Introduction. Intraarticular calcaneal fractures often need open reduction and internal fixation (ORIF) with plate osteosynthesis. The wound complication is one of the common problems encountered following this and affects the outcome adversely. Our study was done to assess how far postoperative slab/cast can avert wound complications. Methods. Out of 42 patients with unilateral intraarticular calcaneal fractures, 20 were offered postoperative slab/cast and this was continued for six weeks. The remaining 22 patients were not offered any plaster. All patients were followed-up for two years. Results. The incidence of wound dehiscence was 2 in the plaster group as well as 8 in the non-plaster group and this was statistically significant (p = 0.02). Also, significantly lower heel widening was reported in the plaster group (p = 0.03). Although, there was no significant difference in the patient-reported outcome (Maryland Foot Score) and the incidence of pain between the two groups, the occurrence of neurological deficit following surgery and the postoperative range of movements were comparable in these two groups. Conclusion. Thus, it may be concluded that postoperative plaster application for the initial six weeks could be a low-cost yet effective way to reduce wound complications following plate osteosynthesis in intraarticular calcaneal fractures

Background. Open fracture wounds are well known to be associated with infection & prolonged healing. Activity in scientific research to improve wound healing has often provided variable results. This study was done to question the de facto nature of Normal Saline as best irrigant in management of such wounds and to find out a better irrigant, if so, that does exist with due consideration to the mechanism by which saline dressings act. Material and methods. 30 patients with Grade 3 open fracture wounds were assessed over a period of three months according to Ganga Hospital Injury severity Score and were divided equally in study and control groups after adequate matching. A standard dressing protocol consisting of debridement and external fixation within 6 hours, avoidance of any antiseptic or surfactant agent, high-volume low-pressure pulsatile lavage irrigation and saline soaked gamgee pad packings with concerned solutions changed twice daily was done in respective groups. Follow-up was done by colour of healing granulation tissue, pus culture and soft tissue biopsy at Day 1, 3,7,10 & 14. Results. 6 out of 15(40%) wounds in study group were observed to have reached pink healthy granulation with low exudate by Day 14 as compared to only 3 out of 15(20%) in control group. The time taken to traverse from each stage of healing granulation was also observed to be smaller with 3% NaCl as compared to 0.9% NaCl. Although once healthy granulation stage was reached, further dressing with 3% NaCl in study group was shown to have worsening of granulation in about 33% of cases with none such observed in control. Conclusion. 3% NaCl is a better irrigant than 0.9% NaCl for dressing of Open trauma wounds during initial stages of dressing. Their effectivity in maintaining advanced granulation is although questionable, probably owing to its desiccative action

Background. The duration and extent of postoperative wound leakage after joint arthroplasty in patients with or without a complicated course, like a prosthetic joint infection (PJI), is currently unknown. Adequate differentiation between normal postoperative wound leakage and wound leakage due to a postoperative PJI is important and prevents unnecessary surgical procedures. We investigated the association between postoperative wound leakage and development of PJI in patients who used a previously developed mobile wound care app. Methods. A multicenter, prospective cohort study with patients aged 18 years or older after primary implantation or revision of a total joint arthroplasty. During 30 post-operative days after arthroplasty, patients recorded their wound status in the woundcare app. An algorithm calculated a daily score from imputed data. If the daily score exceeded a predefined threshold, the patients received an alert that advised them to contact their physician. Results. Of 1020 included patients from 11 centers, 14 patients developed a PJI. Of 1006 patients without PJI, any form of postoperative wound leakage occurred in 51%, 12%, 7% and 3% during the 1. st. , 2. nd. , 3. rd. and 4. th. postoperative week, respectively. Median duration of wound leakage was eight days (IQR 3.5–12.5) for patients with PJI and two days (IQR 0–4) for patients without PJI (p <0.001). In total, 498 (49%) patients received 2589 alerts. Receiving an alert was not predictive for the development of a PJI. The odds ratio for a PJI was higher in patients with wound leakage compared to patients without wound leakage: OR 1.76 (0.59–5.29), OR 45.42 (10.04–205.53), OR 16.76 (3.68–76.28) and OR 18.09 (1.59–205.66) in the 1. st. , 2. nd. , 3. rd. and 4. th. postoperative week, respectively. Conclusion. In patients who received a knee or hip arthroplasty, the odds ratios for PJI were significantly increased in patients with postoperative wound leakage. However, the high absolute number of patients with wound leakage and no PJI showed that wound leakage alone is not a sensitive, i.e. discriminative, indicator to guide the decision whether to reoperate patients for a suspected PJI. The abstract was submitted on behalf of the Woundcare app study group: H.M.J. van der Linden, Leiden University Medical Centre; D. Broekhuis, Leiden University Medical Centre; M. de Jong, Leiden University Medical Centre; M.R. Benard, Alrijne Hospital; A.P. Wassenaar, Alrijne hospital; A.S.B. Mol, Alrijne Hospital; M. Rutgers, Reinier Haga Orthopedic Center; J.Pasma, Reinier Haga Orthopedic Center; R. Bazuin, Reinier Haga Orthopedic Center; N. Mathijssen, Reinier Haga Orthopedic Center; C.E. Van Der Wijngaart, Onze Lieve Vrouwe Gasthuis; N.W. Willigenburg, Onze Lieve Vrouwe Gasthuis; M.E. Van Der Hoorn, Onze Lieve Vrouwe Gasthuis; B. Dijkstra, Medical Center Leeuwarden; L.D. De Jong, Rijnstate Hospital; H. Haan, University Medical Centre Groningen; M. Stevens, University Medical Centre Groningen; M. Reijman, Erasmus Medical Centre Rotterdam; H. Hoogeboom, Nijsmellinghe Medical Centre; C. Meijer, Park Medical Centre + all authors listed above this article

