Abstract. Introduction. Minimising postoperative complications and mortality in COVID-19 patients who were undergoing trauma and orthopaedic surgeries is an international priority. Aim was to develop a predictive nomogram for 30-day morbidity/mortality of COVID-19 infection in patients who underwent orthopaedic and trauma surgery during the coronavirus pandemic in the UK in 2020 compared to a similar period in 2019. Secondary objective was to compare between patients with positive PCR test and those with negative test. Methods. Retrospective multi-center study including 50 hospitals. Patients with suspicion of SARS-CoV-2 infection who had underwent orthopaedic or trauma surgery for any indication during the 2020 pandemic were enrolled in the study (2525 patients). We analysed cases performed on orthopaedic and trauma operative lists in 2019 for comparison (4417). Multivariable Logistic Regression analysis was performed to assess the possible predictors of a fatal outcome. A nomogram was developed with the possible predictors and total point were calculated. Results. Of the 2525 patients admitted for suspicion of COVID-19, 658 patients had negative preoperative test, 151 with positive test and 1716 with unknown preoperative COVID-19 status. Preoperative COVID-19 status, sex, ASA grade, urgency and indication of surgery, use of torniquet, grade of operating surgeon and some comorbidities were independent risk factors associated with 30-day complications/mortality. The 2020 nomogram model exhibited moderate prediction ability. In contrast, the prediction ability of total points of 2019 nomogram model was excellent. Conclusions. Nomograms can be used by orthopaedic and trauma surgeons as a practical and effective tool in postoperative complications and mortality risk estimation

Graphene is a two-dimensional structure that is made of a single-atom-thick sheet of carbon atoms organised in hexagonal shapes. It is considered to be the mother of all graphite or carbon-based structures. It has shown exceptional physical and chemical properties which possess potential future applications. Graphene has an elasticity index similar to rubber and a hundred times tensile strength of steel and is even sturdier than diamonds. It is a very efficient biosensor with its exceptional electronic conductivity far greater than even copper. It is a potential future low cost material and its scalable production ability makes it even more attractive. The rediscovery of Graphene in 2008 saw few potential medical applications, specifically in the field of drug delivery, gene and cancer therapy.

Nao graphene has extensive thermal conductivity and reflexivity, which can conceivably change imaging especially muskeloskeletal imaging and notably as a contrast material. It has been found to be a safe and a cheaper IV contrast agent in USA in 2012. Being an efficient biosensor especially in conducting electricity, it could assist in prosthetic and bionic limbs or prosthesis. Its durable stubborn properties, a composition which exceeds the strength of steel and light weight structure may create a potential material to develop into a new generation of a low profile internal fixing devices like plats. Most importantly, its scaffolding cell culturing assets could change the whole concept of prosthesis from mechanical press fit fixation to more dependence on bio adhesiveness.

Aims. This observational cross-sectional study aimed to answer the following questions: 1) how has nonunion incidence developed from 2009 to 2019 in a nationwide cohort; 2) what is the age and sex distribution of nonunions for distinct anatomical nonunion localizations; and 3) how high were the costs for surgical nonunion treatment in a level 1 trauma centre in Germany?. Methods. Data consisting of annual International Classification of Diseases (ICD)-10 diagnosis codes from German medical institutions from 2009 to 2019, provided by the Federal Statistical Office of Germany (Destatis), were analyzed. Nonunion incidence was calculated for anatomical localization, sex, and age groups. Incidence rate ratios (IRRs) were determined and compared with a two-sample z-test. Diagnosis-related group (DRG)-reimbursement and length of hospital stay were retrospectively retrieved for each anatomical localization, considering 210 patients. Results. In 2019, a total of 11,840 nonunion cases (17.4/100,000 inhabitants) were treated. In comparison to 2018, the incidence of nonunion increased by 3% (IRR 1.03, 95% confidence interval (CI) 0.53 to 1.99, p = 0.935). The incidence was higher for male cases (IRR female/male: 0.79, 95% CI 0.76 to 0.82, p = 0.484). Most nonunions occurred at the pelvic and hip region (3.6/100,000 inhabitants, 95% CI 3.5 to 3.8), followed by the ankle and foot as well as the hand (2.9/100,000 inhabitants each). Mean estimated DRG reimbursement for in-hospital treatment of nonunions was highest for nonunions at the pelvic and hip region (€8,319 (SD 2,410), p < 0.001). Conclusion. Despite attempts to improve fracture treatment in recent years, nonunions remain a problem for orthopaedic and trauma surgery, with a stable incidence throughout the last decade. Cite this article: Bone Joint Res 2022;11(8):541–547

