Aims. The new COVID-19 variant was reported by the authorities of the UK to the World Health Organization (WHO) on 14 December 2020. We aim to describe the clinical characteristics and nosocomial infection rates in major trauma and orthopaedic patients comparing the first and second wave of COVID-19 infection. Methods. A retrospective analysis of a prospectively collected trauma database was reviewed at a level 1 major trauma centre from 1 December 2020 to 18 February 2021 looking at demographics, clinical characteristics, and nosocomial infections and compared to our previously published first wave data (26 January 2020 to 14 April 2020). Results. From 1 December 2020 to 18 February 2021, 522 major trauma patients were identified with a mean age of 54.6 years, and 53.4% (n = 279) were male. Common admissions were falls (318; 60.9%) and road traffic accidents (RTAs; 71 (13.6%); 262 of these patients (50.2%) had surgery. In all, 75 patients (14.4%) tested positive for COVID-19, of which 51 (68%) were nosocomial. Surgery on COVID-19 patients increased to 46 (61.3%) in the second wave compared to 13 (33.3%) in the first wave (p = 0.005). ICU admissions of patients with COVID-19 infection increased from two (5.1%) to 16 (20.5%), respectively (p = 0.024). Second wave mortality was 6.1% (n = 32) compared to first wave of 4.7% (n = 31). Cardiovascular (CV) disease (35.9%; n = 14); p = 0.027) and dementia (17.9%; n = 7); p = 0.030) were less in second wave than the first. Overall, 13 patients (25.5%) were Black, Asian and Minority ethnic (BAME), and five (9.8%) had a BMI > 30 kg/m. 2. The mean time from admission to diagnosis of COVID-19 was 13.9 days (3 to 44). Overall, 12/75 (16%) of all COVID-19 patients died. Conclusion. During the second wave, COVID-19 infected three-times more patients. There were double the number of operative cases, and quadruple the cases of ICU admissions. The patients were younger with less dementia and CV disease with lower mortality. Concomitant COVID-19 and the necessity of major trauma surgery showed 13% mortality in the second wave compared with 15.4% in the first wave. In contrast to the literature, we showed a high percentage of nosocomial infection, normal BMI, and limited BAME infections. Cite this article: Bone Jt Open 2021;2(8):661–670

Introduction: A multiplicity of factors can increase the risk of nosocomial infection in polytraumatized patients. Infections in the hospital environment are still a serious public health hazard. Nonetheless, only a few studies have been published on nosocomial infections in poly-traumatized pediatric patients. Materials and methods: A 4-month prospective study was carried out of patients admitted to the traumatology department and to the pediatric intensive-care unit between July and November 2003 in order to assess all the procedures the patients were subjected to. Infections were considered to be nosocomial when they appeared 72 hours after admission. Results: 121 patients were included in the study. 77% (93) were boys and 23% (28) girls, with a mean age of 10.6 years. The number of infected patients was 6 (5%) and the number of episodes of nosocomial infection diagnosed was 12. 33% of infected patients had a single episode and 67% had two or more infections. When considering the intrinsic risk factors considered in the study one should mention that 10% of patients who were admitted were in a coma, 4,1% had a respiratory syndrome and 2% were diagnosed as obese. The most frequently isolated micro-organisms in this group of patients were Gram positive bacteria (50%), while the most common pathogen was coagulase-negative staphylococcus (85,7%). Conclusions: The paper reveals the profile of nosocomial infections in ploytraumatized pediatric patients in our hospital environment and defines their connection with the use of invasive measures as well as with the length of the patient’s hospital stay

To prevent nosocomial transmission (NT) of multiresistent germs (MRG) the German Robert Koch Institute (RKI) recommends to isolate patients with MRG. At a so-called normal ward isolating patients is a challenging and stressful procedure for both patients and hospital staff. The present study proposes the hypothesis that, compared to normal wards, an isolation ward reduces the nosocomial infection rate. After an isolation ward with twelve beds has been established in 2005, patients with MRG on the wards of the department for spinal cord injury as well as on the isolation ward were monitored using a prospective screening and meeting the requirements of the RKI. Apart from detecting transmitter of MRG the NT of these bacteria was identified and registered between 2006 and 2013. The total length of a patients stay in the hospital, the number of isolation days and the rate of NTs were documented. The quotient of MRG load per ward and the number of NTs per ward were compared. In the investigation period of eight years 262175 patient days, 33416 isolation days and 33 transmissions were registered. On the spinal cord injury ward 223167 of the patient days, 1120 of the isolation days and 29 of the NTs were documented. On the isolation ward 39008 of the patient days and 32296 of the isolation days with four of the transmissions were registered. The mean load of MRG resulted from the quotient of the number of days with MRG per 100 patient days. The effective nosocomial frequency of transmission resulted from the quotient of the mean load of MRG to the number of transmissions. As a result, the frequency of transmission on the isolation ward was significantly lower (p=0,001) in comparison to the spinal cord injury ward. The presented results suggest that, despite multiple higher loads of MRG, constructional measures combined with contact isolation facilitate a reduction of NT rates of MRG. The reservation must be made, however, that in case of known MRG the screening was performed under isolation conditions, with unkown MRG without meeting requirements of isolation. The present comparison of NT rates on an isolation ward and a normal spinal cord injury ward emphasizes the importance and function of an isolation ward through constructional (physical) separation and pooling of professional competency for successful management of MRG in healthcare facilities

Aims. The primary aim was to determine the influence of COVID-19 on 30-day mortality following hip fracture. Secondary aims were to determine predictors of COVID-19 status on presentation and later in the admission; the rate of hospital acquired COVID-19; and the predictive value of negative swabs on admission. Methods. A nationwide multicentre retrospective cohort study was conducted of all patients presenting with a hip fracture to 17 Scottish centres in March and April 2020. Demographics, presentation blood tests, COVID-19 status, Nottingham Hip Fracture Score, management, length of stay, and 30-day mortality were recorded. Results. In all, 78/833 (9.4%) patients were diagnosed with COVID-19. The 30-day survival of patients with COVID-19 was significantly lower than for those without (65.4% vs 91%; p < 0.001). Diagnosis of COVID-19 within seven days of admission (likely community acquired) was independently associated with male sex (odds ratio (OR) 2.34, p = 0.040, confidence interval (CI) 1.04 to 5.25) and symptoms of COVID-19 (OR 15.56, CI 6.61 to 36.60, p < 0.001). Diagnosis of COVID-19 made between seven and 30 days of admission to hospital (likely hospital acquired) was independently associated with male sex (OR 1.73, CI 1.05 to 2.87, p = 0.032), Nottingham Hip Fracture Score ≥ 7 (OR 1.91, CI 1.09 to 3.34, p = 0.024), pulmonary disease (OR 1.68, CI 1.00 to 2.81, p = 0.049), American Society of Anesthesiologists (ASA) grade ≥ 3 (OR 2.37, CI 1.13 to 4.97, p = 0.022), and length of stay ≥ nine days (OR 1.98, CI 1.18 to 3.31, p = 0.009). A total of 38 (58.5%) COVID-19 cases were probably hospital acquired infections. The false-negative rate of a negative swab on admission was 0% in asymptomatic patients and 2.9% in symptomatic patients. Conclusion. COVID-19 was independently associated with a three times increased 30-day mortality rate. Nosocomial transmission may have accounted for approximately half of all cases during the first wave of the pandemic. Identification of risk factors for having COVID-19 on admission or acquiring COVID-19 in hospital may guide pathways for isolating or shielding patients respectively. Length of stay was the only modifiable risk factor, which emphasizes the importance of high-quality and timely care in this patient group. Cite this article: Bone Joint J 2021;103-B(5):888–897

The study aimed to determine if THR deep infection rate correlated with the Nosocomial Infection National Surveillance Scheme (NINSS) data on the surgical site infection (SSI) rate in our institution. Deep infection is a serious complication of hip replacement but presents late. It has recently been reported that 10% of superficial infections develop deep prosthetic infections. NINSS data could therefore be used to predict a unit’s infection risk. This District General Hospital has only recently entered NINSS. In the first quarter of 2001, NINSS reported an 11.9% surgical site infection rate in THRS performed in this unit. A clinical audit of all the primary THRs done between 1/4/94 – 9/9/2001, using revision surgery as the end point, was conducted to determine the true deep infection rate. Patients were identified using the OPCS coding system database and a casenote review was performed on all revision hip operations done locally. A search for our primary THRs that underwent revision surgery at the regional tertiary referral centre was completed to avoid omissions secondary to migration. Of 1258 primary THRS, there were 13 revisions (1%) of which 2 were done for infection (0.16%). NINSS data placed our unit on the 90th centile for infection risk but our historical true deep infection rate of 0.16% compares favourably with the Swedish and Trent hip registry rates of 0.58% and 1.4% respectively. We therefore urge careful interpretation of NINSS data and argue against its use in the media. The quarterly reporting of SSIs may be too short to play a role in ranking hospitals but may be helpful in prophylactic antibiotic selection

Aims. The first death in the UK caused by COVID-19 occurred on 5 March 2020. We aim to describe the clinical characteristics and outcomes of major trauma and orthopaedic patients admitted in the early COVID-19 era. Methods. A prospective trauma registry was reviewed at a Level 1 Major Trauma Centre. We divided patients into Group A, 40 days prior to 5 March 2020, and into Group B, 40 days after. Results. A total of 657 consecutive trauma and orthopaedic patients were identified with a mean age of 55 years (8 to 98; standard deviation (SD) 22.52) and 393 (59.8%) were males. In all, 344 (approximately 50%) of admissions were major trauma. Group A had 421 patients, decreasing to 236 patients in Group B (36%). Mechanism of injury (MOI) was commonly a fall in 351 (52.4%) patients, but road traffic accidents (RTAs) increased from 56 (13.3%) in group A to 51 (21.6%) in group B (p = 0.030). ICU admissions decreased from 26 (6.2%) in group A to 5 (2.1%) in group B. Overall, 39 patients tested positive for COVID-19 with mean age of 73 years (28 to 98; SD 17.99) and 22 (56.4%) males. Common symptoms were dyspnoea, dry cough, and pyrexia. Of these patients, 27 (69.2%) were nosocomial infections and two (5.1%) of these patients required intensive care unit (ICU) admission with 8/39 mortality (20.5%). Of the patients who died, 50% were older and had underlying comorbidities (hypertension and cardiovascular disease, dementia, arthritis). Conclusion. Trauma admissions decreased in the lockdown phase with an increased incidence of RTAs. Nosocomial infection was common in 27 (69.2%) of those with COVID-19. Symptoms and comorbidities were consistent with previous reports with noted inclusion of dementia and arthritis. The mortality rate of trauma and COVID-19 was 20.5%, mainly in octogenarians, and COVID-19 surgical mortality was 15.4%. Cite this article: Bone Joint Open 2020;1-7:330–338

COVID 19 led to massive disruption of elective services across Scotland. This study was designed to assess the impact on elective service that the COVID-19 pandemic had, to what extent services have been restarted and the associated risks are in doing so. This is a retrospective observational study. The primary outcomes are the number of operations completed, 30-day mortality, 30-day complication rates and nosocomial infection with COVID-19 compared to previous years. Data was collected from 4 regions across Scotland from 27th March 2020 - 26th March 2021. This was compared to the same time period the previous year. 3431 elective operations were completed in the year post-pandemic compared with 12255, demonstrating a reduction of 72%. Both groups had comparable demographics. Major joint arthroplasty saw a 72% reduction, with TKR seeing a reduction of 82%. Each of the 4 health boards were affected in a similar fashion. Nosocomial COVID-19 infection was 0.4% in the post covid group. 30 day mortality was the same at 0.1%. Total complications rose from 5.7% to 10.1% post covid. This study shows that there has been a substantial reduction in elective activity across Scotland that is disproportionate to the level of COVID-19. The risk of developing COVID-19 from elective surgery is low at 0.4%, however all complications saw a significant rise. This is likely multifactorial. This study will inform decision makers in future pandemics, that it is safe to continue elective orthopaedic surgery and of the potential impact of cessation of services

Aims. It is imperative to understand the risks of operating on urgent cases during the COVID-19 (SARS-Cov-2 virus) pandemic for clinical decision-making and medical resource planning. The primary aim was to determine the mortality risk and associated variables when operating on urgent cases during the COVID-19 pandemic. The secondary objective was to assess differences in the outcome of patients treated between sites treating COVID-19 and a separate surgical site. Methods. The primary outcome measure was 30-day mortality. Secondary measures included complications of surgery, COVID-19 infection, and length of stay. Multiple variables were assessed for their contribution to the 30-day mortality. In total, 433 patients were included with a mean age of 65 years; 45% were male, and 90% were Caucasian. Results. Overall mortality was 7.6% for all patients and 15.9% for femoral neck fractures. The mortality rate increased from 7.5% to 44.2% in patients with fracture neck of femur and a COVID-19 infection. The COVID-19 rate in the 30-day postoperative period was 11%. COVID-19 infection, age, and Charlson Comorbidity Index were independent risk factor for mortality. Conclusion. There was a significant risk of contracting COVID-19 due to being admitted to hospital. Using a site which was not treating COVID-19 respiratory patients for surgery did not identify a difference with respect to mortality, nosocomial COVID-19 infection, or length of stay. The COVID-19 pandemic significantly increases perioperative mortality risk in patients with fractured neck of femora but patients with other injuries were not at increased risk. Cite this article: Bone Jt Open 2021;2(5):330–336

Aims. Elective orthopaedic surgery was cancelled early in the COVID-19 pandemic and is currently running at significantly reduced capacity in most institutions. This has resulted in a significant backlog to treatment, with some hospitals projecting that waiting times for arthroplasty is three times the pre-COVID-19 duration. There is concern that the patient group requiring arthroplasty are often older and have more medical comorbidities—the same group of patients advised they are at higher risk of mortality from catching COVID-19. The aim of this study is to investigate the morbidity and mortality in elective patients operated on during the COVID-19 pandemic and compare this to a pre-pandemic cohort. Primary outcome was 30-day mortality. Secondary outcomes were perioperative complications, including nosocomial COVID-19 infection. These operations were performed in a district general hospital, with COVID-19 acute admissions in the same building. Methods. Our institution reinstated elective operations using a “Blue stream” pathway, which involves isolation before and after surgery, COVID-19 testing pre-admission, and separation of ward and theatre pathways for “blue” patients. A register of all arthroplasties was taken, and their clinical course and investigations recorded. Results. During a seven-month period, 340 elective arthroplasties were performed. There was zero mortality. One patient had a positive swab for COVID-19 while an inpatient, but remained asymptomatic. There were two readmissions within a 12-week period for hip dislocation. Patients had a mean age of 68 years (28 to 90), mean BMI of 30 kg/m. 2. (19.0 to 45.6), and mean American Society of Anesthesiologists grade of 2 (1 to 3). Conclusion. Results show no increased morbidity or mortality in this cohort of patients compared to the same hospital’s morbidity and mortality pre-COVID-19. The screened pathway for elective patients is effective in ensuring that patients can be safely operated on electively in an acute hospital. This study should reassure clinicians and patients that arthroplasties can be carried out safely when the appropriate precautions are in place. Cite this article: Bone Jt Open 2021;2(11):940–944

