Aim. Antimicrobial peptides occur naturally in our intrinsic immune system. PLG0206 is a novel, engineered, 24-amino acid peptide which has broad-spectrum antimicrobial activity, including in biofilm and against multi-drug resistant pathogens (1,2). This is the first clinical study to evaluate the safety and tolerability of PLG0206 when administered via an irrigation solution in patients with periprosthetic joint infections (PJI) following total knee arthroplasty (TKA) during debridement, antibiotics, and implant retention (DAIR). Secondary objectives were to evaluate pharmacokinetics (PK), biomarkers and initial clinical efficacy at one year post-DAIR procedure. Method. This prospective, multicenter, open-label, interventional study assessed two dose levels of PLG0206. Fourteen patients underwent revision for PJI after TKA. At the end of debridement, they received a single intra-articular irrigation of PLG0206 into the wound cavity lasting 15 minutes at concentrations of 3 mg/mL (n=7) or 10 mg/mL (n=7). Patients received post-operative care and intravenous/oral antimicrobial therapy as per their institutional guidelines. Patients were monitored for safety and signs of relapse or persistent infection for 12 months post study drug administration and PK and blood biomarkers were assessed. Results. All patients completed their final study assessment at Day 365. Over the 1-year follow-up, only one recurrence (7%) was noted at Day 169 in the low-dose cohort. Following dosing, nine patients (64.3%) had limited systemic exposure; maximum plasma concentration occurred 1-hour post-administration and declined rapidly to undetectable levels by 24 hours following treatment in all patients. The incidence of drug related treatment-emergent adverse events (TEAEs) was low. Two patients, both in the higher dose cohort, experienced a transient drug related TEAE; one of hypertransaminasaemia and one of neuralgia. Both events were moderate in severity and resolved within two weeks of onset. Conclusions. A single 15-minute irrigation of PLG0206 into the wound cavity of patients undergoing a DAIR procedure for PJI following TKA, is safe and well tolerated by patients. This new antimicrobial peptide offers a promising therapeutic option in musculoskeletal infection. The initial clinical efficacy is encouraging but now needs to be investigated in a much larger clinical trial

Aim. Suppressive antimicrobial therapy (SAT) is used worldwide for patients with a prosthetic joint infection (PJI but clear definitions or guidelines regarding the indications, antimicrobial strategy or treatment duration are currently lacking in the literature. The aim of this study was to identify the global differences in the clinical practice of SAT for PJI. Method. An online survey was designed to investigate the current opinion on indication and treatment goals, preferred antimicrobial drugs, dosing and treatment duration and follow-up of patients with PJI on suppression. The survey was distributed using e-mail lists of several international bone and joint infection societies and study groups. Recipients were asked to share the survey with colleagues who were not a member of one of the societies but who were involved in PJI care. Results. The questionnaire was fully completed by 330 physicians from 43 different countries on six continents (Europe, n=134, 41%; Oceania n=112, 34%; North America, n=51, 16%; other, n=33, 10%; total response rate 14%). Antimicrobial treatment for PJI was discussed in a multidisciplinary team in Europe (90%), Oceania (42%) and North America (12%). In six of eight (75%) different clinical scenarios, respondents from North America would most often place a patient on SAT. In seven of eight (88%) scenarios, SAT was started least often by European respondents. The presence of a fistula was considered a contra-indication for suppression by 74 respondents (22%). First choices of SAT for staphylococcal PJI were: oral cephalosporins (39%) and tetracyclines (31%) in North America; anti-staphylococcal penicillins (55%) and oral cephalosporins (24%) in Oceania; tetracyclines (27%) and anti-staphylococcal penicillins (22%) in Europe. For streptococcal PJI, most clinicians preferred penicillins (91% in Oceania, 67% in Europe, and 53% in North America). Preferred SAT for gram negative PJI was: fluoroquinolones and a penicillin/betalactamase inhibitor in North America (26% and 18%, respectively) and Oceania (23% and 27%, respectively); fluoroquinolones (31%) and Cotrimoxazole (28%) in Europe. The dosage of SAT was never lowered (n=126, 38%), standardly lowered for all antibiotics (n=79, 24%) or only lowered for specific antibiotics (n=125, 38%). SAT was prescribed for an indefinite duration (n=43, 13%), as fixed duration between six months and three years (n=104, 32%) or for an undetermined prespecified duration (n=154, 47%). Conclusions. Substantial variation in the practice of SAT for PJI exists between physicians worldwide and throughout the different continents. This reflects the paucity of data regarding the indication and treatment of PJI with SAT

