Aims. Current National Institute for Health and Clinical Excellence (NICE) guidance advises that MRI direct from the emergency department (ED) should be considered for suspected scaphoid fractures. This study reports the current management of suspected scaphoid fractures in the UK and assesses adherence with NICE guidance. Methods. This national cross-sectional study was carried out at 87 NHS centres in the UK involving 122 EDs and 184 minor injuries units (MIUs). The primary outcome was availability of MRI imaging direct from the ED. We also report the specifics of patient management pathways for suspected scaphoid fractures in EDs, MIUs, and orthopaedic services. Overall, 62 of 87 centres (71%) had a guideline for the management of suspected scaphoid fractures. Results. A total of 11 of 87 centres (13%) had MRI directly available from the ED. Overall, 14 centres (17%) used cross-sectional imaging direct from the ED: MRI in 11 (13%), CT in three (3%), and a mixture of MRI/CT in one (1%). Four centres (6%) used cross-sectional imaging direct from the MIU: MRI in three (4%) and CT in two (2%). Of 87 centres’ orthopaedic specialist services, 74 (85%) obtained repeat radiographs, while the most common form of definitive imaging used was MRI in 55 (63%), CT in 16 (19%), mixture of MRI/CT in three (3%), and radiographs in 11 (13%). Conclusion. Only a small minority of centres currently offer MRI directly from the ED for patients with a suspected scaphoid fracture. Further research is needed to investigate the facilitators and barriers to the implementation of NICE guidance. Cite this article: Bone Jt Open 2021;2(11):997–1003

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. Methods. Data on SSF were retrospectively gathered from virtual fracture clinics (VFCs) across a large Scottish Health Board over a four-year period, from 1 January 2018 to 31 December 2021. The Bluespier Electronic Patient Record System identified any surgical procedure being undertaken in relation to a scaphoid injury over the same time period. Isolating patients who underwent surgical intervention for SSF was performed by cross-referencing the unique patient Community Health Index number for patients who underwent these scaphoid procedures with those seen at VFCs for SSF over this four-year period. Results. In total, 1,739 patients were identified as having had a SSF. Five patients (0.28%) underwent early open reduction and internal fixation (ORIF). One patient (0.06%) developed a nonunion and underwent ORIF with bone grafting. All six patients undergoing surgery were male (p = 0.005). The overall rate of intervention following a SSF was 0.35%. The early intervention rate in those undergoing primary MRI was one (0.36%), compared with three in those without (0.27%) (p > 0.576). Conclusion. Surgical intervention was rare following a SSF and was not required in females. A primary MRI policy did not appear to be associated with any change in primary or secondary intervention. These data are the first and largest in recent literature to quantify the prevalence of surgical intervention following a SSF, and may be used to guide surveillance and screening pathways as well as define medicolegal risk involved in missing a true fracture in SSFs. Cite this article: Bone Jt Open 2024;5(4):312–316

Aims. The aim of the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was to evaluate the clinical and cost implications of using immediate MRI in the acute management of patients with a suspected fracture of the scaphoid with negative radiographs. Patients and Methods. Patients who presented to the emergency department (ED) with a suspected fracture of the scaphoid and negative radiographs were randomized to a control group, who did not undergo further imaging in the ED, or an intervention group, who had an MRI of the wrist as an additional test during the initial ED attendance. Most participants were male (52% control, 61% intervention), with a mean age of 36.2 years (18 to 73) in the control group and 38.2 years (20 to 71) in the intervention group. The primary outcome was total cost impact at three months post-recruitment. Secondary outcomes included total costs at six months, the assessment of clinical findings, diagnostic accuracy, and the participants’ self-reported level of satisfaction. Differences in cost were estimated using generalized linear models with gamma errors. Results. The mean cost up to three months post-recruitment per participant was £542.40 (. sd. £855.20, n = 65) for the control group and £368.40 (. sd. £338.60, n = 67) for the intervention group, leading to an estimated cost difference of £174 (95% confidence interval (CI) -£30 to £378; p = 0.094). The cost difference per participant increased to £266 (95% CI £3.30 to £528; p = 0.047) at six months. Overall, 6.2% of participants (4/65, control group) and 10.4% of participants (7/67, intervention group) had sustained a fracture of the scaphoid (p = 0.37). In addition, 7.7% of participants (5/65, control group) and 22.4% of participants (15/67, intervention group) had other fractures diagnosed (p = 0.019). The use of MRI was associated with higher diagnostic accuracy both in the diagnosis of a fracture of the scaphoid (100.0% vs 93.8%) and of any other fracture (98.5% vs 84.6%). Conclusion. The use of immediate MRI in the management of participants with a suspected fracture of the scaphoid and negative radiographs led to cost savings while improving the pathway’s diagnostic accuracy and patient satisfaction. Cite this article: Bone Joint J 2019;101-B:984–994

