Maggots were used as adjunct treatment for infected wounds that showed no response to the classical approach of wound debridement and antibiotic therapy. We summarize findings for 11 patients with necrotic wounds who received treatment with "surgical" maggots (100-2900 applied in 3-10 changes of dressing) for 11-34 days, which apparently aided in tissue remodeling and cure, and describe 2 typical patients in detail.

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 c...

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 ± 2.15 on the day of surgery, 2.5 ± 1.86 on the first postoperative day and 2.08 ± 1.81 on the second day, and 6.2 ± 2.38, 5.77 ± 2.34 and 4.71 ± 2.48 on movement respectively in the UTKA group. In the BTKA group, the mean VAS pain scores at rest were 4.39 ± 2.25 on the day of surgery, 3.98 ± 2.36 on the first postoperative day and 3.05 ± 2.12 on the second day and 6.21 ± 2.38, 5.77 ± 2.34 and 4.71 ± 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 ± 0.41 g% and 0.5%, 1.85 ± 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.

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 þ 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 þ 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 þ ACB group (n ¼ 151) compared to LIA (n ¼ 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.

Abstract. 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.