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

Aim. The aim of the present work was (i) to survey the situation of healthcare regarding the use of antibiotics in orthopaedics and trauma surgery in Germany, (ii) to determine which empiric antibiotic regimens are preferred in the treatment of periprosthethic joint infections (PJI) and (iii) to evaluate the hypothetical antibiotic adequacy of the applied empirical antibiotic therapy regimens based on a patient collective of a German university hospital. Method. A survey on empirical and prophylactic antibiotic therapy was conducted at German university and occupational health clinics (BG clinics), each in the specialties of orthopedics and trauma surgery. A total of 71 clinics were contacted by email. The questionnaire sent included open-ended questions on systemic antibiotic prophylaxis in primary hip arthroplasty; a distinction was made between hip arthroplasty due to femoral fractures and elective hip arthroplasty. In addition, the empirical antibiotic therapy used in PJIs was surveyed. To determine the success rate of prophylaxis and therapy according to sensitivity to the antibiotics applied, the survey results were compared with previously published data on antimicrobial treatment in n=81 PJI patients treated in our department between 2017 and 2020. Results. In 93.2% (elective) and 88.6% (fracture care) of the hospitals, 1st- and 2nd-generation cephalosporins are administered perioperatively for infection prophylaxis in primary hip arthroplasty. In contrast, empiric antibiotic treatment for PJI showed a clearly inhomogeneous therapeutic picture. Monotherapy with an aminopenicillin/betalactamase inhibitor is most frequently used (38.7%); 1st- and 2nd-generation cephalosporins are second most frequently used as monotherapy (18.2%). In addition, dual combination therapies have become established, mostly aminopenicillin/betalactamase inhibitor or 1st- and 2nd-generation cephalosporins, whose administration is supplemented with another antibiotic. The most common combination in PJI is aminopenicillin/betalactamase inhibitor + vancomycin (11.4%). The most widely used therapy (monotherapy with aminopenicillin/betalactamase inhibitor) would have covered 69.0% of PJI patients. Monotherapy with 1st- and 2nd-generation cephalosporins would have been susceptible to 57.8% of PJI patients. In contrast, a combination of vancomycin + 1st- and 2nd-generation cephalosporins would have been most effective, with an efficacy of 91.5% according to the resistograms, but this was used by only two hospitals. Conclusions. Empirical antibiotic therapy for the treatment of PJI is applied in more than half of the clinics with a single broad-spectrum beta-lactamase inhibitor antibiotic. This discrepancy between the everyday care in the clinics and the administration of clearly more effective combination therapies underlines the need for recommendation guidelines

Background: Musculo-skeletal conditions account for at least 10% of General Practice consultations yet the average time spent by UK medical students in orthopaedic and trauma surgery is only 2.7 weeks. Aim: This study assessed whether a seven-week undergraduate musculoskeletal teaching program introduced in 2006 improved performance. Methods: This seven week program combined Orthopaedic and Trauma Surgery with Rheumatology and allied specialities. Its main elements were weekly plenary sessions, specialist clinics, a task-based workbook, regular assessments and traditional firm based teaching. The performance of 139 students who attended the new curriculum in its first year of introduction was assessed using multiple choice questions just before their final examinations in 2008 and was compared to that of a control group of students assessed in 2005 prior to program introduction. Results: The 2008 students showed a 6% improvement in MCQ scores (p< 0.001) over the 2005 graduates. There was no difference between the 2005 students and a second control group of 46 students from 2008, who did not attend the new teaching program. Conclusion: The program improved performance by providing more focused musculoskeletal training using available resources and by increasing the program duration

