Matías Vicente

Background: Infected tibial pilon fractures are among the most challenging conditions in orthopaedic trauma. Whether successful limb salvage can be reproduced across markedly different healthcare settings remains unknown. This study compared the characteristics, treatment strategies, and outcomes of infected tibial pilon fractures managed with circular external fixation devices (CEFD) at two specialised referral centres in Spain and South Africa.Methods: A retrospective comparative cohort study was performed including consecutive adult patients treated between 2013 and 2023 for infected tibial pilon fractures definitively managed with CEFD. The primary outcomes were infection eradication and bone union. Secondary outcomes included limb salvage and functional outcomes.Results: Twenty-four patients met the inclusion criteria, including nine treated at the Spanish Centre (SPC) and fifteen at the South African Hospital (SAH). Patients treated at SPC represented a more complex reconstructive population, having undergone significantly more previous surgical procedures and requiring flap coverage more frequently, whereas patients treated at SAH more commonly presented with compromised host characteristics, including diabetes mellitus and HIV infection. Despite these marked differences, infection eradication (88.9% vs 86.7%), bone union (88.9% vs 93.3%), and limb salvage (100% vs 93.3%) were comparable between centres.Conclusions: Despite substantial differences in patient characteristics, reconstructive complexity, and reconstructive pathways, specialised centres achieved comparable rates of infection eradication, bone union, and limb salvage. These findings suggest that adherence to fundamental fracture-related infection principles may be more important than the healthcare setting itself in determining successful limb salvage.

The role of soft tissue reconstruction in infection control of knee periprosthetic joint infection (PJI) treated with a two-stage exchange strategy remains controversial. This retrospective observational study analysed consecutive patients with chronic knee PJI managed with a two-stage protocol between 2010 and 2023, comparing outcomes between cases requiring flap-based soft tissue reconstruction and those achieving primary closure. A total of 118 patients with a minimum follow-up of 24 months were included. Forty patients (33.9%) required soft tissue reconstruction (STR), including 25 pedicled medial gastrocnemius flaps and 15 anterolateral thigh (ALT) microsurgical free flaps. Patients requiring STR showed greater baseline complexity, with a higher number of previous surgical procedures (3.03 vs. 2.08; p = 0.0057) and a higher prevalence of diabetes mellitus and sinus tracts. Despite this, infection control was superior compared with non-reconstructed cases (100% vs. 88.5%; p = 0.029). Within the STR group, both pedicled and microsurgical techniques achieved complete infection eradication; however, ALT flaps were associated with higher complication rates (46.7%), with partial flap necrosis being the most frequent event. The use of microsurgical reconstruction increased progressively over time, reflecting growing reconstructive complexity. Formal soft tissue reconstruction does not compromise and may facilitate infection control within a multidisciplinary pathway.

The role of soft tissue reconstruction in infection control of knee periprosthetic joint infection (PJI) treated with a two-stage exchange strategy remains controversial. This retrospective observational study analysed consecutive patients with chronic knee PJI managed with a two-stage protocol between 2010 and 2023, comparing outcomes between cases requiring flap-based soft tissue reconstruction and those achieving primary closure. A total of 118 patients with a minimum follow-up of 24 months were included. Forty patients (33.9%) required formal coverage, including 25 pedicled medial gastrocnemius flaps and 15 anterolateral thigh (ALT) microsurgical free flaps. Reconstructed patients showed greater baseline complexity, with a higher number of previous surgical pro-cedures (3.03 vs 2.08; p = 0.0057) and a higher prevalence of diabetes mellitus and sinus tracts. Despite this, infection control was superior compared with non-reconstructed cases (100% vs 88.5%; p = 0.029). Within the reconstruction group, both pedicled and micro-surgical techniques achieved complete infection eradication; however, ALT flaps were associated with higher complication rates (53.3%), with partial flap necrosis being the most frequent event. The use of microsurgical reconstruction increased progressively over time, reflecting growing reconstructive complexity.

Background Distal femur replacement (DFR) with a stemmed megaprosthesis represents a challenge due to high rates of loosening and limited reconstructive options if the implant fails. Such an unfavourable scenario is even more complex where there are also infected bone defects. The Compress® device was developed to provide an alternative to traditional intramedullary stems. We report on the outcomes of a staged protocol using the Compress® DFR, protected with a vancomycin–gentamicin-loaded hydrogel, in infected non-oncological scenarios. Methods Retrospective longitudinal cohort study including patients with infected defects of the distal femur following orthopaedic trauma or periprosthetic joint infection (PJI) and managed with the protocol described. Protocol features, microbiological data, radiological results, complications, infection control, and implant survivorship were assessed. Minimum follow-up was 18 months or until implant removal. Results 21 cases of Compress® DFR were included. On average, patients had 4.9 prior surgeries and 14.5 cm distal femur bone defects after pseudo-oncological resection. After median follow-up of 42 months (18–83 months), no infection recurrence occurred; limb salvage was achieved in all cases. Five patients experienced aseptic loosening, all within the first 7 post-operative months. Beyond this time threshold, no further implant failures were observed, resulting in a cumulative implant survival rate of 75% at 1 and 5 years, and of 75% at final follow-up. Conclusion Staged Compress® DFR with antibiotic-loaded hydrogel protection is a reliable option for selected patients with distal femoral bone defects, offering high infection control, durable implant survivorship, and simplified revision. Aseptic failures occurred primarily within the early post-operative months, highlighting the need for close monitoring during this critical period. This approach provides a promising solution for complex non-oncological cases involving infected distal femoral bone defects.

