Aims. Closed suction subfascial drainage is widely used after instrumented posterior spinal fusion in patients with a spinal deformity. The aim of this study was to determine the effect of this wound drainage on the outcomes in patients with adolescent idiopathic scoliosis (AIS). This was a further analysis of a randomized, multicentre clinical trial reporting on patients after posterior spinal fusion using segmental pedicle screw instrumentation. In this study the incidence of deep surgical site infection (SSI) and chronic postoperative pain at two years’ follow-up are reported. Methods. We conducted a randomized, multicentre clinical trial on adolescents undergoing posterior spinal fusion for AIS using segmental pedicle screw instrumentation. A total of 90 consecutive patients were randomized into a ‘drain’ or ‘no drain’ group at the time of wound closure, using the sealed envelope technique (1:1). The primary outcomes in the initial study were the change in the level of haemoglobin in the blood postoperatively and total blood loss. A secondary outcome was the opioid consumption immediately after surgery. The aim of this further study was to report the rate of deep SSI and persistent postoperative pain, at two years' follow-up. Results. As previously reported, the mean 48-hour opioid consumption was significantly higher in the no drain group (2.0 mg/kg (SD 0.8) vs 1.4 mg/kg (SD 0.7); p = 0.005). There were no delayed deep SSIs. At two years’ follow-up, the mean Scoliosis Research Society 24-item questionnaire (SRS-24) total score did not differ between the groups (4.11 (SD 0.47) vs 4.16 (SD 0.33); p = 0.910). The mean SRS-24 pain score was 4.28 (SD 0.48) in the no drain group compared with 4.33 (SD 0.66) in the drain group (p = 0.245). Seven patients (19%) in the no drain group and six in the drain group (14%) reported moderate to severe pain (numerical rating scale ≥ 4) at two years’ follow-up (p = 0.484). The general self-image domain score was significantly higher in the no drain group compared with the drain group (4.02 (SD 0.74) vs 4.59 (SD 0.54); p < 0.001). Conclusion. The main finding in this study was that more severe pain immediately after surgery did not result in a higher incidence of chronic pain in the no drain group compared with the drain group. Back pain and health-related quality of life at two years’ follow-up did not differ between the groups. The patient-reported self-image domain was significantly better in the no drain group compared with the drain group. Cite this article: Bone Joint J 2024;106-B(10):1176–1181

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The purpose of this study was to determine the association between prior sleeve gastrectomy in patients undergoing primary total hip and knee arthroplasty, and 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up.

The June 2024 Spine Roundup. 360. looks at: Intraoperative navigation increases the projected lifetime cancer risk in patients undergoing surgery for adolescent idiopathic scoliosis; Intrawound vancomycin powder reduces delayed deep surgical site infections following posterior spinal fusion for adolescent idiopathic scoliosis; Characterizing negative online reviews of spine surgeons; Proximal junctional failure after surgical instrumentation in adult spinal deformity: biomechanical assessment of proximal instrumentation stiffness; Nutritional supplementation and wound healing: a randomized controlled trial

Aims. The aim of this study was to compare outcomes after growth-friendly treatment for early-onset scoliosis (EOS) between patients with skeletal dysplasias versus those with other syndromes. Methods. We retrospectively identified 20 patients with skeletal dysplasias and 292 with other syndromes (control group) who had completed surgical growth-friendly EOS treatment between 1 January 2000 and 31 December 2018. We compared radiological parameters, complications, and health-related quality of life (HRQoL) at mean follow-up of 8.6 years (SD 3.3) in the dysplasia group and 6.6 years (SD 2.6) in the control group. Results. Mean major curve correction per patient did not differ significantly between the dysplasia group (43%) and the control group (28%; p = 0.087). Mean annual spinal height increase was less in the dysplasia group (9.3 mm (SD 5.1) than in the control group (16 mm (SD 9.2); p < 0.001). Mean annual spinal growth adjusted to patient preoperative standing height during the distraction period was 11% in the dysplasia group and 14% in the control group (p = 0.070). The complication rate was 1.6 times higher (95% confidence interval (CI) 1.3 to 2.0) in the dysplasia group. The following complications were more frequent in the dysplasia group: neurological injury (rate ratio (RR) 5.1 (95% CI 2.3 to 11)), deep surgical site infection (RR 2.2 (95% CI 1.2 to 4.1)), implant-related complications (RR 2.0 (95% CI 1.5 to 2.7)), and unplanned revision (RR 1.8 (95% CI 1.3 to 2.5)). Final fusion did not provide additional spinal height compared with watchful waiting (p = 0.054). There were no significant differences in HRQoL scores between the groups. Conclusion. After growth-friendly EOS treatment, patients with skeletal dysplasias experienced a higher incidence of complications compared to those with other syndromes. Surgical growth-friendly treatment for skeletal dysplasia-associated EOS should be reserved for patients with severe, progressive deformities that are refractory to nonoperative treatment. Cite this article: Bone Joint J 2024;106-B(6):596–602

