We retrospectively reviewed 45 children treated between 1987 and 2002. Their mean age was 9 years (3 to 13). Fifteen patients had subacute osteitis. Only patients with Bledhill and Roberts type II, III and IV were included. Biopsy provided histological proof of subacute osteitis in nine patients, and six were successfully treated non-surgically with flucloxacillin. Six patients had Ewing’s sarcoma, 24 had osteosarcoma, 23 Enneking stage-IIB (extracompartmental) and one Enneking stage-IIA (intracompartmental). The preoperative clinical signs, radiographs and MRI studies were reviewed. On plain radiographs, cortical destruction and periosteal reaction were assessed. On MRI the extent and nature of bone marrow involvement and the size of the soft tissue mass/oedema was analysed and correlated clinically. On plain radiographs, cortical destruction was present in all patients with Ewing’s sarcoma and stage-IIB osteosarcoma and in 50% of patients with subacute osteitis. An ill-defined zone of transition was found in all patients with Ewing’s sarcoma and osteosarcoma and in 50% of those with subacute osteitis. These findings therefore did not help to differentiate between the two groups. The periosteal reaction was well-defined in subacute osteitis and lucencies between laminations were thin. In the malignant group the periosteal reaction was always ill-defined, with or without a Codman’s triangle, sunray spicules and hair-on-end. Lucencies between laminations were broad and broken. This was useful in differentiating between the two groups. On MRI, patients with subacute osteitis had no soft tissue mass, with an infiltrative type of bone marrow involvement. In the malignant group, the soft tissue mass was large and the bone marrow involvement well demarcated. We concluded that where there was a well-defined periosteal reaction on plain radiographs, and no soft tissue mass with infiltrative bone marrow involvement on MRI, patients could initially be treated as subacute osteitis without biopsy

Study design: Randomized controlled trial. Objectives: To investigate the long-term effectiveness, costs, and effect modifiers of a mini-intervention, provided in addition to the usual care, and the incremental effect of a worksite visit for patients with subacute disabling low back pain (LBP). Methods: 164 subacute LBP patients randomized into a mini-intervention (A, n=56), a mini-intervention plus a worksite visit (B, n=51) or the usual care (C, n=57). Mini-intervention consisted of a detailed assessment of the patients’ history, beliefs and physical findings by a physician and a physiotherapist, followed by recommendations and advice. The usual care patients received the conventional care. Pain, disability, health-related quality of life, satisfaction with care, days on sick leave, and health care consumption and costs were measured during a 24-month follow-up. Thirteen candidate modifiers were tested for each outcome. Results: There were no differences between the three treatment arms regarding the intensity of pain, the perceived disability or the health-related quality of life. However, mini-intervention decreased occurrence of daily (A vs, C, P=0.01) and bothersome (A vs C, P< 0.05) pain and increased treatment satisfaction. Costs resulting from LBP were lower in the intervention groups (A 4670 €, B 5990 €) than in C (C 9510 €) (A vs. C, p=0.04 and B vs. C, n.s). The average number of days on sick leave was 30 in A, 45 in B and 62 in C (A vs. C, p=0.03, B vs. C, n.s). The perceived risk for not recovering was the strongest modifier of treatment effect. Mental & mental-physical workers in A and B were less often on sick leave than those in C. Conclusions: Mini-intervention is an effective treatment for subacute LBP. Despite lack of a significant effect on intensity of low back pain and perceived disability, mini-intervention including proper recommendations and advice, according to the “active approach”, is able to reduce LBP-related costs. The perceived risk of not recovering was the strongest modifier of treatment effect. In alleviating pain the intervention was most effective among the patients with a high perceived risk of not recovering

