Haematomas, drainage, and other non-infectious wound complications following total knee replacement (TKR) have been associated with long-term sequelae, in particular, deep infection. However, the impact of these wound complications on clinical outcome is unknown. This study compares results in 15 patients re-admitted for wound complications within 90 days of TKR to 30 matched patients who underwent uncomplicated total knee replacements. Patients with wound complications had a mean age of 66 years (49 to 83) and mean body mass index (BMI) of 37 (21 to 54), both similar to that of patients without complications (mean age 65 years and mean BMI 35). Those with complications had lower mean Knee Society function scores (46 (0 to 100 vs 66 (20 to 100), p = 0.047) and a higher incidence of mild or greater pain (73% vs 33%, p = 0.01) after two years compared with the non re-admitted group. Expectations in patients with wound complications following TKR should be tempered, even in those who do not develop an infection. Cite this article: Bone Joint J 2014;96-B:619–21

Aims. Although internal hemipelvectomy is associated with a high incidence of morbidity, especially wound complications, few studies have examined rates of wound complications in these patients or have identified factors associated with the consequences. The present study aimed to: 1) determine the rate of wound and other complications requiring surgery after internal hemipelvectomy; and 2) identify factors that affect the rate of wound complications and can be used to stratify patients by risk of wound complications. Methods. The medical records of 123 patients undergoing internal hemipelvectomy were retrospectively reviewed, with a focus on both overall complications and wound complications. Logistic regression analyses were performed to examine the association between host, tumour, and surgical factors and rates of postoperative wound complications. Results. The overall rate of postoperative complications requiring surgery was 49.6%. Wound complications were observed in 34.1% of patients, hardware-related complications in 13.2%, graft-related complications in 9.1%, and local recurrence in 5.7%. On multivariate analysis, extrapelvic tumour extension (odds ratio (OR) 23.28; 95% confidence interval (CI), 1.97 to 274.67; p = 0.012), both intra- and extrapelvic tumour extension (OR 46.48; 95% CI, 3.50 to 617.77; p = 0.004), blood transfusion ≥ 20 units (OR 50.28; 95% CI, 1.63 to 1550.32; p = 0.025), vascular sacrifice of the internal iliac artery (OR 64.56; 95% CI, 6.33 to 658.43; p < 0.001), and use of a structural allograft (OR, 6.57; 95% CI, 1.70 to 25.34; p = 0.001) were significantly associated with postoperative wound complications. Conclusion. Internal hemipelvectomy is associated with high rates of morbidity, especially wound complications. Several host, tumour, and surgical variables are associated with wound complications. The ability to stratify patients by risk of wound complications can help refine surgical and wound-healing planning and may lead to better outcomes in patients undergoing internal hemipelvectomy. Cite this article: Bone Joint J 2020;102-B(3):280–284

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

Major wound complication risk factors following soft tissue sarcoma resection. Wound-healing complications represent an important source of morbidity in patients treated surgically for soft tissue sarcomas (STS). The purpose of this study was to determine which factors are predictive of major wound complication rates following STS resection, including tumour site, size, grade, and depth, as well as radiotherapy and chemotherapy. We reviewed 256 cases of STS treated surgically between 2000 and 2011. The primary outcome was occurrence of major wound complications post STS resection. Major wound complications were more likely to occur post STS resection with larger tumour diameters (p = 0.001), high grade tumours (p = 0.04), location in the proximal lower extremity (p = 0.01), and use of preoperative radiotherapy (p = 0.01). Tumours located in the adductor compartment were at highest risk of complications. We did not demonstrate a significant difference in complications rates based on method of closure. Diabetes, smoking, obesity, tumour diameter, tumour location in the proximal lower extremity, and preoperative radiotherapy were independent predictors on multivariate analysis. There are multiple predictors for major wound complications post STS resection. A more aggressive resection of irradiated soft tissues, combined with primary reconstruction, should be considered in cases with multiple risk factors