Abstract. Objective. In this systematic review we aim to compare wound complication rates from Negative Pressure Wound Therapy (NPWT) to dry sterile surgical dressings in primary and revision total knee arthroplasty (TKA). Methods. A search was performed using PubMed, Embase, Science Direct, and Cochrane Library. Eligible studies included those investigating the use of NPWT in primary and revision TKA. Exclusion criteria included studies investigating NPWT not related to primary or revision TKA; studies in which data relating to NPWT was not accessible; missing data; without an available full text, or not well reported. We also excluded studies with poor scientific methodology. All publications were limited to the English language. Abstracts, case reports, conference presentations, and reviews were excluded. Welch independent sample t-test was used for the statistical analysis. Results. Our review identified 11 studies evaluating 1,414 patients. Of the 1,181 primary TKA patients analysed (NPWT = 416, surgical dressing = 765), the overall wound complication rates in patients receiving NPWT ranged from 0% – 63% (Median 7.30%, SD ± 21.44) This is in comparison to complication rates of 2.8% – 19% (Median 6.50%, SD ± 6.59) in the dry dressing group. The difference in complication rates between the two groups was not statistically significant (p =0.337). In the revision TKA cohort of 279 patients (NPWT group = 128, dry dressing group = 151), the overall wound complication rates in the NPWT group ranged between 6.7% – 12% (Median 9.80%, SD ± 2.32) vs 23.8% – 30% (Median 26.95%, SD ± 2.53) in the dry dressing group. This difference was statistically significant (p<0.001). Conclusion. NPWT dressing demonstrated statistically significant reduction in wound complication rates when used in revision TKA but not primary TKA when compared to dry sterile dressings. This is probably due to higher wound related risks encountered with revision TKA surgery compared to primary TKA surgery. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aim. Wound leakage has been shown to increase the risk of prostetic joint infections (PJIs) in primary total hip (THA) and knee arthroplasty (unicondylar and total knee arthroplasty; KA). The aim of this study is to determine whether the addition of a continuous subcuticular bonding stitch to a conventional 3-layer closure method reduces the incidence of prolonged wound leakage and PJIs after THA and KA. Method. This retrospective cohort study included all patients receiving a THA or KA. Patients in the control group with a 3-layer closure method had surgery between November 1. st. 2015 and 2016, and were compared to the study group with a 4-layer closure method that had surgery between January 1. st. 2017 and 2018. The primary outcome was incidence of prolonged wound leakage longer than 72 hours. Differences were evaluated using logistic regression. Incidence of PJIs was the secondary outcome. Results. A total of 439 THA and 339 KA in the control group and 460 THA and 350 KA in the study group were included. In the control group 11.7% of the patients had a prolonged leaking wound compared to 1.9% in the study group (p<0.001). The modified wound closure method showed a protective effect for obtaining prolonged wound leakage; odds ratios were 0.09 (95%CI 0.04–0.22; p<0.001) for THA and 0.21 (95%CI 0.10–0.43; p<0.001) for KA. PJIs decreased from 1.54% to 0.37% (p=0.019). Conclusions. The addition of a continuous subcuticular bonding stitch reduces the incidence of prolonged wound leakage and PJIs after THA and KA compared to a conventional 3-layer wound closure method. The large reduction of incidence in wound leakage and PJIs in this study, combined with relatively negligible cost and effort of the modified wound closure method, would advocate for implementing this wound closure method in arthroplasty