The coronavirus 2019 (COVID-19) global pandemic has had a significant impact on trauma and orthopaedic (T&O) departments worldwide. To manage the peak of the epidemic, orthopaedic staff were redeployed to frontline medical care; these roles included managing minor injury units, forming a “proning” team, and assisting in the intensive care unit (ICU). In addition, outpatient clinics were restructured to facilitate virtual consultations, elective procedures were cancelled, and inpatient hospital admissions minimized to reduce nosocomial COVID-19 infections. Urgent operations for fractures, infection and tumours went ahead but required strict planning to ensure patient safety. Orthopaedic training has also been significantly impacted during this period. This article discusses the impact of COVID-19 on T&O in the UK and highlights key lessons learned that may help to proactively prepare for the next global pandemic. Cite this article: Bone Joint Open 2020;1-7:420–423

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period. Cite this article: Bone Joint Open 2020;1-6:222–228

Abstract. Introduction. The risk of Covid-19 community and hospital acquired infection (HAI) on patient outcomes in trauma is still relevant. Patient's should be routinely consented for this risk to ensure informed consent for perioperative contraction. Method. A prospective audit was completed from December-March 2022 examining a consecutive series of patient admissions with capacity to consent. The standards for compliance was RCOS Toolkit 5#3 stating the importance of enhanced consent for risk of contraction, in operating and changes to care pathways. The target was 95% compliance. 2/2 contingency tables were generated to determine odds ratio for compliance versus Covid+ rate. Results. This audit generated 80 consecutive patients from which 28 were excluded as non-operative or lacking capacity. It was found that 25% (13/52) had been specifically consented for risks of Covid-19. The rate of PCR-positive results was 15% (8/52) with a mortality of 25%. Approximately 2% of patients in this series were informed of the risk and had a positive Covid-PCR. An odds ratio of 0.38 indicates that being informed of the risk is not associated with rate of infection e.g by adopting enhanced personal protective measures. Conclusions. The pandemic recovery has not removed this substantial community and nosocomial risk. Our results demonstrate poor compliance with RCS guidance despite ongoing relevance to care. Consent includes the counselling of a patient to specific Covid-related risks including thrombosis & death. Dissemination of these results will be followed by completion of the audit cycle to look for improvements in compliance

Aims. Elective operating was halted during the COVID-19 pandemic to increase the capacity to provide care to an unprecedented volume of critically unwell patients. During the pandemic, the orthopaedic department at the Aneurin Bevan University Health Board restructured the trauma service, relocating semi-urgent ambulatory trauma operating to the isolated clean elective centre (St. Woolos’ Hospital) from the main hospital receiving COVID-19 patients (Royal Gwent Hospital). This study presents our experience of providing semi-urgent trauma care in a COVID-19-free surgical unit as a safe way to treat trauma patients during the pandemic and a potential model for restarting an elective orthopaedic service. Methods. All patients undergoing surgery during the COVID-19 pandemic at the orthopaedic surgical unit (OSU) in St. Woolos’ Hospital from 23 March 2020 to 24 April 2020 were included. All patients that were operated on had a telephone follow-up two weeks after surgery to assess if they had experienced COVID-19 symptoms or had been tested for COVID-19. The nature of admission, operative details, and patient demographics were obtained from the health board’s electronic record. Staff were assessed for sickness, self-isolation, and COVID-19 status. Results. A total of 58 surgical procedures were undertaken at the OSU during the study period; 93% (n = 54) of patients completed the telephone follow-up. Open reduction and internal fixation of ankle and wrist fractures were the most common procedures. None of the patients nor members of their households had developed symptoms suggestive of COVID-19 or required testing. No staff members reported sick days or were advised by occupational health to undergo viral testing. Conclusion. This study provides optimism that orthopaedic patients planned for surgery can be protected from COVID-19 nosocomial transmission at separate COVID-19-free sites. Cite this article: Bone Joint Open 2020;1-6:302–308

During the COVID-19 pandemic, video/phone consultations (VPC) were increasingly utilised as an alternative to face-to-face (F2F) consultations, to minimise nosocomial viral exposure. We previously demonstrated that VPCs were highly rated by both patients and clinicians. This study compared satisfaction between both clinic modalities in contemporaneously delivered outpatient surveys. We also assessed the feasibility and effects of converting F2F orthopaedic consultations to VPC. Surveys were posted to patients who attended VPCs and F2F consultations at a large tertiary centre from August to October 2020 inclusive, across 51 specialties. F2F and VPC patients ranked their overall satisfaction with their consultation on a 10-point numerical scale (10=highest satisfaction). Simultaneously, a pilot study was undertaken of outpatient fracture clinics to identify patients suitable for VPCs, with X-rays (if needed) taken and transferred from satellite sites to reduce tertiary centre footfall. For F2F consultations, 1419 of 4465 surveys (31.8%) were returned with similar rates for VPCs (1332 of 4572, 29.1%). While mean satisfaction ratings were high for both clinic modalities, they were significantly higher for F2F: 9.13 (95% CI 9.05-9.22) for F2F clinics, compared to 8.23 (95% CI 8.11-8.35) for VPCs (p<0.001, t-test). F2F patients were almost four times more likely to state a preference for future F2F appointments compared to VPCs, whereas patients who attended VPCs showed an equal preference for either option (p< 0.001, chi2 test). 53% of 111 fracture clinic patients sampled were identified as suitable for VPCs. 1 patient (1.7%) requested their VPC to be converted to F2F due to poor symptom control. Our study showed patients reported high satisfaction ratings for both F2F clinics and VPCs, with prior experience of VPCs affecting patients’ future preferences. Only 1.7% of F2F patients converted to VPCs declined their virtual appointment. Our results support future use of VPCs

As of April 2010 all NHS institutions in the United Kingdom are required to publish data on surgical site infection, but the method for collecting this has not been decided. We examined 7448 trauma and orthopaedic surgical wounds made in patients staying for at least two nights between 2000 and 2008 at our institution and calculated the rate of surgical site infection using three definitions: the US Centers for Disease Control, the United Kingdom Nosocomial Infection National Surveillance Scheme and the ASEPSIS system. On the same series of wounds, the infection rate with outpatient follow-up according to Centre for Disease Control was 15.45%, according to the UK Nosocomial infection surveillance was 11.32%, and according to ASEPSIS was 8.79%. These figures highlight the necessity for all institutions to use the same method for diagnosing surgical site infection. If different methods are used, direct comparisons will be invalid and published rates of infection will be misleading

Aims. The risk to patients and healthcare workers of resuming elective orthopaedic surgery following the peak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been difficult to quantify. This has prompted governing bodies to adopt a cautious approach that may be impractical and financially unsustainable. The lack of evidence has made it impossible for surgeons to give patients an informed perspective of the consequences of elective surgery in the presence of SARS-CoV-2. This study aims to determine, for the UK population, the probability of a patient being admitted with an undetected SARS-CoV-2 infection and their resulting risk of death; taking into consideration the current disease prevalence, reverse transcription-polymerase chain reaction (RT-PCR) testing, and preassessment pathway. Methods. The probability of SARS-CoV-2 infection with a false negative test was calculated using a lower-end RT-PCR sensitivity of 71%, specificity of 95%, and the UK disease prevalence of 0.24% reported in May 2020. Subsequently, a case fatality rate of 20.5% was applied as a worst-case scenario. Results. The probability of SARS-CoV-2 infection with a false negative preoperative test was 0.07% (around 1 in 1,400). The risk of a patient with an undetected infection being admitted for surgery and subsequently dying from the coronavirus disease 2019 (COVID-19) is estimated at approximately 1 in 7,000. However, if an estimate of the current global infection fatality rate (1.04%) is applied, the risk of death would be around 1 in 140,000, at most. This calculation does not take into account the risk of nosocomial infection. Conversely, it does not factor in that patients will also be clinically assessed and asked to self-isolate prior to surgery. Conclusion. Our estimation suggests that the risk of patients being inadvertently admitted with an undetected SARS-CoV-2 infection for elective orthopaedic surgery is relatively low. Accordingly, the risk of death following elective orthopaedic surgery is low, even when applying the worst-case fatality rate. Cite this article: Bone Joint J 2020;102-B(9):1256–1260

Abstract. Background. During COVID-19 pandemic, there has been worldwide cancellation of elective surgeries to protect patients from nosocomial transmission and peri-operative complications. With unfolding situation, there is definite need for exit strategy to reinstate elective services. Therefore, more literature evidence supporting exit plan to elective surgical services is imperative to adopt a safe working principle. This study aims to provide evidence for safe elective surgical practice during pandemic. Methods. This single centre, prospective, observational study included adult patients who were admitted and underwent elective surgical procedures in the trust's COVID-Free environment at Birmingham Treatment Centre between 19th May and 14th July’2020. Data collected on demographic parameters, peri-operative variables, surgical specialities, COVID-19 RT-PCR testing results, post-operative complications and mortality. The study also highlighted the protocols it followed for the elective services during pandemic. Results. 303 patients were included with mean age of 49.9 years (SD 16.5) comprising of 59% (178) female and 41% (125) male. They were classified according to American Society of Anaesthesiologist Grade, different surgical specialities and types of anaesthesia used. 96% patients were discharged on the same day. 100% compliance to pre-operative COVID-19 testing was maintained. There was no 30-day mortality or major respiratory complications. Conclusion. Careful patient selection, simultaneous involvement of the pre-assessment and anaesthetic team, strict adherence to peri-operative protocols and delivering vigilant post-operative care for COVID-19 infection can help providing safe elective surgical services if the community transmission under reasonable control. However, it is particularly important to maintain COVID-free safe environment for such procedures

Proximal femoral fracture (PFF) is already epidemic and projected to increase. 50% of patients fail to recover their preaccident mobility, resulting in protracted hospitalisation and exposure to nosocomial (hospital acquired) infections which impairs recovery further. The aim of this study was to establish the rate at which patients with PFF regain mobility, the point at which they cease to recover and the incidence, time of onset and effect of nosocomial infections. Recovery of mobility and nosocomial infection was prospectively recorded in 170 consecutive patients with PFF. 53% regained their best level of mobility within 6 days of admission, 81% within 8 and 91% within 14. The mean hospital stay was 21 days and delay to discharge was 14 days. During the delay, mobility deteriorated in 22% of patients and 58% developed nosocomial infection of which 18 were methicillin resistant staphylococcus aureus. The risk of infection doubled after a delay of 6 days. Protracted hospitalisation after PFF is unhelpful and dangerous to patients and wasteful of healthcare resource. There is a small window of opportunity to discharge patients after PFF that is often missed. Thus there are often no beds for patients with acute fractures because they are occupied by patients who do not benefit from hospital admission or remain because they have acquired iatrogenic disease

The aim was to determine the influence of COVID-19 on 30-day mortality in hip fracture. Secondary aims were to examine: (1) predictors of COVID-19 on presentation and later in the admission; (2) rate of hospital-acquired COVID-19; (3) predictive value of negative swabs on admission. A nationwide multicentre retrospective cohort study of all patients with hip fracture in all 17 Scottish hospitals in March-April. Demographics, blood results, COVID-19 status, Nottingham Hip Fracture Score (NHFS), management, length of stay (LOS), and 30-day mortality were recorded. 78/833 (9.4%) patients had COVID-19 (65 swab-proven). 30-day survival with COVID-19 was lower than without (65.4% vs 91%; p<0.001). COVID-19 within 7 days of admission (likely community-acquired) was independently associated with male sex (OR 2.34, p=0.040, CI 1.04–5.25) and COVID-19 symptoms (OR 15.56, CI 6.61–36.60, p<0.001). COVID-19 within 7–30 days (probable hospital-acquired) was independently associated with male sex (OR 1.73, CI 1.05–2.87, p=0.032), NHFS □7 (OR 1.91, CI 1.09–3.34, p=0.024), pulmonary disease (OR 1.68, CI 1.00–2.81, p=0.049), ASA □3 (OR 2.37, CI 1.13–4.97, p=0.022) and LOS □9 days (OR 1.98, CI 1.18–3.31, p=0.009). 38/65 (58.5%) of COVID-19 cases were probably hospital-acquired. The false negative rate of swabs on admission was 0% in asymptomatic and 2.9% in symptomatic patients. COVID-19 was associated with a threefold-increased 30-day mortality. Nosocomial transmission may have accounted for half of all cases. Identification of risk factors for having COVID-19 on admission, or acquiring COVID-19 later, may guide patient pathways. LOS was the only modifiable risk factor, emphasising the importance of high-quality, timely care

Blood transfusion is associated with an increased incidence of post-operative nosocomial infections following surgery. In a prospective study we evaluated the association of blood transfusion and the changes in the immune status with the incidence of infection in the post-operative period following primary hip arthroplasty and subsequently for two years following surgery. Method: Prospective analysis of 100 patients undergoing primary total hip replacement. 25 patients received predonated autologus blood transfusions, 26 received SAGM whole blood, 23 received leukocyte depleted blood and 26 did not require a transfusion. T-helper cell, cytotoxic T cell and NK cell activity was recorded using a Beckton Dickson flow cytometer and assays of Plasma viscosity, CRP, Staph. Epidermis and ASO titres were analysed. All infections were recorded for 2 years following surgery. Results: he incidence of confirmed or suspected nosocomial infections following hip replacement was the same in non transfused patients as those receiving predonated autologus blood (19%). The incidence of nosocomial infection in patients receiving leukocyte depleted blood was 32% and 42% in those receiving a SAGM blood transfusion. ASO titres were raised in 16.9% of the patients on day 8 following surgery and Staph. Epidermis assays were raised in 20.2% of the patients however the frequency was unrelated to the type of blood transfusion. The incidence of nosocomial infections was reflected by a greater reduction in NK activity and CD4: CD8 ratio following surgery in patients receiving SAGM blood transfusion. Conclusion: Homologus blood transfusion may produce an immune compromise in patients, which is still detectable at 6 weeks following surgery. This is clinically reflected by a higher incidence of systemic infections in the postoperative period. Homologus blood should be used judiciously in joint arthroplasty with a preference to either leukocyte depleted blood or predonated autologus blood