Tranexamic Acid (TA) has been shown to reduce transfusion rates in Total Knee Replacement (TKR) without complication. In our unit it was added to our routine enhanced recovery protocol. No other changes were made to the protocol at this time and as such we sought to examine the effects of TA on wound complication and transfusion rate. All patients undergoing primary TKR over a 12 month period were identified. Notes and online records were reviewed to collate demographics, length of stay, use of TA, thromboprophylaxis, blood transfusion, wound complications and haemoglobin levels. All patients received a Columbus navigated TKR with a tourniquet. Only patients who received 14 days of Dalteparin for thromboprophylaxis were included. 124 patients were included, 72 receiving TA and 52 not. Mean age was 70. Four patients required a blood transfusion all of whom did not receive TA (p = 0.029). Mean change in Hb was 22 without TA and 21 with (p = 0.859). Mean length of stay was 6.83 days without Tranexamic Acid and 5.15 with (p < 0.001). 15% of patients (n=11) of the TA group had a wound complication, with 40% of patients (n=21) in the non TA group (p = 0.003). There was one ultrasound confirmed DVT (non TA group). No patients were diagnosed with pulmonary embolus. In our unit we have demonstrated a significantly lower transfusion rate, wound complication rate and length of stay, without any significant increase in thromboembolic disease with the use of TA in TKR

Background. The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Methods. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR). Results. There were significantly more wound infections in the Rivaroxaban group (3.85% vs. 2.81%, OR=0.72; 95% CI 0.58–0.90). There were no significant differences between the two groups for PE (OR=1.52; 0.77–2.97), major bleed (OR=0.73; 0.48–1.12), all-cause mortality (OR=0.93; 0.46–1.87) and re-admission rate (OR=1.21; 0.88–1.67). There were significantly fewer symptomatic DVTs in the Rivaroxaban group (0.91% vs. 0.36%, OR=2.51; 1.30–4.82). Discussion. This study is the first to describe the real impact of the use of Rivaroxaban in the NHS. When compared with LMWH in lower limb arthroplasty patients, there were fewer DVTs in the Rivaroxaban group. However, wound infection rates were significantly higher following Rivaroxaban use whilst providing no reduction in symptomatic PE or all-cause mortality

Impaired vascularity of the skin in elderly ankle fracture patients causes the skin and wound complications. This is part of a RCT comparing ORIF and close contact casting (CCC) for isolated unstable ankle fractures in patients > 60 years. Assessments over 6-months. trans-cutaneous O2 saturation (TcP02) of medial and lateral ankle skin. Ankle-Brachial Pressure Index (ABPI). 3-vessel arterial duplex scan. distal calf perforator artery patency. The uninjured limb was the control. Eighty-nine patients eligible; 59 participated (76% female). 30 randomised to ORIF; 29 to CCC. Each had one death and one withdrawal. Vascular data available on 55. Two patients had delays in wound healing (> 25% for > 6-weeks). Two further developed wound infections. No skin breakdowns in CCC group. There was a reduced TcP02 on day-3 in the injured limb. The TcP02 rose at 6-weeks compared to day-3 (medial 58mmHg; lateral 53mmHg, p=0.002) in the injured leg. At 6-months the TcP02 measurements were not different to uninjured leg. A critical TcP02 (< 20mmHg) found in 4, correlated with skin problems (p=0.003). Two of these had the only major delays in wound healing and one of the two wound infections. 94% of participants had normal ABPI’s (> 1.0). There was no difference between patients with or without an impaired ABPI (< 0.7 mm Hg) and wound problems (p=0.20). There was no difference in patent perforators between the injured and uninjured (p=0.39). Occult vascular insufficiency is present but at low incidence. ABPI and Duplex-US are insensitive for predicting infection or delayed healing. The ankle fracture injury does not disrupt the local perforators. TcPO2 is sensitive and specific for predicting skin problems. Impairment of skin oxygenation is transient. Current TcPO2 technology however is impractical as a clinical tool

Aims. We investigated the efficacy and safety profile of commonly used venous thromboembolism (VTE) prophylaxis agents following hip and knee arthroplasty. Methods. A systematic search of PubMed, Embase, Cochrane Library, Web of Science, and OrthoSearch was performed. Prophylaxis agents investigated were aspirin (< 325 mg and ≥ 325 mg daily), enoxaparin, dalteparin, fondaparinux, unfractionated heparin, warfarin, rivaroxaban, apixaban, and dabigatran. The primary efficacy outcome of interest was the risk of VTE, whereas the primary safety outcomes of interest were the risk of major bleeding events (MBE) and wound complications (WC). VTE was defined as the confirmed diagnosis of any deep vein thrombosis and/or pulmonary embolism. Network meta-analysis combining direct and indirect evidence was performed. Cluster rank analysis using the surface under cumulative ranking (SUCRA) was applied to compare each intervention group, weighing safety and efficacy outcomes. Results. Of 86 studies eligible studies, cluster rank analysis showed that aspirin < 325 mg daily (SUCRA-VTE 89.3%; SUCRA-MBE 75.3%; SUCRA-WC 71.1%), enoxaparin (SUCRA-VTE 55.7%; SUCRA-MBE 49.8%; SUCRA-WC 45.2%), and dabigatran (SUCRA-VTE 44.9%; SUCRA-MBE 52.0%; SUCRA-WC 41.9%) have an overall satisfactory efficacy and safety profile. Conclusion. We recommend the use of either aspirin < 325 mg daily, enoxaparin, or dabigatran for VTE prophylaxis following hip and knee arthroplasty. Cite this article: Bone Joint J 2024;106-B(9):924–934