Introduction. Hip and knee replacements are predictable orthopaedic procedure with excellent clinical outcomes. Discharging or leaking wounds affect length of hospital stay, affect bed planning and predispose to superficial and potentially deep wound infection. Predictable wound healing therefore remains the first hurdle. This trial aims to study the effectiveness of portable disposable incisional negative pressure wound therapy (NPWT) dressings in hip and knee replacements. This trial aims to study the effectiveness of portable disposable incisional negative pressure wound dressings in hip and knee replacements and the impact on wound healing, length of stay and wound complications. Patients/Materials & Methods. Following ethical approval 110 patients each were randomised to ‘Control group’ and ‘Study group’. Patients in control group received traditional dressings and those in study group received an incisional NPWT (PICO) manufactured by Smith & Nephew. Post operatively, state of the wound, level of wound exudate, length of hospital stay and complications were documented. Results. The average length of stay for control group was 4.72 ± 0.69 (Mean ± SEM) and for the study group 3.79±0.19 (mean ± SEM. Eight percent of the control group patients had wound related complications as opposed to 2% complications in the study group. The mechanical and device related issues in the study group accounted to 10%. Discussion. There is little evidence as to whether wound dressing choices affect wound healing in incisional wounds. There is good evidence for negative pressure wound therapy (NPWT) in complex, open and chronic wounds; however the concept of application of NPWT to routine incisional wounds is novel. Advances such as disposable and portable negative devices have made this option attractive in elective surgery. Conclusion. Our study shows that its application in routine primary hip and knee replacement can improve wound healing, facilitate early and predictable discharge from the hospital and reduce post discharge complications. This is particularly true for high risk wounds such as patients with BMI of >35 and is cost effective

Aim. This was a multicenter, randomized, clinical trial to compare the 90-day 1) incidence of surgical site complications (SSC); 2) health care utilization (the number of dressing changes, readmission, and reoperation); and 3) the patient-reported outcomes (PRO) in high-risk patients undergoing revision total knee arthroplasty (rTKA) with postoperative closed incision negative pressure wound therapy (ciNPT) versus a standard of care (SOC) silver-impregnated occlusive dressing. Method. A total of 294 rTKA patients (15 centers) at high-risk for wound complications were prospectively randomized to receive either SOC or ciNPT (n = 147 each). The ciNPT system was adjusted at 125 mmHg of suction. Investigated outcomes were assessed weekly up to 90 days after surgery. A preset interim analysis was conducted at 50% of the intended sample size, with planned discontinuation for clear efficacy/harm if a significance of p < 0.005 was attained. Results. A total of 242 patients completed the required follow-up (ciNPT: n = 124 (84.4%); SOC: n = 118 (80.3%)). Demographics, baseline comorbidities, causes of revision (prosthetic joint infection, aseptic loosening, implant-related, and periprosthetic fractures), and duration of treatment were similar in both cohorts (p > 0.05). Intention to treat analysis demonstrated lower rates of SSC with ciNPT (3.4%) compared to SOC (14.3%) (p = 0.0013) (Table 1 – not included in the proceeding). Similar outcomes were obtained with the modified intention to treat analysis (p = 0.0013). The ciNPT cohort exhibited lower readmission rates (p = 0.0208), and number of dressing changes (p = 0.0003). Conversely, differences in the 90-day incidence of SSI and measured patient-reported outcomes did not reach statistical significance (p > 0.05). Conclusions. ciNPT mitigates the risk of SSC and readmission among high-risk rTKA patients. The lower frequency of dressing changes within the ciNPT cohort may provide added value for healthcare utilization without compromising pain and function. For the table, please contact authors directly