Introduction: Older age is a risk factor for a poorer survival prognosis after hip fracture. Some other variables, such as male sex, dependency and dementia also contribute to a worse result expectations. However, since the association between surgery complications and other variables, such as age has been poorly researched, in this paper we study, within a major project on hip fractures, the association between age and nosocomial infections after hip fracture surgical treatment. Material and Methods: We have designed a cohort study and have followed them after surgery with the aim of studying NI rates. We reviewed the records of all patients operated on for hip fracture in our Institution between 2006, and 2008. Data on all hip fractures were prospectively collected as from patient admission. The data collection was based on the “Minimum Data Base Group” at our National Health System. Together with affiliation, full clinical history, and also complications are all included in our Hospital data base. We considered a nosocomial infection (NI) as any infection developed within three months after a main surgical procedure was addressed for a hip fracture (infection either at the surgical site, pneumonia, urological infection, or others). Patients were classified, in terms of co-morbibidity, according to worldwide accepted Charlson et al criteria. A univariate and multivariate analysis were performed, by using simple and multiple logistic regression model. Results: We collected 912 patients operated on for a hip fracture. Age was associated to infection, either in considering it alone (crude OR 0,96, CI of 95% = 0,95; 0,97; p=0,0004) or in considering it together with the other variables (multivariate analysis: adjusted OR 1,04; CI of 95% = 1,01; 1,07; p=0,007). None of the other variables were associated to nosocomial infection. Mental disease (crude OR 0,79, CI of 95% = 0,41; 1,53; p=0,49; adjusted OR 0,74, CI of 95% = 0,37;1,46; p=0,38), gender (OR=0,93 [CI of 95% 0,51; 1,68] p=0,78; adjusted OR=1,14 [0,62; 2,10] p=0,67), or co-morbidities (crude OR for index 1: 1,07 [CI of 95% 0,60; 1,90]; OR=1,07 [CI of 95% 0,43; 2,65] p=0,97) adjusted OR for index 1: 0,99 [CI of 95% 0,54; 1,80] p=0,97], for index 2, which includes 2–7, OR=1,02 [CI of 95% 0,40; 2,62] p=0,96). Discussion: Since age, in this research, has shown to have a definite correlation with nosocomial infections, whenever older patients are operated on for hip fracture treatment, prophylactic protocols for infection prevention should be individualized, according to patient age. The likelihood of adding communitarian infections when studying non surgical site infections, incubated before or after hospital stay is unknown. However, since the earliest infection developed at the second hospitalization day, we believe that the aim of this research is not affected for that

Implementation of new diagnostic methods (i.e. MALDI-TOF MS) has made it possible to identify coagulase-negative staphylococci (CoNS) to species level in routine practice. Further knowledge about clinical and microbiological characteristics of prosthetic joint infections (PJIs) caused by different CoNS may both facilitate interpretation of microbiological findings and improve clinical algorithms. The aim of this study was clinical and microbiological characterization of PJIs caused by Staphylococcus capitis. Patients with PJIs caused by S. capitis (growth in ≥2 perioperative tissue samples, n=19, identified by MALDI-TOF MS) from three centres between 2005–2014 were included. Medical records were examined (n=16). Further characterization of S. capitis was performed; rep-PCR (Diversilab, BioMerieux), standard antibiotic susceptibility testing, GRD Etest and macromethod Etest for detection of heteroresistant subpopulations and microtitre plate assay for detection of biofilm production. Multi-drug resistant (MDR) S. capitis (R≥3 antibiotic groups) was detected in 5/19(26%) of isolates, 1/19(5%) were ciprofloxacin resistant and no isolates was rifampin resistant. Biofilm formation was present in 14/19(74%). The dendrograms created by rep-PCR showed two distinct clusters, including one that contained isolates from all centres, as well as the reference isolates. Furthermore, three additional clusters were identified, all of these mainly obtained from single centres. In two of these, MDR was highly prevalent. In one of these clusters, 4 of the 8 strictly monomicrobial infections were found. All of the PJIs were defined as either early postinterventional (10/16) or chronic (6/16). No late haematogenous infection was found. The highest CRP values were reported in monomicrobial infections. Wound healing disturbances was noted in 8/10 early postinterventional infections. Fever was absent in chronic infections, sinus tracts rare (1/6), while pain was a common symptom (5/6). S. capitis has the potential to cause PJIs, both by itself as well as part of a polymicrobial infection. The antibiotic susceptibility patterns were more favourable than has previously been reported in S. epidermidis isolated from PJIs(1). Clinical data suggests that PJIs caused by S. capitis were acquired perioperatively or in the early postoperative phase. The clustering found by rep-PCR together with data showing high prevalence of S. capitis in the air of operation rooms during prosthetic joint surgery(2) implicates that nosocomial spread might be present. Epidemiological surveillance may be of value in order to ensure early detection of nosocomial transmission. Grants were received from the research committees of Värmland County Council and Örebro University, Sweden

The Department of Health and the Public Health Laboratory Service established the Nosocomial Infection National Surveillance Scheme in order to standardise the collection of information about infections acquired in hospital in the United Kingdom and provide national data with which hospitals could measure their own performance. The definition of superficial incisional infection (skin and subcutaneous tissue), set by the Center for Disease Control (CDC), should meet at least one of the defined criteria which would confirm the diagnosis and determine the need for specific treatment. We have assessed the interobserver reliability of the criteria for superficial incisional infection set by the CDC in our current practice. The incisional site of 50 patients who had an elective primary arthroplasty of the hip or knee was evaluated independently by two orthopaedic clinical research fellows and two orthopaedic ward sisters for the presence or absence of surgical-site infection. Interobserver reliability was assessed by comparison of the criteria for wound infection used by the four observers using kappa reliability coefficients. Our study demonstrated that some of the components of the current CDC criteria were unreliable and we recommend their revision

INTRODUCTION. In recent years, there has been a shift toward outpatient and short-stay protocols for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). We developed a peri-operative THA and TKA short stay protocol following the Enhance Recovery After Surgery principles (ERAS), aiming at both optimizing patients’ outcomes and reducing the hospital length of stay. The objective of this study was to evaluate the implementation of our ERAS short-stay protocol. We hypothesized that our ERAS THA and TKA short-stay protocol would result in a lower complication rate, shorter hospital length of stay and reduced direct health care costs compared to our standard procedure. METHODS. We compared the complications rated according to Clavien-Dindo scale, hospital length of stay and costs of the episode of care between a prospective cohort of 120 ERAS short-stay THA or TKA and a matched historical control group of 150 THA or TKA. RESULTS. Significantly lower rate of Grade 1 and 2 complications in the ERAS short-stay group compared with the standard group (mean 0.8 vs 3.0, p<0.001). Postoperative complications that were experienced by significantly more patients in the control group included pain (67% vs 13%, p<0.001), nausea (42% vs 12%, p<0.001), vomiting (25% vs 0.9%, p<0.001), dizziness (15% vs 4%, p=0.006), headache (4% vs 0%, p=0.04), constipation (8% vs 0%, p=0.002), hypotension (26% vs 11%, p=0.003), anemia (8% vs 0%, p=0.002), oedema of the operated leg (9% vs 1%, p=0.005), persistent lameness (4% vs 0%, p=0.04), urinary retention (13% vs 4%, p=0.006) and anemia requiring blood or iron transfusion (8% vs 0%, p=0.002). No difference was found between the 2 groups for Grade 3, 4, or 5 complications. The mean hospital length of stay for the ERAS short-stay group decreased by 2.8 days for the THAs (0.1 vs 2.9 days, p bellow 0.001) and 3.9 days for the TKAs (1.0 vs 4.9 days, p<0.001). The mean estimated direct health care costs reduction with the ERAS short-stay protocol was 1489% per THA and 4206% per TKA. DISCUSSION AND CONCLUSION. Shorter hospitalization time after THA and TKA is associated with lower risk of nosocomial infections and adverse events related to reduced mobilization such as venous thromboembolism, pulmonary atelectasis, and constipation. In addition, it increases bed availability in a restricted environment and is very favorable economically for the care provider. Multiple strategies have been described to reduce hospital length of stay. One attractive option is to follow the ERAS principles to improve patient experience to a level where they will feel confident to leave for home earlier. Implementation of a ERAS short-stay protocol for patients undergoing THA or TKA at our institution resulted not only in reduced hospital length of stay, but also in improved patient care and reduced direct health care costs

At the Orthopedic Hospital Vienna Speising 7.857 surgeries were performed in 2008. 2.211 of these surgeries required implants. The number of performed Total Hip Arthroplasties (THA) was 836. All of these surgeries were elective. Approximately 0,5% of the patients who underwent a surgery at our institution had a postoperative infection, 0,8% were admitted because of an already existing infection, which required treatment at our department. In order to achieve a basis for international compatibility and to meet the legal postulations the Orthopedic Hospital Vienna Speising actively participates in ANISS (Austrian Nosocomial Infection Surveillance System)/HELICS (Hospital in Europe Link for Infection Control through Surveillance). In 2008 a survey on incidences for Total Hip Arthroplasties was started. So the possibility of specific measures is given when interventions should be necessary. The stuff unit for Hospital Hygiene gathers data from clinical records and conducts an evaluation by means of a standardised (equivalent surgeries) and stratified (differentiation of the patients after ASA-score- American Society of Anaesthesiologists, duration of the surgery, etc) procedure. Three times a week the stuff unit for Hospital Hygiene visits the wards and collect selected indicator-surgeries, which are entered in a specific program for registering infections. By finding noticeable problems, a detailed analysis is continued with the examination of microbiologic, histological and radiologic data as well as questions to the surgeon or attending staff and ward rounds for inspecting for instance changes of dressing. The infectdiagnoses, based upon CDC (Center of Desease Control) definitions for nosocomial infections, are encrypted and sent to the control center quarterly. In turn our hospital receives an analysis and feedback once a year. A biannual exchange of experiences on behalf of the active members including an interpretation of the data allows to settle discrepancies and dubieties in evaluation. This data on surveillance allows a detailed analysis of information gathered in recent years as well as a discussion with authorities. As a result specific consequences could already been deducted like written guidelines for surgical management, recommendations for antibiotic treatment, preoperative shaving of the surgical area as well as preoperative screening for staphylococcus in Total Hip Arthroplasties

Purpose: Operative site infections can have catastrophic consequences after orthopaedic surgery. Prevention is particularly difficult due to the large number of factors involved. We describe here an exceptional epidemic of meti-R Staphylococcus aureus (MRSA) operative site infections whose source was successfully identified and eradicated. Material and methods: The epidemic affected seven patients who underwent orthopaedic surgery during a thirteen-month period. All patients developed acute MRSA operative site infection. The epidemic nature of the infections was confirmed by the bacteriological study which identified the causal germ as a specific MRSA strain very different from strains generally identified in hospital infections. The causal strain was sensitive to quinolones and resistant to amikacin. Antibiotic therapy prescribed in all cases was combined with surgical lavage in four patients. Search was undertaken to identify an environmental or human source. An audit of the operating theatre was performed and nasal swabs were obtained from all personnel present at the last operation complicated by operative site infection. One non-medical assistant was found to be a carrier of the same MRSA strain incriminated as the cause of the epidemic. Nasal application of mupirocin successfully eradicated the carrier-state. No new case of operative site infection was noted for more than fourteen months. Discussion: Operative site infections in orthopaedic surgery led to longer inpatient care and can compromise functional outcome. These nosocomial infections have a significant impact on mortality and constitute a major cost burden for hospitals. Prevention, control and treatment of MRSA nosocomial infections is a major challenge in hospitals throughout the world. Most operative site infections are caused by direct contamination during the operation. This epidemic highlights the importance of strict application of rigorous preventive measures not only by the surgical team but also by all healthcare workers and hospital personnel in general. Conclusion: The specific antibiotic susceptibility pattern of a Staphylococcus aureus strain incriminated in several operating site infections enabled identification of the source of the epidemic and its eradication

Purpose: With the growing risk of nosocomial infections, one might expect to see a reinforcement of septic isolation wards in orthopaedics and traumatology units. The question is however being revisited because of several factors. 1st: General Orthopaedics Units are practically the only hospital units caring for a minority of septic patients with often resistant germs and a majority of non-septic patients in the same setting. 2nd: The growing number of single-patient rooms procures confidence (whether justified or not). 3rd: Hygiene specialists are particularly wary of occult carriers of resistant bacteria and apply a single set of protective measures for all patients. 4th: Economic performance is given priority. Material and methods: We studied 1) the current situation in Orthopaedic units in University Hospitals in France and 2) the statistics from the Besançon University Hospital Hygiene Unit and from data in the literature. Results: 1) Interrogation of the 71 University Orthopaedics Units in France revealed that: 11 units have strict isolation wards; 40 have incomplete isolation wards; 20 make no distinction between septic and non-septic patients. 2) According to the Hygiene Unit statistics, the epidemiological load of S. aureus meti-R (SAMR), strains often implicated in orthopaedic infection, is much higher in the University Hospital polyvalent wards than in the Orthopaedic septic ward. Contamination between septic patients is low. Furthermore, hand-borne and airborne contamination are not controlled in wards other than septic wards. Data in the literature are not in agreement concerning this new trend in prevention by isolation. Discussion: a) One argument retained by all is that septic wards have an advantage in terms of efficacy and concentration of preventive measures. b) The growing workload in mixed units hinders strict application of preventive measures. c) A large number of temporary personnel (trainees, temporary employees, personnel untrained in sepsis prevention) are present in polyvalent units. d) Standardisation of preventive measures leads to an average level of prevention which lengthens the duration of care for non-septic patients and simplifies care for septic patients. e) The financial argument is impertinent compared with the consequences of contamination. Furthermore, a departmental structure would allow common use of the septic ward. Conclusion : Septic isolation wards (or a septic department) should be preserved. The orthopaedic surgeon, as a responsible actor in the fight against nosocomial infections, should in concert with the consulting hygienist, oppose purely administrative decisions

Aims

Wrist arthroscopy is a standard procedure in hand surgery for diagnosis and treatment of wrist injuries. Even though not generally recommended for similar procedures, general administration of perioperative antibiotic prophylaxis (PAP) is still widely used in wrist arthroscopy.