Abstract. Background. The aim of the present experimental study was to analyse vancomycin elution kinetics of nine bone fillers used in orthopaedic and trauma surgery over 42 consecutive days. Methods. Two allograft bone chips (carriers 1 and 2), a calcium-sulfate matrix (carrier 3), a hydroxyapatite/calcium-sulphate composite (carrier 4), four bone cements (carriers 5-8) and a pure tricalcium phosphate matrix (carrier 9), either already contained vancomycin, or were mixed with it following manufacturer's recommendations. Over 42 days, half of elution medium was substituted by the same amount of PBS at 9 distinct time points. Vancomycin concentration in obtained samples were measured with a kinetic microparticle immunoassay, and masses consecutively calculated. To enhance comparability between carriers analysed, vancomycin mass released related to overall mass within each probe was determined. Notably, elution kinetics of carriers 1 to 4 have been published previously. Results. All carriers initially released high vancomycin masses, followed by constant reduction later into the experiment. Mean initial vancomycin masses released after 4 hours were highest for carriers 1 (337.7 ± 76.2 mg), 9 (68.4 ± 4.9 mg), and 2 (49.0 ± 54.6 mg). From prefinal (35 days) to last measurement (42 days) carriers 2 (8.6 ± 4.8 mg), 1 (2.4 ± 1.0 mg), and 5 (0.1 ± 0.1 mg) had released highest vancomycin masses. Notably, all five bone cements tested only released a small percental amount of their total mass up to the last measurement (42 days; 2.1% – 9.3%), whilst allografts and resorbable synthetic bone fillers discarded high percental values (22.5% – 79.2%). Conclusions. Elution kinetics differ between 9 antibiotic-loaded bone fillers, with high vancomycin masses released by allografts and resorbable bone fillers over time. Transferred to clinical practice, these may be favoured over bone cements in case prolonged and high antibiotic release is warranted rather than mechanical stability

Introduction. Surgical site infections (SSI) are related to a surgical procedure and affect the surgical wound or deeper tissues. With continuing emphasis on clinical governance and quality control, there is increasing demand from both patients and government for methods of assessing surgical results. Rates of morbidity and mortality may play important roles in these assessments. When crude comparisons between hospitals in the incidence of SSI are made, these should at least be stratified by the type of procedure. The aim of this study is to fix SSI incidence in relation to surgical procedure. Methods. This report contains data of 19.948 procedures collected from 1996 to 2008 at a Specialist Orthopaedic Hospital and analyzed by a specific software designed for the study of infection in orthopaedic and trauma surgery. The SSI surveillance is focused on categories of surgical procedure (Hip Arthroplasty, Knee Arthroplasty, Spine Surgery and Hip Fracture Surgery) with each category containing a defined set of similar procedures. A basic of demographic data and details about operation itself are collected for each procedure. Patients are followed up throughout their hospital stay and after hospital discharge. We present the incidence of SSI by risk group and surgical procedure. SSI are categorized in type, moment of diagnosis and micro-organisms reported. Analysis of the data was performed (SPSSv15.0 ®). Statistical methods used to determine significance were the independent samples t test, Pearson X2 test, Odds ratio and Spearman correlation coefficient, with a significance level of p<0,05. Results. Rates of SSI are highest in hip hemiarthroplasty after fracture and in hip and knee revision procedures. Rates of SSI increase with the number of risk factors present in the patient, especially after fracture procedures. The most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. 38% of the infections arise after one year of surveillance. Conclusions. Our results confirm difference in rates of SSI depending of surgical procedure in orthopaedic and trauma surgery. We believe that our decision to monitor infection with a long term follow up it's the better way to avoid under-reporting of infection. Our study has also demonstrated the extent to which the emerging problem of infection due to MRSA has affected orthopaedic surgery. The risk of acquiring SSI caused by MRSA was particularly high in patients after hip fracture surgery. Rates of SSI increase with the number of risk factors present in the patient, especially after fracture procedures. Globally, the most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. 38% of the infections arise after one year of surveillance