Aims. The primary objective of this study was to compare the postoperative infection rate between negative pressure wound therapy (NPWT) and conventional dressings for closed incisions following soft-tissue sarcoma (STS) surgery. Secondary objectives were to compare rates of adverse wound events and functional scores. Methods. In this prospective, single-centre, randomized controlled trial (RCT), patients were randomized to either NPWT or conventional sterile occlusive dressings. A total of 17 patients, with a mean age of 54 years (21 to 81), were successfully recruited and none were lost to follow-up. Wound reviews were undertaken to identify any surgical site infection (SSI) or adverse wound events within 30 days. The Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) score were recorded as patient-reported outcome measures (PROMs). Results. There were two out of seven patients in the control group (28.6%), and two out of ten patients in the intervention group (20%) who were diagnosed with a SSI (p > 0.999), while one additional adverse wound event was identified in the control group (p = 0.593). No significant differences in PROMs were identified between the groups at either 30 days (TESS, p = 0.987; MSTS, p = 0.951) or six-month (TESS, p = 0.400) follow-up. However, neoadjuvant radiotherapy was significantly associated with a SSI within 30 days of surgery, across all patients (p = 0.029). The mean preoperative modified Glasgow Prognostic Score (mGPS) was also significantly higher among patients who developed a postoperative adverse wound event (p = 0.028), including a SSI (p = 0.008), across both groups. Conclusion. This is the first RCT comparing NPWT with conventional dressings following musculoskeletal tumour surgery. Postoperative wound complications are common in this group of patients and we observed an overall SSI rate of 23.5%. We propose proceeding to a multicentre trial, which will help more clearly define the role of closed incision NPWT in STS surgery. Cite this article: Bone Jt Open 2021;2(12):1049–1056

Objectives. Wound complications are reported in up to 10% hip and knee arthroplasties and there is a proven association between wound complications and deep prosthetic infections. In this randomised controlled trial (RCT) we explore the potential benefits of a portable, single use, incisional negative pressure wound therapy dressing (iNPWTd) on wound exudate, length of stay (LOS), wound complications, dressing changes and cost-effectiveness following total hip and knee arthroplasties. Methods. A total of 220 patients undergoing elective primary total hip and knee arthroplasties were recruited into in a non-blinded RCT. For the final analysis there were 102 patients in the study group and 107 in the control group. Results. An improvement was seen in the study (iNPWTd) group compared to control in all areas. Peak post-surgical wound exudate was significantly reduced (p = 0.007). Overall LOS reduction (0.9 days, 95% confidence interval (CI) -0.2 to 2.5) was not significant (p = 0.07) but there was a significant reduction in patients with extreme values of LOS in the iNPWTd group (Moses test, p = 0.003). There was a significantly reduced number of dressing changes (mean difference 1.7, 95% CI 0.8 to 2.5, p = 0.002), and a trend to a significant four-fold reduction in reported post-operative surgical wound complications (8.4% control; 2.0% iNPWTd, p = 0.06). Conclusions. Based on the results of this RCT incisional negative pressure wound therapy dressings have a beneficial role in patients undergoing primary hip and knee arthroplasty to achieve predictable length of stay, especially to eliminate excessive hospital stay, and minimise wound complications. Cite this article: S. L. Karlakki, A. K. Hamad, C. Whittall, N. M. Graham, R. D. Banerjee, J. H. Kuiper. Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: A randomised controlled trial. Bone Joint Res 2016;5:328–337. DOI: 10.1302/2046-3758.58.BJR-2016-0022.R1