Aim. Nasal colonization with S.aureus (SA) is a risk factor for developing nosocomial infections in cardiac surgery. However, the risk in orthopedic surgery remains unclear, especially in adolescent idiopathic scoliosis (AIS) surgery were data are missing. This study aims to evaluate the efficacy of a preoperative nasal decontamination program in SA healthy carriers on early surgical site infections (SSI) after AIS posterior surgery in a pediatric universitary Parisian hospital. Method. Between 01-01-2014 and 03-31-2017, all AIS patients were screened preoperatively with nasal swabs and decontaminated with mupirocine if positive during the 5 days before surgery. Early SSI were prospectively identified and microorganisms' findings were compared to a previous serie published before the beginning of the decontamination program (2007–2011). Results. Among the 316 AIS posterior procedures performed during the study period, nasal swabs were performed at the average of 100 ± 92 days before surgery. Incidence of positive nasal swab was 22 % (n=71) and all were preoperatively decontaminated. Compared to the series (n=496) published before the decontamination program, the early SSI rate remains stable (8.2% versus 8.5%). But incidence of S.aureus early SSI decreased to 1% (n=4), while it represented 5% (n=25) in the previous study. In our study, none of the S. aureus decontaminated patients had an early S.aureus SSI. For the 4 S.aureus early SSI, preoperative nasal swab was negative, but done with a mean delay of 328 days before surgery, suggesting a possible S.aureus intermittent carriage and the need of shorter delays between nasal swab and surgery to improve the screening. Moreover, the stable rate of early SSI between the 2 periods is due to an increase rate of Propionibacterium acnes, which incidence grown from 0.08% to 6% in our actual series. Conclusions. To conclude, in our study, nasal decontamination divided by 5 the incidence of S.aureus SSI. It seems that nasal swabs should be performed as close as possible to the surgery to optimise the S.aureus screening. In addition, the SSI rate remains very high with the emergence of Propionibacterium acnes and is currently addressed by a multifactorial approach

Research into COVID-19 has been rapid in response to the dynamic global situation, which has resulted in heterogeneity of methodology and the communication of information. Adherence to reporting standards would improve the quality of evidence presented in future studies, and may ensure that findings could be interpreted in the context of the wider literature. The COVID-19 pandemic remains a dynamic situation, requiring continued assessment of the disease incidence and monitoring for the emergence of viral variants and their transmissibility, virulence, and susceptibility to vaccine-induced immunity. More work is needed to assess the long-term impact of COVID-19 infection on patients who sustain a hip fracture. The International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics (IMPACT) formed the largest multicentre collaborative audit conducted in orthopaedics in order to provide an emergency response to a global pandemic, but this was in the context of many vital established audit services being disrupted at an early stage, and it is crucial that these resources are protected during future health crises. Rapid data-sharing between regions should be developed, with wider adoption of the revised 2022 Fragility Fracture Network Minimum Common Data Set for Hip Fracture Audit, and a pragmatic approach to information governance processes in order to facilitate cooperation and meta-audit. This editorial aims to: 1) identify issues related to COVID-19 that require further research; 2) suggest reporting standards for studies of COVID-19 and other communicable diseases; 3) consider the requirement of new risk scores for hip fracture patients; and 4) present the lessons learned from IMPACT in order to inform future collaborative studies.

Cite this article: Bone Joint Res 2022;11(6):342–345.

The total hip arthroplasty (THA) is an effective operation for the restoration of the hip function. The number of operations is steadily climbing and is going to reach new heights in the future. The most devastating complication is the deep infection of the joint and has to be treated with a total revision of the prostheses. The risk factors for an infection play a very important role in the preoperative assessment of the patient and for the antibiotic treatment. There are many different opinions on which risk factors are associated with the development of a deep infection in the literature. Our goal was to analyze and find the risk factors, which matter most in the clinical treatment of patients. We searched the database “PubMed” and “Embase” with the keywords: „(((hip AND infection)) AND (arthroplasty OR replacement)”. With the help of check lists and limits we extracted the most viable studies for our research. Risk factors associated with a deep infection included the BMI (Body mass index), male gender, prolonged duration of surgery, diabetes mellitus type 2, the ASA (American society of anesthesiologists) score, the Charlson score and the NNIS (National Nosocomial Infections Surveillance System) risk index score. Female gender, age and the diagnosis of rheumatoid arthritis were not associated with deep infections. Patients with risk factors should be assessed preoperatively and receive an appropriate prophylactic antibiotic treatment, to reduce the risk of a deep infection. With the reduction of their weight and adjustment of the diabetes, patients can reduce the risk for infection by their own. Total hip replacement is still a safe and effective operation and thus should not be withheld from patients

Background. Post-traumatic immunosuppression (PTI) after surgery increases vulnerability to nosocomial infections, sepsis, and death. Knee arthroplasty offers a sterile clinical model to characterise PTI and explore its underlying mechanisms. Methods. This prospective non-randomised cohort study of primary total knee arthroplasty was approved by the Local Ethics Committee. Exclusion criteria included revision-arthroplasty, pre-existing infections, blood-transfusions, malignancy, and auto-immune disease. 48 recruited patients fell into two groups, the first received unwashed anti-coagulated autologous salvaged blood transfusions after surgery (ASBT cohort, n=25). The second received no salvaged blood transfusions (NSBT cohort, n=18). Venous blood was sampled pre-operatively and within 3–7 days post-operatively. Salvaged blood was sampled at one and six hours post-operatively. Biomarkers of immune status included: interleukins (IL) or cytokines (x15), chemokines (x3), Damage-Associated-Molecular-Patterns (DAMPS) (x5), anti-microbial proteins (x3), CD24, and Sialic-acid-binding-Immunoglobulin-type-Lectin-10 (Siglec-10). Results were expressed as fold-change over pre-operative values. Only significant changes are described. Results. Certain biomarkers associated with sterile trauma were common to all 43 patients, including supra-normal: IL-6, IL-1-Receptor-Antagonist, IL-8, Heat-Shock-Protein-70 (HSP70), Calprotectin, CD24 and Siglec-10. But, whereas in NSBT patients post-operative pro-inflammatory biomarkers were sub-normal consistent with PTI, they were supra-normal in ASBT patients implying its reversal. These PTI-biomarkers included: IL-1β, IL-2, IL-17A, Interferon-gamma (IFN-γ), Tumour-Necrosis-Factor-alpha (TNF-α), and Annexin-A2. Reversal of PTI by salvaged blood was further endorsed in ASBT by sub-normal levels of the anti-inflammatory biomarkers: IL-4, IL-5, IL-10, and IL-13. Salvaged blood analyses revealed sustained supra-normal levels of DAMPs, CD24 and Siglec-10; and increasingly elevated levels of cytokines and chemokines during the six hour collection period. Interestingly, plasma CD24, Siglec-10, HSP70 and Calprotectin levels were significantly correlated, implying physical association within the circulation. Conclusions. Several anti-inflammatory processes triggered by traumatised tissue induce systemic PTI, thereby increasing vulnerability to infections. Reversal of PTI by re-infusion of anti-coagulated salvaged blood suggests a novel source of immuno-stimulants

Report of a case of migrating periprosthetic infection from a hip replacement to a contralateral knee joint undergoing a total knee replacement. We present a 74-year old female patient who underwent a total hip arthroplasty of the left hip after a subcapital fracture of the femur. Four months after the index procedure the patient presented with signs and symptoms of infection of the operated joint. Staph aureus and Enterococcus faecalis were recognized as the infecting bacteria. The implants were removed, cement spacers were placed and a total hip arthroplasty was performed again after three months. Unfortunately, infection ensued again and the patient underwent three more procedures until the joint was considered clean and t he hip remained flail without implants. The patient elected to undergo a total knee arthroplasty due to severe osteoarthritis of right knee. Intraoperatively tissue samples were taken and sent for cultures which identified Enterococcus faecalis present in the knee joint. Enterococcus migrated from the infected hip to nonoperated knee joint. Intravenous antibiotics were administered for three weeks but the knee presented with infection of the arthroplasty ten months after its insertion. The implants were removed the joint was debrided and cement spacers were inserted. The patient decided not to proceed with another procedure and she remains with the cement spacers in her knee. Rare report of migrating periprosthetic infection. Nosocomial enterococci acquired resistance cannot be ruled out. Unique characteristics in enterococci antibiotic resistance and biofilm formation

Aims

Periprosthetic joint infection (PJI) in total hip arthroplasty in the elderly may occur but has been subject to limited investigation. This study analyzed infection characteristics, surgical outcomes, and perioperative complications of octogenarians undergoing treatment for PJI in a single university-based institution.

The prevalence of Staphylococcus infections do not decrease despite the preventive measures. The methicillin-resistant staphylococcus aureus (MRSA) has become a major nosocomial pathogen in community hospitals and responsible 60% of staph infections. Through this study we try to study the epidemiology of methicillin-resistant Staphylococcus in the bone and joint infections. We report a 2-year study retrospectipevelly about 25 cases of bone and joint infection staphilococcus methicillin-resistant. All patients underwent clinical examination, an inflammatory balance and surgical treatment with sampling and bacteriological study of the removal liquid and regular monitoring in all patients. The mean age was 5 years and a half. The sexe ratio was 1.2. mean follow-up of 3 months. One patient had dificit G6PD. The mostaffected area was the capital in 64% of cases. The most common location was at the knee in 32%. The most frequent diagnosis was arthritis followed by osteomyelitis. The antibiotics of the first intention was based on amoxicillin and clavulanic acid associated with an aminoglycoside. It was effective in 75%, and modified according to the results of susceptibility testing in 10 cases. The average duration of antibiotic therapy in IV was ten days. The duration of treatment by oral route relay varies from 10 to 21 days. The apyrexia on day 1 postoperatively was obtained in 73%. The screening of patients at risk of carrying MRSA and isolation should help keep to a minimum cross transmission of infections and the number of non-colonized patients. Place of antibiotic therapy is preponderant and meets pharmacodynamic and pharmacokinetic criteria that must be followed in order to optimize medical treatment

Aims

The aim of this meta-analysis was to determine the pooled incidence of postoperative urinary retention (POUR) following total hip and knee arthroplasty (total joint replacement (TJR)) and to evaluate the risk factors and complications associated with POUR.

Aims

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

[Introduction]. Surgical-site-infections (SSI) prolong hospital stay, and they are leading nosocomial cause of morbidity and a source of excess cost. Recently, a waterless hand-rubbing protocol containing aqueous 1% chlorhexidine gluconate was developed before surgery, but there is no literature in orthopaedic surgery. The aim was to compare the SSI rates between waterless hand-rubbing and traditional hand-scrubbing protocol. [Materials and Methods]. STUDY 1: A total of 996 consecutive patients who underwent orthopaedic surgery between August 1, 2012 and January 31, 2014, were screened for SSI within 30 days after surgery. 500 patients from August 1, 2012 to April 1, 2013 were used by traditional hand-scrubbing, and 496 patients from June 1, 2013 to January 1, 2014 were by waterless hand-rubbing. STUDY 2: The twelve operating room staff members were randomly recruited, and the participants were assigned equally to use either a traditional hand-scrubbing protocol or a waterless hand-rubbing on 2 separate days. Washing times were recorded and microorganisms on hands were sampled on bacterial culture plates. Two days after sampling, the grown colonies were counted. [Results]. STUDY 1: SSI rates were 6 of 500 (1.2%) in the traditional hand-scrubbing protocol (2 deep and 4 superficial infecitons) and 4 of 496 (0.9%) in the waterless hand-rubbing protocol (all superficial infections). There were no significant differences. The cost for scrub liquids in one hand-wash was about $2 for traditional hand-scrubbing and less than $1 for waterless hand-rubbing. STUDY 2: Microorganism found on 4 of the 12 plates in the traditional hand-scrubbing protocol and on 0 of 12 in the waterless hand-rubbing protocol. The difference between the groups was statistically significant (p < 0.05). The consuming time for wash was 4 minutes 24 seconds in the traditional hand-scrubbing protocol and 2 minute 43 seconds in the waterless hand-rubbing protocol. [Discussion]. Waterless hand rubbing with aqueous alcoholic solution was as effective as traditional hand scrubbing with antiseptic soap in preventing SSI in orthopaedic surgery. Waterless hand rubbing with liquid aqueous alcoholic solution can be safely, quickly and cost-effectively used as an alternative to traditional hand-scrubbing

Silicon nitride spinal fusion cages have been successfully used in the treatment or correction of stenosis, disc herniation, trauma, and other deformities of the spinal column since 2008. To date over 14,000 devices have been implanted with perioperative and postoperative complication rates of less than 0.2%. This remarkable achievement is due in part to the material itself. Silicon nitride is an ideal interbody material, possessing high strength and fracture toughness, inherent phase stability, biocompatibility, hydrophilicity, excellent radiographic imaging, and bacterial resistance. These characteristics can lead to implants that aid in prevention of nosocomial infections and achieve rapid osteointegration. In this paper, we will review the various in vitro and in vivo studies that demonstrate silicon nitride's effective bacteriostatic and osteointegration characteristics, and compare these to the two most common cage materials – titanium and poly-ether-ether-ketone (PEEK). Human case studies will be also reviewed to contrast the clinical performance of these biomaterials. In comparison to the traditional devices, silicon nitride shows lower infection rates, higher bone apposition, and essentially no fibrous tissue growth on or around the implant. To better understand the mechanisms underlying these benefits, surface characterization studies using scanning electron microscopy coupled with XPS chemical analyses, sessile water drop techniques and streaming zeta potential measurements will be reported. Data from these studies will be discussed in relation to the physiochemical reasons for the observed behavior. Silicon nitride is a non-oxide ceramic in its bulk; but possesses a protective Si-N-O transitional layer at its surface. It will be shown that the chemistry and morphology of this layer can be modified in composition, thickness and structure resulting in marked changes in chemical species, surface charge, isoelectric points and wetting behavior. It is postulated that the needle-like grain structure of silicon nitride coupled with its enhanced wettability play important roles in inhibiting biofilm formation, while its surface chemical environment consisting of silicon diimide Si(NH). 2. , silicic acid Si(OH). 4. , and derivatives of ammonia, NH. 3. , NH. 4. OH, lead to improved bone reformation and bacteriostasis, respectively. Few materials have this combination of properties, making silicon nitride a unique biomaterial that provides improved patient care and outcomes with low comorbidities

