 349) had drains kept for a total of 8 h-clamped for the first 4 h and unclamped for a further 4, between March 2013 to September 2016. Drainage volume, as well as the hemodynamic markers-hemoglobin (Hb) drop, transfusion rate were evaluated. RESULTS: Mean drain output in Group- A was significantly higher than Group- B (215.64 ml versus 28.34 ml). The postoperative Hb was significantly higher in Group-B (11.46 g/dl versus 10.57 g/dl). Mean Hb drop was significantly higher in Group A (2.16  g/dl versus 1.18 g/dl). The transfusion rates were lower in Group-B, though not statistically significant. CONCLUSIONS: The 4- hour clamping method effectively reduces drain output and fall in hemoglobin. For those who continue using closed suction drains, clamping could prove to be an effective way of reducing post-operative blood loss and the need for transfusions.

Twisted Plating - A Method of Distal Fibula Fixation / Uso de placa retorcida - Um método de fixação da fíbula distal

Abstract Objective The literature entails various intramedullary and extramedullary methods for distal fibula fracture fixation; with no consensus yet over the ideal method of fixation. We have retrospectively analyzed the results of using a twisted and contoured 3.5 mm locking compression plate (LCP) as a posterior buttress plate. Methods Of the 62 cases with ankle fractures managed at our institute by the senior author from 1st January 2012 to 31st December 2015, 41 patients met our inclusion criteria (Danis-Weber types B and C). Results All 41 distal fibular fractures healed uneventfully, at a mean of 10.4 weeks (8-14 weeks) (Figs. 6, 7, 8 to 9) with no complications. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 92.6 (86-100) at a mean follow-up of 31.5 months (14-61 months). Conclusions We have achieved excellent clinical and radiological outcomes using a twisted 3.5 mm LCP as a posterior buttress by combining the advantages of posterior antiglide plating and lateral LCP.

Resumo Objetivo A literatura discute diversos métodos intramedulares ou extramedulares para fixação de fraturas da fíbula distal, mas não há consenso acerca do método ideal de fixação. Analisamos retrospectivamente os resultados do uso de uma placa bloqueada de compressão (LCP) de 3,5 mm retorcida e com contorno como placa de apoio posterior. Métodos Dos 62 casos de fraturas de tornozelo tratadas em nosso instituto pelo autor sênior entre 1° de janeiro de 2012 e 31 de dezembro de 2015, 41 pacientes atenderam aos critérios de inclusão (tipos B e C de Danis-Weber). Resultados Todas as 41 fraturas fibulares distais cicatrizaram sem intercorrências, em uma média de 10,4 semanas (8-14 semanas) (Figuras 6 a 9) e sem complicações. A pontuação American Orthopaedic Foot & Ankle Society (AOFAS) média foi de 92,6 (86-100) em um período médio de acompanhamento de 31,5 meses (14-61 meses). Conclusões Obtivemos excelentes resultados clínicos e radiológicos com uso de LCP retorcida de 3,5 mm como apoio posterior ao combinar as vantagens da placa antideslizante posterior e a LCP lateral.

Multidimensional management of a vascular injury following total knee arthroplasty: A rare case report.

Acute vascular injury during total knee arthroplasty (TKA) is an extremely rare complication, but one which can have devastating consequences threatening the limb and/or life of the patient if not diagnosed and managed at the earliest. The clinical presentation can vary from acute haemorrhage or ischemia in the peri operative period; to a delayed presentation of recurrent swelling and pain secondary to a geniculate or popliteal artery pseudoaneurysm. This is the first reported case of an acute inferolateral genicular artery haemorrhage following TKA and the associated medical complications. It was successfully managed with emergency percutaneous endovascular coiling and appropriate medical management. This case highlights that clinical suspicion, prompt diagnosis and urgent intervention with a multidisciplinary approach can help successfully manage a vascular insult.

Reduction of Gamma Radiation-Induced Damage by Hydro-Alcoholic Extract of Nardostachys jatamansi.

The search for a nontoxic radioprotector has not yielded any promising results. Many antioxidant compounds, though effective under in vitro conditions as radioprotectors, have failed under in vivo settings due to their toxicity. The Indian medical system of Ayurveda uses a variety of plants with antioxidant potential, and these may be harboring molecules with radioprotective properties. In the present work, the radioprotective property of Nardostachys jatamansi was investigated. A hydro-alcoholic extract of this plant provided protection to the cellular DNA and membrane from 4 Gy gamma radiation. Depletion of cellular antioxidant status was also prevented by this extract. Molecular-level analysis in the intestines of mice revealed a lower bax/bcl2 ratio suggestive of a reduction of radiation-induced apoptosis. Expression levels of the DNA repair gene atm were elevated, along with a reduction in the expression of the inflammatory gene cox2. The extract also provided a survival advantage to mice exposed to lethal doses of gamma radiation. These results suggest a possible radioprotective role for Nardostachys jatamansi.