Reported wound complication in below knee surgery can be quite high. Recent study demonstrated that increased blood loss and hematoma formation increase wound complications especially in foot and ankle surgeries. Despite the evidence on the benefit of TXA on blood loss in TKA and THA it is not routinely used by surgeon in below knee surgery. To assess the efficacy and safety of this medication in reducing wound complication and blood loss and the risk of thromboembolic complications in patients undergoing below knee surgery. A systematic literature search of PubMed, Embase, Ovid, the Cochrane Library and AAOS and AOFAS conference proceedings was conducted. The primary outcome was the rate of wound complications. Data were analyzed using the Review Manager 5.3 software. Nine studies involving 861 patients met the inclusion criteria. The meta-analysis indicated that TXA, when compared to a control group, reduced wound complications (OR, 0.54; 95% IC, 0.31 to 0.95, p = 0,03), blood loss (MD = −149,4 ml; 95% CI, −205,3ml to −93,6ml), post-operative drainage (MD = −169,8 ml; 95% CI, −176,7 to −162,9 ml) and hemoglobin drop (MD = −8,75 g/dL; 95% IC, −9,6 g/dL to −7,8 g/dL). There was no significant difference in thromboembolic events (RR 0,53; 95% CI, 0,15 - 1,90; p = 0,33). This study demonstrated that TXA could be use in below knee surgery to reduce wound complication and blood loss without increased thromboembolic complications. The small number of studies limit the findings interpretation. Further studies are needed to sustain those resutls

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

Lateral approach open calcaneal osteotomy is the described gold standard procedure in the management of hindfoot deformity. With development of minimally invasive surgery, a MIS approach has been described, citing fewer wound complications and lower risk of sural nerve injury. This audit compares MIS to the traditional procedure. A retrospective review of all patients undergoing calcaneal osteotomy in Northumbria Trust in the past 5 years was performed. A total of 105 osteotomies were performed in 97 patients; 28 (13M:15F) in MIS group and 77 (40M:37F) had an open approach. The average age was 52.1 (range 16–83) for MIS and 51.5 (range 18–83) in the open group. All patients were followed up for development of wound complication, nerve injury and fusion rate. Wound complications were similar (10.7% in MIS group vs 10.3% in Open group) with no significant difference (p=0.48). Patients were treated for infection in 3(3.8%) cases in the open group and 2(7.1%) in the MIS group. This difference was not significant (p=0.43). 4 (14.3%) patients in the MIS group had evidence of sural nerve dysfunction post-operatively (managed expectantly), compared to 12(15.5%) patients in the open group (p=0.44). Of these, 2 went on to undergo neuroma exploration. There was no difference in nerve dysfunction in varus or valgus correction. Mean translation in the open group was measured as 7.3mm(SD=1.91;3 to 13mm) and 7.5mm(SD=1.25;5 to 10mm) in the MIS group. Translation was similar in varus or valgus correction. Non-union occurred in 2 patients in the MIS group and none in the open group (p= 0.06). MIS calcaneal osteotomy is a safe technique, that works as effectively as osteotomy performed through an open approach. There were lower rates of nerve injury, wound complication and infection, but this was not significantly different comparing groups. There was a higher risk of non-union in MIS technique

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

Aims. No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA. Methods. Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler’s angle and calcaneal width, and posterior facet reduction. Results. Although four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001). Conclusion. The ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286–293

Introduction. Wound complications following revision total hip arthroplasty (THA) are associated with an increased risk of superficial and deep infections. Closed incision negative-pressure therapy (ciNPT) has been reported to decrease this risk. This study's purpose was to assess if ciNPT decreases the rate of wound complications following revision THA versus a conventional, silver-impregnated dressing. Methods. This was a single center, randomized controlled trial of patients undergoing both septic and aseptic revision THA. Patients received either ciNPT or a silver-impregnated dressing (control) for 7 days. Wound complications within 90 days of the procedure were recorded, including: surgical site infection (SSI), periprosthetic joint infection (PJI), prolonged drainage greater than 5 days, erythema requiring antibiotics, and hematoma formation. An a priori power analysis determined 201 patients per cohort were necessary to demonstrate a 10% decrease in wound complication rate. Results. Between 2017 and 2020, 113 patients have been enrolled: 57 (50.4%) to ciNPT and 56 (49.6%) to the control dressing. Two revisions (1.8%) were performed via a direct lateral approach; all others via a posterior approach. There were no differences in age, BMI, ASA score, revision performed, wound closure method (staples, superficial nylons, subcuticular), or postoperative anti-coagulation (p=0.2–0.8). Seven (12.3%) patients in the ciNPT cohort sustained a wound complication versus 4 (7.1%) in the control cohort (p=0.2). There was no difference in type of wound complication sustained (p=0.4). Four (7.0%) patients in the ciNPT cohort underwent re-operation for wound-related complications (2 PJI, 1 SSI, 1 prolonged drainage) versus zero in the control cohort (p=0.04). Conclusion. Prior studies have shown ciNPT to be effective in decreasing the rate of wound complications in total joint arthroplasty. Preliminary results of this randomized trial of revision THA patients do not corroborate these prior reports. Continued enrollment is required to confirm these initial findings