Introduction and Aims: This disease has an insidious onset and develops as a result of increased host resistance and decreased bacterial virulence. The aim of this paper is to describe the spectrum of primary subacute forms of haematogenous osteomyelitis and highlight the difficulties in diagnosis and the importance of histology. Method: Twenty-five children aged two to 12 years were reviewed between 1990 and 2002. Symptoms and signs were mild. Complaints were present for two to eight weeks; laboratory tests were non-contributory. Bone scans were done in all patients. All patients had biopsy with curettage of cavitating lesions. Microscopy, culture and histology were done in all patients. Four patients had MRI scans. Results: There were 28 osseous lesions in 24 children. The anatomical sites were: the tibia, 24 lesions, femur three and ulna one. One child had multifocal involvement involving both tibiae and the ulna. The lesions were classified using the system of Roberts et al. Two lesions were in the epiphysis, six in the metaphysis and 20 in the diaphysis. Radiologically, the lesions resembled several benign and malignant conditions such as tuberculosis and fungal infections, Ewing’s sarcoma, leukaemia, osteosarcoma, chondroblastoma and osteoid osteoma. Bone scan was positive in all cases. Histology of bone showed features of subacute osteomyelitis – inflammatory cells, plasma cells and polymorphonuclear leukocytes. Staphylococcus aureus was cultured in eight patients. All children were treated with Cloxacillin for six weeks. Follow-up ranged from six months to five years. All diaphyseal and epiphyseal lesions healed completely. Residual sclerosis was seen in metaphyseal lesions. No growth disturbance or articular changes were seen in this study. Conclusion: Primary subacute haematogenous osteomyelitis is uncommon. Metaphyseal and epiphyseal forms are more commonly reported in the literature. The diaphyseal form was the predominant type in this study. Bone lesions mimic benign and malignant conditions. Biopsy is mandatory. The diagnosis is made on histology. Staphylococus aureus is the usual causative organism, but difficult to culture

“Subacute Synovities of the Hip”, which runs a more fluctuant clinical progress and slower response to treatment than those of acute transient synovitis, is always posing diagnostic and management challenge in children presented with acute hip pain. This study aims to identify the special features of this distinct entity, and the important diagnostic parameters in differentiation of acute transient synovitis, subacute arthritis and also septic arthritis in children presented with acute painful pain. From 1985–1999, 427 children have been admitted into our centre with subsequent diagnosis of acute transient synovitis, subacute synovitis & septic arthritis. 320 cases with full records are available for review, with 270 cases 85%) having acute transient synovitis, 35 cases (10%) of subacute arthritis and 15 cases (5%) of septic arthritis. Statistical results showed that patient having subacute arthritis different significantly from those with acute transient synovitis in terms of age of presentation & duration of symptoms before hospitalization. Moreover, patient having transient synovitis significantly different from those with septic arthritis in terms of temperature on admission, ESR and White Cell Count

Salmonella osteomyelitis occurs infrequently in children without a sickle cell disease, and its subacute form is rare. Diagnosis is often delayed because its slow onset, intermittent pain and it can be confused with bone tumors. An otherwise healthy 13-year-old boy was admitted from another center in order to discard bone tumor in proximal tibia, with compatible radiologic findings. There was no history of trauma or previous illness. Twenty days ago, he had flu symptoms and myalgia. On the physical examination the child was feverless, showed increased heat over his left knee, considerable effusion and painful restriction of movement. Inflammatory laboratory results revealed erythrocyte sedimentation rate 46mm/h and C-Reactive protein, 11,2 mg/L. Radiographs revealed a lytic lesion localized in the proximal metaphysis and epiphysis. The MRI showed an area of edema around the lytic lesion and surrounding soft tissues. Images supported the diagnosis of subacute osteomyelitis, (Brodie abscess). Empirically, intravenous cefuroxime was started. Forty-eight hours post admission, the patient underwent abscess surgical debridement, washout and cavity curettage. Samples were sent for cytology, culture and sensitivity and acid fast bacilli culture and sensitivity. Collection´s count cell was 173.000/ L white cells. Collection´s culture revealed Salmonella B sensitive to ciprofloxacin. Stool culture did not yield any growth. Intravenous cefuroxime was administered during 10 days. The patient responded well as evidenced by clinical and laboratory improvement He was discharged with his left leg immobilized in a cast during 1 month and treatment was completed with oral ciprofloxacin 500mg /12 h during 2 months. The patient had full range of knee motion after 2 months. Last reviewed, after two years of the income, he was completed recovered, and the radiograph showed bone healing without physeal neither damage nor limb leg discrepancy. The most effective therapy of a confirmed salmonella osteomyelitis is a combination of radical operative intervention and targeted intravenous antibiotics as in our case. Faced with a subacute osteomyelitis, we have to remember that it may mimic bone tumors. We highlight the isolation of Salmonella B in a patient without sickle cell disease

In the last six months 6 cases of subacute epiphyseal osteomyelitis have presented to the Paediatric Orthopaedic Department at the University Hospital of Wales, Cardiff. We present a clinical review of these cases illustrating the salient points in their varied presentation and management, together with the results of a retrospective analysis of the incidence of this rare condition. We ask “is there an increasing incidence of this rare condition or have we become increasingly aware of this potential diagnosis in children?”