Radiation-Induced Wound Infections in Operated Soft Tissue Sarcomas: An Unbelievable Challenge in a Series of Five Cases.

INTRODUCTION: The standard modality for the treatment of soft tissue sarcomas is a wide excision followed by radiation therapy either in the form of external beam radiation or brachytherapy. Radiation therapy thus is an integral part of management and limb salvage in these cases. This, however, subjects the irradiated tissue to a greater risk for necrosis and local infection. This study suggests a protocol to manage these infections. A multimodal approach to these problems is important. Studies have shown that the use of negative pressure wound therapy (NPWT) in non-healing wounds significantly reduces edema by removing excessive fluid from the wound bed as well as facilitating removal of the infective pathogen after an aggressive wound debridement. The author has judiciously used NPWT in each of these patients with encouraging results. With no well-defined guidelines to manage radiation-induced wound infections, this retrospective study gives an overview and protocol for a systematic approach. CASE REPORT: This is a retrospective series of five cases managed between January 2014 and December 2016. All were men with a mean age of 30.6 years with a mean follow-up of 27 months. We analyzed their demographic, clinical data, history, wound locations, primary diagnosis on histopathology, organisms isolated on culture, surgical details, antibiotics administered, and special interventions such as skin flaps or grafting and clinical outcome.Of the five, three patients received exclusive external beam radiation therapy (EBRT) and two were given intralesional brachytherapy and EBRT. Three received additional chemotherapy. 7/9 isolated organisms were multidrug-resistant mean 5.4 cycles of NPWT after aggressive debridement was needed to achieve healthy granulation tissue bed. Wounds were closed at median 31.5 days (three split-thickness split skin grafting, one local rotation flap, and one healing with secondary intention). We had two mortalities secondary to metastasis. CONCLUSION: We recommend aggressive debridement, prolonged use of NPWT in infected irradiated wounds, and appropriate antibiotics with soft tissue cover by a multidisciplinary team to achieve good results.

Rare Case of Iliopsoas Abscess Secondary to Mucinous Adenocarcinoma of the Colon: A Case Report.

INTRODUCTION: Iliopsoas abscess (IPA) has varied clinical symptomatology and various clinical disorders may mimic it. Tuberculosis of spine is the most common source of secondary IPA in the developing countries. However, IPA may be rarely caused by colon cancer which is the most common gastrointestinal malignancy. A mixed culture gives an indication of gastrointestinal or genitourinary etiology. We present here, a rare case of an 86-year-old patient with IPA secondary to adenocarcinoma of colon. CASE REPORT: An 86-year-old female presented with pain in the right thigh in February 2014. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the abdomen confirmed the clinical suspicion of right IPA which was drained surgically. Intraoperatively, mucinous material was noted, emerging from a small opening in a rounded structure located lateral to the psoas muscle, which could not be identified. On post-operative day 2, the right flank swelling recurred. Culture reports showed a polymicrobial infection with viridans group Streptococci and Pseudomonas aeruginosa. The abscess was re-explored and biopsy of the opening was taken. Histopathology of the tissue sample revealed metastatic cells of a mucin-secreting adenocarcinoma that had infiltrated the psoas muscle with a secondary pyogenic abscess. On reviewing the CT scan, there was a suspicion that the abscess was communicating with a tumor in the colon. No further active intervention was done for the tumor in view of advanced age and stage of tumor. The patient had significant pain relief and was able to resume walking. The infection resolved with 6 weeks of oral linezolid and ciprofloxacin. The patient died 8 months later secondary to metastasis. CONCLUSION: Although the diagnosis of IPA does not pose problems, diagnosing secondary IPA requires a high index of clinical suspicion. A Gram-negative culture must raise the suspicion of gastrointestinal or genitourinary pathology. Colon carcinoma, although extremely rare, can lead to secondary IPA. CT and MRI though extremely useful, may not pick up the pathology and a definitive diagnosis of colon neoplasia perforating into the psoas muscle may be evident only intraoperatively. Atypical presentation may delay the diagnosis of colon cancer and subsequently result in higher morbidity and mortality.

Careful interpretation of the wound status is needed with use of antibiotic impregnated biodegradable synthetic pure calcium sulfate beads: Series of 39 cases.