The purpose of this modified Delphi study was to obtain consensus on wound closure (including best practices for each tissue layer of closure) and dressing management in total hip arthroplasty (THA), using an evidence-based approach. The Delphi panel included 20 orthopedic surgeons from Europe and North America. Eighteen statements were identified (14 specific to THA and 4 relating to both THA and total knee arthroplasty) using a targeted literature review. Consensus was developed on the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of 75% was required for consensus. In Round 1, 15 of 18 statements achieved consensus via a structured electronic questionnaire. In Round 2, the 3 statements that did not achieve consensus were revised during a virtual face to face meeting. An additional 2 statements were edited for clarity. In Round 3, the 5 revised statements achieved consensus via a structured electronic questionnaire. Wound closure related interventions that were recommended for use in THA included: 1) barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); 2) subcuticular sutures over skin staples (lower risk of infections and higher patient preference); 3) mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); 4) negative pressure wound therapy over other dressings (lower wound complications and reoperations and fewer dressing changes); 5) triclosan coated sutures (lower risk of surgical site infection). Using a modified Delphi approach, a panel of 20 orthopedic surgeons achieved consensus on 18 statements pertaining to multi-layer wound closure and dressing management in THA. This study forms the basis for identifying critical evidence gaps within wound management to help reduce variability in outcomes during THA

Aim. There are no studies in literature that analyze the effectiveness of closed-incisional negative pressure wound therapy (ciNPWT) in the treatment of bone and joint infections (BJI). The aim of the study was to evaluate the efficacy and the safety of the application of ciNPWT in the postsurgical wound management of patients with osteoarticular infections. Method. We conducted a perspective single-center study on patients with BJI treated between 01/2022 and 10/2022 with ciNPWT dressing application at the end of the surgical procedure. All patients were treated by a multidisciplinary team (MDT) approach and operated by the same surgical equipe. Inclusion criteria were: presence of periprosthetic joint infection (PJI), fracture-related infection (FRI), osteomyelitis (OM), septic arthritis (SA) surgically treated, after which ciNPTW was applied over the closed surgical wound. 30 patients (19M, 11F) have been analyzed with mean age of 56,10±17,11 years old; BJIs were all localized in the lower limb (16 PJI, 12 FRI, 1 SA, 1 OM). Results. We considered the following clinical local pre-operative parameters: presence of fistula (10 patients, 33,33%), presence of erythema (18 patients, 60%), presence of previous flap in the incisional site (7 patients, 23,33%). In 11 cases (36,67%) more than 3 previous surgical procedures were performed in the surgical site. The following surgical procedures were performed: 8 debridement and implants removal, 7 DAIR, 3 one-stage exchange, 6 two-stage exchange, 3 spacer exchange, 3 resection arthroplasty. Nineteen patients (63,34%) showed no occurrence of any local post-operative complication (erythema, hematoma, wound breakdown, wound blister, necrosis). Seven (23,33%) patients showed the presence of one or more postoperative complications that didn't require additional surgery. We observed four (13,33%) failures, defined as the need for further surgical procedures following the onset of a local complication: two patients had a wound breakdown before wound closure and two had a recurrence of infection after an uneventfully wound closure. All failures were within the group of joint infection (PJI+SA) and were affected by a multi drug resistant pathogen. Conclusions. In our series four patients required further surgery, but only two cases were related to incisional wound problems, that is consistent with aseptic joint revision surgeries data that are available in literature (3.4%-6.9%)[1-2]. Patients affected by BJI are a group with significant high risk of failure and therefore the use of ciNPWT should be considered. However, randomized clinical trials are needed to establish the superiority of the ciNPWT dressing over the standard one

Treatment for delayed wound healing resulting from peripheral vascular diseases and diabetic foot ulcers remain a challenge. A novel surgical technique named Tibial Cortex Transverse Transport has been developed for treating peripheral ischaemia, with encouraging clinical effects. However, its underlying mechanisms remain unclear. In present study, we aimed to explore the wound healing effects after undergoing this novel technique via multiple ways. A novel rat model of Tibial Cortex Transverse Transport was established with a designed external fixator and effects on wound healing were investigated. All rats were randomized into 3 groups, with 12 rats per group: sham group (negative control), fixator group (positive control) and Tibial Cortex Transverse Transport group. Laser speckle perfusion imaging, vessel perfusion, histology and immunohistochemistry were used to evaluate the wound healing processes. Gross and histological examinations showed that Tibial Cortex Transverse Transport technique accelerated wound closure and enhanced the quality of the newly formed skin tissues. In Tibial Cortex Transverse Transport group, HE staining demonstrated a better epidermis and dermis recovery, while immune-histochemical staining showed that Tibial Cortex Transverse Transport technique promoted local collagen deposition. Tibial Cortex Transverse Transport technique also benefited to angiogenesis and immunomodulation. In Tibial Cortex Transverse Transport group, blood flow in the wound area was higher than that ofother groups according to laser speckle imaging with more blood vessels observed. Enhanced neovascularization was seen in the Tibial Cortex Transverse Transport group with double immune-labelling of CD31 and α-SMA. The M2 macrophages at the wound site in the Tibial Cortex Transverse Transport group was also increased. Tibial cortex transverse transport technique accelerated wound healing through enhanced angiogenesis and immunomodulation