Introduction. Up to 16% of scaphoid fractures are radiologically occult; failure to diagnose scaphoid fractures may lead to delayed union, nonunion or avascular necrosis. Fractures may take weeks to be excluded and many patients are unnecessarily immobilised increasing work absence, clinical reviews and cost. The use of CT early in the management of suspected occult scaphoid fractures has been evaluated. Methods. The radiology and clinical notes of all patients that had scaphoid CT scans over the preceding 3 years were retrospectively reviewed. 84 patients that had CT scans within 14 days from injury were identified. Results. 64% of CTs excluded fracture (N=54) and these patients were mobilised promptly and reviewed within six weeks. No patients returned with any complications, such as carpal instability, from this management strategy. Mean number of clinic appointments for this group was 2.34 (range 2–6). 36% of CTs were abnormal (N=30). 7% revealed occult scaphoid fractures; 18% revealed occult carpal fractures of the triquetrum, capitate and lunate respectively and 5% distal radius fractures. All patients diagnosed with fractures were successfully managed with plaster immobilisation, with one case of regional pain syndrome. Conclusions. Early CT immediately alters therapeutic decision making in suspected occult fractures preventing unnecessary immobilisation. Early CT also reduces clinic attendances for clinical and radiological review without increase in cost

Introduction:. Isolated Weber B lateral malleolus fractures heal uneventfully, but concern that late subluxation may occur due to unrecognised medial ligament tearing, despite an intact mortice on initial radiographs, often results in overtreatment. The aim of this study was to determine the incidence of late talar shift with nonoperative management in a cohort of patients with no initial talar shift, and also record functional outcomes at 16–28 months following injury. Methods:. This was a retrospective review of 129 patients with Weber B lateral malleolar fractures initially referred to the fracture clinic between October 2011 and October 2012. Eight had obvious talar shift and therefore underwent surgery, with the remaining 121 treated in plaster (n=41), a Velcro boot (n=70) or bandage (n=10). No stress x-rays or MRI scans were performed. Weight-bearing was permitted as pain allowed. Radiographs taken on discharge from the clinic were reviewed to assess talar shift. Functional outcomes assessment was carried out using Manchester Oxford Foot Questionnaire and Olerud-Molander score. Results:. None of the 121 patients had talar shift initially; 21 patients where medial injury was strongly suspected were closely followed and had check x-rays more often (average 2.9 appointments per patient) than the other groups. No patients had talar shift in any of the subsequent x-rays and therefore none underwent delayed internal fixation. The mean MOXFQ and Olerud-Molander scores were 27 and 78 respectively in 57 patients and the functional outcomes were not influenced by type of immobilisation or suspected medial injury. Conclusion:. Our observation is that the risk of late talar shift is likely to be low in patients where initial x-rays had showed no talar displacement. It may be unnecessary to perform additional tests/imaging to establish the integrity of the medial ligament as satisfactory functional results are routinely observed