The February 2024 Trauma Roundup³⁶⁰ looks at: Posterior malleolus fractures: what about medium-sized fragments?; Acute or delayed total hip arthroplasty after acetabular fracture fixation?; Intrawound antibiotics reduce the risk of deep infections in fracture fixation; Does the VANCO trial represent real world patients?; Can a restrictive transfusion protocol be effective beyond initial resuscitation?; What risk factors result in avascular necrosis of the talus?; Pre-existing anxiety and mood disorders have a role to play in complex regional pain syndrome; Three- and four-part proximal humeral fractures at ten years.

This study aims to determine the incidence of surgical site infection leading to reoperation for sepsis following minor hand procedures performed outside the main operating room using field sterility in the South African setting. The investigators retrospectively reviewed the records of 485 patients who had WALANT-assisted minor hand surgery outside a main operating theatre, a field sterility setting between March 2019 and April 2023. The primary outcome was the presence or absence of deep surgical site infection that required reoperation within four weeks. Cases included where elective WALANT minor hand procedures, a minimum age of 18 with complete clinical records. The patients were mostly female (54.8%), with a mean age of 56.35 years. The majority of cases were trigger finger and carpal tunnel release. An overall 485 cases were reviewed, the deep surgical site infection rate resulting in reoperation within 4 weeks post-operatively was 1.24% ((95% Confidence Interval (CI) 0.0034 to 0.0237); p = 0.009). Minor hand procedures performed under field sterility using WALANT have a low surgical site infection rate. The current study's infection rates are comparable to international surgical site infection rates for similar surgeries performed in main operating rooms using standard sterilisation procedures. Field sterility is a safe and acceptable clinical practice that may improve work efficiency in public sector

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This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures.

Aims. This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection. Methods. This is a retrospective population-based cohort study using prospectively collected patient-level data between 1 January 2013 and 1 March 2020. The diagnosis of deep SSI was defined as per the Centers for Disease Control/National Healthcare Safety Network criteria. The Mann-Kendall Trend test was used to detect monotonic trends in annual rates of early-onset deep SSI over time. Multiple logistic regression was used to analyze the effect of different patient, surgical, and healthcare setting factors on the risk of developing a deep SSI within 90 days from surgery for patients with complete data. We also report 90-day mortality. Results. A total of 39,038 patients underwent primary TKA for osteoarthritis during the study period. Of these, 275 patients developed a deep SSI within 90 days of surgery, representing a cumulative incidence of 0.7%. The annual infection rate did not significantly decrease over the seven-year study period (p = 0.162). Overall, 13,885 (35.5%) cases were excluded from the risk analysis due to missing data. Risk factors associated with early-onset deep SSI included male sex, American Society of Anesthesiologists grade ≥ 3, blood transfusion, acute length of stay, and surgeon volume < 30 TKAs/year. Early-onset deep SSI was not associated with increased 90-day mortality. Conclusion. This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis using robust Infection Prevention and Control surveillance data, and identifies several potentially modifiable risk factors. Cite this article: Bone Joint J 2023;105-B(9):971–976

Telehealth has the potential to change the way we approach patient care. From virtual consenting to reducing carbon emissions, costs, and waiting times, it is a powerful tool in our clinical armamentarium. There is mounting evidence that remote diagnostic evaluation and decision-making have reached an acceptable level of accuracy and can safely be adopted in orthopaedic surgery. Furthermore, patients’ and surgeons’ satisfaction with virtual appointments are comparable to in-person consultations. Challenges to the widespread use of telehealth should, however, be acknowledged and include the cost of installation, training, maintenance, and accessibility. It is also vital that clinicians are conscious of the medicolegal and ethical considerations surrounding the medium and adhere strictly to the relevant data protection legislation and storage framework. It remains to be seen how organizations harness the full spectrum of the technology to facilitate effective patient care.

Cite this article: Bone Joint J 2023;105-B(8):843–849.

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The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery.