Aims. In orthopaedic and trauma surgery, implant-associated infections are increasingly treated with local application of antibiotics, which allows a high local drug concentration to be reached without eliciting systematic adverse effects. While ceftriaxone is a widely used antibiotic agent that has been shown to be effective against musculoskeletal infections, high local concentrations may harm the surrounding tissue. This study investigates the acute and subacute cytotoxicity of increasing ceftriaxone concentrations as well as their influence on the osteogenic differentiation of human bone progenitor cells. Methods. Human preosteoblasts were cultured in presence of different concentrations of ceftriaxone for up to 28 days and potential cytotoxic effects, cell death, metabolic activity, cell proliferation, and osteogenic differentiation were studied. Results. Ceftriaxone showed a cytotoxic effect on human bone progenitor cells at 24 h and 48 h at concentrations above 15,000 mg/l. With a longer incubation time of ten days, subtoxic effects could be observed at concentrations above 500 mg/l. Gene and protein expression of collagen, as well as mineralization levels of human bone progenitor cells, showed a continuous decrease with increasing ceftriaxone concentrations by days 14 and 28, respectively. Notably, mineralization was negatively affected already at concentrations above 250 mg/l. Conclusion. This study demonstrates a concentration-dependent influence of ceftriaxone on the viability and mineralization potential of primary human bone progenitor cells. While local application of ceftriaxone is highly established in orthopaedic and trauma surgery, a therapeutic threshold of 250 mg/l or lower should diminish the risk of reduced osseointegration of prosthetic implants. Cite this article: Bone Joint Res 2021;10(3):218–225

Purpose. To compare the contribution of physical, psychological and social indicators to predicting disability after one year between consulters with low back pain (LBP) of less than 3 months duration and more than 3 months duration. Methods. Data from two large prospective cohort studies of consecutive patients consulting with LBP in general practices were merged, with disability measured by the Roland Morris Disability Questionnaire (RMDQ). There were complete data for 258 cases with acute/subacute LBP and 668 cases with chronic LBP at 12 months follow-up. Univariate and adjusted multivariate regression analyses of various potential prognostic indicators for disability at 12 months were carried out. Results. There were significant differences between those with acute/subacute versus chronic LBP with regard to baseline characteristics and clinical course of disability during the year of follow-up. The final multivariate regression models, adjusting for baseline disability scores, age, gender, and study sample, showed that being non-employed, having widespread pain, a high level of Chronic Pain Grade, and catastrophising were the strongest prognostic indicators for disability at 12 months in both those with acute/subacute and those with chronic LBP. Fear of pain was significantly associated with disability in chronic LBP but not in acute/subacute LBP. Conclusion. Despite significant differences between acute/subacute and chronic LBP in baseline characteristics and clinical course over one year, a similar set of prognostic indicators influence long-term disability in both groups. This provides further evidence that chronicity is determined early in an episode of LBP and highlights again the potential for prevention if these prognostic factors can be systematically identified and targeted

The purpose of this study is to clarify optimal timing of anterior cruciate ligament (ACL) reconstruction from the point of view of meniscus injury. One hundred thirty-five ACL injuries (under 40 years of age) were analyzed in this study. All knees had undergone primary reconstruction without other ligament injury, and follow-up arthroscopy. ACL reconstruction was performed by the semitendinosus and gracilis method. The rehabilitation protocol was based on that of Shelbourne. Cases were divided into 4 groups by the period from injury to reconstruction. Nineteen knees were of the acute phase, which is within 1 month from the injury to reconstruction. Thirty-one knees were of the subacute phase, which is from 1 month over to reconstruction. Thirty-one knees were of the subacute phase, which is from 1 month over to 3 months from the injury to reconstruction. Forty knees were of the subchronic phase, which is from 3 months over to 1 year from the injury to reconstruction. Forty-five knees were of the chronic phase, which is over 1 year from the injury to reconstruction. We compared arthroscopic findings as well as clinical follow-up results of each phase. The rate of lateral meniscus injury were 84% in the acute phase, 39% in the subacute phase, 58% in the subchronic phase, and 51% in the chronic phase. The rates of medial meniscus injury were 32% in the acute phase, 29% in the subacute phase, 53% in the sub-chronic phase, and 60% in the chronic phase. Horizontal tear and degenerative tear of the lateral meniscus were increased with time. Osteoarthritic change at follow-up arthroscopy was observed 3 knees in the acute phase, 4 knees In the subacute phase, 8 knees In the subchronic phase, and 13 knees in the chronic phase. There was no difference between clinical results of our ACL reconstruction in the acute phase and chronic phase. ACL reconstruction in the acute phase was the effective method for preventing secondary osteoarthritis after medial meniscus injury