Aim. Efficacious antibiotic treatment is crucial for managing and preventing orthopedic infections due to their complexity and associated risk of treatment failure. Previous reviews on antibiotic target tissue concentrations have primarily focused on static measurements, which may not accurately reflect the dynamic pharmacokinetic/pharmacodynamic (PK/PD) changes encountered in clinical settings. This review aimed to summarize the current literature on antibiotic distribution in orthopedically relevant tissues and settings using dynamic sampling methods. Method. In accordance with PRISMA guidelines, a literature search was conducted with a scientific librarian's assistance. PubMed and Embase databases were systematically searched using relevant MeSH terms, entries, and keywords. English-published studies between 2004 and 2023 involving systemic antibiotic administration and dynamic measurements were included. 4467 titles were identified. After title and abstract screening, 77 eligible studies remained. Results. The studies covered clinical and pre-clinical studies on both healthy and infected tissue. Dynamic measurements were obtained from various tissues including bone, intervertebral discs, joints, muscles, and subcutaneous tissue. Microdialysis was the predominant sampling method (98.70%, 76/77). Antibiotics like cefuroxime, linezolid, and vancomycin were extensively studied. Fluoroquinolones, tetracyclines, and most beta-lactams typically presented good tissue penetration in relation to relevant PK/PD-targets. In contrast, glycopeptides, macrolides, and flucloxacillin exhibited poorer penetration. Conclusions. This review provides valuable insights of antibiotic distribution in orthopedically relevant target tissues and settings, which may help improve dosing recommendations and treatment outcomes. Our findings are limited to the investigated dosing regimens and administration methods and depend on the chosen PK/PD target. Many antibiotics still require further research to address the significant knowledge gaps, such as the lack of dynamic evaluations for certain antibiotic types and further investigation across various orthopedic settings and tissues

Aim. We prospectively evaluated four different microbiological tools for diagnostics of prosthetic joint infections (PJI), and assessed their impact on the categorization of infection according to EBJIS guidelines. We compared culture, in-house real-time mPCR for S. aureus, S. lugdunensis, S. hominis, S. epidermidis, S. capitis, S. haemolyticus, C. acnes (mPCR), broad-spectrum PCR (Molzym) with 16S rRNA V3-V4 amplicon Sanger sequencing (16S PCR), and 16S rRNA V3-V4 amplicon next-generation sequencing (16S NGS) on MiSeq (Ilumina). Methods. A total of 341 samples (sonication fluid, tissue biopsy, synovial fluid) were collected from 32 patients with suspected PJI who underwent 56 revision surgeries at the Orthopaedic Centre University Hospital Ljubljana, between 2022 and 2024. Samples were processed using standard protocols for routine culture, followed by DNA isolation using the MagnaPure24 (Roche). All samples were tested with mPCR, and an additional ≥4 samples from each revision (244 in total) were subjected to further metagenomic analysis. Culture results were considered positive if the same microorganism was detected in ≥2 samples, ≥50 CFU/ml were present in the sonication fluid, or ≥1 sample was positive for a more virulent microorganism or if the patient had received antibiotic treatment. Results. Each tool demonstrated high sensitivity for correct EBJIS categorization (100% culture and 16S NGS, 96.88% mPCR and 16S PCR). The highest specificity was observed with mPCR and 16S PCR (87.5%), while culture (79.17%) and NGS (37.5%) showed lower specificity. In 27% (15/56) of revisions, all microbiological tests were negative, although infection was confirmed with histology in one case, and four cases were classified as infection-likely based on clinical signs. In 20% (11/56) of cases, all microbiological tests were positive; in three cases a combination of other EBJIS criteria (without microbiology) categorized the episodes as infection-likely and one as infection-unlikely, emphasizing the importance of microbiological tests in diagnostic criteria. In 43% (24/56) of revisions categorized as infection-unlikely using a combination of other EBJIS criteria, five had positive culture, and three had positive mPCR and 16S PCR. Fifteen (62%) had positive 16S NGS, 12 due to a low number of reads, which may indicate low-grade infection or possible contamination. Conclusion. To date, no test can be established as the ultimate gold standard. The lack of interpretation criteria can result in low specificity of some methods, as the threshold is difficult to determine. A multidisciplinary approach with combination of microbiological tools is still considered the most efficient