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The aim of this investigation was to compare risk of infection in both cemented and uncemented hemiarthroplasty (HA) as well as in total hip arthroplasty (THA) following femoral neck fracture.

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To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration.

Surgical site infections following orthopaedic surgery are a serious complication associated with increased morbidity and mortality. Intra-wound antibiotic powder may be able to provide infection prophylaxis locally with less systemic adverse effects, and promising results have been reported in systematic reviews of its use in spine surgery. This study aims to analyse the efficacy and adverse effect profile of intra-wound antibiotics in reducing surgical site infections in orthopaedic surgery for traumatic pelvic and lower limb fractures. A systematic review was conducted for studies reporting on the incidence of surgical site infections following administration of intra-wound antibiotic powder in pelvic and lower limb trauma surgery. Randomised controlled trials, cohort and case-control studies were included. A meta-analysis was conducted for deep surgical site infections. Seven studies were included in the systematic review including six retrospective case-control studies and one randomised controlled trial. Results of the meta-analysis suggest a potential 23% reduction in the odds of developing a deep surgical site infection in patients treated with intra-operative antibiotic powder compared with those managed with intravenous antibiotics alone (OR 0.77, 95% CI 0.52 – 1.13), although the results did not reach statistical significance. Notable selective bias against intra-wound antibiotics and suboptimal study design were found in the retrospective studies, however the randomised controlled trial reported a significant reduction in deep surgical site infections with intra-wound vancomycin powder. There were no reports of systemic adverse outcomes and minimal risk of wound complications with the use of intra-wound antibiotics. This review suggests the use of intra-wound antibiotic powder in pelvic and lower limb trauma surgery may reduce the incidence of deep surgical site infections. Further powered studies including randomised controlled trials are required to confirm the results highlighted in this study

Surgical site infections (SSIs) after spinal fusion surgery increase healthcare costs, morbidity and mortality. Routine measures of obesity fail to consider site specific fat distribution. We aimed to assess the association between the spine adipose index and deep surgical site infection and determine a threshold value for spine adipose index that can assist in preoperative risk stratification in patients undergoing posterior instrumented lumbar fusion (PILF). A multicentre retrospective case-control study was completed. We reviewed patients who underwent PILF from January 1, 2010 to December 31, 2018. All patients developing a deep primary incisional or organ-space SSI within 90 days of surgery as per US Centre for Disease Control and Prevention criteria were identified. We gathered potential pre-operative and intra-operative deep infection risk factors for each patient. Spine adipose index was measured on pre-operative mid-sagittal cuts of T2 weighted MRI scans. Each measurement was repeated twice by three authors in a blinded fashion, with each series of measurement separated by a period of at least six weeks. Forty-two patients were included in final analysis, with twenty-one cases and twenty-one matched controls. The spine adipose index was significantly greater in patients developing deep SSI (p =0.029), and this relationship was maintained after adjusting for confounders (p=0.046). Risk of developing deep SSI following PILF surgery was increased 2.0-fold when the spine adipose index was ≥0.51. The spine adipose index had excellent (ICC >0.9; p <0.001) inter- and intra-observer reliabilities. The spine adipose index is a novel radiographic measure and an independent risk factor for developing deep SSI, with 0.51 being the ideal threshold value for pre-operative risk stratification in patients undergoing PILF surgery

Complex acetabular reconstruction for oncology and bone loss are challenging for surgeons due to their often hostile biological and mechanical environments. Titrating concentrations of silver ions on implants and alternative modes of delivery allow surgeons to exploit anti-infective properties without compromising bone on growth and thus providing a long-term stable fixation. We present a case series of 12 custom acetabular tri-flange and custom hemipelvis reconstructions (Ossis, Christchurch, New Zealand), with an ultrathin plasma coating of silver particles embedded between layers of siloxane (BioGate HyProtect™, Nuremberg, Germany). At the time of reporting no implant has been revised and no patient has required a hospital admission or debridement for a deep surgical site infection. Routine follow up x-rays were reviewed and found 2 cases with loosening, both at their respective anterior fixation. Radiographs of both cases show remodelling at the ilium indicative of stable fixation posteriorly. Both patients remain asymptomatic. 3 patients were readmitted for dislocations, 1 of whom had 5 dislocations within 3 weeks post-operatively and was immobilised in an abduction brace to address a lack of muscle tone and has not had a revision of their components. Utilising navigation with meticulous implant design and construction; augmented with an ultrathin plasma coating of silver particles embedded between layers of siloxane with controlled and long-term generation of silver ion diffusion has led to outstanding outcomes in this series of 12 custom acetabular and hemipelvis reconstructions. No patients were revised for infection and no patients show signs of failure of bone on growth and incorporation. Hip instability remains a problem in these challenging mechanical environments and we continue to reassess our approach to this multifaceted problem