Objective. Guidelines published by the British Association of Spine Surgeons (BASS) and Society of British Neurological Surgeons (SBNS) recommend urgent MRI imaging and intervention in individuals suspected of having CES. The need for an evidence based protocol is driven by a lack of 24/7 MRI services and centralisation of neurosurgery to tertiary centres, compounded by CES's significant medico-legal implications. We conducted an audit to evaluate the pathway for suspected CES in BCUHB West between 2018 and 2021. Methods. A retrospective audit of patients managed for suspected CES between 01/11/2018 and 01/05/2021 was performed, using the SBNS/BASS guidelines as the standard. Results. A total of 252 patients received an emergency MRI for suspected CES between 2018 and 2021. 99% of patients were scanned in compliance with SBNS/BASS standards. Radiological evidence of CES was found in 18% of patients. 33% of emergency scans were performed by out-of-hours services. 4% of patients had repeated scans within the same 6-month period. The majority of referrals originated from Orthopaedics surgeons (78%), or staff in the Emergency Department (8%). 92% of ambulatory patients were not admitted to hospital. During the peak of the COVID-19 pandemic, referrals increased from 2.5 to 3.5 per week. Conclusion. SBNS/BASS standards were largely met, avoiding life changing disability and medico-legal consequences. The department should continue to follow SBNS/BASS guidance on the management of individuals with suspected CES. Challenges regarding the use of repeated scans should be addressed to avoid unnecessary costs. Introduction of new early recognition guidelines and Same Day Emergency Care (SDEC) has likely driven an increase in suspected CES referrals, and subsequent MRI demand. This audit should be utilised as an ongoing tool to ensure best practice continues, and to implement simple measures which may improve compliance with the pathway

In current practice in the UK there are three main approaches to investigating suspected scaphoid fractures not seen on initial plain film x-rays. Early MRI of all cases. Review all cases in clinic at two weeks with repeat x-rays. Hybrid model. Virtual Fracture Clinic (VFC) triage to reduce those who are seen in clinic at two weeks by:. ∘. Organising early MRI for those with high-risk presentation. ∘. Discharging those with an alternative more likely diagnosis. Our unit uses the VFC model. We aimed to evaluate its efficiency, safety, clinical outcomes and economic viability. All patients attending the emergency department with either a confirmed or suspected scaphoid fracture between March and December 2020 were included (n=305). Of these 297 were referred to the VFC: 33 had a confirmed fracture on x-ray and 264 had a suspected fracture. Of the suspected fractures reviewed in VFC 14% had an MRI organised directly owing to a high-risk presentation, 79% were brought for fracture clinic review and 17% discharged with an alternative diagnosis such as osteoarthritis. Of those subsequently reviewed in fracture clinic at two weeks: 9% were treated as scaphoid fractures (based on clinical suspicion and repeat x-rays), 17% had MRI or CT imaging organised, 5% did not attend and 69% were discharged. Overall, 17% of cases initially triaged, had further imaging – 41 MRIs and 5 CTs. MRI detected: 5% scaphoid fracture, 17% other fracture, 24% bone contusion, complete ligament tear 10%, partial ligament tear 39% and normal study 10%. The results of MRI minimally affected management. 3 patients were taken out of plaster early, 1 patient was immobilized who was not previously and no patients underwent operative management. In the following 12-month period one patient re-presented with a hand or wrist issue. This approach avoided 218 MRIs, equating to £24000 and 109 hours of scanner time. VFC triage and selective use of MRI scanning is a safe, efficient and cost-effective method for the management suspected scaphoid fractures. This can be implemented in units without the resource to MRI all suspected scaphoid fractures from the emergency department

Aim. Surgical treatment of ankle fractures comes with a substantial risk of complications, including infection. An unambiguously definition of fracture-related infections (FRI) has been missing. Recently, FRI has been defined by a consensus group with a diagnostic algorithm containing suggestive and confirmatory criteria. The aim of the current study was to report the prevalence of FRI in patients operated for ankle fractures and to assess the applicability of the diagnostic algorithm from the consensus group. Method. Records of all patients with surgically treated ankle fractures from 2015 to 2019 were retrospectively reviewed for signs of postoperative infections. Patients with suspected infection were stratified according to confirmatory or suggestive criteria of FRI. Rate of FRI among patients with confirmatory and suggestive criteria were calculated. Results. Suspected infection was found in 104 (10%) out of 1004 patients. Among those patients, confirmatory criteria were met in 76/104 (73%) patients and suggestive criteria were met in 28/104 (27%) at first evaluation. Patients with clinical confirmatory criteria (N= 76) were diagnosed with FRI. Patients with suggestive criteria were further examined with either bacterial sampling at the outpatient clinic, revision surgery including bacterial sampling, or a wait-and-see approach. Eleven (39%) of the 28 patients had positive cultures and were therefore diagnosed as having FRI at second evaluation. In total 87 (9%) patients were diagnosed with FRI according to the consensus definition. Only 73 (70%) of the 104 patients with suspected FRI had adequate bacterial sampling. Conclusions. The prevalence of FRI, applying the FRI-consensus criteria, for patients with surgically treated ankle fractures was 9%. Twenty-two percent of patients who met the confirmatory criteria had negative bacterial cultures. The current study shows that we did not have a systematic approach to patients with suspected FRI as recommended by the consensus group. A systematic approach to adequate bacterial sampling when FRI is suspected is paramount. The consensus definition of FRI and its diagnostic algorithm facilitates such an approach