Aim. Swedish guidelines on antibiotic prophylaxis in arthroplasty surgery recommend cloxacillin in fixed doses that pay little attention to the patient's renal function and weight. Nevertheless, there are no studies on whether the resulting free prophylactic cloxacillin in vivo concentrations are optimal. We aimed to evaluate whether the current recommended prophylactic dosage of cloxacillin is adequate. Method. We performed a prospective two-centre study, measuring the free (active) cloxacillin concentrations in plasma throughout surgery, in patients subject to primary hip and knee prosthetic joint replacements, aiming at 100 patients per centre. To account for plasma-bone exposure differences, concentrations were considered adequate if twice the epidemiological cut-off value for cloxacillin concerning wild type Staphylococcus aureus whereas two-three times were labelled threshold values. The two enrolling hospitals are acute care hospitals in central Sweden, also performing 600 - 1200 primary hip and knee joint arthroplasties annually. All patients scheduled for elective primary hip or knee replacements from January 2022 to April 2024 were eligible for participation. Exclusion criteria were allergy towards penicillins, cognitive disorders leading to inability to sign informed consent, and an absence of interpreter in case of a patient not speaking Swedish or English. Results. We present results from the first 49 patients included. Four patients had free cloxacillin concentrations below cut-off (8.2%). These four cases had prolonged surgeries of 77-100 minutes. An additional 5/49 (10.2%) had threshold values. Conversely 5/49 (10.2%) cases had concentrations exceeding 15 times the needed. No cases with threshold or low cloxacillin concentrations were attributable to a lack of concerning timing and dosing of cloxacillin. All concentrations were above or equal to our cut-off at the start of surgery. Eighteen percent of patients were of normal of weight (BMI 18.5- 25). Of the rest 4% were morbidly obese (BMI >40), 41% obese (BMI 30-40) and 37% overweight (BMI 25-30). Twenty seven percent (43/159) had diabetes and 45% suffered cardiac disease. Conclusions. Some patients in our cohort had insufficient active cloxacillin levels at the end of prosthetic joint surgery. Previous studies indicate that insufficient prophylactic antibiotic concentrations might lead to an enhanced risk of prosthetic joint infections. Other patients were massively overdosed, leading to unnecessary ecological effects and potentially adverse reactions. As inadequate cloxacillin concentrations were not associated with a lack of compliance to current guidelines a change in practise might be needed. Our final results may help to determine how dosing should be adjusted

Aim. A substantial portion of periprosthetic joint infections (PJI) literature is comprised of observational studies. The Strengthening the Reporting of Observational Studies in Epidemiology guidelines emphasize the importance of clearly defining variables and providing diagnostic criteria. Well-defined variables in these studies play a crucial role in ensuring data consistency, fostering comparability among studies, and laying a robust foundation for evidence-based decision-making. We aimed to determine the definition of these variables and determine the objectivity of the definitions. Method. We reviewed observational studies on hip or knee PJI that focused on variables and their association with treatment outcomes. The inclusion criteria comprised studies from Jan 2017 to Jan 2023. We focused on 13 variables that were possibly subjective. These were smoking, alcohol use, diabetes mellitus, hypertension, lung disease, rheumatoid arthritis, liver diseases, kidney diseases, cardiovascular diseases, malignancy, immunosuppression, use of antibiotics, and type of infection. The reviewers examined the text of the articles, along with any available online supplements or protocols, for definitions of the selected variables. We classified a definition as objective if there was the presence of time element, severity, staging, frequencies, laboratory cut-off, medication dependence, among others. Chart review was deemed subjective. Results. We included 75 studies in the analysis. The most common factors studied were diabetes mellitus (79%), cardiovascular disease, smoking history, and rheumatoid arthritis (47% each). The variables that were objectively defined most often were antibiotic use (100%) and type of infection (95%). Smoking history (16%) and alcohol use (20%) were the least frequently objectively defined variables. Further analysis revealed that a considerable number of studies incorporated variables into their primary analyses without clear definitions. For instance, out of the 59 studies where diabetes was considered a variable, 41 studies (70%) included diabetes in their main analyses as a factor for PJI treatment outcomes, despite only 34 studies having defined this variable. Moreover, of the 34 provided definitions of diabetes mellitus, only 12 provided objective criteria for diagnosis. The rest of the provided definitions relied on “chart review” without further specification. Table 1 outlines the proportion of studies with variables defined and included in their analysis. Conclusions. Study variables were not clearly defined in most of the observational studies raising concerns about the reproducibility and reliability of findings. Our study underscores the vital need for standardized variable definitions in PJI research. Professional societies may play a crucial role in setting standards for the definition of variables. For any tables or figures, please contact the authors directly