Introduction: The use of antibiotic impregnated biodegradable synthetic high purity calcium sulfate (SHPCS) beads is frequently reported as they offer increased concentration of antibiotics locally, without need for removal. However some wound discharge following their use has been noted. The purpose of this study was to determine any correlation between wound discharge and infection remission. Methodology: Retrospective study of 39 cases of Osteoarticular infections from April 2013 to November 2016 in whom SHPCS beads were used. All patients underwent the standard staged protocol of aggressive debridement, deep tissue biopsy, implant removal where indicated and early soft tissue cover. SHPCS beads were used locally in the second stage combined with appropriate antibiotics based on tissue culture. All patients received systemic antibiotics for a period of 6 weeks and followed up for a minimum period of six months. The study analysed the patient demographics, etiology, surgical procedures, culture patterns, local antibiotics used, radiological status of beads, incidence and characteristics of wound discharge and outcome. Results: There were 25 cases of chronic osteomyelitis, eight infected non unions, three peri prosthetic joint infections, two soft tissue infections and one case of acute osteomyelitis. 17 of these infections were following osteosynthesis. The cultures were negative on eight occasions in seven patients. A total of 40 organisms were isolated in the other patients; commonest being Staphylococcus aureus (n=16) and E coli (n=7). SHPCS beads were mixed with vancomycin in 17 cases, colistin in 11, vancomycin with colistin in eight and vancomycin with gentamicin in four. Voriconazole was used in one case with fungal infection. Eight cases (20.51 %) developed discharge from the wound at an average of 6 days after inserting the beads. The discharge was serous with no foul smell in six and purulent in two inflamed wounds. Four cases underwent re-debridement; two cases with purulent discharge and subsequent positive cultures; two with serous discharge early in the series and no evidence of infection on re-exploration with negative cultures. The remaining four patients with serous wound discharge were observed without any further surgical intervention, with the discharge stopping spontaneously between 15 to 36 days post operatively. There was no correlation between antibiotic used and wound discharge. Radiographic analysis showed dissolution of all the beads at an average of 36 days in the 39 cases. Heterotrophic ossification was not observed. Clinical and radiological remission of infection was observed in 37 cases (94.9%). Two patients died during the course of hospitalization, secondary to septicaemia and multi organ failure. Three patients had an infection recurrence within six months, managed successfully by re-debridement and appropriate antibiotics. Radiological union was achieved in seven of the eight infected non unions. Conclusions: With the encouraging rates of infection remission we have observed, we continue to use antibiotic loaded SHPCS as an alternative for local antibiotic delivery in the treatment of osteoarticular infections. However, wound discharge is a known potential observation following implantation of calcium sulfate beads, subsiding typically within four to six weeks. The appearance of wound discharge can vary, ranging from purulent discharges to non-purulent, serous/ sero sanguineous fluid wound discharges. The presence of a wound discharge alone does not necessarily imply a failure to treat the infection. It is important to be aware of this side effect and guard against unnecessary re- operations, by careful consideration and monitoring all of the available clinical signs of infection, in addition to blood test results and radiographic evidence. Further research is needed to determine the relationship between the implantation of antibiotic loaded calcium sulfates and the incidence and duration of drainage.

Cerclage Wiring as an Adjunct for the Treatment of Femur Fractures: Series of 11 Cases.

INTRODUCTION: Cerclage wiring has been used in the past for osteosynthesis of femoral fractures. However, the technique went into disrepute as extensive soft tissue dissection, and periosteal stripping increased the risk of bone necrosis and delayed union. Advent of new instrumentation and minimally invasive technique has significantly reduced these complications. In spite of the limited indications for its application, reduction and stabilization with cerclage wiring can supplement osteosynthesis especially in spiral or oblique fracture morphology or those with a butterfly fragment instead of interfragmentary screw fixation. This series attempts to describe the feasibility and evaluate outcomes of cerclage wiring as an adjunct to osteosynthesis and reestablish its place in reduction and fixation of femur fractures. CASE REPORT: This is a retrospective case series of patients (January 2011 to October 2015) in whom cerclage wiring was used as an adjunct to osteosynthesis of primary and periprosthetic fractures of femur. Patient demographics, number of wires used, implant used for osteosynthesis, number of days to union, union rate and complications were recorded and analyzed. The patients were followed up for a minimum of 6 months. 11 patients (7 female and 4 male) with a mean age of 67.10 ± 21.64 years were studied. The number of patients with intertrochanteric, subtrochanteric, diaphyseal, and periprosthetic fractures of the femur was two, five, one, and three, respectively. Internal fixation was done with plates in six and cephalomedullary nails in five patients. Mean total number of wires used was 2.10 ± 0.70. Mean duration of follow-up was 15.91 ± 10.03 months. Union was achieved in all cases with a mean duration of 86.63 ± 22.44 days. There were no complications in our study. CONCLUSION: Cerclage wiring technique helps to achieve stable reduction of femoral fractures which can then be supplemented with a nail or a plate. The minimally invasive technique and instrumentation offer the advantage of minimal soft tissue dissection, and the procedure is associated with excellent outcomes without any major complications.