Aims. Metal particles detached from metal-on-metal hip prostheses (MoM-THA) have been shown to cause inflammation and destruction of tissues. To further explore this, we investigated the histopathology (aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) score) and metal concentrations of the periprosthetic tissues obtained from patients who underwent revision knee arthroplasty. We also aimed to investigate whether accumulated metal debris was associated with ALVAL-type reactions in the synovium. Methods. Periprosthetic metal concentrations in the synovia and histopathological samples were analyzed from 230 patients from our institution from October 2016 to December 2019. An ordinal regression model was calculated to investigate the effect of the accumulated metals on the histopathological reaction of the synovia. Results. Median metal concentrations were as follows: cobalt: 0.69 μg/g (interquartile range (IQR) 0.10 to 6.10); chromium: 1.1 μg/g (IQR 0.27 to 4.10); and titanium: 1.6 μg/g (IQR 0.90 to 4.07). Moderate ALVAL scores were found in 30% (n = 39) of the revised knees. There were ten patients with an ALVAL score of 6 or more who were revised for suspected periprosthetic joint infection (PJI), aseptic loosening, or osteolysis. R2 varied between 0.269 and 0.369 for the ordinal regression models. The most important variables were model type, indication for revision, and cobalt and chromium in the ordinal regression models. Conclusion. We found that metal particles released from the knee prosthesis can accumulate in the periprosthetic tissues. Several patients revised for suspected culture-negative PJI had features of an ALVAL reaction, which is a novel finding. Therefore, ALVAL-type reactions can also be found around knee prostheses, but they are mostly mild and less common than those found around metal-on-metal prostheses. Cite this article: Bone Joint Res 2024;13(4):149–156

Aims. This study aimed to explore the diagnostic value of synovial fluid neutrophil extracellular traps (SF-NETs) in periprosthetic joint infection (PJI) diagnosis, and compare it with that of microbial culture, serum ESR and CRP, synovial white blood cell (WBC) count, and polymorphonuclear neutrophil percentage (PMN%). Methods. In a single health centre, patients with suspected PJI were enrolled from January 2013 to December 2021. The inclusion criteria were: 1) patients who were suspected to have PJI; 2) patients with complete medical records; and 3) patients from whom sufficient synovial fluid was obtained for microbial culture and NET test. Patients who received revision surgeries due to aseptic failure (AF) were selected as controls. Synovial fluid was collected for microbial culture and SF-WBC, SF-PNM%, and SF-NET detection. The receiver operating characteristic curve (ROC) of synovial NET, WBC, PMN%, and area under the curve (AUC) were obtained; the diagnostic efficacies of these diagnostic indexes were calculated and compared. Results. The levels of SF-NETs in the PJI group were significantly higher than those of the AF group. The AUC of SF-NET was 0.971 (95% confidence interval (CI) 0.903 to 0.996), the sensitivity was 93.48% (95% CI 82.10% to 98.63%), the specificity was 96.43% (95% CI 81.65% to 99.91%), the accuracy was 94.60% (95% CI 86.73% to 98.50%), the positive predictive value was 97.73%, and the negative predictive value was 90%. Further analysis showed that SF-NET could improve the diagnosis of culture-negative PJI, patients with PJI who received antibiotic treatment preoperatively, and fungal PJI. Conclusion. SF-NET is a novel and ideal synovial fluid biomarker for PJI diagnosis, which could improve PJI diagnosis greatly. Cite this article: Bone Joint Res 2023;12(2):113–120