A retrospective study was undertaken in our unit to investigate any change in osteomyelitis trends in the last ten years (1991-2001). These results were then compared to 3 previous studies conducted by our unit on childhood osteomyelitis, 1977-1979 45 cases(O’Brien et al)1, 1980-87 (84 cases) and 1988-1991 (54 cases). 149 patients were identified from hospital discharge database with a diagnosis of osteomyelitis between 1991 and 2001. 136 fully completed charts were discovered and included in the study. 22 children did not fulfil the criterion for the diagnosis of acute or subacute osteomyelitis and were excluded. Cellulitis was the actual diagnosis 18/22 cases, leukaemia or other neoplasm in 4/22 cases. 28% of the children 32/114 had acute haematog-enous osteomyelitis with classical signs and symptoms the remaining 72% fell into the subacute osteomyelitis category as described by Gledhill. Table 1 shows the comparison between the 4 studies. 89% of patients underwent 3 phase bone scanning, and 90% of these were positive. Blood cultures were performed in 87% of patients and were positive in 8.5%, 2 patients being positive and symptomatic of Nesseria meningitis, 4 Staph aureus, 2 Strep Pneumonia, 1 staph epidermidis and 1 E.Coli. As compared to previous 3 studies no case of haemophilus influenza type B was encountered. Aspiration was performed in 22 patients and 18 demonstrated bacteria, the two commonest pathogens were Staphylococcus aureus 66% and epider-midis 16%. 8 patients underwent surgical debridement or drilling if clinically septic or because of failure to improve despite medical treatment. Initial antibiotic treatment comprised of i.v. penicillins and oral fucidin in 92% of patients, the remainder receiving cephalosporins as favoured by physicians or erythromycin if history of hypersensitivity. Antibiotics arethen tailored to clinical picture or culture results. Table 2 shows the changing duration pattern of antibiotic administration. There were four cases of complications, 2 cases of chronic osteomyelitis and 2 cases of limb shortening both around the knee joint. Our results correlate well with other authors. Surgery has an ever-decreasing role in the management of osteomyelitis, with conservative antibiotic management and splintage being the treatment of choice. Subacute osteomyelitis is an ever-increasing entity as reflected in other studies. The incidence of osteomyelitis presenting to our unit has fallen to 2.34 per 10000 per yea. A possible explanation may lie in altered host pathogen interactions, increased host resistance, the frequent administration of broad-spectrum antibiotics in general practice. Increased population wealth as experienced in Ireland in the last 8 years may also have a role

Purposes And Background. Having found a significant limitation of neural movement (66.6%) during SLR performed on the symptomatic side in patients with sub-acute lumbar intervertebral disc herniation (LIDH), we followed up on the same patients over 1.5 years to ascertain if changes in cord excursion accompany changes in clinical symptoms. Methods. 14 patients, who originally had sciatic symptoms due to subacute LIDH, were re-assessed both clinically and radiologically with a 1.5T magnetic resonance (MR) scanner. Displacement of the conus medullaris during the unilateral and bilateral SLR was quantified reliably with a randomized procedure and compared between maneuvers and with data from baseline. Multivariate regression models and backward variable selection method were employed to identify variables more strongly associated with decrease in low back pain and radicular symptoms. Results. Compared to previously presented baseline values, the data showed an extensive increase in neural sliding of 323.4% (2.52mm, p≤0.001) with the symptomatic SLR, 37.1% (0.82mm, p=0.0058) with asymptomatic SLR, and 48.2% (1.64mm, p≤0.001) with the bilateral SLR. Increase in neural sliding correlated significantly with decrease of both radicular symptoms (Pearson=−0.719, p≤0.001) and low back pain (Pearson=−0.693, p≤0.001). Multivariate regression models and backward variable selection method confirmed that improvement of neural sliding effects (p≤0.004) as the main variable being associated with improvement of self-reported clinical symptoms. Conclusion. To our knowledge, these are the first non-invasive data to objectively support the association between increase in magnitude of neural adaptive movement and decrease in clinical symptoms in in-vivo and structurally intact human subjects. No conflicts of interest. Sources of funding: This research was partly funded by Finnish National VTR Grant for Medical Research, grant number 128/2012