Introduction Outcomes for silver coated megaprostheses (SC-MP) used in cases of end-stage periprosthetic joint infection (PJI) have not been clearly defined. Although attractive, concerns over implant longevity and the risk of infection relapse exist among the scientific community. Therefore, we sought to investigate the effect of silver coating in lower-extremity MPs used in such difficult-to-treat scenarios. The study’s primary hypothesis was that the periprosthetic infection control rate would be higher in patients with silver-coated implants. Materials and methods Non-interventional retrospective study with a historical comparison group. We identified all consecutive end-stage hip and knee PJI cases at our center managed with exchange arthroplasty using a silver-coated megaprosthesis from January 2016 to March 2021, these cases were compared with a historical cohort of end-stage PJI cases managed with uncoated megaprostheses. The main outcome studied was infection control rate. Secondarily, we analyzed the short-to-medium-term survivorship of this type of silver-coated implant. Results Fifty-nine megaprostheses used in cases of end-stage PJI were included in this study. We identified 30 cases of chronic hip or knee PJI in which a silver-coated modular megaprosthesis was implanted. Our non-coated megaprosthesis (NC-MP) historical group included 29 patients. Both groups had similar demographic characteristics. We found no statistically significant differences in infection control rate (80% vs. 82.8%, p = 0.47) or implant survivorship (90% vs. 89.65%, p = 1) after a mean follow-up for SC-MP of 46.43 months, and 48 months for the non-coated MP group. In relapsed cases, there were no differences in infection eradication after DAIR (66% SC-MP vs. 60% NC-MP success rate, p = 1). During the follow-up we observed one case of skin argyria without further repercussion. Conclusion We were unable to confirm our initial hypothesis that use of silver-coated implants in end-stage PJI scenarios may be associated with better outcomes in terms of infection control or implant survivorship.

Purpose: Surgical approach can impact the reliability of the debridement after a chronic total knee periprosthetic joint infection (PJI), a factor of utmost importance to eradicate the infection. The most adequate knee surgical approach in cases of PJI is a matter of debate. The purpose of this study was to determine the influence of performing a tibial tubercle osteotomy (TTO) in a two-stage exchange protocol for knee PJI treatment. Methods: Retrospective cohort study examining patients managed with two-stage arthroplasty due to chronic knee PJI (2010–2019). Performance and timing of the TTO were collected. Primary end-point was infection control with a minimum FU of 12 months and according to internationally accepted criteria. Correlation between TTO timing and reinfection rate was reviewed. Results: Fifty-two cases were finally included. Overall success (average follow-up: 46.2 months) was 90.4%. Treatment success was significantly higher among cases addressed using TTO during the second stage (97.1% vs. 76.5%, pvalue 0.03). Only 4.8% of the patients relapsed after performing a sequential repeated TTO, that is, during both first and second stages, compared to 23.1% cases in which TTO was not done (p value 0.28). No complications were observed among patients in the TTO group with a significant decrease in soft tissue necrosis (p: 0.052). Conclusion: Sequential repeated tibial tubercle osteotomy during a two-stage strategy is a reasonable option and offers high rates of infection control in complex cases of knee PJI with a low rate of complications.

Purpose: Use of prefabricated mobile spacers in end-stage cases of hip periprosthetic joint infection (HPJI) is hindered when large bone defects exist. In such cases, prefabricated custom-made antibiotic spacers (P-CMAS) offer an alternative. Such spacers are individually designed according to the size and anatomical characteristics of the bone defect. The purpose of this study is to describe and evaluate the use of such patient-specific spacers in a two-stage strategy to treat end-stage HPJI cases, and to report on clinical outcomes. Methods: A retrospective study identified all patients with end-stage HPJIs from January 2015 through December 2019, treated using a P-CMAS. Primary outcome: infection eradication rate. Secondary outcomes: spacer-related complications and patient satisfaction. Minimum follow-up: 12 months after the second-stage surgery. Results: A total of 7 end-stage cases (mean of 6.7 previous surgical procedures) were included. Mean bone defect size was 191.57 (range 47–304) mm. Polymicrobial infection was detected in 42.86% of these cases. During the spacer stage there were no periprosthetic fractures, spacer dislocations or breakages, nor spacer-drug-related complications. All patients proceeded with the second stage uneventfully, with an average time between stages of 178 (range 119–326) days. In 5 cases a total femur arthroplasty was the reconstructive procedure performed. After a mean follow-up of 27.29 (range 14–49) months the infection was clinically eradicated in all patients, despite their difficult-to-treat scenarios. Conclusions: Industrially custom-made spacers offer an effective and safe option in performing 2-stage exchange arthroplasty in cases of end-stage HPJI with extensive bone defects.