Purpose and background. Cauda equina syndrome (CES) leads to nerve compression in the lumbar spine, and requires immediate treatment to prevent permanent neurological dysfunction, including urinary/anorectal incontinence. The consequences for the patient are significant as, in the decade to 2018, CES has cost the NHS £186,134,049. No study has reported patients’ experiences of being managed with suspected CES in an emergency department (ED), and this study explores patients’ experiences and how the NHS can optimise care for patients experiencing this condition. Methods and Results. In this qualitative secondary analysis, 14 participants (aged 23–63 years) with suspected CES were purposively sampled from 4 EDs in England. Online, semi-structed interviews were undertaken (in 2021, during the pandemic), and were audio-recorded and transcribed verbatim. Data were managed using a Framework approach and analysed thematically. Three themes were identified: quality of care; environmental factors; and expectations. The quality of care included managing uncertainty, the importance of communication, appropriate assessment and follow-up care. Environmental factors, including the chairs, waiting times and the busy nature of the ED, negatively impacted patients’ experiences. Furthermore, an expectation gap was identified, as most individuals came to the ED expecting to receive a scan, an accurate diagnosis and a cure. Despite frustrations, patients expressed gratitude towards the ED staff. Conclusion. This study highlights the importance of empathically acknowledging the patient's pain and providing comprehensive assessments and management plans for people attending ED with suspected CES. Optimising the ED environment to minimise patients’ pain and distress while waiting to access care is paramount and overdue. No conflicts of interest.  . Sources of funding. Funding for primary data: Health Education England & National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Aim. Periprosthetic joint infection (PJI) is one of the main reasons for revision surgery after primary unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA) or total hip arthroplasty (THA). Currently the MSIS and EBJIS criteria sets are considered to be the gold standards in determining PJI. These criteria sets are complex and contain tests that are time-consuming and many are rather costly. Therefore, further research is indicated to find a simpler but equally reliable diagnostic test. In this study we evaluated the additional value of calprotectine measurement in synovial fluid in patients undergoing hip and knee (revision) arthroplasty following routine work-up. Method. In a retrospective cohort study, we analyzed 182 synovial fluid samples from 143 patients with suspected PJI after UKA, TKA, THA or revision arthroplasty. Twenty-six of those cases were classified as PJI according to the MSIS and EBJIS criteria. Subsequently, synovial calprotectin was determined, using a lateral flow assay and two cut-off thresholds of ≥14 mg/L and ≥50 mg/L. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of synovial calprotectin was determined. Results. When applying the MSIS and EBJIS criteria and a calprotectin level ≥14 mg/L, synovial calprotectin revealed an area under the curve of 0.96 (95% CI 0.90-1.00), with 92.3% sensitivity and 100% specificity. The PPV and NPV were 100% and 92.9% respectively. When applying the MSIS and EBJIS criteria and a calprotectin level ≥ 50 mg/L, synovial calprotectin revealed an area under the curve of 0.94 (95% CI 0.87-1.00), with 88.5% sensitivity and 100% specificity. The PPV and NPV were 100% and 89.7% respectively. Conclusions. The value of calprotectin in synovial fluid gives valuable information with a single test result, resulting in high predictive value in the diagnosis of PJI after hip or knee arthroplasty and should seriously be considered as part of PJI diagnostics in an outpatient clinical setting. The high specificity can help rule in patients that are suspected of PJI. Therefor this test can be helpful in a preop diagnostic work-up to avoid unnecessary revisions in patients with well-placed and well-fixed arthroplasties with a suspected PJI. These conclusions are independent of which criteria set was used as a gold standard