Diagnosis. a. History and exam. i. True Lisfranc fracture dislocations are NOT difficult to diagnose. b. Midfoot sprains or subtle injuries. i. These are DIFFICULT to diagnose. - subtle x-ray findings with minimal displacement. i) Exam: - be “suspicious” of midfoot sprains. - TMT tenderness, swelling. - inability to WB. ii) Mechanism of injury:. - indirect twisting injury (athletic). - crush injury of the foot (trauma). - axial forefoot loading (dancers, jumpers). iii) Investigations:. - X-rays usually normal or subtle widening. need to assess all 3 views in detail. standing AP compare to the other side. -Stress x-rays: - if clinical symptoms indicate - severe injury + pain but x-ray looks normal. - MRI useful for anatomic/instability correlation. - CT scan good for subtle injuries/fractures and displacement. - Bone scan positive in subacute/chronic pain situation. Treatment. a) Surgical Indications. i) Any displacement/positive stress xrays/test. ii) Surgical technique. - open reduction or closed and percutaneus fixation. - anatomic reduction essential. - NWB period up to 6 weeks. - WB with protection for another 4-6 weeks. iii. Screw vs tightrope fixation. iv. Hardware removal. b) Non-operative. i) Stable non-displaced sprain (need to make sure this is stable, ie stress views). - 6 to 8 weeks NWB. - expect prolonged recovery up to 6 months with. proper treatment. Controversial Issues:. a. Do all injuries with mild displacement have to be fixed operatively?. b. Arthrodesis vs fixation for soft tissue lisfranc with mild displacement?. c. Arthrodesis vs fixation subacute or chronic presentation?. d. Hardware removal?

Introduction and purpose: Infections of total hip prostheses are one of the most serious complications that beset this procedure. Their incidence in the world literature is of 1%. However this figure rises to 16% in the case of implants secondary to fractures in patients with multiple pathologies. In this study we conduct a descriptive analysis of the qualitative variables after the implementation of an action protocol to address this complication. Materials and methods: A consecutive series of 694 patients was studied (420 females, 60.52%, and 274 males, 39.48%). Out of these 233 cases were secondary to fractures ( 60 males and 173 females), which meant that treatment was administered as an emergency (in the first 48 hours), and 461 were primary (241 males and 247 females). The variables related to an infection risk were studied, a distinction being made between an acute and a chronic infection based on CCD criteria. In acute cases, surgical cleaning was performed; in subacute cases, a two-stage replacement was chosen and for chronic infections we performed a resection arthroplasty if the two-stage replacement failed. Results: We performed a frequency and exponential chi square study which yielded 37 cases (5.33%) of implant infection (11 males, 26 females).The most frequently isolated germ was Staphilococus Aureus. 74% of cases treated with surgical cleaning after a diagnosis of acute infection are now infection-free after a two-year follow-up. 60% of subacute cases, where a two-stage replacement was performed, show a satisfactory result. As regards resection arthroplasty, the success of treatment was around 92%,with a p< 0.005 value. Conclusions: Careful patient selection and early diagnosis are fundamental to obtain good results in the treatment of THP infections