Aim. Rifampicin and fluoroquinolone based therapy is generally considered as first-choice targeted oral antimicrobial therapy for staphylococcal prosthetic joint infections (PJI) treated with debridement, antibiotics and implant retention (DAIR). Alternative equally effective antimicrobial strategies are urgently needed due to toxicity and drug-drug interactions that frequently occur with this strategy. Data from recent clinical studies suggests equipoise for other antimicrobial treatment regimens. The objective of the Rifampicin Combination Therapy versus Targeted Antimicrobial Monotherapy in the Oral Antimicrobial Treatment Phase of Staphylococcal Prosthetic Joint Infection (RiCOTTA)-trial is to evaluate whether monotherapy with clindamycin is non-inferior to rifampicin/fluoroquinolone combination therapy in patients with staphylococcal PJI that are treated with DAIR. Method. The RiCOTTA-trial is a multicenter, non-inferiority, open-label, randomized controlled trial evaluating clindamycin versus rifampicin/fluoroquinolone combination therapy in the oral treatment phase in patients with staphylococcal PJI managed with DAIR. The trial is performed in 16 hospitals in the Netherlands. Eligible patients are adults with staphylococcal knee or hip PJI managed by DAIR. Patients are included one to six days before antibiotic treatment is switched from intravenous to oral therapy. Patients with a contraindication for rifampicin, with a megaprosthesis or who receive intravenous antibiotics for more than three weeks after initial debridement are excluded. Primary outcome is treatment success one year after finishing antimicrobial treatment. Success is defined as the absence of: i. Infection related re-surgery, ii. New episode of antibiotic treatment for infection of the index joint after the initial treatment phase of 12 weeks, iii. Ongoing use of antibiotics for the index joint at the end of follow-up, iv. Death. The estimated treatment success of rifampicin combination therapy is 85% and the monotherapy strategy is considered not inferior when the difference in treatment success will be less than 10%. Enrolment of 158 patients per group (316 in total) is needed to confirm non-inferiority of monotherapy with a power of 80%. The trial is currently open for enrolment. The study is approved by the Medical Ethics Committee Leiden, the Hague, Delft, the Netherlands and registered under EU trial number 2022-501620-26-00 in Clinical Trial Information System. Conclusions. Currently, the RiCOTTTA study is the largest randomised clinical trial that compares targeted oral monotherapy with rifampicin combination treatment for staphylococcal PJI. Noninferiority of monotherapy would result in a change in national PJI guidelines and enable clinicians to use a more patient-tailored approach when considering antibiotics for patients during the oral treatment phase of PJI

Aim. Dalbavancin is a lipoglycopeptide with a broad antimicrobial spectrum against Gram-positive bacteria and effect against microorganisms in biofilm in vitro. Its pharmacokinetic properties, with an exceptionally long half-life of approximately 300 hours, allow for simplified administration that may be of value in the long-term treatment of bone and joint infections, such as prosthetic joint infections (PJIs). Several case reports and case series with “off-lable” treatment with dalbavancin of PJIs exist, but the optimal dosing regimen remains to be defined. Therapeutic drug monitoring (TDM) is recommended for treatment with >2 doses of dalbavancin. In the absence of TDM, the Swedish national guidelines for bone and joint infections (2023, . www.infektion.net. ) recommends a loading dose of dalbavancin 1,500 mg on day 1 and 1,500 mg on days 8 – 14, after which from day 28 1,000 mg is given biweekly or 500 mg every week. The aim of the present study was to determine trough levels of dalbavancin in patients with long-term treatment of PJIs according to the national guidelines. Method. Twelve patients with PJI were treated with at least 6 doses of dalbavancin, of which the first two doses were 1500 mg and the following doses were 1000 every second week, and prospectively sampled biweekly for determination of serum concentrations (trough levels) of dalbavancin which was measured by liquid chromatography coupled to electrospray tandem mass spectrometry (LC-MS/MS). The renal function was also examined. Results. The median serum concentration 14 days after the first dose of dalbavancin 1500 mg was 36.3 mg/L (range 6.6 – 62.4 mg/L). The median value 14 days after the second dose of 1500 mg (day 27 – 28) was 48.2 mg/L (range 12.2 – 77.3 mg/L). The trough value after the last dose of a total of 6 – 7 doses was as median 43.1 mg/L (range 26.2 – 97.5 mg/L). Three patients showed a tendency towards successive accumulation of dalbavancin during treatment. None of the patients, including those three with increasing through levels during treatment, showed any significant alteration in creatinine nor glomerular filtration rate. Conclusions. TDM during long-term treatment with dalbavancin is recommended to avoid the risk of accumulation and unnecessarily high trough values. With TDM, the dosing interval can be extended in several cases. In addition, with the support of TDM, subtherapeutic serum concentrations, with the risk of developing resistance, can be avoided