Background. Cauda equina syndrome (CES) is a spinal condition requiring emergency spinal surgery once diagnosed. The patient-reported symptoms are often subtle and none have been shown to be sensitive or specific in confirming CES. Magnetic resonance image (MRI) is the diagnostic gold standard, and guidelines recommend MRI access within 24-hours of symptom presentation. Limited sequence MRI scans (sagittal T2 sequences of the whole spine) have been shown to successfully identify patients with scan-positive CES despite reducing the duration of an MRI. The aim of this audit was to examine utilisation of same-day MRI requests by spinal practitioners from a newly operational same-day emergency care spinal unit over the two-year period. Methods and results. Data was routinely collected over the two-year period and retrospectively reviewed. Data extraction occurred for cases of suspected CES with a same-day scan. Data extraction included type of MRI scan (lumbar/ whole spine/ CES protocol); outcome (admission/ discharge); final diagnosis. After clinical examination, only 258 (24% of 1085) suspected CES cases were identified and scanned within 24 hours, 58% (n=149) of which were with CES limited sequence scans. Only 12% (n=30) demonstrated scan- positive CES resulting in surgery within 24-hours. MRI same-day requests increased between 2020 (n=81, 21%) and 2021 (n=177, 26%), although utilisation of limited sequence scans improved (n=39, 48% in 2020; n=109, 62% in 2021). Conclusion. Limited sequence MRI scans are a time- and cost-saving means of providing screening for those with suspected CES. Improved utility was demonstrated over the 2-year period by the spinal practitioners. Conflicts of interest: No conflicts of interest. Sources of funding: No sources of funding

This study describes the introduction of a virtual pathway for the management of suspected scaphoid fractures and reports patient-reported outcome measures (PROMs) and satisfaction following treatment with this service. All adult patients that presented with a clinically suspected scaphoid fracture that was not visible on presentation radiographs over a one-year period were eligible for inclusion in the pathway. Demographics, examination findings, clinical scaphoid score (CSS) and standard four view radiographs were collected at presentation. All radiographs were reviewed virtually by a single consultant hand surgeon, with patient-initiated follow-up on request. PROMs were assessed at a minimum of one year post presentation and included the QuickDASH, EQ-5D-5L, the Net Promoter Score (NPS) and return to work. There were 221 patients referred to the virtual pathway. The mean age was 41 (range 16–87; SD 18.4 years) and there were 99 men (45%). There were 189 (86%) patients discharged with advice and 19 (9%) patients were recalled for clinical review (seven undisplaced scaphoid fractures, six other acute fractures of the hand or wrist, two scapholunate ligament injuries, and four cases where no abnormality was detected). Thirteen patients (6%) initiated follow-up with the hand service; no fracture or ligament injury was identified within this group. PROMs were available for 179 (81%) patients at a mean of 19 months follow-up (range: 13 – 33 months). The median QuickDASH score was 2.3 (IQR, 0–15.9), the median EQ-5D-5L was 0.85 (IQR, 0.73–1.00), the NPS was 76, and 173 (97%) patients were satisfied with their treatment. There were no documented cases of symptomatic non-union one year following injury. This study reports the introduction of a virtual pathway for suspected scaphoid fractures, demonstrating high levels of patient satisfaction, excellent PROMs, and no detrimental effects in the vast majority of cases

The Australia and New Zealand Sarcoma Association established the Sarcoma Guidelines Working Party to develop national guidelines for the management of Sarcoma. We asked whether surgery at a specialised centre improves outcomes. A systematic review was performed of all available evidence pertaining to paediatric or adult patients treated for bone or soft tissue sarcoma at a specialised centre compared with non-specialised centres. Outcomes assessed included local control, limb salvage rate, 30-day and 90-day surgical mortality, and overall survival. Definitive surgical management at a specialised sarcoma centre improves local control as defined by margin negative surgery, local or locoregional recurrence, and local recurrence free survival. Limb conservation rates are higher at specialised centres, due in part to the depth of surgical experience and immediate availability of multidisciplinary and multimodal therapy. A statistically significant correlation did not exist for 30-day and 90-day mortality between specialised centres and non-specialised centres. The literature is consistent with improved survival when definitive surgical treatment is performed at a specialised sarcoma centre. Evidence-based recommendation: Patients with suspected sarcoma to be referred to a specialised sarcoma centre for surgical management to reduce the risk of local recurrence, surgical complication, and to improve limb conservation and survival. Practice point: Patients with suspected sarcoma should be referred to a specialised sarcoma centre early for management including planned biopsy