Aim. Implant-associated infection usually require prolonged treatment or even removal of the implant. Local application of antibiotics is used commonly in orthopaedic and trauma surgery, as it allows reaching higher concentration in the affected compartment, while at the same time reducing systematic side effects. Ceftriaxone release from calcium sulphate has a particularly interesting, near-constant release profile in vitro, making it an interesting drug for clinical application. Purpose of the present study was to investigate the potential cytotoxicity of different ceftriaxone concentrations and their influence on osteogenic differentiation of human pre-osteoblasts. Method. Human pre-osteoblasts were cultured up to 28 days in different ceftriaxone concentrations, ranging between 0 mg/L and 50’000 mg/L. Cytotoxicity was determined quantitatively by measuring lactate dehydrogenase release, metabolic activity, and cell proliferation. Gene expression analysis of bone-specific markers as well as mineralization and protein expression of collagen-I (Col-I) were investigated to assess osteogenic differentiation. Results. Cytotoxic effects on human pre-osteoblasts could be shown above 15’000 mg/L after 1 and 2 days, whereas subtoxic effects could be observed at concentrations at 500 mg/L after 10 days. Cell proliferation showed no clear alteration up to 1000 mg/L, though a notable decline at 1500 mg/L could be seen after 10 days. Gene and protein expression of Col-I showed a concentration-dependent decrease at day 10 and 14, but also mineralization levels of human pre-osteoblasts presented a similar trend at day 28. Interestingly, the degree of mineralization was already impaired at concentrations above 250 mg/L. Conclusions. These findings provided extensive insights into the influence of different ceftriaxone concentrations on viability, proliferation, gene, and protein expression but also mineralization of human bone pre-osteoblasts. While short-term cytotoxicity is observed only at very high concentrations, metabolism may be impaired at much lower concentrations when exposure is prolonged. Release of ceftriaxone expected from calcium sulphate however remains below thresholds of impaired bone mineralization, even after 4 weeks of exposure. This study demonstrates the importance of properly selecting and monitoring antibiotic concentrations during clinical application

Device-associated infection remains a serious clinical problem in orthopaedic and trauma surgery. The emergence of resistant organisms such as methicillin resistant Staphylococcus aureus (MRSA) has further exacerbated this problem by limiting the range of treatment options. Currently, systemic antibiotic therapy is the cornerstone of treatment, alongside surgical resection of infected tissues and implant removal. The potential for antibiotic loaded biomaterials to support the prevention and treatment of infection is significant, although the currently available options are limited in number and often re-purposed from other applications e.g. antibiotic loading of bone cement. The first part of the talk will cover the basic concepts involved in antibiotic treatment, with an emphasis on the ideal antibiotic release kinetics from biomaterials, and how bacterial biofilms and antibiotic resistance influence antimicrobial efficacy. The next generation of biomaterials for antibiotic delivery should be specifically designed with this knowledge in mind. Regulatory approval of antimicrobial combination devices, however, is an evolving process as regulatory bodies seek more robust and clinically relevant efficacy data. Approval will require preclinical efficacy using standardized animal models that recapitulate the key features of the clinical disease. The second part of this talk will cover best practice in this important stage of development

Aim. Fracture related infection (FRI) remains a challenging diagnosis in orthopedic and trauma surgery. In addition to clinical signs and imaging, serum inflammatory markers are often used to estimate the probability of FRI. To what extent serum inflammatory markers can be used to rule out and diagnose FRI remains unclear. The aim of this systematic review was to assess the diagnostic value of the serum inflammatory markers C-reactive protein (CRP), leukocyte count (LC) and erythrocyte sedimentation rate (ESR) in suspected fracture related infection. Method. PubMed, Embase and Cochrane databases were searched for all articles focusing on the diagnostic value of CRP, LC and ESR in FRI. Studies on other inflammatory markers or other types of orthopedic infection, such as periprosthetic and diabetic foot infections, were excluded. For each serum inflammatory marker, all reported sensitivity and specificity combinations were extracted and graphically visualized. Average estimates were obtained using bivariate mixed effects models. This study utilized the QUADAS-2 criteria and was reported following the PRISMA statement. Results. The search resulted in 8280 articles, of which seven were eligible for inclusion. One study was excluded after quality assessment. CRP was reported in all included studies, with sensitivity ranging from 60.0 to 100.0% and specificity from 34.3 to 85.7%. Five of these studies were pooled. The average pooled sensitivity and specificity of CRP were, respectively, 77.0% (95% CI 66.5–85.0%) and 67.9% (95% CI 38.7–87.6%). LC was reported in five studies. Sensitivity ranged from 22.9 to 72.6% and specificity from 73.5 to 85.7%. The results of four of these studies were pooled, resulting in a 51.7% (95% CI 27.2–75.5%) sensitivity and 67.1% (95% CI 19.3–50.2%) specificity. ESR was reported in five studies. Sensitivity and specificity ranged from 37.1 to 100.0% and 59.0 to 85.0% respectively. Three of these studies were pooled, showing a 45.1% (95% CI 37.8–52.6%) sensitivity and 79.3% (95% CI 71.7–85.2%) specificity of ESR. Four studies analyzed the combined value of inflammatory markers, reporting an increased diagnostic accuracy. These results could not be pooled due to heterogeneity. Conclusions. The serum inflammatory markers CRP, LC and ESR are insufficiently accurate to diagnose FRI. These markers cannot rule out the presence of FRI, but they may be used as a suggestive sign in the diagnosis of FRI

