Aims

Treatment of high-grade limb bone sarcoma that invades a joint requires en bloc extra-articular excision. MRI can demonstrate joint invasion but is frequently inconclusive, and its predictive value is unknown. We evaluated the diagnostic accuracy of direct and indirect radiological signs of intra-articular tumour extension and the performance characteristics of MRI findings of intra-articular tumour extension.

The August 2024 Trauma Roundup³⁶⁰ looks at: Does topical vancomycin prevent fracture-related infections in closed fractures undergoing open reduction and internal fixation? A randomized controlled trial; Is postoperative splinting advantageous after upper limb fracture surgery?; Does suprapatellar nailing resolve knee pain?; Locking versus non-locking plate fixation in comminuted talar neck fractures: a biomechanical study using cadaveric specimens; Revolutionizing recovery metrics: PROMIS versus SMFA in orthopaedic trauma care; Dorsal hook plating of patella fractures: reliable fixation and satisfactory outcomes; The impact of obesity on subtrochanteric femur fracture outcomes; Low-dose NSAIDs (ketorolac) and cytokine modulation in orthopaedic polytrauma: a detailed analysis.

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Metal particles detached from metal-on-metal hip prostheses (MoM-THA) have been shown to cause inflammation and destruction of tissues. To further explore this, we investigated the histopathology (aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) score) and metal concentrations of the periprosthetic tissues obtained from patients who underwent revision knee arthroplasty. We also aimed to investigate whether accumulated metal debris was associated with ALVAL-type reactions in the synovium.

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As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach.

Aims. Intra-articular (IA) tumours around the knee are treated with extra-articular (EA) resection, which is associated with poor functional outcomes. We aim to evaluate the accuracy of MRI in predicting IA involvement around the knee. Methods. We identified 63 cases of high-grade sarcomas in or around the distal femur that underwent an EA resection from a prospectively maintained database (January 1996 to April 2020). Suspicion of IA disease was noted in 52 cases, six had IA pathological fracture, two had an effusion, two had prior surgical intervention (curettage/IA intervention), and one had an osseous metastasis in the proximal tibia. To ascertain validity, two musculoskeletal radiologists (R1, R2) reviewed the preoperative imaging (MRI) of 63 consecutive cases on two occasions six weeks apart. The radiological criteria for IA disease comprised evidence of tumour extension within the suprapatellar pouch, intercondylar notch, extension along medial/lateral retinaculum, and presence of IA fracture. The radiological predictions were then confirmed with the final histopathology of the resected specimens. Results. The resection histology revealed 23 cases (36.5%) showing IA disease involvement compared with 40 cases without (62%). The intraobserver variability of R1 was 0.85 (p < 0.001) compared to R2 with κ = 0.21 (p = 0.007). The interobserver variability was κ = 0.264 (p = 0.003). Knee effusion was found to be the most sensitive indicator of IA involvement, with a sensitivity of 91.3% but specificity of only 35%. However, when combined with a pathological fracture, this rose to 97.5% and 100% when disease was visible in Hoffa’s fat pad. Conclusion. MRI imaging can sometimes overestimate IA joint involvement and needs to be correlated with clinical signs. In the light of our findings, we would recommend EA resections when imaging shows effusion combined with either disease in Hoffa’s fat pad or retinaculum, or pathological fractures. Cite this article: Bone Joint J 2023;105-B(6):696–701

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Distraction osteogenesis with intramedullary lengthening devices has undergone rapid development in the past decade with implant enhancement. In this first single-centre matched-pair analysis we focus on the comparison of treatment with the PRECICE and STRYDE intramedullary lengthening devices and aim to clarify any clinical and radiological differences.

Abstract. Background. With the increasingly accepted method of suprapatellar tibial nailing for tibial shaft fractures, we aimed to compare intraoperative and postoperative outcomes of infrapatellar (IP) vs suprapatellar (SP) tibial nails. Methods. A retrospective cohort analysis of 58 patients. 34 SP tibial nails over 3 years versus 24 IP tibial nails over a similar time frame. We compared; radiation exposure, patient positioning time (PPT), non-union rate and follow-up time. Knee pain in the SP group was evaluated, utilising the Hospital for Special Surgery (HSS) Knee injury and Osteoarthritis outcome score (KOOS). Results. 58 patients with a mean age of 43 years were included. Mean intraoperative radiation dose for SP nails was 61.78cGy (range 11.60 to 156.01cGy) vs 121.09cGy (range 58.01 to 18.03cGy) for IP nails (p < 0.05). Mean PPT for SP nails was 10 minutes vs 18 minutes for IP nails (p < 0.05). All fractures united in the SP group vs one non-union in the IP group. Mean follow-up was 5.5 months vs 11 months in the SP and IP group respectively. Mean KOOS was 7 (range 0 to 22) at 6 months for the SP group. Conclusion. The semi extended position (SP group) leads to reduced radiation exposure because of ease of imaging. All Patients in the SP group showed improved outcomes, with shorter follow-up and fracture union. The KOOS revealed SP nail patients had minimal pain and good knee function. This study establishes a management and PROMs baseline for ongoing evaluation of SP nails