Purpose and background. Cauda Equina Syndrome (CES), a rare (<1 per 100,000) and potentially devasting condition, involves compression of the lumbosacral nerve roots. If not quickly identified and treated, it can lead to lasting disability, and high medicolegal costs (>£186 million in the decade to 2018). This study identified why people with suspected CES attend the emergency department (ED) and explored any delays in attending. Methods and Results. The design was a secondary analysis of a qualitative dataset comprising patients with back pain who attended the ED, undertaken using an interpretivist approach. Fourteen patients (8M:6F, aged 23–63 years) with suspected CES were purposively sampled from 4 EDs (2 Northern and 2 Southern) in England between August and December 2021. Semi-structured interviews were conducted online, audio-recorded, transcribed verbatim and analysed thematically. Acopia with pain was the biggest factor in a participant's decision to attend the ED, along with the need for a diagnosis. This pain was the worst ever experienced and debilitating, leaving people unable to cope and desperate for relief. 12/14 were advised to attend the ED following identification of red flags by: GPs (n=9); physiotherapists (n=2); surgical colleague (n=1); and 111 (n=1). Factors such as guilt, previous experience of being disregarded, and symptom misattribution were seen to cause delays in seeking care. Conclusion. This paper revealed a disconnect between the priorities of patients and clinicians prior to attending the ED. Clinicians need to validate the pain experience, communicate clearly why signs and symptoms are concerning, and convey the urgency and potential impact of CES. Conflicts of interest. None. Sources of funding. Funding for primary data: Health Education England & National. Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Abstract. Background. In 2018 NICE produced their guidelines with regards to the prevention of hospital-acquired thrombosis which extended the age range to include 16- and 17-years old patients, suggesting that these patients are risk assessed and receive thromboprophylaxis if indicated. We analysed the incidence of VTE in this age group in our institution and found it to be extremely low and often not related to risk factors commonly included in adult risk assessment tools. Methods. We retrospectively reviewed the data of 13,951 patients aged 16- and 17-years of age in our admission database at the University Hospitals of Leicester (UHL) over a period of 7 years between 2013 and 2019. This was cross-referenced with our imaging database which identified scans carried out for suspected Venous Thromboembolism (VTE). Results. There were 1,275 admissions and 12,676-day-case attendances over the study period. Of these, 145 patients had scans for suspected VTE. 13 patients had positive scans and fulfilled the inclusion criteria. Of the 13 positive scans, 10 were excluded and 3 patients were included in the study. Conclusion. This study shows that the risk of VTE in the 16- and 17-year-old age group is extremely low in patients attending hospital (0.1% in admitted patients and 0.007% in day attenders). We question whether routine risk assessment for VTE in this age group, especially using existing adult tools, is efficacious. The guidance acknowledges the evidence for prescribed drugs is both lacking and the prescription for such agents being outside their Licencing Authorisation

Aim. Successful management of native Joint septic arthritis (SA) hinges on the timely initiation of appropriate antibiotic therapy coupled with thorough joint debridement. Since 2018 we have implemented a protocol for empirical antibiotic in patients with suspected SA recommending amoxicillin/clavulanate (and cotrimoxazole in cases of beta-lactams allergy) based on local flora. Nevertheless we have recently found that institutional compliance to the protocol is only about 50% and many physicians are still choosing alternative wider spectrum regimens. The aim of this study is to assess whether current clinical and epidemiological characteristics of patients treated for this condition justify an update or whether previous recommendations are still valid. Method. All adult patients admitted to our institution with suspected SA between 2018-2022 were retrospectively reviewed. Data was collected from electronic medical records and then compared to similar data previously collected concerning the 2009-2017 period (that served as a basis for the aforementioned protocol). Results. A summary of available data from both time periods can be found in table 1. Overall, among the 35 patients with positive microbiology treated between 2018-2022, amoxicillin/clavulanate is appropriate for 30 (86%) of isolates (vs 88% in historic control). Analysing the whole cohort, we found that previous contact with healthcare services (hospital admission or prolonged ER stay) (p=0.0044) and antibiotic treatment for any infection (p= 0.0213) in the previous six months correlate with resistance to amoxicillin/clavulanate. In these patients, the proposed alternative cotrimoxazole is effective in 77% of cases. Conclusions. The institutional guideline for empirical antibiotic therapy in native joint SA remains adequate and there seems to be no justification to deviate from protocol except in cases of patients admitted to the hospital or antibiotic treatment in the previous six months. In these cases methicillin-resistance coverage is probably appropriate. Pseudomonal coverage is seldom required in SA. For any tables or figures, please contact the authors directly