Purpose: Previous work demonstrated that negative pressure wound therapy (NPWT) resulted in less Pseudomonas aeruginosa than standard wet-to-dry (WTD) dressings in a complex orthopaedic wound model. Staphylococcus aureus is more clinically relevant in open fractures, and is the most prevalent bacteria in osteomyelitis. The purpose of this study is to determine if S. aureus responds similarly to P. aeruginosa when treated with NPWT. Methods: A complex musculoskeletal wound was created on the hindlimb of 20 goats and contaminated with S. aureus (lux) bacteria. The bacteria are genetically engineered to emit photons, allowing for quantification with a photon-counting camera system. The wounds were débrided and irrigated with 9 L of normal saline using gravity flow irrigation 6 hours after inoculation. Goats were assigned to two different treatment groups: a control group using WTD dressing changes and an experimental group using NPWT. The wounds were débrided and irrigated every other day for 6 days. Bacteria within the wounds were quantified both before and after each débridement. Results: There was no difference between treatment groups in amounts of bacteria in the wound at all time points (p≥0.37). Conclusion: Previous work demonstrated that NPWT resulted in a significant and clinically relevant reduction of P. aeruginosa at all time points in a similar model. We presume that NPWT was effective because it created an environment that allowed the body to ward off this “opportunistic” gram negative. However, as shown in this study, S. aureus is less affected by NPWT and persists within the wound

Extracellular matrix (ECM) mechanical cues guide healing in tendons. Yet, the molecular mechanisms orchestrating the healing processes remain elusive. Appropriate tissue tension is essential for tendon homeostasis and tissue health. By mapping the attainment of tensional homeostasis, we aim to understand how ECM tension regulates healing. We hypothesize that diseased tendon returns to homeostasis only after the cells reach a mechanically gated exit from wound healing. We engineered a 3D mechano-culture system to create tendon-like constructs by embedding patient-derived tendon cells into a collagen I hydrogel. Casting the hydrogel between posts anchored in silicone allowed adjusting the post stiffness. Under this static mechanical stimulation, cells remodel the (unorganized) collagen representing wound healing mechanisms. We quantified tissue-level forces using post deflection measurements. Secreted ECM was visualized by metabolic labelling with non-canonical amino acids, click chemistry and confocal microscopy. We blocked cell-mediated actin-myosin contractility using a ROCK inhibitor (Y27632) to explore the involvement of the Rho/ROCK pathway in tension regulation. Tissue tension forces reached the same homeostatic level at day 21 independent of post compliance (p = 0.9456). While minimal matrix was synthesized in early phases of tissue formation (d3-d5), cell-deposited ECM was present in later stages (d7-d9). More ECM was deposited by tendon constructs cultured on compliant (1Nm) compared to rigid posts (p = 0.0017). Matrix synthesized by constructs cultured on compliant posts was less aligned (greater fiber dispersion, p = 0.0021). ROCK inhibition significantly decreased tissue-level tensional forces (p < 0.0001). Our results indicate that tendon cells balance matrix remodeling and synthesis during tissue repair to reach an intrinsically defined “mechanostat setpoint” guiding tension-mediated exit from wound healing towards homeostasis. We are identifying specific molecular mechanosensors governing tension-regulated healing in tendon and investigate the Rho/ROCK system as their possible downstream pathway