The first generation of surgical robots which has been used in orthopaedics was characterized by automatic performance of certain tasks like milling of bone cavities or planes. These systems have not been successful as their application and operation suffered from a number of unacceptable drawbacks. Presently computer assisted surgery is dominated by surgical navigation systems where position and orientation of manually guided instruments are visualized on a computer screen as an overlay to the picture of the anatomical structure. However, new concepts of surgical robots make the benefits of using robotic systems more evident. Such robots do not operate automatically but are designed as assistance systems which support the surgeon by interactive operating modes. Compared to manual instrument guidance in pure navigation they offer several additional advantages some of which are particularly valuable to support less or minimal invasive operating techniques. No problems due to tremor or unintentional slipping of the tool. Precise drilling or reaming by stable tool guidance, surgery will be exact and reproducible to achieve pre-operatively planned targets, to overcome the ergonomic problems, such as difficult hand-eye-coordination and frequent changes of viewing direction. The application of interactive assistance robots in orthopaedic and trauma surgery is illustrated by describing exemplary procedures

Introduction: Scapholunate dissociation can occur after trauma or as part of a degenerative process. In the acute situation, it can be a difficult finding to recognise. There is little doubt that the best results of treatment in acute cases are obtained after an early primary repair. However, many patients do not present within a timescale considered optimum for primary repair. I will discuss a personal approach to managing this condition at each stage of presentation, considering how appropriate each alternative treatment may be, and describing in detail what happens to such patients in my practice. Diagnosis: This is perhaps the biggest challenge in this condition. As specialist hand surgeons, we pride ourselves on a diagnostic suspicion whenever we are met with an appropriate history or likely injury mechanism. We are able to assess the patient individually, their plain radiographs, MRI arthrograms and arthroscopic findings. The challenge in providing a service for this injury, is to extend that knowledge (or make it readily accessible) to a wider group of generalists in Orthopaedic Surgery, Trauma Surgery and Emergency Medicine. I will describe my method of assessment with preferred imaging techniques. Decision making: Decision making in managing scaph-olunate ligament dissociation is not straightforward. A ‘recipe book’ approach will not provide the best for each individual patient, and management must be tailored to patients, injury types, duration and surgeon’s abilities. I will illustrate some of the pitfalls in decision making with a series of case examples, and explain my personal approach. Treatment: Operative treatments fall into 3 categories;. Acute repair. Reconstruction. Salvage. I will describe my preferred techniques, which procedures I no longer perform (and why) and rehabilitation programmes in detail for these categories