Purpose of the study: Infection is a rare complication of shoulder arthroplasty (0–4% according to Cofield). Many therapeutic options are available. Here we evaluated the midterm results obtained after arthroplastic resection used for the treatment of acute or subacute infections. Material and methods: This series included nine patients (five females and four males) treated by arthroplastic resection. The dominant side was involved in five patients. Mean age at implantation was 63.5 years. The cause was a traumatic event in six cases, the others involving centered osteoarthritic degeneration, with one excentered case and one radiation-induced necrosis. Mean age at removal was 66 years. Mean duration of implantation was 2.39 years. The infection was subacute (two months to one year) in one patient and chronic (longer than one year) in eight. Implants were: cemented seven Aequalis prostheses (four for trauma, two with humerus prosthesis only, one total arthroplasty), one Depuy delta III reversed prosthesis, and one long Neer stem. The mean Constant score was 57.166 and the subjective outcome was considered good in six shoulders, fair in one, and poor in two before the infection-related degradation. Outcome of treatment was assessed clinically (Constant score and subjective assessment), and radiographically. Blood cell counts, erthrocyte sedimentation rate, and C-reactive protein levels were noted preoperatively and at last follow-up. The bacteriological results were available in all cases. Treatment consisted in arthroplastic resection in all nine shoulders, one using a spacer. Mean duration of postoperative antibiotic therapy was four months. Results: A staphylococcal infection was identified in eight of the nine patients. Intraoperative complications were noted in 20%. Bacteriological cure was achieved in all patients at mean follow-up of four years, but with a significant functional impact (mean Constant score 28 points). Pain relief was satisfactory or very satisfactory in 100%. The subjective outcome was noted fair or poor in eight of the nine patients. Discussion: Our results are compared with the data in the literature from the two main international series (Cofield, Boileau). Conclusion: Our technique enabled bacteriological cure in 100% of patients who were all pain free, but at the cost of lost function

Background. There is a recent interest and focus on reducing the length of stay and early discharge after total joint replacement (TJR). However, safety criteria for same-day (SD) or next-day (ND) home discharge are not well defined. We implemented a screening questionnaire to identify patients that qualify for early home discharge. The aim of this study was to assess the efficiency of this questionnaire and short-term outcomes including re-admission and peri-operative complications after TJR. Methods. Between January 2016 and July 2017, 423 consecutive primary hip and knee arthroplasties were performed by the two senior surgeons at our institution. All cases were followed for a minimum of 3-month prospectively after institutional review board approval. Patients were divided based on using a pre-operative questionnaire to determine their disposition after surgery. Group 1 includes 121 cases as control and group 2 includes 302 cases with pre-operative questionnaire. Spinal anesthesia and multimodal pain management including peri-articular injection was used in all cases. The pre-operative questionnaire (PQ, Swiftpath, Inc) included an overall score based on age, comorbidities, body mass index, physical assessment, motivation, comprehension, family support, home setup (i.e. easy access/stairs), proximity to the hospital and lack of serious barriers to early home discharge. Patients were divided into 3 categories based on the score: SD/ND home, regular home discharge and rehabilitation/subacute nursing facility (SNF) discharge. Length of stay (LOS), post-operative complications, readmissions, and discharge destination were assessed. Correlation the questionnaire score and outcomes were assessed. Results. In group 1, 29% of the patients were discharged home after minimum 2 days after surgery with home services and 71% were discharged to short- or long-term rehabilitation center. The mean length of stay was 4.6 ± 2.5 days (range 2 to 7 days). 3% had symptomatic DVT and one patient pulmonary embolism during hospital stay, all after total knee arthroplasty. There was one re-operation for acute periprosthetic infection (0.8%), two cardiopulmonary events (1.6%), and 4 other ER visits for inadequate pain control (3%). In group 2, 51% of the patients were discharged home, 6% of which (10 patients) were same-day discharge. The mean length of stay was 2.2 ± 0.8 days (range 0 to 5 days). One patient (1%) had symptomatic DVT. There were 5 (1.6%) ER visits for wound concerns and pain. There were no acute re-admissions, infections or re-operations. Conclusions. Implementation of a screening questionnaire for SD/ND early discharge is safe and results in significant reduction of length of stay, higher discharge to home, lower rate of DVT/PE/cardiopulmonary complications and less ER visits

Aims

National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD.

Aims

Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analyzed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days.