Swelling following an ankle fracture is commonly believed to preclude surgical fixation, delaying operative treatment to allow the swelling to subside. This is in an attempt to achieve better soft tissue outcomes. We aim to identify whether pre-operative ankle swelling influences postoperative wound complications following ankle fracture surgery. This is a prospective cohort study of 80 patients presenting to a tertiary referral centre with operatively managed malleolar ankle fractures. Ankle swelling was measured visually and then quantitatively using the validated ‘Figure-of-eight’ technique. Follow-up was standardised at 2, 6, and 12 weeks post-operatively. Wound complications, patient co-morbidities, operative time, surgeon experience, and hospital stay duration were recorded. The complication rate was 8.75% (n=7), with 1 deep infection requiring operative intervention and all others resolving with oral antibiotics and wound cares. There was no significant difference in wound complication rates associated with quantitative ankle swelling (p=0.755), visual assessment of ankle swelling (p=0.647), or time to operative intervention (p=0.270). Increasing age (p=0.006) and female gender (p=0.049) had a significantly greater probability of wound complications. However, BMI, smoking status, level of the operating surgeon, and tourniquet time were not significantly different. Visual assessment of ankle swelling had a poor to moderate correlation to ‘Figure-of-eight’ ankle swelling measurements ICC=0.507 (0.325- 0.653). Neither ankle swelling nor time to surgery correlates with an increased risk of postoperative wound complication in surgically treated malleolar ankle fractures. Increasing patient age and female gender had a significantly greater probability of wound infection, irrespective of swelling. Visual assessment of ankle swelling is unreliable for quantifying true ankle swelling. Operative intervention at any time after an ankle fracture, irrespective of swelling, is safe and showed no better or worse soft tissue outcomes than those delayed for swelling

Between 2016–2019, 4 patients developed hip infections post-hemiarthroplasty. However, between 2020–2021 (Covid-19 pandemic period), 6 patients developed hip infections following hip hemiarthroplasty. The purpose of the investigation is to establish the root causes and key learning from the incident and use the information contained within this report to reduce the likelihood of a similar incident in the future. 65 patients presented with a neck of femur fracture during Covid-19 pandemic period between 2020–2021, 26 had hip hemiarthroplasty of which 6 developed hip infections. Medical records, anaesthetic charts and post-hip infections guidelines from RCS and NICE were utilised. Proteus, Enterococci and Strep. epidermis were identified as the main organisms present causing the hip infection. The average number of ward moves was 4 with 90% of patients developing COVID-19 during their hospital stay. The chance of post-operative wound infection were multifactorial. Having had 5 of 6 patients growing enterococci may suggest contamination of wound either due to potential suboptimal hygiene measures, inadequate wound management /dressing, potential environmental contamination if the organisms (Vancomycin resistant enterococci) are found to be of same types and potential hospital acquired infection due to inadequate infection control measures or suboptimal hand hygiene practices. 3 of the 5 patients grew Proteus, which points towards suboptimal hygiene practices by patients or poor infection control practices by staff. Lack of maintenance of sterility in post op wound dressings alongside inexperience of the handling of post-operative wound in non-surgical wards; multiple ward transfers exceeding the recommended number according to trust guidelines especially due to pandemic isolation measures and COVID-19 infection itself had resulted in an increased rate of hip infections during the COVID-19 pandemic. Multidisciplinary team education and planned categorisation and isolation strategy is essential to minimise the rate of further hip infections during the pandemic period in future

Introduction. Introduction: Pin site infection is a common complication during treatment with a circular frame external fixator and increases time and support patients require from the limb reconstruction team. Wound swabs were not routinely sent by the clinical nurse specialists prior to this study, with most pin site infections treated as Staphylococcus aureus with flucloxacillin (clindamycin in penicillin allergy). The aim of this study was to ascertain whether routine sending of wound swabs in pin site infection would change antibiotic treatment. Materials & Methods. Materials and Method: Patients presenting at clinic or physiotherapy with clinical signs of pin site infection were assessed using the Maz Oxford Nuffield (MON) Pin Site Infection Grading System© (OUH, 2021). Antibiotics were commenced as per unit guidelines and swabs sent for microscopy, culture and sensitivity. Results. Results: There were forty patients treated with pin site infections. Swab results showed S. aureus in 60% (N=24), other organisms in 15% (N=6) and no growth or mixed skin organisms in 10% (N=10). Flucloxacillin was prescribed to 77.5% (n=31) of patients with the remaining 22.5% (n=9) of patients receiving clindamycin (due to allergy) or rifampicin and ciprofloxacin (due to a previous MRSA diagnosis). Antibiotic management was subsequently changed in only 5% (n=2) of patients due to one patient with a new MRSA diagnosis and one patient growing Enterobacter in three pin sites tested. Conclusions. Conclusion: This study has shown that routine swab testing of pin sites does not usually change antibiotic management but should still be used in multiple, severe or unresolving pin site infections

