Open Intra-articular Distal Femur Fracture with 21 cm Bone Loss Managed by Early Vascularized Fibula Grafting and Antibiotic Loaded Synthetic Calcium Sulfate Beads - A Case Report.

Introduction: Open fractures with massive bone defect presents as challenging clinical scenario in clinical practice. If neglected, this can result in infection, non-union or severe limb length discrepancy. Autogenous vascularized fibula grafting along with stable fixation in the form of internal fixation is a viable option in such situations. Synthetic calcium sulfate is a suitable antibiotic carrier to deliver antibiotics locally to prevent infection. We report the case of an adult male who had an open fracture of the distal femur with segmental bone loss of 21 cm, managed with autogenous vascularized fibula graft and locking plates. We used antibiotic-loaded absorbable synthetic calcium sulfate beads locally during the procedure. Case Report: A 52-year-old male, a known case of uncontrolled diabetes mellitus, presented to the emergency department with a comminuted open intra-articular fracture of the left distal femur with bone loss of 21 cm (arbeitsgemeinschaft fur osteosynthesefragen 33C3) following a road traffic accident. He was initially treated with meticulous debridement and internal fixation with locking compression plate. Considering the massive bone defect of 21 cm, he was planned for fibula grafting at a later stage. After 6 weeks, he underwent vascularized fibula grafting from opposite leg and an additional medial plate to stabilize the graft and augment the initial fixation. He was on regular follow-up in the outpatient department. The fracture united with no signs of infection or residual limb length discrepancy. At the latest follow-up at 7 months, he is walking independently without support and is having a functional range of knee movements. There were no post-operative complications in the right leg from where fibula was harvested. Conclusion: Autogenous vascularized fibula graft together with a locking compression plate is a practical choice in managing open fractures with segmental bone loss. The high concentration of local antibiotic delivery with the help of synthetic calcium sulfate beads helped prevent infection, which is the most dreaded complication associated with open fractures. In addition, the calcium sulfate beads promote endochondral ossification resulting in early bone union.

An unusual case of metaphyseal osteonecrosis of humerus in a post covid patient: a case report.

Osteonecrosis of the metaphysis is often rare as it is a highly vascular region. Here we report an unusual case of non-traumatic osteonecrosis of the humerus predominantly involving the metaphysis in a post covid elderly female. The patient had a pathological fracture of humerus during the post-operative period of intertrochanteric femur fracture surgery. She was evaluated for the causes of pathological fracture and the fracture was managed with hemi replacement of the shoulder because of the extensive bone loss. The pathology here could only be explained as some sequelae of hyper inflammatory state associated with COVID-19 infection. The possible differentials are also discussed here. This case report will help clinicians to consider COVID-19 infection as a cause for non-traumatic osteonecrosis among other reported causes of osteonecrosis.

Emphysematous Osteomyelitis of Tibia - A Rare Case Treated with Antibiotic-loaded Absorbable Calcium Sulfate Beads.

Introduction: Emphysematous osteomyelitis (EO) is an uncommon and deadly pathology characterized by occurrence of intraosseus air within the bone. However, only few of them have been reported. The use of local antibiotic delivery system has proven to be very effective in bone and joint infections as they offer decreased hospital stay and early clearance of infection. To the best of our knowledge, there are no reports on local antibiotic delivery using absorbable synthetic calcium sulfate beads in EO. Case Report: A 59-year-old male with Type II diabetes mellitus, chronic kidney, and liver disease came with pain and swelling over left leg. After blood investigations and radiological evaluation, he was diagnosed to have EO of tibia with unknown source of infection. We successfully treated him with immediate surgical decompression and application of antibiotic impregnated absorbable calcium sulfate beads locally for improved local antibiotic delivery. Following this, he was further treated with culture sensitive intravenous antibiotics and his symptoms resolved. Conclusion: Early diagnosis and aggressive surgical intervention along with local antimicrobial therapy using calcium sulfate beads can offer better outcome in EO. The local antibiotic delivery system can decrease the use of prolonged intravenous antibiotic therapy and long hospital stay.