Because life expectancy is increasing, the number of primary knee arthroplasties performed is projected to increase 673% by 2030, according to Westrich et al. Also, Toulson et al. in a recent study predict that the incidence of deep infection associated with primary total knee arthroplasty ranges from 1% to 2%. Periprosthetic knee infection is one of the most dramatic and difficult to manage complications following total knee arthroplasty. Therefore, periprosthetic knee infection will continue to be a significant complication and an economic burden in the future. Our objective was to identify the risk factors that may provide greater likelihood of infection and thus select high-risk patients and to take maximum prevention strategies. Case-control study, between infected and non infected patients, undergoing primary total knee arthroplasty between January 2008 and January 2013. The risk factors evaluated were: duration of hospital stay, surgery duration, prophylactic antibiotics and timing for administration, volume of blood transfusion, autologous blood recovery system use, anesthetic technique, ASA classification, Diabetes Mellitus, Obesity (BMI>30), immunosuppression and history of any infection in the month preceding surgery. The presence of infection was defined by the criteria of the Center for Disease Control for Nosocomial Surgical Site Infections1. Statistical analysis IBM SPSS Statistics 20 (Fisher's exact test, Mann-Whitney U test and Student's t-test). Statistical significance for p ≤ 0.05. We evaluated 540 patients with a mean follow-up of 56 months. We identified 21 deep infections (3,8%), and 35 superficial wound infections and found a positive correlation between infection and obesity (p <0.01), immunosuppression (p <0.01), volume of blood transfusion (p=0.02), history of any infection in the month preceding surgery (p <0.01). We found a negative correlation with the use of a autologous blood recovery system (p <0.01). Other factors, commonly referred in the literature, showed no association or did not reach statistical significance. The incidence of periprosthetic knee infection after primary total knee arthroplasty stays high. The presence of obesity, immunosuppression, blood transfusion, history of any infection in the month preceding surgery were identified as significant risk factors for infection to occur. The identification, modification or eviction of the risk factors implied are essential to reduce and prevent infection in arthroplasty

Aims

Elective orthopaedic services have had to adapt to significant system-wide pressures since the emergence of COVID-19 in December 2019. Length of stay is often recognized as a key marker of quality of care in patients undergoing arthroplasty. Expeditious discharge is key in establishing early rehabilitation and in reducing infection risk, both procedure-related and from COVID-19. The primary aim was to determine the effects of the COVID-19 pandemic length of stay following hip and knee arthroplasty at a high-volume, elective orthopaedic centre.

Surgical Site Infection (SSI) is one of the most frequent nosocomial infections and depends on many factors: patient, microorganism, antiseptic solution use, antibiotic prophylaxis, hand scrubbing, wound care or hospital stay lenght. With the present paper the authors aim to study the SSI incidence after Total Knee (TKA) or Hip Arthroplasty (THA). All patients who underwent primary TKA or THA between January 2011 and May 2012 at our institution were considered. Patients who died within 1 year after the procedure of unrelated causes were excluded. Data collected included ASA classification, type of procedure, total and post-operative hospital stay, type and duration of antibiotic prophylaxis. Data were collected from the consultation at 1 month and 1 year post-operative, clinical registries and telephone interview. SSI was defined according to the Centers for Disease Control and Prevention criteria. Suspected cases of SSI included antibiotic administration longer than 5 days or absence of antibiotic prescription, hospital stay after the procedure longer than 9 days, patient referring infection symptoms, and clinical data reports of infection or re-intervention. During the studied period and after exclusion of 5 cases, a total of 251 surgeries (104 TKA, 147 THA) were performed, of which 2 were urgent. For both TKA and THA, the average total hospital stay was 9 days (8 days post-operative). The majority were American Society of Anesthesiologists (ASA) classification 2 and 3. There were 4 SSI (1,60%), 2 TKA (1,92%) and 2 THA (1,36%), all of them after discharge. Their average total hospital stay was 10,5 days. Antibiotic prophylaxis was used in 93% of the patients (97,4% a cephalosporin), with an average length of 5,7 days. Recommended hospital stay after a TKA or THA is about 5 days. On HELICS-CIRURGIA 2006–2010 report it was 10 days, similar to ours. In infected patients, our total hospital stay was lower (10,5 vs 26). Recommended duration of antibiotic prophylaxis is 24h. On HELICS-CIRURGIA more than 50% had it for more than 24h, which also happened with us; our antibiotic coverage was similar. Comparing to HELICS-CIRURGIA, the predominance of ASA 2 and 3 classifications was similar, but the overall SSI rate was lower (1,6% vs 2,24%). We conclude we must reduce hospital stay and antibiotic duration and keep the surveillance of SSI after TKA or THA

Despite a lack of evidence, the UK's Department of Health introduced a policy of ‘Bare below the elbows’ attire to try to reduce the incidence of nosocomial infection. This study investigates the link between attire and hand contamination. A prospective observational study of doctors working in a District General Hospital was performed. The fingertips were imprinted on culture medium, and the resulting growth assessed for number of colony forming units, presence of clinically significant pathogens and multiply resistant organisms. These findings were correlated with attire, grade, gender and specialty. 92 doctors were recruited of which 49 were ‘Bare below the elbows’ compliant and 43 were not. There was no statistically significant difference between those doctors who were ‘bare below the elbows’ and those that were not for either the number of colony forming units (p=1.0), or the presence of significant organisms (p=0.77). No multiply resistant organisms were cultured from doctors' hands. ‘Bare below the elbows’ attire is not related to the degree of contamination on doctors' fingertips or the presence of clinically significant pathogens. Further studies are required to establish whether investment in doctor's uniforms and patient education campaigns are worthwhile

The incidence of MRSA infection is increasing worldwide. Costs incurred in treating MRSA infection are over twice that of normal patients, and the duration of hospital stay is up to 10 times longer. Risk factors are age, previous MRSA infection, prolonged hospitalization, patients from convalescent homes, immunocompromised states, vascular and pulmonary disease. Methods. A retrospective chart review was conducted on 14 patients who developed MRSA infection in our unit, over a period of six years. Data included: age, gender, neurological status, length of hospital and ICU admission, type of procedure performed, HIV status, co-morbidities, nutritional status, haemoglobin, sensitivities and treatment. Results. Age ranged from 2 to 52 (mean 15.75 years) and included four males, six females, and four children. Of the thirteen patients who developed Surgical Site Infection (SSI), nine were posterior surgical wounds. Two patients were HIV positive. Mean albumin and lymphocyte count was 34.88 and 2.37 respectively. The average wait to surgery was 23.8 hospital days, average length of ICU admission was 5.01 days. Signs of SSI developed at 11.75 days on average. Four cases showed sensitivity to Vancomycin, while ten were sensitive to Clindamycin. Patients were treated for a total of six weeks with antimicrobial therapy. Five patients required debridement, two required implant removal for chronic infection. Infection subsequently resolved in all patients. Conclusion. The risk factors were prolonged hospitalization, and posterior surgical wounds. Infection by community acquired MRSA was twice as common as nosocomial MRSA. Current recommendations are to treat superficial sepsis with topical Mupirocin, while systemic antibiotics are reserved for patients at risk for MRSA bacteraemia and who have prosthetic implants. Screening for patient colonization is recommended when risk factors are present, while staff screening is recommended following outbreaks. The cornerstone in preventing MRSA infection is strict hand hygiene

Prosthetic joint infection (PJI) remains a devastating complication of arthroplasty. There is significant heterogeneity in treatment approaches to these infections and information on their efficacy relies on single-centre studies. This is the first multi-centre study examining current treatment approaches to patients with PJI. A retrospective cohort study was conducted over a 3-year period (January 2006 – December 2008) involving 10 hospitals in Victoria, Australia. Cases of prosthetic joint infections of hips and knees were identified using an established statewide nosocomial infection surveillance network. Individual medical records were accessed to describe the management and record the outcomes of these patients. Interim analysis from seven hospitals revealed 121 patients with PJI. Staphylococcus aureus was isolated in half of the infections with equal representation of methicillin resistant and methicillin sensitive strains. Debridement and retention (DR) was the most common treatment modality (72%), followed by resection arthroplasty without reimplantation (10%), superficial debridement and antibiotics (9%), one-stage exchange (6%) and two-stage exchange arthroplasty (3%). The timing and number of surgical interventions was however highly variable. The majority of patients underwent arthrotomy with an average of 3 debridements of the infected joint (range 0–10, standard deviation 1.7). Two-thirds of the patients with staphylococcal infections received a rifampicin-containing regimen. The course of oral antibiotic therapy was prolonged with a median duration of 132 days (interquartile range 13–357) but ranged from no oral antibiotic therapy to 1032 days. Overall 72% of patients remained infection-free after a mean follow-up of 15 months, however there was marked variation in outcomes between hospitals with success ranging from 50%-95%. This multi-centre study demonstrates that there is a wide spectrum of treatment approaches to PJI. In addition, DR is the favoured treatment modality, which differs to our European and Northern American counterparts. This study reports real-life management and outcomes from patients at several centres, including many that do not have dedicated research interest in PJI

Purpose. Antibiotic prophylaxis plays an important role in minimizing surgical site infections as well as other nosocomial peri-operative infections in orthopaedic trauma patients. Pre-operative prophylaxis has been shown to be efficacious, but the role and duration of post-operative prophylaxis remains controversial. The goal of this study was to assess whether patients receive their antibiotic prophylaxis as prescribed. What dose and duration of antibiotics are typically ordered, what patients actually receive, and factors causing the ordered antibiotic regime to be altered were also investigated. This study did not investigate infection rates or the efficacy of various antibiotic prophylactic regimes. Method. This study presents data collected through a retrospective chart review of 205 patients treated surgically for a closed fracture at one institution. A national survey was also distributed to all surgeon members of the Canadian Orthopaedic Trauma Society (COTS) concerning antibiotic prophylaxis in the setting of surgical treatment for closed fractures. Results. Ninety three percent (179/193) of patients received an appropriate pre-operative dose, while less than 32% (58/181) of patients received their post-operative antibiotics as ordered. The most common stated reason for patients not receiving their post-operative antibiotics as ordered was patients being discharged before completing three post-op doses. There was a 70% (39/56) response rate to the survey sent to COTS surgeons. A single dose of a first-generation cephalosporin pre-operatively followed by three doses post-operatively is the most common practice amongst orthopaedic trauma surgeons across Canada, but several surgeons use only pre-operative prophylaxis. Conclusion. Adherence to multi-dose post-operative antibiotic regimens is poor. Meta-analyses have failed to demonstrate the superiority of multi-dose regimens over single-dose prophylaxis. Single-dose pre-operative antibiotic prophylaxis may be a reasonable choice for most orthopedic trauma patients with closed fractures

Recent interest has focused on minimally invasive hip surgery, with less attention being directed to maximising the potential benefits of this type of surgery. We have developed a new multidisciplinary programme for patients undergoing total hip replacement in order to facilitate an overnight hip replacement service. The programme involves a pre-operative regimen of education and physiotherapy, a modified anaesthetic technique, a minimally invasive surgical approach and a portable local anaesthetic pump infusion for post-operative pain control. Strict inclusion and exclusion criteria were developed based on age, medical status and social circumstances. Patients were mobilised on the day of their operation and discharged home with an ‘outreach team’ support network. No patient complained that their discharge was early. Independent evaluation was performed using the Oxford Hip Questionnaire, the Merle d'Aubigné clinical rating system and Visual Analogue Pain Scores. Thirty seven patients underwent total hip replacement using the new protocol. The average length of stay was 1.2 days. The mean pain score on discharge was 1.3/10. The Oxford Hip Questionnaire and Merle d'Aubigné scores were comparable to patients who underwent surgery prior to the introduction of the new protocol. Minimising in-patient stay for total hip replacement benefits the patient by reducing exposure to nosocomial infection and expediting the return to a normal environment for faster rehabilitation. This new programme allows patients undergoing total hip replacement to be discharged after 1 night post-operatively without compromising safety or quality of care. Minimally invasive surgery with a suitable infrastructure can be used to dramatically reduce the length of stay in suitable patients. This can be achieved reliably, safely and with high patient satisfaction. In order to gain the benefit of Minimally Invasive Surgery we recommend introducing this type of comprehensive programme

Aims

With resumption of elective spine surgery services in the UK following the first wave of the COVID-19 pandemic, we conducted a multicentre British Association of Spine Surgeons (BASS) collaborative study to examine the complications and deaths due to COVID-19 at the recovery phase of the pandemic. The aim was to analyze the safety of elective spinal surgery during the pandemic.

Currently there is an elevated public awareness of the consequences of nosocomial infection, of which, 14.5% is due to surgical site infection (SSI). Hip fracture patients are at increased risk of SSI due to their age related poor medical health, immune response impairments and decreased capacity of wound healing. Superficial SSI following hip fracture surgery can affect up to 16.9% with deep infection affecting 3.7%. Deep infection represents a major complication, from which hip fracture patients are 4.5 times less likely to survive to discharge and carries a 50% mortality at 1 year, compared to 33% without infection. Treatment requires a prolonged hospital stay, additional diagnostic testing, antibiotic therapy and surgery, resulting in the total cost of treating deep infection to be more than double that of non-infected hip fracture surgery. Wound closure aims to accurately appose the skin edges thereby promoting rapid healing and restoration of the protective dermal barrier. Failure to provide accurate skin apposition can result in delayed wound healing which has been shown to have a 3 fold risk of developing late infection. Importantly, delayed wound healing is reflected by prolonged wound ooze. We hypothesized that skin closure via sutures is better at achieving skin edge apposition than wounds closed with staples, providing more rapid wound healing. We compared staples and sutures for wound closure in hip fracture patients by using ooze duration as an outcome measure for wound healing. Duration of wound ooze was recorded in 170 patients. 65 wounds, closed with sutures, had an average duration of ooze of 1.82 days. 105 wounds, closed with staples, had an average duration of ooze of 4.97 days. This study suggests that sutures are superior to staples with regard to early wound healing in hip fracture patients

Aims

The primary aim was to assess the rate of postoperative COVID-19 following hip and knee arthroplasty performed in March 2020 in the UK. The secondary aims were to assess whether there were clinical factors associated with COVID-19 status, the mortality rate of patients with COVID-19, and the rate of potential COVID-19 in patients not presenting to healthcare services.