Introduction and Aims: Randomised controlled trials (RCTs) are frequently presented as the best design for studies of treatment effect because they minimise bias from unknown confounders. But, very few have been performed in orthopaedic and trauma surgery in comparison to other areas of medicine. This study investigated the perceived obstacles to performing RCTs, in order to identify areas where novel aspects of study design may facilitate randomisation in orthopaedic research. Method: A qualitative study was performed using a deliberate maximum variation sample of 24 orthopaedic surgeons from four countries, involved in all aspects of practice, teaching, research, research funding, ethical approval and publication. A semi-structured interview was used to explore surgeons’ perceptions of obstacles to performing RCTs. A computer-assisted framework approach was used to analyse transcripts of these interviews, and to identify consistent themes and connections between them. Results: Thirty-four discrete obstacles to performing RCTs in trauma and orthopaedic surgery were identified and classified. Many of these fell into six main themes:. A non-evaluative culture;. Misunderstanding of the scientific basis of trial design;. Lack of individual equipoise;. The complexity of the relationship between patient and surgeon;. Inadequate measures of outcome;. Practical problems associated with long follow-up, clinical work load and lack of funding. Conclusion: A complex set of perceived problems were identified. None of these problems is insurmountable. The performance of RCTs would be encouraged by development of a more evaluative culture, collaboration between surgeons and epidemiologists, and greater resources for, and commitment to, clinical research. Novel study designs to address lack of individual equipoise are possible and offer the prospect of much greater use of randomisation

Introduction: Extracorporeal shock wave therapy (ESWT) covers a multitude of different indications in modern orthopedics, however, bacterial infections are still considered as contraindications. The goal of the present study was to determine the effect of ESWT on growth of clinically relevant bacteria in orthopedic and trauma surgery. Methods: Standardised suspensions of a methicillin sensitive and a methicillin resistant strain of Staphylococcus aureus, and reference strains of Staphylococcus epidermidis, Pseudomonas aeruginosa and Enterococ-cus faecalis were subjected to 4000 impulses of high-energy shock waves with an energy flux density (EFD) of 0.96 mJ/mm2 and a frequency of 2 Hz. Furthermore, corresponding suspensions of S. aureus ATCC 25923 were exposed to different impulse rates of shock waves (1000 to 6000 impulses) and to different EFDs up to a maximum of 0.96 mJ/mm2 (2 Hz) to evaluate the influence of shock wave parameters. Subsequently, viable bacteria were quantified by culture and compared with an untreated control. Results: A highly significant antibacterial effect of the ESWT was demonstrated for all bacterial strains with a reduction of growth to values between 1,1% and 29,7% (P < 0.01). Reference strains of S. aureus and S. epidermidis reacted most sensitive whereas E. faecium demonstrated highest resistance against high-energy shock waves. After applying different energy levels to S. aureus, a significant bactericidal effect was observed only with a minimum threshold EFD of 0.59 mJ/mm2 (P < 0.05). A threshold impulse rate of more than 1000 impulses could be defined to reduce bacterial growth of S. aureus (P < 0.05). Further elevation of energy and impulse rate exponentially increased bacterial killing. Conclusions: ESWT proved to exert significant antibacterial effect in an energy-dependent manner. The results suggest that infections are not necessarily contraindications to shock wave therapy and could even represent a new indication for ESWT. However, clinical relevance should be assessed in vivo in an animal model

Introduction: There has been a substantial increase of Clostidium Difficile (C.difficile) in Europe over the last decade. This increased incidence of C.difficile has been attributed in part to the prophylactic use of antibiotics during orthopaedic and trauma surgery. The consequences of a C.difficile infection can be an increase in mortality, length of stay and cost of medical care. The mortality associated with C.difficile has been quoted to be up to 25% in frail elderly people and the cost of treating a single case of C. difficile infection has been estimated at 4500 Euros (£4000). The antibiotic prophylaxis for orthopaedic and trauma patients undergoing metal work implantation was changed in our unit to specifically reduce the incidence of C.difficile. The aim of this study was to determine whether this change did reduce the incidence of post-operative C.difficile infections presenting on the orthopaedic ward. The secondary aim was to ensure that the change in prophylaxis did not increase the incidence of deep wound infections. Method: The old prophylactic protocol involved a dose of Cefuroxime at induction, followed by two further doses post-operatively. The new protocol was a single dose of Gentamicin and Flucloxacillin or a single dose of Gentamicin and Teicoplanin (if MRSA positive or penicillin allergy) at induction. The incidence of C.difficile infection and deep wound infection were recorded for a six month period prior to the protocol change and for a six month period once the new antibiotic protocol had been established. Patients included into the study were those undergoing a primary arthroplasty of the knee or hip and patients undergoing metalwork implantation for a proximal femoral fracture. Results: 1566 patients were included in the study. The overall rate of C.difficle infection reduced form 3.7% to 1.3% (p less than 0.005) after the prophylactic antibiotic protocol was changed. This was most marked in the trauma patients from 8% to 3% (p less than 0.05). There was no significant difference in the incidence of deep wound infections for the trauma patients (p equals 0.5) or the elective patients (p equals 0.7). Conclusion: The change in antibiotic prophylaxis did significantly reduce the incidence of C.difficile in patients undergoing metalwork implantation and did not change the rate of deep wound infections