Aim. Propionibacterium acnes (PA) is an important cause of shoulder prosthetic joint infections (SPJIs) for which the optimal treatment has not yet been determined. Rifampicin and Levofloxacin both showed not benefit in recent experimental models of PA-SPJIs. We describe herein the experience of five different medical French centers in order to assess factors associated with patient's outcome with special emphasize on antibiotic regimens. Method. A multicentric retrospective study was performed, on consecutive patients with PA – related SPJIs diagnosed on the basis of at least 2 or more positive cultures of either per-operative or joint aspiration and clinical history compatible with a PJI according to the current guidelines. All patients had surgical management, followed by systemic antibiotic therapy. Remission was defined as an asymptomatic patient with functioning prosthesis at the last contact. Results. Fifty-nine patients of mean age 66.2 ± 10.5 years were included. Most patients were at least ASA 2 (66%), 8 (14%) diabetes mellitus, 3 (5%) had neoplasia. Fourteen patients (24%) had acute, 34 (58%) subacute, and 11 late infections (19%). The mean delay from symptoms of infection to surgery was 89 ± 141 days (1–660). Surgical management consisted in implant exchange in 40 (68%) patients. Antibiotic treatment included mainly clindamycin (49%), levofloxacin (44%) and rifampin (17%), with a mean duration of 52.3 ± 31.9 days. The mean follow-up duration was 540 days ± 488 (range 12 ™ 1925). Forty-five patients were in remission (76%) in this study, 8 patients had a relapsing infection (14%), 1 a recurrence (2%) and 5 a superinfection ™ i.e, due to a different pathogen − (8%). In monovariate analysis, rifampicin/levofloxacin treatment was significantly associated with failure (p=0.038). In multivariate analysis, levofloxacin use and implants retention were significantly related to failure (p=0.02 and p=0.003, respectively). Conclusions. Our results suggest that implant retention and levofloxacin use are two independents factors of failure in patients treated for PA – related SPJIs

Aim. Infections after total elbow arthroplasty are more frequent than after other joint arthroplasties. Therapeutic management varies depending of the patient status, the time of diagnosis of the infection, the status of the implant as well as the remaining bone stock around the implants. Method. Between 1997 and 2017, 180 total elbow arthroplasties were performed in our department. Eleven (6%) sustained a deep infection and were revised. Infection occurred after prosthesis of first intention in 4 and after a revision procedure in 7. Etiologies were: rheumatoid arthritis in 6, trauma sequela in 4 and osteosarcoma in 1. There were 7 women and 4 men of 59 years on average (22–87). Delay between the prosthesis and the diagnosis of infection was 66 months (0.5–300). The infection was stated as acute (<3week) in one, subacute (between 3 week and 3 months) in 1, and chronic (>3 months) in 9. Isolated bacteria were: Staphylococcus (10), Streptococcus (1), P. acnes (1), and Proteus mirabilis (1). Infection were poly microbial in 2 cases. A simple lavage with debridement was performed in 3 cases (Group 1), a 2-stage revision in 4 (Group 2), and a definitive removal of the prosthesis in 4 (Group 3). Adapted antibiotics were prescribed for all patients during at least 6 weeks. Results. All patients were reviewed with 59 months average follow-up. Eight patients were cured of their infection thanks to the initial therapeutic strategy. For 2 patients of Group 2, infection reccurrency required a new surgical procedure with one simple lavage/debridement for one, and 3 lavage/debridement for the other making it possible to cure the infection. For one patient of Group 1, a failure of lavage/debridement required removal of the implants. The MEPS reached 72 points: 67 points for patients of Group 1, 76 points for patients of Group 2, and 74 points for patients of Group 3. Complication rate was 36% (4): 2 ulnar nerve impairment with dysesthesia, one radial nerve palsy, and one humeral stem loosening. Conclusions. An adapted therapeutic strategy can allow suppression of the responsible bacteria after infection of total elbow arthroplasty. Sometimes, several procedures are necessary to obtain the cure. Better functional results were obtained when the prosthesis could be retained or replaced, but satisfactory results could also be obtained after resection arthroplasty when the humeral columns have been preserved to stabilize the joint

Aims

The underlying natural history of suspected scaphoid fractures (SSFs) is unclear and assumed poor. There is an urgent requirement to develop the literature around SSFs to quantify the actual prevalence of intervention following SSF. Defining the risk of intervention following SSF may influence the need for widespread surveillance and screening of SSF injuries, and could influence medicolegal actions around missed scaphoid fractures.