Aim. Diagnosis and isolation of a causative organism is imperative for successful treatment of periprosthetic joint infections (PJI). While there are several diagnostic algorithms using microbiology, serum and synovial markers, the preoperative diagnosis of a low-grade infection remains a challenge, particularly in patients with unsuccessful aspiration. An incisional biopsy may be used in these cases as additional diagnostic tool. In this retrospective study we evaluated microbiological findings, sensitivity, and specificity of open synovial biopsies in cases of inconclusive preoperative diagnostics. Methods. In a retrospective databank analysis (2010–2018), we identified 80 TKAs that underwent an open biopsy because of inconclusive results after applying the CDC Criteria (2010) or the MSIS (2011–2018) for PJI. Infection makers in the serum (C-reactive protein [CRP], leucocytes count and interleukin-6 [IL-6]) and in the synovial aspirate (leucocyte count, percentage of neutrophiles) prior to the biopsy were analyzed. All biopsies were performed by suprapatellar mini-arthrotomy. If a subsequent revision surgery was performed, the isolated organisms in the open biopsy were compared to the results in the revision surgery and sensitivity and specificity were calculated. Serum markers were checked for correlation with a positive result in the open biopsy using Cramer-V and Chi. 2. -Test. Results. A positive result in the open biopsy occurred in 32 cases (40%) while 48 cases (60%) showed no growth of microorganisms. A preoperative elevated serum CRP (≥1mg/dl) showed a significant correlation for a positive biopsy (p=0.04). The odds ratio for a positive biopsy was 2.57 (95% CI 1.02–6.46) with elevated serum CRP. A revision surgery of the TKA with additional tissue sampling was performed in 27 (84%) cases with a positive biopsy and in 32 (67%) cases with a negative biopsy. The intraoperative tissue samples from the revision surgery showed microbial growth in only 52% of cases that were believed to be culture positive from the biopsy results, while positive cultures occurred in 41% of the cases with an initially negative biopsy. Patients with ≥ two cultures of the same microorganism in the biopsy presented a positive result in 73% of their revision surgeries. The open biopsy showed a sensitivity of 48% with a specificity of 62% in our collective if revision surgery was performed. Conclusion. Open biopsy may be considered with inconclusive preoperative serum and synovial fluid diagnostics for PJI, but sensitivity and specificity were rather low in this special collective. Further studies with bigger collectives should be performed to determine potential markers with a higher sensitivity

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The study objective was to prospectively assess clinical outcomes for a pilot cohort of tibial shaft fractures treated with a new tibial nailing system that produces controlled axial interfragmentary micromotion. The hypothesis was that axial micromotion enhances fracture healing compared to static interlocking.

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Rotating-hinge knee prostheses are commonly used to reconstruct the distal femur after resection of a tumour, despite the projected long-term burden of reoperation due to complications. Few studies have examined the factors that influence their failure and none, to our knowledge, have used competing risk models to do so. The purpose of this study was to determine the risk factors for failure of a rotating-hinge knee distal femoral arthroplasty using the Fine-Gray competing risk model.

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The diagnosis of joint infections is an inexact science using combinations of blood inflammatory markers and microscopy, culture, and sensitivity of synovial fluid (SF). There is potential for small molecule metabolites in infected SF to act as infection markers that could improve accuracy and speed of detection. The objective of this study was to use nuclear magnetic resonance (NMR) spectroscopy to identify small molecule differences between infected and noninfected human SF.

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In wound irrigation, 1 mM ethylenediaminetetraacetic acid (EDTA) is more efficacious than normal saline (NS) in removing bacteria from a contaminated wound. However, the optimal EDTA concentration remains unknown for different animal wound models.

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Stiffness is a common complication after total knee arthroplasty (TKA). Pathogenesis is not understood, treatment options are limited, and diagnosis is challenging. The aim of this study was to investigate if MRI can be used to visualize intra-articular scarring in patients with stiff, painful knee arthroplasties.

Aims. The aticularis genu (AG) is the least substantial and deepest muscle of the anterior compartment of the thigh and of uncertain significance. The aim of the study was to describe the anatomy of AG in cadaveric specimens, to characterize the relevance of AG in pathological distal femur specimens, and to correlate the anatomy and pathology with preoperative magnetic resonance imaging (MRI) of AG. Methods. In 24 cadaveric specimens, AG was identified, photographed, measured, and dissected including neurovascular supply. In all, 35 resected distal femur specimens were examined. AG was photographed and measured and its utility as a surgical margin examined. Preoperative MRIs of these cases were retrospectively analyzed and assessed and its utility assessed as an anterior soft tissue margin in surgery. In all cadaveric specimens, AG was identified as a substantial structure, deep and separate to vastus itermedius (VI) and separated by a clear fascial plane with a discrete neurovascular supply. Mean length of AG was 16.1 cm ( ± 1.6 cm) origin anterior aspect distal third femur and insertion into suprapatellar bursa. In 32 of 35 pathological specimens, AG was identified (mean length 12.8 cm ( ± 0.6 cm)). Where AG was used as anterior cover in pathological specimens all surgical margins were clear of disease. Of these cases, preoperative MRI identified AG in 34 of 35 cases (mean length 8.8 cm ( ± 0.4 cm)). Results. AG was best visualized with T1-weighted axial images providing sufficient cover in 25 cases confirmed by pathological findings.These results demonstrate AG as a discrete and substantial muscle of the anterior compartment of the thigh, deep to VI and useful in providing anterior soft tissue margin in distal femoral resection in bone tumours. Conclusion. Preoperative assessment of cover by AG may be useful in predicting cases where AG can be dissected, sparing the remaining quadriceps muscle, and therefore function. Cite this article: Bone Joint Open 2020;1-9:585–593

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Methicillin-resistant Staphylococcus aureus (MRSA) can cause wound infections via a ‘Trojan Horse’ mechanism, in which neutrophils engulf intestinal MRSA and travel to the wound, releasing MRSA after apoptosis. The possible role of intestinal MRSA in prosthetic joint infection (PJI) is unknown.

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Biopsy of the periprosthetic tissue is an important diagnostic tool for prosthetic joint infection (PJI) as it enables the detection of the responsible microorganism with its sensitivity to antibiotics. We aimed to investigate how often the bacteria identified in the tissue analysis differed between samples obtained from preoperative biopsy and intraoperative revision surgery in cases of late PJI; and whether there was a therapeutic consequence.