Despite biomechanical well established implants and improved operation techniques we still have a too high rate of complications in orthopaedic and trauma surgery like non-union, implant loosening or implant associated infections. The development of bioactive implants could improve the clinical outcome. Growth factors are important regulators of bone metabolism. During fracture healing many growth factors or cytokines were locally released at the facture site. In several studies, different growth factors demonstrated osteoinductive and fracture stimulating properties. In vitro and in vivo studies showed a stimulating effect of Insulin-like growth factor-I (IGF-I), Transforming growth factor-A71 (TGF-A71) and Bone morphogenetic protein-2 (BMP-2) on osteo- and chondrogenetic cells. The exact effectiveness and the interaction of these growth factors during fracture healing is not known so far. Further, the local application of these factors for therapeutically use in fracture treatment is still a problem. A biodegradable poly(D,L-lactide)-coating of implants allows the local and controlled release of incorporated growth factors directly at the fracture site. The coated implant serves on the one hand for fracture stabilization and on the other hand as a drug delivery system. The coating has a high mechanical stability. The incorporated growths factors remain biologically active in the coating and were released in a sustained and controlled manner. To investigate the effect of locally released growth factors IGF-I, TGF-A71 and BMP-2 and the carrier PDLLA on fracture healing, standardised closed fracture models were developed with a close relationship to clinical situation. Further, possible local and systemic side effects were analysed. The results demonstrated a significantly higher stimulating effect of IGF-I on fracture healing compared to TGF-A71. The combined application of both growth factors showed a synergistic effect on the mechanical stability and callus remodeling compared to single treatment. The local release of BMP-2 also enhanced fracture healing significantly – comparable to combination of IGF-I and TGF-A71. However, a higher rate of mineralisation was measurable outside the fracture region using BMP-2 in a rat fracture model. Using a large animal model on pigs with a 1 mm osteotomy gap, the effectiveness of locally released growths factors could be confirmed. Further, the PDLLA-coating without any incorporated growth factors demonstrated a significantly effect on healing processes in both models. These investigations showed, that the local release of growth factors from PDLLA coated implants significantly stimulate fracture healing without any local or systemic side effects. Comparing systemic with local stimulation techniques, we found an improvement of fracture healing by systemic administration of growth hormone and local application of IGF-I and TGF-A71. However, the combined use of both simulation techniques did not lead to a further increase of healing processes. Investigations on the effectiveness and the interaction of growth factors during fracture healing demonstrated an dramatic effect in the early phases of healing processes. The growth factors stimulate the differentiation of osteoblasts with a higher production of collagen I in vitro and increase osteogenesis and vascularisation of the fracture callus in vivo. Further applications of the coating technology are the use of PDLLA and growth factor coated cages for the stimulation of intervertebral fusion and the use of PDLLA and Gentamicin coated implants in order to prevent implant associated infections. The first patients with open tibia fractures were treated with PDLLA and Gentamicin coated IM nails

Aims

Fracture-related infections (FRIs) are a devastating complication of fracture management. However, the impact of FRIs on mental health remains understudied. The aim of this study was a longitudinal evaluation of patients’ psychological state, and expectations for recovery comparing patients with recurrent FRI to those with primary FRI.

Aims

Bacteriophages infect, replicate inside bacteria, and are released from the host through lysis. Here, we evaluate the effects of repetitive doses of the Staphylococcus aureus phage 191219 and gentamicin against haematogenous and early-stage biofilm implant-related infections in Galleria mellonella.