Introduction. As per national guidelines for Ankle fractures in the United Kingdom, fractures considered stable can be treated with analgesia, splinting and allowed to weight bear as tolerated. The guidelines also suggest further follow-up not mandatory. This study was aimed at evaluating the current clinical practice of managing stable ankle fractures at a university hospital against national guidelines. Method. The study was undertaken using retrospectively collected data, the inclusion criteria being all adults with stable ankle fracture pattern treated non-operatively between December 2022 and April 2023. Collected data included age of patient, date of injury, type of immobilization, number of clinical visits and any complications. Results. 41 cases were identified and analyzed. The mean age of the cohort was 49.8 years (Standard deviation 20.01). Twelve percent (n = 5) were reviewed in clinic, treated and discharged as stable Weber B type fracture pattern as per national guidelines after the first visit. About 52% (n = 21) were seen in clinic twice before discharge, first visit between 1-2 weeks and the last clinic visit between 5-7 weeks. About a third of patients (30%, n = 12) were seen in clinic on more than two occasions. At the first clinic visit 87% (n = 36) were given a boot and allowed to weight bear as tolerated. Two patients were diagnosed with deep vein thrombosis/pulmonary embolism during the treatment duration. Three patients had extended duration of follow up for ongoing symptoms. None discharged after first or second visit needed surgery for displaced or malunited fracture. Conclusion. Patients discharged from clinic after first or second visit did not need any further surgery. As per national guidelines, patients deemed stable weber B lateral malleolus fracture pattern after weight bearing radiograph can be treated safely with a weight bearing walking boot with no further follow up

Introduction. Patients with external fixators are at risk of pin site infection. A more objective assessment of possible pin site infection is warranted, particularly for future home-based monitoring of pin sites. The aim was to determine if thermography can detect signs of inflammation around pin sites by 1) Establishing a maximum temperature cut-off value 2) Investigating the correlation between local temperature and visual signs of inflammation 3) Adjust for anatomical location and ambient room temperature. Method. This was a cross-sectional international multi-center study following STROBE guidelines. All patients with external ring-fixators scheduled for a visit in the out-patient clinic were eligible. Visual signs of inflammation were categorized using the Modified Gordon classification System (MGS, simplified sMGS). Thermographic imaging was done with an infrared camera (FLIR T540) and the maximum temperature within the ROI (MaxTp) was the primary outcome measure. Sample size and reliability were estimated. Cohen-Kappa, ROC-curve/AUC and Poisson regression were used for statistical analysis. Result. Data from 1970 pin sites were included. Inter-rater reliability of MGS was Kappa=0.79 and for MaxTp ICC=0.99 (95%CI: 0.99;0.99). Overall, a tendency of rising temperature with increasing sMGS was seen. The difference between sMGS=0 and sMGS>0 was significant. The performance of MaxTp as a screening tool to detect inflammation was reasonable with an AUC of 0.71 (95% CI: 0.65-0.76). The empirically optimal cut-off value was 34.1°C (Sensitivity=65%, Specificity=72%, Positive predictive value=23%, Negative Predictive value=94%). A 1°C increase in MaxTp increased the RR of visual signs of inflammation by a factor 1.5 (95% CI: 1.3; 1.7). Conclusion. We found a clinical positive association between the temperature at the pin site measured with thermography and visual signs of inflammation. The empirically optimal temperature cut-off value for inflammation screening was 34.1°C. Thermography may be a promising tool for a for a future point of care technology