Aim. Magnetic resonance imaging (MRI) and 2-[. 18. F]-fluoro-2-deoxy-D-glucose (. 18. F-FDG) Positron Emission Tomography, paired with Computed Tomography (PET/CT) are two indicated advanced imaging modalities in the complicated diagnostic work-up of osteomyelitis. PET/MRI is a relatively novel hybrid modality with suggested applications in musculoskeletal infection imaging. The goal of this study was to assess the value of hybrid . 18. F-FDG PET/MRI for chronic osteomyelitis diagnosis and surgical planning. Method. Five suspected chronic osteomyelitis patients underwent a prospective . 18. F-FDG single-injection/dual-imaging protocol with hybrid PET/CT and hybrid PET/MR. Diagnosis and relevant clinical features for the surgeon planning treatment were compared. Subsequently, 36 patients with . 18. F-FDG PET/MRI scans for suspected osteomyelitis were analysed retrospectively. Sensitivity, specificity, and accuracy were determined with the clinical assessment as the ground truth. Standardized uptake values (SUV) were measured and analysed by means of receiver operating characteristics (ROC). Results. The consensus diagnosis was identical for PET/CT and PET/MRI in the prospective cases, with PET/CT missing one clinical feature. The retrospective analysis yielded a sensitivity, specificity, and accuracy of 78%, 100%, and 86% respectively. Area under the ROC curve was .736, .755, and.769 for the SUVmax, target to background ratio, and SUVmax_ratio respectively. These results are in the same range and not statistically different compared to diagnostic value for . 18. F-FDG PET/CT imaging of osteomyelitis in literature. Conclusions. Based on our qualitative comparison, reduced radiation dose, and the diagnostic value that was found, the authors propose . 18. F-FDG PET/MRI as an alternative to . 18. F-FDG PET/CT in osteomyelitis diagnosis, if available

Aim. Treatment algorithms for fracture-related nonunion depend on the presence or absence of bacterial infection. However, the manifestation of septic nonunion varies. Low-grade infections, unlike manifest infections, lack clinical signs of infection and present similarly to aseptic nonunion. The clinical importance of low-grade infection in nonunion is not entirely clear. Therefore, the aim of this study was to evaluate the clinical relevance of low-grade infection in the development and management of femoral or tibial nonunion. Method. A prospective, multicenter clinical study enrolled patients with nonunion and regular healed fractures. Preoperatively, complete blood count without differential, C-reactive protein (CRP), and procalcitonin were obtained, clinical signs of infection were recorded, and a suspected septic or aseptic diagnosis was made based on history and clinical examination. During surgical nonunion revision or routine implant removal, tissue samples were collected for microbiology and histopathology, and osteosynthesis material for sonication. Nonunion patients were followed for 12 months. Definitive diagnosis of “septic” or “aseptic” nonunion was made according to diagnostic criteria for fracture-related infection, considering the results of any further revision surgery during follow-up. Results. 34 patients with regular healed fractures were included. 62 nonunion patients were diagnosed as aseptic, 22 with manifest, and 23 with low-grade infection. The positive predictive value was 88% and the negative predictive value 72% for the suspected diagnosis. The nonunion groups had significantly higher CRP levels than the regular healer group. Differentiation between septic and aseptic nonunion based on blood values was not possible. Low-grade infection demonstrated less frequently histopathologic signs of infection than manifest infection (22% vs. 50%, p=0.048), with 15% of regular healers having histopathologic signs of infection. Cutibacterium acnes was less present in manifest compared to low-grade infection (p=0.042). Healing rates for septic nonunion involving C. acnes were significantly lower for manifest infection (20%) than for low-grade infection (100%, p=0.002). Patients with low-grade infection were treated with systemic antibiotics less frequently than patients with manifest infection (p=0.026), with no significant difference in healing rate (83% vs. 64%), which was slightly lower for low-grade infection than for aseptic nonunion (90%). Conclusions. Low-grade infections play a significant role in nonunion development and are difficult to diagnose preoperatively due to the lack of clinical signs of infection and unremarkable blood counts. However, our results imply that for low-grade infections, antibiotic therapy may not always be mandatory to heal the nonunion. This study was supported by the German Social Accident Insurance (FF-FR0276)