Background. Meticillin-resistant Staphylococcus aureus (MRSA) are endemic in hospitals throughout Ireland and present a major concern in hospital hygiene causing significant morbidity, mortality and imposing a significant financial burden. This is particularly true in the field of orthopaedic surgery where a nosocomial MRSA infection can prove catastrophic to a patient's recovery from surgery. Much has been made of the possibility of healthcare workers acting as vectors for the transmission of MRSA and other pathogenic bacteria in the hospital setting. This focus has led to the implementation of strict hand decontamination policies in hospitals in order to counter the possibility of staff - patient transmission of such bacteria. Investigations have also attempted to assess the bacterial contamination of work uniforms such as white coats, ties and scrubs. An area that has been generally overlooked however, is the assessment of the bacterial contamination some of the most commonly handled items of many healthcare workers, namely pagers and mobile phones. In this study we aimed to assess the potential for these items to act as reservoirs for MRSA contamination and thus propagate its transmission in the hospital setting. Methods. Our study was performed at Cappagh National Orthopaedic Hospital, Dublin. We swabbed and cultured a sample of the pagers and mobile phones of staff. Questionnaires to assess the demographics of the staff sampled as well as the routine cleaning habits for their phone/pagers were also administered. Results. Bacteria were isolated from all pagers and mobile phones. Included in these isolated bacteria were MRSA and other potentially pathogenic organisms. Regular cleaning/disinfection of mobile phones and pagers was virtually non existent, either on a personal or institutional level. Conclusions. Mobile phones/pagers have thus far been generally overlooked as a possible reservoir and vector for the transmission of potentially pathogenic bacteria such as MRSA. We suggest that education about these possibilities takes place along with regular disinfection of these items in order to reduce the transmission of MRSA and other potentially pathogenic bacteria in the hospital setting

The role of spinal instrumentation in the presence of infection is still controversial, radical debridement of infected vertebrae and disc material may leave the spine unstable despite the use of bone graft, and some form of spinal stabilisation may deem necessary. We reviewed 27 cases of primary pyogenic spinal infection treated in addition to an appropriate antimicrobial agents, by radical debridement, bone grafting and posterior (22) or anteror (5) spinal instrumentation. The indication for surgery was the failure of conservative treatment (4), progressive neurological deficit (20) and the lack of diagnosis (3). The infection was caused by pyogenic bacteria (19), Mycobacterium Tuberculosis (6), Candida Albicans (1) Echinococcus granulosus (1). The mean period of follow-up was 3.8 years (1–12). The infection was eradicated in all our patients, the neurological recovery was full in 19 out of 20 patients with neurological deficits. Deep wound infection (Three immunocompromised patients, they all responded to repeated wound debridement); implant failure (Two patients, both required revision of fixation), early postoperative death due to nosocomial infection (1). Spinal instrumentation may be indicated when after debridement and bone grafting, the stability of spine is compromised

Aims

Hip fracture is a common condition of the older, frailer person. This population is also at risk from SARS-CoV-2 infection. It is important to understand the impact of coexistent hip fracture and SARS-CoV-2 for informed decision-making at patient and service levels.

Nosocomial infection with methicillin-resistant Staphylococcus aureus (MRSA) is on the increase and is expensive to treat. MRSA surgical wound infection may have disastrous consequences, particularly in an orthopaedic setting. We studied the rate of MRSA colonization in an important subgroup of orthopaedic patients. 50 nursing home residents were retrospectively reviewed with regard to their MRSA status on admission to an orthopaedic ward with fractured neck of femur. As is policy in our institution, all patients from nursing homes or other institutions are screened for MRSA on admission. Of the 50 nursing home patients requiring a hemi-arthroplasty, 16%(8) were MRSA positive. 2%(1/50) acquired MRSA infection while I hospital, while the remaining 14%(7/50) were carriers on admission. 4%(2/50) developed sepsis postoperatively, followed by multiorgan failure and death. 4% had their MRSA cleared prior to discharge, while 8% remained positive on discharge. All patients undergoing hemiarthroplasty received cefuroxime, unless allergic, as prophylaxis at induction. These findings of considerable MRSA carriage in nursing home patients is particularly relevant today, as the number of patients in nursing homes continues to grow as the population ages. The patient population in nursing homes is susceptible to infection because of the physiological changes that occur with ageing, the underlying chronic diseases of the patients and the institutional environment within which residents socialize and live. Nursing home residents presenting to orthopaedic units for surgery are a unique group in repairing careful consideration

Aims

During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery.

Summary. Coagulase-negative staphylococci, including S. epidermidis, have emerged as the leading pathogens of hospital-acquired biomaterial-related infections. These infections can be clinically indolent and challenging also for diagnostic imaging. In the current model of catheter-related infections, . 68. Ga-labeled Siglec-9 PET/CT imaging was able to detect peri-implant S. epidermidis bone infections. Introduction. Coagulase-negative staphylococci, including S. epidermidis, have emerged as the leading pathogen of nosocomial (hospital-acquired) biomaterial-related infections, including periprosthetic infections and intravascular catheter-related bloodstream infections. Pathogenic S. epidermidis strains exhibit robust attachment to implant surfaces and subsequent biofilm formation. By nature, the clinical picture of periprosthetic S. epidermidis infections can be indolent with vague signs of infection. These infections are also highly challenging for diagnostic imaging and microbiologic studies. Our recent experimental study of . 18. F-FDG-PET/CT confirmed that subacute peri-implant S. epidermidis infections, reflecting limited inflammatory reaction, are characterised by low . 18. F-FDG uptake. Vascular adhesion protein-1 (VAP-1) is an inflammation inducible endothelial protein, which controls leukocyte migration to sites of inflammation and infection. Siglec-9 is a leukocyte ligand of VAP-1. We hypothesised that . 68. Ga-labeled Siglec-9, developed for PET imaging of inflammation and cancer, could be a novel tracer also for early defection of S. epidermidis peri-implant bone infections. Material & Methods. Thirty adult male Sprague-Dawley rats were randomised into three groups (n=10/group). A clinical intravenous polymer catheter was introduced into the medullary cavity of the left tibia followed by injections of a clinical isolate of S. epidermidis (T-54580, 3 × 10. 8. CFU/mL) and an adjunct sodium morrhuate. In the positive control group, a clinical isolate of S. aureus (52/52A/80, 3 × 10. 5. CFU/mL) with sodium morrhuate was injected. In the negative control group, equal amount of sterile saline was injected via the catheter. The catheter, cut at the level of tibial tuberosity, was left in situ to serve as the implant. Two weeks after surgery, PET imaging with . 68. Ga-DOTA-Siglec-9 was performed with quantitative analysis of the standardised uptake value (SUV) in the region of interests both in vivo and ex vivo. SUV ratio between the operated and contralateral intact tibia was calculated. The presence of infections and the absence of contamination in the negative control group were verified by separate microbiological analyses of bone samples and retrieved implants. The presence of microbial biofilms on catheters was verified ex vivo with fluorescence microscope. Histologic inflammatory reaction was graded using a scoring system. Intergroup differences were tested by means of ANOVA with a post-hoc test. Results. Both staphylococcal strains caused histologically acute osteomyelitic changes. In . 68. Ga-DOTA-Siglec-9 PET/CT imaging of the negative control group, there was a significant difference (29.5%, p<0.001) in the SUV ratio of the operated and contralateral tibia, demonstrating aseptic inflammatory reaction to catheter implantation. The corresponding SUV ratio values were 58.1% in the S. epidermidis group and 41.7% in the S. aureus group. The uptake in the S. epidermidis group was significantly (p=0.009) higher than in the negative control group. Discussion/Conclusion. The animal model was reproducible in creation of culture-positive biomaterial-related infections. . 68. Ga-labeled Siglec-9 PET/CT imaging was able to demonstrate aseptic inflammation in the negative control group and the tracer also detected peri-implant bone infections caused by S. epidermidis

Introduction: Recently there has been much interest in minimally invasive hip surgery, with less attention being directed to maximising the potential benefits of this type of surgery. We have developed a new multidisciplinary program for patients undergoing total hip replacement in order to facilitate an overnight hip replacement service. Methods: The program involves a pre-operative regimen of education and physiotherapy, a modified anaesthetic technique, a minimally invasive surgical approach and a portable local anaesthetic pump infusion for post-operative pain control. Strict inclusion and exclusion criteria were developed based on age, medical status and social circumstances. Patients were mobilised on the day of their operation and discharged home with an ‘outreach team’ support network. No patient complained that their discharge was too early. Independent evaluation was performed using the Oxford Hip Questionnaire, the Merle d’Aubigne clinical rating system and Visual Analogue Pain Scores. Results: Thirty seven patients underwent total hip replacement using the new protocol. The average length of stay was 1.2 days. The mean pain score on discharge was 1.3/10. The Oxford Hip Questionnaire and Merle d’Aubigne scores were comparable to patients who underwent surgery prior to the introduction of the new protocol. Minimising in-patient stay for total hip replacement benefits the patient by reducing exposure to nosocomial infection and expediting the return to a normal environment for faster rehabilitation. This new program allows patients undergoing total hip replacement to be discharged after 1 night post operatively without compromising safety or quality of care. Conclusion: Minimally invasive surgery with a suitable infrastructure can be used to dramatically reduce the length of stay in suitable patients. This can be achieved reliably, safely and with high patient satisfaction. In order to gain the benefit of Minimally Invasive Surgery we recommend introducing this type of comprehensive program

Purpose of the study: Misalignment after insufficient treatment of unstable fracture of the pelvis is often poorly tolerated, compromising quality-of-life due to limping, leg length discrepancy, posterior pain, uncomfortable sitting position and/or sexual disorders due to mechanical problems. Secondary surgical treatment can be proposed despite its invasive nature (generally three phase surgery). The purpose of this work was to present the technique and the results of standardized correction of pelvis misalignment using a two-phase procedure. Material and methods: Eight consecutive patients (May 2002–May 2004) with sequelae of Tile C fractures were treated on average eight years after the initial trauma. A double-approach was used. The series included four men and four women, aged 18–43 years. The first posterior approach in the ventral supine position was used for osteotomy of the sacroiliac callus and systematic debridement by section of the sacroiliac ligaments. The secondary ilioinguinal approach was performed in the dorsal supine position to achieve osteotomy of the symphyseal callus, reduction of the iliac wing, and symphyseal synthesis using a sacroiliac plate anteriorly and percutaneous screws. Results: The mean operative time was four hours 30 minutes. Blood loss required transfusion of 3.5 packed red cell units on average. Anatomic reduction was achieved in six cases, partial reduction in two. Despite one nosocomial infection and two partial popliteal external sciatic deficits, all patients wer satisfied with the operation at mean eight months follow-up. Bone healing was achieve din all cases. Discussion: Standard two-phase surgery is possible for a wide range of cases. The anatomic result is reliable with good clinical outcome. The duration of the operation and blood loss are reduced compared with classical techniques. Conclusion: Despite the advantage of this original operative strategy, surgery for correction of pelvis misalignment remains a difficult surgical procedure for selected and motivated patients informed of the operative risks

Aim: The purpose of this study was to evaluate the prevalence of methicillinresistant Staphylococcus aureus (MRSA) isolates in the Orthopaedic Department of a new University Hospital, two years from its opening. Methods: Forty-three consecutive S. aureus isolates, collected from cultures (pus 90%) from consecutive orthopaedic inpatients were included in the study. Resistance to antimicrobial agents was assessed by the disk diffusion method. The mecA-gene was detected by PCR assay, whereas molecular typing of the isolates was performed by PFGE. Results: Only 5 of the 43 strains (11.6%) expressed high level resistance to oxacillin (MIC ≥ 64mg/L). All these isolates possessed mecA-gene and exhibited resistance, except oxacillin, to more than four classes antimicrobial groups. The remaining 38 isolates (34 beta-lactamase positive) were susceptible to oxacillin (MIC ≤ 2mg/L), and expressed a less resistant type than that of MRSA. Molecular typing by PFGE showed apparent heterogeneity among isolates and the absence of predominant clones. Conclusions: The 11.6% prevalence of MRSA is well below the reported average in the literature. Apparently the isolates originated from different sources of contamination. All patients had previous hospitalizations, where they acquired the infections and subsequently transferred the MRSAs to our department. Precautions and measures taken in the wards limited the spread and dissemination of the isolates as demonstrated by the heterogeneity and the absence of predominant clones. These þndings further reiterate the value of the low-cost, standard preventive procedures to control nosocomial infections in a high-risk orthopaedic department

Purpose: Neck of femur fractures increasingly form a large bulk of in-patient admissions to trauma units. These patients often require multi-disciplinary input before discharge. Delayed discharge not only exposes patients to nosocomial infections, it places strain on limited bed numbers. The use of a single screening question at time of admission to identify those patients suitable for fast-track discharge was investigated. Methods: Prospective study. 122 patients in the study. Basic epidemiological data was collected. At admission the patient was asked whether they were able to do their own shopping or not. Following discharge: the length of stay and discharge destination was recorded. Results were analysed using standard statistical methods. Results: 122 patients were identified. 43 of the patients(35%) able to do their own shopping. There was a significant difference in length of stay between the two groups as well as mortality rate. Those able to do their own shopping stayed in hospital on average 4 days longer. In the group who could do their own shopping, 100% were discharged home from the trauma ward. Conclusions: This study demonstrated that through the use of a single question it is possible to identify elderly patients suitable for home rehabilitation. All those patients who could do their own shopping were discharged home from the trauma ward without need for transfer to an in-patient rehabilitation ward. All patients who could do their own shopping were assessed as suitable for discharge home once they had completed a basic course of rehabilitation. This resulted in a longer length of stay in hospital. Identifying this group of patients it is possible to reduce their average length of stay in hospital from 14 days to 5 days. This is achieved using a fast track system for elective arthroplasty patients, based on a system of home rehabilitation. This results in improved care for the patients as well as financial savings on in-patient care