Introduction. Epiphysiodesis, defined as the process of closing the growth plate (physis), have been used for several years as a treatment option of cases where the predicted leg-length discrepancy (LLD) falls between 2 to 5 cm. The aim of this study was to systematically review the existing literature on the effectiveness of three different epiphysiodesis techniques with implant usage for the treatment of leg-length discrepancy in the pediatric population. The secondary aim was to address the reported complications of staples, tension-band plates (TBP) and percutaneous epiphysiodesis screws (PETS). Method. This systematic review was performed according to PRISMA guidelines. We searched MEDLINE (PubMed), Embase, Cochrane Library, Web of Science and Scopus for studies on skeletally immature patients with LLD treated with epiphysiodesis with an implant. The extracted outcome categories were effectiveness of epiphysiodesis (LLD measurements pre/post-operatively, successful/unsuccessful) and complications that were graded on severity. Result. Forty-four studies (2184 patients) were included, from whom 578 underwent TBP, 455 PETS and 1048 staples. From pooled analysis of the studies reporting success rate, 64% (150/234) successful TBP surgeries (10 studies), 78% (222/284) successful PETS (9 studies) and 52% (212/407) successful Blount staples (8 studies). Severe complications rate was 7% for PETS, 17% for TBP and 16% for Blount staples. TBP had 43 cases of angular deformity (10%), Blount staples 184 (17%) while PETS only 18 cases (4%). Conclusion. Our results highlighted that PETS seems to be the most successful type of epiphysiodesis surgery with an implant, with higher success rate and lower severe complications than TBP or Blount staples

Introduction. Selective screening of children at risk for developmental dysplasia of the hip (DDH) is based on clinical examination and risk factor identification. Two meta-analyses published in 2012 found breech presentation, family history of DDH, female sex and primiparity to increase the risk of DDH. However, the DDH definition, reference tests and age of the examined children vary considerably, complicating the translation of those findings to current screening guidelines. The aim of this meta-analysis was to evaluate the association of previously proposed risk factors to the risk of sonographically verified DDH. Method. We searched PubMed, EMBASE and Cochrane library to identify cohort, RCTs, case-control and cross-sectional studies from 1980 to 2023 in English language. Eligible studies included participants under three months of age, where the diagnosis of DDH was made by hip ultrasound using the gold standard Graf method and reported information on one or more of the proposed risk factors and final diagnosis was available. Result. Of 5363 studies screened, 20 studies (n=64543 children) were included. Breech presentation (OR: 4.2, 95%CI 2.6-6.6), family history (3.8, 95%CI 2.1-7.2), female sex (2.5, 95%CI 1.7-3.6), oligohydramnios (3.8, 95%CI 1.7-8.5) and high birthweight (2.0, 95%CI 1.6-2.5) significantly increased the risk of DDH. C-section, primiparity, multiple births, low birthweight and prematurity were not found to increase the risk for DDH, and there was only one study about clubfoot as a risk factor. Heterogeneity was high (I. 2. >75%) in all the tested factors except high birthweight (I. 2. =0%). Subgroup analysis was performed to investigate these heterogeneities. Conclusion. Family history of DDH and breech presentation are associated with significant increase of the risk of sonographic DDH in children aged three months. A similar risk increase was detected for oligohydramnios, which was not detected in previous meta-analyses. Additionally, the DDH risk increase of female sex was found to be lower than previously reported

Introduction. Plantar heel pain, or plantar fasciopathy (PF), is a common musculoskeletal complaint, affecting 39% of lower-extremity tendinopathies in general practice. Conservative management is recommended as the first-line treatment, yet many patients continue to experience symptoms even after ten years. There is a significant lack of high-quality evidence for the effectiveness of various treatments, highlighting the need for more research. Minimally invasive surgical options, such as endoscopic plantar fascia release and radiofrequency microtenotomy, have shown promise in reducing pain and improving outcomes. This systematic review aims to evaluate the effectiveness of these minimally invasive surgical treatments compared to non-surgical options in managing PF. Method. The systematic review, registered on PROSPERO (CRD42024490498) and adhering to PRISMA guidelines, searched databases including PubMed, Embase, Cochrane, and others for studies from January 1991 to May 2024. Keywords included plantar fasciitis, plantar fasciopathy, and heel pain. Limited to human trials, the search strategy was refined with an information specialist and found no protocol duplicates. Result. The systematic review identified eight studies involving 495 patients (56.2% women, average age 46.5 years). The studies compared various treatments, including endoscopic plantar fascia release (EPF), mini-scalpel needle (MSN) treatment, ultrasound-guided pulsed radiofrequency (UG-PRF), and needle electrolysis (NE), to non-surgical interventions and corticosteroid injections (CSI). Primary outcomes focused on pain reduction, with some needle treatments showing superior results (between-group diffence). No severe adverse events were reported. Conclusion. In conclusion, plantar fasciopathy (PF) remains a prevalent and challenging condition, that can be resistant to conservative treatments. This systematic review highlights the potential of minimally invasive surgical options, such as endoscopic plantar fascia release and needle treatments, in reducing pain and improving functional outcomes. Despite some needle treatments showing superior results, the overall lack of high-quality evidence underscores the need for further research to establish the most effective management strategies for PF