Fractures of the ankle are common, and they mostly affect young adults. Wound complications are not uncommon following the fixation of these fractures. This study evaluated the impact of HIV on wound healing after plate osteosynthesis in patients with closed ankle fractures. This is an observational retrospective study of patients operated on at a tertiary level hospital. We reviewed hospital records for patients above 18 years of age who presented with wound breakdown following ankle open reduction and internal fixation. The patients’ hospital records were retrieved to identify all the patients treated for closed ankle fractures and those who developed wound breakdown. Patients with Pilon fractures were excluded. The National Health Laboratory System (NHLS) database was accessed to retrieve the CD4 count, viral load, haematology study results, and biochemistry results of these patients at the time of surgery and subsequent follow-up. The x-rays were retrieved from the electronic picture archiving system (PACS) and were assessed for fracture union at a minimum of 3 months follow-up. We reviewed the medical records of 172 patients with closed ankle fractures treated from 2018 to 2022. Thirty-one (18.0%) developed wound breakdown after surgery, and they were all tested for HIV. Most of the patients were male (58.0%), and the average age of the cohort was 43.7 years (range: 21 years to 84 years). Ten of these patients (32.2%) were confirmed HIV positive, with CD4 counts ranging from 155 to 781. Viral load levels were lower than detectable in 40% of these patients. All patients progressed to fracture union at a minimum of 3 months follow-up. We observed no difference between HIV-positive and HIV-negative patients in terms of wound breakdown and bone healing post-plate osteosynthesis for closed ankle fractures

For soft tissue sarcoma patients receiving preoperative radiation therapy, wound complications are common and potentially devastating; they may result in multiple subsequent surgeries and significant patient morbidity. The purpose of this study was to assess the feasibility of intraoperative indocyanine green fluorescent angiography (ICGA) as a predictor of wound complications in resections of irradiated soft tissue sarcoma of the extremities. A consecutive series of patients of patients with soft tissue sarcoma of the extremities or pelvis who received neoadjuvant radiation and a subsequent radical resection received intraoperative ICGA with the SPY PHI device (Stryker Inc, Kalamazoo MI) at the time of closure. Three fellowship trained Orthopaedic Oncologic Surgeons were asked to prospectively predict likelihood of wound complications based on fluorescence. Retrospective analysis of fluorescence signal along multiple points of the wound length was performed and quantified. The primary endpoint was wound complication, defined as delayed wound healing or wound dehiscence, within 3 months of surgery. An a priori power analysis demonstrated that 5 patients were necessary to achieve statistical significance. Univariate and multivariate statistical analyses were performed to identify predictors of wound complications. 14 patients were consecutively imaged. The diagnosis was undifferentiated pleomorphic sarcoma in 9 (64.3%) of patients; 11 (78.6%) tumors were high grade. There were 6 patients with wound complications classified as “aseptic” in 5 cases and secondary to hematoma in 1 case. Using the ICGA, blinded surgeons correctly predicted wound complications in 75% of cases. In the area of wound complication, the mean % of maximal signal for wound complications was 49% during the inflow phase and 48% during the peak phase. The mean % maximal signal for peri-incisional tissue without wound complications was 77% during the inflow phase and 83% during the peak phase (p=0.003 and p<0.001). During the inflow phase, a mean ratio of normal of 0.62 maximized the area under the curve (AUC=0.90) for predicting wound complications with a sensitivity of 100% and specificity of 77.4%. During the peak phase, a mean ratio of normal of 0.55 maximized the area under the curve (AUC=0.95) for predicting wound complications with a sensitivity of 88.9% and a specificity 100%. Intraoperative use of indocyanine green fluorescent angiography may help to predict wound complications in patients undergoing resection of preoperatively irradiated soft tissue sarcomas of the extremities and pelvis. Future studies are necessary to validate this technology in a prospective manner and to determine if interventions can be instituted to prevent predicted wound complications