Purpose: The purpose of this study was to evaluate the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) isolates in the Orthopaedic Department of a new University Hospital, two years from its opening. Material and Methods: Forty-three consecutive S. aureus isolates, collected from cultures (pus 90%) from consecutive orthopaedic inpatients were included in the study. Resistance to antimicrobial agents was assessed by the disk diffusion method. The mecA-gene was detected by PCR assay, whereas molecular typing of the isolates was performed by PFGE. Results: Only 5 of the 43 strains (11.6%) expressed high level resistance to oxacillin (MIC ≥ 64mg/L). All these isolates possessed mecA-gene and exhibited resistance, except oxacillin, to more than four classes antimicrobial groups. The remaining 38 isolates (34 beta-lactamase positive) were susceptible to oxacillin (MIC ≤ 2mg/D, and expressed a less resistant type than that of MRSA. Molecular typing by PFGE showed apparent heterogeneity among isolates and the absence of predominant clones. Conclusions: The 11.6% prevalence of MRSA is well below the reported average in the literature. Apparently the isolates originated from different sources of contamination. All patients had previous hospitalizations, where they acquired the infections and subsequently transferred the MRSAs to our department. Precautions and measures taken in the wards limited the spread and dissemination of the isolates as demonstrated by the heterogeneity and the absence of predominant clones. These findings further reiterate the value of the low-cost, standard preventive procedures to control nosocomial infections in a high-risk orthopaedic department

Introduction: A recent JBJS(Br) article examined skin markers after contamination with a standard MRSA inoculum and cultured on MRSA-indicator nutrient agar. The Penflex™ marker showed no survival after 15 minutes, whereas the Viomedex™ marker produced MRSA cultures for up to three weeks. Research undertaken at Wrightington has shown that in primary joint replacement coagulase-negative staphylococci account for 67.2% – 76% of contaminants isolated from the ultra clean zone. It is the most prevalent and persistent species on human skin and mucous membranes and accounts for 58% of failures due to deep infection of primary THR. Further studies of nosocomial infection transmission show bacterial contamination of healthcare workers’ scissors, ballpoint pens, stethoscopes and lab coats with MRSA, VRE and gram-negative bacilli. Multiuse skin markers may become colonised, possibly with MRSA, MRSE and gram-negative bacilli. This may contaminate patients and cause premature failure of arthroplasty, leading some units to adopt a single use policy. Our aim was to ascertain bacterial colonisation of multiuse skin markers. Method: Multiuse indelible skin markers were collected from Orthopaedic staff, wards and Day Surgery Units within the Mid-Yorkshire Hospitals. Pens identified by a number, brand, location and approximate pen age. Pen tips were neutralised with 10ml sterile Peptone water and this was used as the inoculum. Cap interior swabbed with sterile swab (pre-dipped in sterile water). Both were inoculated into enrichment broth and plated onto Blood and McConkey media. Incubation at 37°c for 18 hours with plates read at 7 days for colony forming units. Results: 31 pens. 15 different brands. Age 1 month– 3yrs. No growth on all plates after incubation for 7 days. Conclusion: These results indicate that multiuse indelible skin markers are safe. There is no evidence to support subsequent cross contamination or the need for sterile single use pens for preoperative marking

Aims

Within the UK, around 70,000 patients suffer neck of femur (NOF) fractures annually. Patients presenting with this injury are often frail, leading to increased morbidity and a 30-day mortality rate of 6.1%. COVID-19 infection has a broad spectrum of clinical presentations with the elderly, and those with pre-existing comorbidities are at a higher risk of severe respiratory compromise and death. Further increased risk has been observed in the postoperative period. The aim of this study was to assess the impact of COVID-19 infection on the complication and mortality rates of NOF fracture patients.

From 1970, when Buchholz started incorporating antibiotics in bone cements, until now, many studies have been published supporting the beneficial effects of Palacos R with gentamicin in prevention and therapy of infections in orthopaedic surgery. Despite the continuously increasing rates of genta-micin-resistant strains, the empirical use of gentamicin was reduced only as far as its systemic administration is concerned, while its local use in addition to bone cements has increased. The latter is justified by the gradual release of the antibiotic and its low toxicity. We studied during the period of August 2000 to August 2001, 668 operations which were performed with P-G in 6 orthopaedic clinics of KAT hospital (129 total hip arthroplasties, 258 total knee arthroplasties, 29 hip revisions, 11 knee revisions and 241 hip hemiarthroplasties) and 137 operations with simple cement, out of total 1346 operations. All the above surgeries were performed either in 5 classical operational fields or in 2 controlled ventilation ones. The rate of infection was 1,02% in total, and does not differ from the infection rate of the 3rd orthopaedic department of the same hospital that performs the same operations in the same operating rooms without the usage of P-G, with the exception of revisions that P-G was used. We believe that the high gentamicin-resistant rates of nosocomial microorganisms in combination with the non-complete inhibition of biofilm formation, the negative effect that gentamicin has on bone regeneration and the entailed risk of emergence of resistant organisms to gentamicin because of the continuous and long lasting release of the antibiotic in subtherapeutic concentrations, does not justify the use of Palacos R with gentamicin as prevention of infections. Perhaps the development of other bone-loaded antibiotics, that do not affect the strength of the cement, would be better accepted than gentamicin in the future

Introduction Total hip replacement is the commonest arthroplasty procedure performed in the UK. The in-patient stay has gradually reduced and patients now typically spend five to seven days in hospital. We have developed a new multidisciplinary protocol for patients undergoing total hip replacement in order to facilitate early discharge. The aims of this study were to prospectively assess whether this new protocol could be safely applied to patients undergoing total hip replacement and whether it reduced length of stay. Methods The protocol involved a pre-operative program of education and physiotherapy, a modified anaesthetic regime, a minimally invasive surgical approach and a portable local anaesthetic pump infusion for post operative pain control. Strict inclusion and exclusion criteria were developed based on age, medical status and social circumstances. Patients were mobilised on the day of their operation and discharged to an outreach team support network. Independent evaluation was performed using the Oxford Hip Questionnaire, the Merle dAubigne clinical rating system and Visual Analogue Pain Scores. Results Twenty-five patients underwent total hip replacement using the new protocol. All patients were discharged home within 48 hours of surgery. There were two unplanned reattendances neither of which required readmission. The mean pain score on discharge was 3/10. The Oxford Hip Questionnaire and Merle dAubigne scores were comparable to patients who underwent surgery prior to the introduction of the new protocol. Discussion Minimising in-patient stay for total hip replacement benefits the patient by reducing exposure to nosocomial infection and expediting the return to a normal environment for rehabilitation. It may also help to improve efficiency and alleviate pressure on an overburdened health service. This new protocol allows patients undergoing total hip replacement to be discharged within 48 hours of undergoing surgery without compromising safety or quality of care

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In 2020, the COVID-19 pandemic meant that proceeding with elective surgery was restricted to minimize exposure on wards. In order to maintain throughput of elective cases, our hospital (St Michaels Hospital, Toronto, Canada) was forced to convert as many cases as possible to same-day procedures rather than overnight admission. In this retrospective analysis, we review the cases performed as same-day arthroplasty surgeries compared to the same period in the previous 12 months.

Objective: To describe the prevalence and incidence of methicillin resistant Staphylococcus aureus (MRSA) colonisation in patients in the Trauma and Orthopaedic wards of the University Hospital of North Staffordshire. Design Prospective audit. Patients and methods: Over a three month period from 1st March to 31st May 2003 359 patients attending the elective orthopaedic outpatient department for major joint surgery were screened at the pre-operative assessment clinic; 105 of these patients were screened again on the elective orthopaedic wards. 197 patients were screened on the trauma wards. 31 patients of other/outlying specialities were screened. Patients whose stay was expected to be for 48 hours or more were included in the audit. Patients were screened for MRSA colonization on admission, transfer and discharge. Colonised patients were treated according to the local infection control policy. Results: 31 elective orthopaedic patients (29%); 46 trauma patients (23%) and 8 other/outlying patients (26%) were colonized with MRSA. On admission, 23 elective orthopaedic patients (22%), 32 trauma patients (16%), and 7 patients (23%) which were of other/outlying specialties were colonized with MRSA. 22 patients (6.6%) positive on admission, treated with eradication therapy, became negative on discharge. An additional 22 patients (6.6%) positive on admission became negative on discharge without receiving any treatment. During the audit period, 23 patients (6.9%) were negative for MRSA on admission and positive on discharge. 9 patients (39%) and 20 patients (62.5%) colonised in elective and trauma wards respectively, developed an MRSA infection, which required treatment. Conclusion: There is a relatively high prevalence of MRSA colonisation in patients admitted to orthopaedic and trauma wards. A proportion (22%) of patients are colonised with MRSA in the short time between testing and admission. Not all patients positive for MRSA following admission to hospital will have been colonised within the nosocomial environment

Purpose: We report the results of a study using fluoronavigation for distal locking of tibial and femoral nails and for screw fixation of femoral neck fractures in adults. We compared the duration of radiation exposure with the manual methods. Material and methods: Among a cohort of 220, 32 were selected randomly for the distal locking or cervical screwing using fluoronavigation. The series included 22 tibial nails, 3 femoral nails, and seven femoral neck fixations. The Medtronic ION navigation system was used. The computerised system recognises the relative spatial positions of the patient, the fluoroscope and the instrument. Data are transmitted via an optical camera. Results: We noted overall operative time and duration of radiation exposure by type of fracture. The duration of fluoroscopy ranged from 0.6 to 1.4 minutes for a tibial nailing using the conventional technique and 0.5 to 1 minute with fluoronavigation. For triple screwing, the fluoroscopy time was 1 minute 25 seconds. A total of 73 screws were inserted: 72 in correct position (one patient moved during the intervention). There were no nosocomial complications and no cases of compartment syndrome. Discussion: Repeated exposure to x-rays can be a limiting factor for locked nailing. It takes only a short time to install the material and learn the software. During this first experience, the already short radiation exposure was divided in half despite the fact that each screw was controlled separately, which with experience would not be necessary. Improvements in the software will allow controlling the rotation of the limb and avoid length discrepancies. Conclusion: In the traumatology unit, fluoronavigation is not a gadget to produce unnecessary virtual images. On the contrary, it improves safety for both the patient and the surgical team. This study demonstrates that patients can benefit from less radiating minimally invasive surgery allowing more precise insertion of the locking screws to avoid material failure. Future developments should improve the quality of the anatomic results of locked nailing and allow wider indications

Data collected on total knee replacements (TKR) from 77 hospitals in England were analysed to identify risk factors for surgical site infection (SSI). Demographic, operative, and infection data were collected prospectively over a four-year period by the Nosocomial Infection National Surveillance Scheme. There were 213 (1.8%) infections reported in 11552 primary TKR of which 82% were superficial, 10% deep incisional, and 8% joint/bone infections. The incidence of SSI in 687 revision of TKRs was 4.1% (71% superficial incisional, 18% deep incisional and 11% joint/bone). In the single variable analysis of primary TKRs, significant risk factors were male sex (p< 0.01), age (p< 0.001), ASA score (p< 0.001), wound class (p< 0.001) and NNIS risk index (p< 0.001). In revision of TKRs, only age (p< 0.01) and pre-operative hospital stay of more than one day (p< 0.02) were found to be significant. Significant risk factors with multi-variable logistic regression were type of procedure (TKR or revision TKR), hospital where the procedure was performed, male sex, and age. The mean length of stay in primary TKRs was 10 days (19 days with SSI) and 12 days in revision TKR (22 days with SSI). The median time to diagnosis for superficial SSI was 7 days for superficial SSIs, 9 days for deep incisional SSIs and 7.5 days for joint/bone infections. Staphylococcus aureus accounted for 35% of the infections and nearly one third of these were methicillin resistant (MRSA). There is significant inter-hospital variation in the incidence of SSI following total knee replacement. Revision TKR procedures are associated with a significantly higher incidence of SSI than primary TKRs (p< 0.001). Male sex and age are also important risk factors. Patients with SSI had a length of post-operative stay approximately twice that of those without SSI

The Department of Health and the Public Health Laboratory Service established the Nosocomial Infection National Surveillance Scheme (NINSS) in response to the need to standardise the collection of information about infections acquired in hospital. This would provide national data that could be used as a ‘benchmark’ by hospitals to measure their own performance. The definition of superficial incisional infection (skin and subcutaneous tissue), set by Centers of Disease Control (CDC), should meet at least one of the following criteria: I: Purulent drainage from the superficial incision. II: The superficial incision yields organisms from the culture of aseptically aspirated fluid or tissue, or from a swab, and pus cells are present. III: At least two of the following symptoms and signs of inflammation: pain or tenderness, localized swelling, redness or heat, and a. the superficial incision is deliberately opened by a surgeon to manage the infection, unless the incision is culture-negative or b. clinician’s diagnosis of superficial incisional infection. This study assessed the interobserver reliability of the superficial incisional infection criteria, set by the CDC, in current practice. The incisional site of 50 consecutive patients, who underwent elective primary joint arthroplasty (Hips & Knees), were evaluated independently by four observers. The most significant results of the study I: All four observers achieved absolute agreement (kappa=1) for Purulent wound discharge and clinical diagnosis of wound infection. II: The four observers obtained good agreement for pain criteria (kappa=0.76, III: There was significant disagreement (fair to poor) between all four observers for the following criteria: Localized swelling (kappa=0.34), Redness (kappa=0.33) and tenderness (kappa = 0.05). This is the first study to assess the reliability of the criteria, as set by the CDC and recommended by NINSS, for the diagnosis of superficial incisional infection and shows the Criterion III is not reliable and we recommend it should be revised. Failure to do so could lead to inaccurate statistics regarding hospital wound infection and detrimental effect on hospital trusts in the setting of league table

The response to the COVID-19 pandemic has raised the profile and level of interest in the use, acceptability, safety, and effectiveness of virtual outpatient consultations and telemedicine. These models of care are not new but a number of challenges have so far hindered widespread take-up and endorsement of these ways of working. With the response to the COVID-19 pandemic, remote and virtual working and consultation have become the default. This paper explores our experience of and learning from virtual and remote consultation and questions how this experience can be retained and developed for the future.

Cite this article: Bone Jt Open 2021;2(5):301–304.

The transition from shutdown of elective orthopaedic services to the resumption of pre-COVID-19 activity presents many challenges. These include concerns about patient safety, staff safety, and the viability of health economies. Careful planning is necessary to allow patients to benefit from orthopaedic care in a safe and sustainable manner.

Cite this article: Bone Joint J 2020;102-B(7):807–810.

Aims

Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type.