Introduction. Shoulder arthroplasty (SA) has been performed with different types of implants, each requiring different replacement systems. However, data on previously utilized implant types are not always available before revision surgery, which is paramount to determining the appropriate equipment and procedure. Therefore, this meta-analysis aimed to evaluate the accuracy of the AI models in classifying SA implant types. Methods. This systematic review was conducted in Pubmed, Embase, SCOPUS, and Web of Science from inception to December 2023, according to PRISMA guidelines. Peer-reviewed research evaluating the accuracy of AI-based tools on upper-limb X-rays for recognizing and categorizing SA implants was included. In addition to the overall meta-analysis, subgroup analysis was performed according to the type of AI model applied (CNN (Convolutional neural network), non-CNN, or Combination of both) and the similarity of utilized datasets between studies. Results. 13 articles were eligible for inclusion in this meta-analysis (including 138 different tests assessing models’ efficacy). Our meta-analysis demonstrated an overall sensitivity and specificity of 0.891 (95% CI:0.866-0.912) and 0.549 (95% CI:0.532,0.566) for classifying implants in SA, respectively. The results of our subgroup analyses were as follows: CNN-subgroup: a sensitivity of 0.898 (95% CI:0.873-0.919) and a specificity of 0.554 (95% CI:0.537,0.570), Non-CNN subgroup: a sensitivity of 0.809 (95% CI:0.665-0.900) and specificity of 0.522 (95% CI:0.440,0.603), combined subgroup: a sensitivity of 0.891 (95% CI:0.752-0.957) and a specificity of 0.547 (95% CI:0.463,0.629). Studies using the same dataset demonstrated an overall sensitivity and specificity of 0.881 (95% CI:0.856-0.903) and 0.542 (95% CI:0.53,0.554), respectively. Studies that used other datasets showed an overall sensitivity and specificity of 0.995 (95% CI:969,0.999) and 0.678 (95% CI:0.234, 0.936), respectively. Conclusion. AI-based classification of shoulder implant types can be considered a sensitive method. Our study showed the potential role of using CNN-based models and different datasets to enhance accuracy, which could be investigated in future studies

Introduction. Hip prosthetic joint infection (PJI) is a debilitating complication following joint replacement surgery, with significant impact on patients and healthcare systems. The INFection ORthopaedic Management: Evidence into Practice (INFORM: EP) study, builds upon the 6-year INFORM programme by developing evidence-based guidelines for the identification and management of hip PJI. Methods. A panel of 21 expert stakeholders collaborated to develop best practice guidelines based on evidence from the previous INFORM research programme. An expert consensus process was used to refine guidelines using RAND/UCLA criteria. The guidelines were then implemented over a 12-month period through a Learning Collaborative of 24 healthcare professionals from 12 orthopaedic centres in England. Qualitative interviews were conducted with 17 members of the collaborative and findings used to inform the development of an implementation support toolkit. Patient and public involvement contextualised the implementation of the guidelines. The study is registered with the ISCRTN (34710385). Result. The INFORM guidelines, structured around the stages of PJI management, were largely supported by surgeons, although barriers included limited awareness among non-surgical team members, lack of job planning for multidisciplinary teams, and challenges in ensuring timely referrals from primary care. Psychological support for patients was identified as a critical gap. Advanced Nurse Practitioners and multidisciplinary team (MDT) coordinators were seen as potential bridges to address these knowledge gaps. The guidelines were also viewed as a useful tool for service development. Conclusions. This study presents the first evidence-based guidelines for hip PJI management, offering a comprehensive approach to prevention, treatment, and postoperative care. Effective implementation is crucial, involving wider dissemination amongst primary and community care, as well as non-specialist treatment centres. Further resources are needed to ensure job planning for MDTs and psychological support for patients. Overall, this study lays the foundation for improved PJI management, benefiting patients and healthcare systems