The aim of this study was to determine the incidence, annual trend, perioperative outcomes, and identify risk factors of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis. Risk factors for early-onset deep SSI were assessed. We performed a retrospective population-based cohort study using prospectively collected patient-level data from several provincial administrative data repositories between January 2013, and March 2020. The diagnosis of early-onset deep SSI was based on published Centre for Disease Control/National Healthcare Safety Network (CDC/NHSN) definitions. The Mann-Kendall Trend Test was used to detect monotonic trends in early-onset deep SSI rates over time. The effects of various patient and surgical risk factors for early-onset deep SSI were analyzed using multiple logistic regression. Secondary outcomes were 90-day mortality and 90-day readmission. A total of 20,580 patients underwent primary TKA for osteoarthritis. Forty patients had a confirmed deep SSI within 90-days of surgery representing a cumulative incidence of 0.19%. The annual infection rate did not change over the 7-year study period (p = 0.879). Risk factors associated with early-onset deep SSI included blood transfusions (OR, 3.93 [95% CI 1.34-9.20]; p=0.004), drug or alcohol abuse (OR, 4.91 [95% CI 1.85-10.93]; p<0.001), and surgeon volume less than 30 TKA per year (OR, 4.45 [1.07-12.43]; p=0.013). Early-onset deep SSI was not associated with 90-days mortality (OR, 11.68 [0.09-90-58]; p=0.217), but was associated with an increased chance of 90-day readmission (OR, 50.78 [26.47-102.02]; p<0.001). This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis through the use of a robust methodological process. Several risk factors for early-onset deep SSI are potentially modifiable or can be optimized prior to surgery and be effective in reducing the incidence of early-onset SSI. This could guide the formulation of provincial screening programs and identify patients at high risk for SSI

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Factors associated with high mortality rates in geriatric hip fracture patients are frequently unmodifiable. Time to surgery, however, might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery.

Aim. To investigate the incidence and time-trend in reoperation due to deep Surgical Site Infection (SSI) following hip fracture surgery. Method. This was a population-based, nationwide, cohort study. We included 74,771 from the Danish Multidisciplinary Hip Fractures Register (1) consisting of patients 65 years of age or older, who underwent surgery between January 1. st. 2005 and December 31. st. 2016 for all types of hip fracture. Cross-linkage with the Danish National Patient Register and The Danish Civil Registration system was made. Demographic data extracted included vital status, civil status, gender, age, Body Mass Index (BMI), fracture classification (AO/OTA 31A-C) and surgical procedures binary registered as joint replacement or internal fixation, Charlson comorbidity index (CCI) and secondary diseases not included in CCI. Outcome was reoperations due to deep SSI in accordance with the definition from Centre for Disease Control (2). We computed cumulative incidence rates and risk ratios (RR) by calendar year periods and by different risk factors, considering death as competing risk and adjusting for age, gender, CCI, fracture type and surgery type. Results. Within 365 days of primary surgery 2.1% of all hip fractures had undergone reoperation due to deep SSI. During the period 2005–2016, the incidence of reoperation due to SSI decreased from 2.7% to 1.7%, We could not identify differences in reoperation due to SSI within one year regarding gender, BMI or CCI. Patients aged above 85 had about 50% lower risk of being reoperated compared with the youngest age group; 65–74 years (RR: 0.5; 95% CI: 0.4:0.6). The RR for reoperation due to deep SSI was lower for patients with pertrochanteric or subtrochanteric fractures (AO/OTA: 31A1-3) versus femoral neck fractures (AO/OTA: 31B1-3), RR was 0.7 (95%CI: 0.7:0.8). However, RR for surgery type (joint replacement vs internal fixation) at 365 days was significantly lower for joint replacement, RR: 0.6 (95% CI: 0.6:0.7). Conclusions. This study shows reoperation risk due to SSI for all types of hip fractures of 2.1%. There was a 45% decrease in reoperation over time from 2005 to 2016. However, the risk of revision is still high, and further action in avoidance of SSI should be taken

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The aim of this study was to evaluate whether, after correction of an adolescent idiopathic scoliosis (AIS), leaving out the subfascial drain gives results that are no worse than using a drain in terms of total blood loss, drop in haemoglobin level, and opioid consumption.