Purpose: Prevention of post-trauma infections is basically aimed at streptococcal, staphylococcal and anaerobic germs. An increasing number of open fractures are however contaminated with Bacillus cereus leading to a multidisciplinary discussion involving infectious disease specialists, orthopaedic surgeons, and bacteriologists concerning the appropriate management. Bacillus is an ubiquitous genus of sporulated telluric Gram positive germs found in soil and plants. B. cereus can lead to local wound infection. This environmental (including hospital) bacterium is often a temporary host of the skin flora and its isolation can be taken as a simple contamination with no therapeutic consequence. B. cereus is sensitive to fluoroquinolones. Material and methods: Between August 1995 and December 2000, B. cereus was isolated in 41 patients from surgical specimens taken from deep muscle and bone tissues. Ordinary medium was used for culture. Genomic analysis was used to type the Bacillus. Statistical analysis was conducted in cooperation with the epidemiology unit. Results: In our unit, isolation of B. cereus was significantly associated with severe open leg fractures (Gustilo grades IIA and IIIB) with soil contamination. Samples were taken due to fever, wound discharge, elevation of C reactive protein despite antibiotic prophylaxis beyond 48 hours using the standard protocol of aminopenicillin + betalactamase inhibitor, constantly inactive against B. cereus. The strains identified presented different genomic types ruling out nosocomial contramination. One amputation, one chronic osteitis and one anteriolateral leg compartment necrosis resulted from B. cereus infection in this series. Conclusion: Arguments developed here allow us to recall the importance of careful surgical debridement of open fractures and to emphasise the requirement for bacteriological samples and appropriate antibiotic therapy for 48 hours, combining, in agreement with the 1998 Consensus Conference, aminopenicillin + betalactamase inhibitor and gentamycin which is active against B. cereus. Severe open leg fractures which follow an unfavourable course should suggest possible B. cereus infection requiring early antibiotic therapy using a regimen with good bone diffusion including a fluoroquinolone which is always active against B. cereus

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The primary aim of this study was to assess the independent association of the coronavirus disease 2019 (COVID-19) on postoperative mortality for patients undergoing orthopaedic and trauma surgery. The secondary aim was to identify factors that were associated with developing COVID-19 during the postoperative period.

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The primary aim was to assess the patient-perceived effect of restrictions imposed due to COVID-19 on rehabilitation following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Secondary aims were to assess perceived restrictions, influence on mental health, and functional outcome compared to patients undergoing surgery without restriction.

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The aim of this study was to assess orthopaedic oncologic patient morbidity resulting from COVID-19 related institutional delays and surgical shutdowns during the first wave of the pandemic in New York, USA.

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COVID-19 represents one of the greatest global healthcare challenges in a generation. Orthopaedic departments within the UK have shifted care to manage trauma in ways that minimize exposure to COVID-19. As the incidence of COVID-19 decreases, we explore the impact and risk factors of COVID-19 on patient outcomes within our department.

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To investigate whether chronic kidney disease (CKD) is associated with the risk of all-cause revision or revision due to a periprosthetic joint infection (PJI) after primary hip or knee arthroplasty.

Introduction and Aims: Official governmental data indicates that infection rates for hip and knee replacement vary between zero and eight percent between institutions with and average rate of between one and two percent. Despite an apparent increase in our understanding of infection and increased use of antibiotics, decontamination and surgical technology infection remains a major problem, accounting for up to 10% of all revision procedures. The aim of this paper is to review where infection comes from, what turns a contamination into an infection and how infection can be avoided. Method: The organisms causing contamination of 125 primary joint replacements have been studied prospectively and compared to the organisms found at 334 revisions for deep infection. The antibiotic sensitivities, virulence and genetic ability to produce biofilms have been studied. The use of pre-operative screening for MRSA in 9000 patients undergoing elective surgery is compared to 2500 microbiological specimens taken for possible infection during the same time period to assess the importance of MRSA in prosthetic infection. The genetic susceptibility to infection, relationship between post-operative pyrexia and deep prosthetic infection and the use of blood transfusion and infection is investigated. Results: At least 70% of all primary joint replacements are contaminated with bacteria. The commonest contaminant is Staph. epidermidis, which is the commonest organism causing deep infection. The Staph. epidermidis causing deep infection is genetically a much stronger producer of biofilms than other strains of Staph. epidermidis. Five percent of the contaminating Staph. epidermidis is multi-resistant to antibiotics and is not susceptible to routine antibiotic prophylaxis. In our institution all elective patients are screened for MRSA. One percent of patients are carriers. Deep infection with MRSA is uncommon, with MRSA accounting for less than 2% of cases, however infection with Staph. epidermidis is the most common accounting for 60% of all infection, but of concern is that 55% of all infecting Staph. epidermidis is methicillin-resistant. The organism of concern is therefore MRSE not MRSA. Post-operative pyrexia actually protects against infection. The temperature charts of 40 patients who subsequently developed deep infection when compared to the charts of 200 patients without deep infection indicates that a low post-operative temperature is associated with an increased risk of infection, possibly indicating depressed immunity. Post-operative blood transfusion in 100 patients is shown to decrease immunity and increase nosocomial infection and wound healing problems, indicating that the immune modulation at the time of surgery is probably a major factor in post-operative infection. Finally, comprehensive genetic studies in patients undergoing long-term follow-up at Wrightington indicate definite genetic susceptibility to deep infection in certain patient groups. Conclusion: We do not understand prosthetic infection. We screen and worry about the wrong organisms, we wrongly worry about post-operative pyrexia, we increase the susceptibility of our patients to infection by blood transfusion and give the wrong antibiotics. We may be able to completely avoid infection if we redirect our efforts and stop relying on powerful broad spectrum antibiotics alone

In the period from 1999 to 2003 bacterial contamination of explanted cadaver bones and tendons from the Regional Tuscan Tissue and Cell Bank was studied. During this period 1124 explants from 402 donors were taken, of which 311 donors whose heart was beating and from 91 whose heart was not beating. The bone explantation procedure followed a standardized protocol. Al the samples were explanted in the operation room by a team of two surgeons and a nurse during the first 24 hours after death. The protocol concerning the sterility of the explanting procedure was standardized and followed accurately. The bacteriological examination was performed immediately after the explantation and before the samples were treated with antibiotic solution. Three different tests were used: superficial microbiological swabs of the bone surface, one from the medullar canal and a small bone or soft tissue sample. The samples were inoculated immediately in culture medium and incubated for at least 10 days. From 1124 explanted samples 430 were contaminated: 99 with pathological bacteria such as Staphylococcus aureus, Enterococcus, Escherichia coli etc., 331 with nosocomial bacteria such as coagulase neg. Staphylococcus, Corynebacteria, etc. The samples that were contaminated with pathological bacteria were excluded from the study. The other contaminated group was re-processed and re-tested for contamination. The factors influencing the results of contamination were anatomical location of the explants and the experience of the surgical team. In contrast, the donor type (heart beating vs. heart not beating) did not play any role. From 1999 to 2003 the University Hospital of Careggi in Florence, Italy, used 721 explants from which 624 were retrieved from the Regional Tuscan Tissue and Cell Bank, 72 from foreign banks and 14 from another national bank. The explants from foreign banks were all re-tested according to our standards. Among those, 699 samples were sterile and 22 samples (3%) were contaminated. Seventeen (2.3%) of the 22 samples were contaminated with pathological bacteria with low morbidity and 5 (0.7%) with medium morbidity. Compared to the control group contamination of the explants retrieved from the Regional Tuscan Tissue and Cell Bank was 2.8%. However, the contamination of samples of an explant is not necessarily correlated with a true infection of the specimen. This study shows that factors such as retrieval techniques, contamination factors in the operating room and laboratory mistakes can cause false-positive contamination results. In fact, only three of 604 patients who were operated in major orthopaedic procedures using bone and soft tissue allografts developed clinical evidence of infection (0.5%). In conclusion, the infection rate of our allografts in this study is not higher than the standard infection risk of any other major orthopaedic procedure (0.5%)

Aims

Periprosthetic joint infections (PJIs) and osteomyelitis are clinical challenges that are difficult to eradicate. Well-characterized large animal models necessary for testing and validating new treatment strategies for these conditions are lacking. The purpose of this study was to develop a rabbit model of chronic PJI in the distal femur.

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The current pandemic caused by COVID-19 is the biggest challenge for national health systems for a century. While most medical resources are allocated to treat COVID-19 patients, several non-COVID-19 medical emergencies still need to be treated, including vertebral fractures and spinal cord compression. The aim of this paper is to report the early experience and an organizational protocol for emergency spinal surgery currently being used in a large metropolitan area by an integrated team of orthopaedic surgeons and neurosurgeons.

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The COVID-19 pandemic presents an unprecedented burden on global healthcare systems, and existing infrastructures must adapt and evolve to meet the challenge. With health systems reliant on the health of their workforce, the importance of protection against disease transmission in healthcare workers (HCWs) is clear. This study collated responses from several countries, provided by clinicians familiar with practice in each location, to identify areas of best practice and policy so as to build consensus of those measures that might reduce the risk of transmission of COVID-19 to HCWs at work.

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A systematic literature review focusing on how long before surgery concurrent viral or bacterial infections (respiratory and urinary infections) should be treated in hip fracture patients, and if there is evidence for delaying this surgery.

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The primary aim was to assess the rate of patient deferral of elective orthopaedic surgery and whether this changed with time during the coronavirus disease 2019 (COVID-19) pandemic. The secondary aim was to explore the reasons why patients wanted to defer surgery and what measures/circumstances would enable them to go forward with surgery.

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There are reports of a marked increase in perioperative mortality in patients admitted to hospital with a fractured hip during the COVID-19 pandemic in the UK, USA, Spain, and Italy. Our study aims to describe the risk of mortality among patients with a fractured neck of femur in England during the early stages of the COVID-19 pandemic.

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The exact risk to patients undergoing surgery who develop COVID-19 is not yet fully known. This study aims to provide the current data to allow adequate consent regarding the risks of post-surgery COVID-19 infection and subsequent COVID-19-related mortality.

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To compare results of institutional preferences with regard to treatment of soft tissues in the setting of open tibial shaft fractures.

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To evaluate safety outcomes and patient satisfaction of the re-introduction of elective orthopaedic surgery on ‘green’ (non-COVID-19) sites during the COVID-19 pandemic.

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The aim of this paper is to describe the impact of COVID-19 on spine surgery services in a district general hospital in England in order to understand the spinal service provisions that may be required during a pandemic.

The COVID-19 virus is a tremendous burden for the Italian health system. The regionally-based Italian National Health System has been reorganized. Hospitals' biggest challenge was to create new intensive care unit (ICU) beds, as the existing system was insufficient to meet new demand, especially in the most affected areas. Our institution in the Milan metropolitan area of Lombardy, the epicentre of the infection, was selected as one of the three regional hub for major trauma, serving a population of more than three million people. The aims were the increase the ICU beds and the rationalization of human and structural resources available for treating COVID-19 patients. In our hub hospital, the reorganization aimed to reduce the risk of infection and to obtained resources, in terms of beds and healthcare personnel to be use in the COVID-19 emergency. Non-urgent outpatient orthopaedic activity and elective surgery was also suspended. A training programme for healthcare personnel started immediately. Orthopaedic and radiological pathways dedicated to COVID-19 patients, or with possible infection, have been established. In our orthopaedic department, we passed from 70 to 26 beds. Our goal is to treat trauma surgery's patient in the “golden 72 hours” in order to reduce the overall hospital length of stay. We applied an objective priority system to manage the flow of surgical procedures in the emergency room based on clinical outcomes and guidelines. Organizing the present to face the emergency is a challenge, but in the global plan of changes in hospital management one must also think about the near future. We reported the Milan metropolitan area orthopaedic surgery management during the COVID-19 pandemic. Our decisions are not based on scientific evidence; therefore, the decision on how reorganize hospitals will likely remain in the hands of individual countries.

During the pandemic of COVID-19, some patients with COVID-19 may need emergency surgeries. As spine surgeons, it is our responsibility to ensure appropriate treatment to the patients with COVID-19 and spinal diseases. A protocol for spinal surgery and related management on patients with COVID-19 has been reviewed. Patient preparation for emergency surgeries, indications, and contraindications of emergency surgeries, operating room preparation, infection control precautions and personal protective equipments (PPE), anesthesia management, intraoperative procedures, postoperative management, medical waste disposal, and surveillance of healthcare workers were reviewed. It should be safe for surgeons with PPE of protection level 2 to perform spinal surgeries on patients with COVID-19. Standardized and careful surgical procedures should be necessary to reduce the exposure to COVID-19.

Deep infection was identified as a serious complication in the earliest days of total hip arthroplasty. It was identified that airborne contamination in conventional operating theatres was the major contributing factor. As progress was made in improving the engineering of operating theatres, airborne contamination was reduced. Detailed studies were carried out relating airborne contamination to deep infection rates.

In a trial conducted by the United Kingdom Medical Research Council (MRC), it was found that the use of ultra-clean air (UCA) operating theatres was associated with a significant reduction in deep infection rates. Deep infection rates were further reduced by the use of a body exhaust system. The MRC trial also included a detailed microbiology study, which confirmed the relationship between airborne contamination and deep infection rates.

Recent observational evidence from joint registries has shown that in contemporary practice, infection rates remain a problem, and may be getting worse. Registry observations have also called into question the value of “laminar flow” operating theatres.

Observational evidence from joint registries provides very limited evidence on the efficacy of UCA operating theatres. Although there have been some changes in surgical practice in recent years, the conclusions of the MRC trial remain valid, and the use of UCA is essential in preventing deep infection.

There is evidence that if UCA operating theatres are not used correctly, they may have poor microbiological performance. Current UCA operating theatres have limitations, and further research is required to update them and improve their microbiological performance in contemporary practice.

Cite this article: Bone Joint J 2018;100-B:1264–9.

In England and Wales more than 175 000 hip and knee arthroplasties were performed in 2012. There continues to be a steady increase in the demand for joint arthroplasty because of population demographics and improving survivorship. Inevitably though the absolute number of periprosthetic infections will probably increase with severe consequences on healthcare provision. The Department of Health and the Health Protection Agency in United Kingdom established a Surgical Site Infection surveillance service (SSISS) in 1997 to undertake surveillance of surgical site infections. In 2004 mandatory reporting was introduced for one quarter of each year. There has been a wide variation in reporting rates with variable engagement with the process. The aim of this article is to improve surgeon awareness of the process and emphasise the importance of engaging with SSISS to improve the quality and type of data submitted. In Exeter we have been improving our practice by engaging with SSISS. Orthopaedic surgeons need to take ownership of the data that are submitted to ensure these are accurate and comprehensive.

Cite this article: Bone Joint J 2015;97-B:1170–4.