Introduction. Most western countries have implemented fast-track hip fracture aiming at surgery within 24 hours, since the mortality rate hereafter rises markedly. In Greenland, it is not achievable to operate within 24 hours. Arctic people live in sparsely populated areas and Greenland's population is scattered along the vast coastline. All patients must be chartered to Nuuk by airplane which can take up till several days to weeks, due to logistics and the Arctic weather. This presents a challenge regarding adhering to western guidelines. The operative delay may be acceptable though, as it is the impression that the Greenlandic population survives and endures better than patients of western populations. However, as data are lacking, we aimed to describe mortality among hip fracture patients in Greenland taking frailty and comorbidities into account. Method. All patients with ICD-10 codes DS720, DS721 and DS722 from 2018-2022 were identified as 261 patients diagnosed with hip fractures. Variables including time of diagnosis, time to operation, reasons for delay, ASA-score, Charlson Comorbidity index, time of death, and other possible confounding variables were analyzed. Primary outcome was mortality rates at 30-day post-OP and 1-year post-OP. Results. The average time from fracture to operation was 91.4 hours. In the Danish Cohort (DC) 70,6 % of patient were operated within 24 hours. Overall, 30-day mortality was 9,9 %, and 1-year mortality was 29,4 %, compared to the DC with 10,8 % 30-day mortality and 28,3 % 1-year mortality. Multivariate regression was conducted, showing no statiscal significant increase in mortality, despite extended delay. Conclusion. With no increase in death, the authors find it justifiable that patients in Greenland endure longer delays than the western population. The influence on further adverse effects needs to be investigated as well as causes of survival, but perhaps the Arctic people unveil mechanisms for raised survival among other populations

Aims

The incidence of limb fractures in patients living with HIV (PLWH) is increasing. However, due to their immunodeficiency status, the operation and rehabilitation of these patients present unique challenges. Currently, it is urgent to establish a standardized perioperative rehabilitation plan based on the concept of enhanced recovery after surgery (ERAS). This study aimed to validate the effectiveness of ERAS in the perioperative period of PLWH with limb fractures.

Aims

For rare cases when a tumour infiltrates into the hip joint, extra-articular resection is required to obtain a safe margin. Endoprosthetic reconstruction following tumour resection can effectively ensure local control and improve postoperative function. However, maximizing bone preservation without compromising surgical margin remains a challenge for surgeons due to the complexity of the procedure. The purpose of the current study was to report clinical outcomes of patients who underwent extra-articular resection of the hip joint using a custom-made osteotomy guide and 3D-printed endoprosthesis.

Aims. Lower limb fractures are common in low- and middle-income countries (LMICs) and represent a significant burden to the existing orthopaedic surgical infrastructure. In high income country (HIC) settings, internal fixation is the standard of care due to its superior outcomes. In LMICs, external fixation is often the surgical treatment of choice due to limited supplies, cost considerations, and its perceived lower complication rate. The aim of this systematic review protocol is identifying differences in rates of infection, nonunion, and malunion of extra-articular femoral and tibial shaft fractures in LMICs treated with either internal or external fixation. Methods. This systematic review protocol describes a broad search of multiple databases to identify eligible papers. Studies must be published after 2000, include at least five patients, patients must be aged > 16 years or treated as skeletally mature, and the paper must describe a fracture of interest and at least one of our primary outcomes of interest. We did not place restrictions on language or journal. All abstracts and full texts will be screened and extracted by two independent reviewers. Risk of bias and quality of evidence will be analyzed using standardized appraisal tools. A random-effects meta-analysis followed by a subgroup analysis will be performed, given the anticipated heterogeneity among studies, if sufficient data are available. Conclusion. The lack of easily accessible LMIC outcome data, combined with international clinical guidelines that are often developed by HIC surgeons for use in HIC environments, makes the clinical decision-making process infinitely more difficult for surgeons in LMICs. This protocol will guide research on surgical management, outcomes, and complications of lower limb shaft fractures in LMICs, and can help guide policy development for better surgical intervention delivery and improve global surgical care. Cite this article: Bone Jt Open 2024;5(11):1020–1026

Aims

This Delphi study assessed the challenges of diagnosing soft-tissue knee injuries (STKIs) in acute settings among orthopaedic healthcare stakeholders.