Infection following total knee arthroplasty (TKA) can cause significant morbidity to the patient and be associated with significant costs and burdens to the healthcare system. Wound complications often initiate the cascade that can eventually lead to deep infection and implant failure. Galat et al. reported that wound complications following TKA requiring surgical treatment were associated with 2-year cumulative risks of major reoperation and deep infection of 5.3% and 6.0%, respectively. Consequently, developing a systematic approach to the management of wound problems following TKA can potentially minimise subsequent complications. Unlike the hip, the vascular supply to the soft tissue envelope to the knee is less robust and more sensitive to the trauma of surgery. Therefore, proper soft tissue handling and wound closure at the time of surgery can minimise potential wound drainage and breakdown postoperatively. Kim et al. showed, using a meta-analysis of the literature, that primary skin closure with staples demonstrated lower wound complications, decreased closure times, and lower resource utilization compared to sutures. However, a running subcuticular closure enables the most robust skin perfusion following TKA. Finally, the use of hydrofiber surgical dressings following surgery was associated with increased patient comfort and satisfaction and reduced the incidence of superficial surgical site infection. A wound complication following TKA needs to be managed systematically and aggressively. A determination of whether the extent of the involvement is superficial or deep is critical. Antibiotics should not be started without first excluding the possibility of a deep infection. Weiss and Krackow recommended return to the operating room for wound drainage persisting beyond 7 days. While incisional negative pressure wound therapy can occasionally salvage the “at risk” draining wound following TKA, its utilization should be limited only to the time immediately following surgery and should not delay formal surgical debridement, if indicated. Finally, early wound flap coverage and co-management of wound complications with plastic surgery is associated with increased rates of prosthesis retention and limb salvage

Postoperative surgical site infection in patients treated with lumbosacral fusion has been believed to be caused by perioperative contamination (Perioperative Inside-Out infections) in patients with comorbidities. With the proximity of these incisions to the perianal region and limited patient mobility in the early post-operative period, local contamination from gastrointestinal and/or urogenital flora (Postoperative Outside-In infections) should be considered as a major source of complication. A single center, retrospective review of adult patients treated with open posterior lumbosacral fusions between January 2014 and January 2021. We aimed to identify common factors in patients experiencing deep postoperative infections. Oncological, minimally invasive, primary infection, and index procedures carried out at other institutions were excluded. We identified 489 eligible patients, 20 of which required debridement deep to the fascia (4.1%). Mean age (62.9 vs 60.8), operative time (420 vs 390 minutes), estimated blood loss (1772 vs 1790 mL) and median levels fused (8.5 vs 9) were similar between the infected and non-infected groups. There was a higher percentage of deformity patients (75% vs 29%) and increased BMI (32.7 vs 28.4) in the infected group. The mean time from primary procedure to debridement was 40.8 days. Four patients showed no growth on culture. Three showed Staphylococcus species (Perioperative Inside-Out infections) requiring debridement at a mean of 100.3 days (95%CI 0- 225 days). Thirteen patients showed infection with intestinal or urogenital pathogens (Postoperative Outside-In infections) requiring debridement at a mean of 20.0 days (95%CI 9-31 days). Postoperative Outside-In infections led to debridement 80.3 days earlier than Perioperative Inside-Out infections (p= 0.007). In this series, 65% of deep infections were due to early local contamination by gastrointestinal and/or urogenital tracts pathogens. These infections were debrided significantly earlier than the Staphylococcus species infections. Due to the proximity of the incisions to the perianal region, there should be increased focus on post-operative local wound management to ensure these pathogens are away from the wound during the critical stages of wound healing

Abstract. Objective. In this systematic review we aim to analyse the economical impact of using Negative Pressure Wound Therapy (NPWT) in primary total knee arthroplasty (TKA). Methods. Four medical electronic databases were searched. Eligible studies included those investigating the costs of NPWT in primary TKA. Exclusion criteria included studies investigating cost of NPWT not related to primary TKA. We also excluded studies with poor scientific methodology. We retrieved and analysed data on dressing costs and hospital length of stay (LOS). Results. Three studies (359 patients) reported on dressing and associated health care costs, and two further studies (330 patients) reported on hospital LOS in primary TKA. The cost of NPWT ranged between £125 and £196; with an average cost of £155, compared to £23 for the regular surgical dressing. The hospital LOS in NWPT patients ranged from 1.9 – 3.8 days, while LOS in patients managed with regular surgical dressing ranged between 2.3 – 4.7 days. The hospital LOS accounted for delayed discharge due to wound complications. Any extended LOS secondary to medical comorbidities or for other reasons were not included here. Conclusion. Our pooled analysis found a decrease in hospital LOS from wound related problems when using NWPT instead of regular dressings after accounting for other variables responsible for LOS. If the mean cost of overnight inpatient hospital stay for elective TKA is estimated as £275, the range of overnight admission cost for one TKA patient would be £522 - £1045 when NPWT dressing is used, and £632.5 - £1292 when using regular dressings. The cost savings from reduced LOS amounts to £110 - £247 per patient when NPWT is used. We hypothesize that in primary TKA patients with high risk of wound related problems that may delay discharge from hospital, there may be an overall cost saving when using NWPT dressings. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project