Background. Traditionally, the extended lateral approach (ELA) was the favoured approch for calcaneal fractures, but has been reported to have high incidence of wound complications. There has been a move amongst surgeons in the United Kingdom towards the sinus tarsi approach (STA) due to its minimally invasive nature, attempting to reduce such complications. Aims. To evaluate outcomes of ELA and STA for all consecutive calcaneal fracture fixation in our institution over a 10yr period. Method. Retrospective cohort study of all calcaneal fractures surgically treated with either approach between January 2008 and January 2018. Anatomic restoration was assessed radiologically by the change in Gissane's and Bohler's angles and calcaneal width. Post-operative complications including metalwork removal were recorded. Results. 35 calcaneal fractures were managed surgically via either approach during this period (21 STA and 14 ELA). There was a statistically significant improvement in the radiological makers when the post-operative films were compared to pre-operative ones. When the post-operative films from the 2 groups were compared against each other, there was no significant difference (p< 0.05) in any of the radiological markers. In the ELA group, 2 patients (14.3%) developed deep infections requiring metalwork removal and 1 had delayed wound healing (7.1%). No deep infections occurred with the STA; 1 patient (4.8%) had a superficial infection, treated with antibiotics. Of patients who had metalwork in situ for more than 1 year, 37.5% of the STA group required removal due to pain compared to only 16.7% with ELA. Conclusions. We have moved from ELA to STA. Our results have shown no difference in restoration of calcaneal anatomy but with a decrease in post-operative wound complications including infection. However, we have shown an increase in metalware removal in the STA group and it is important to ascertain the cause and significance of this

Aims. The efficacy and safety of intrawound vancomycin for preventing surgical site infection in primary hip and knee arthroplasty is uncertain. Methods. A systematic review of the literature was conducted, indexed from inception to March 2020 in PubMed, Web of Science, Cochrane Library, Embase, and Google Scholar databases. All studies evaluating the efficacy and/or safety of intrawound vancomycin in patients who underwent primary hip and knee arthroplasty were included. Incidence of periprosthetic joint infection (PJI), superficial infection, aseptic wound complications, acute kidney injury, anaphylactic reaction, and ototoxicity were meta-analyzed. Results were reported as odds ratios (ORs) and 95% confidence intervals (CIs). The quality of included studies was assessed using the risk of bias in non-randomized studies of interventions (ROBINS-I) assessment tool. Results. Nine studies involving 4,607 patients were included. Intrawound vancomycin was associated with lower incidence of PJI (30 patients (1.20%) vs 58 control patients (2.75%); OR 0.44, 95% CI 0.28 to 0.69) and simultaneous acute kidney injury (four patients (0.28%) vs four control patients (0.35%), OR 0.71, 95% CI 0.19 to 2.55). However, it did not reduce risk of superficial infection (four patients (0.67%) vs six control patients (1.60%), OR 0.60, 95% CI 0.17 to 2.12) and was associated with higher incidence of aseptic wound complications (23 patients (2.15%) vs eight in control patients (0.96%), OR 2.39, 95% CI 1.09 to 5.23). Four studies reported no anaphylactic reactions and three studies reported no ototoxicity in any patient group. Conclusion. The current literature suggests that intrawound vancomycin used in primary hip and knee arthroplasty may reduce incidence of PJI, but it may also increase risk of aseptic wound complications. Cite this article: Bone Joint Res 2020;9(11):778–788

To systematically review the literature regarding post-surgical treatment regimens on ankle fractures, specifically whether there is a benefit to early weightbearing or early mobilization (6 weeks form surgery). The PubMed, MEDLINE and Embase databases were searched from inception to May 24, 2020. All randomized controlled trials that analyzed the effects of early weightbearing and mobilization following an ankle surgery were included. The primary outcome measure was the Olerud Molander Ankle Score (OMAS). Secondary outcomes included return to work (RTW) and complications. Logistic regression models with random intercepts were used to pool complication data by protocol clustered by study. Twelve RCT's were included, with a total of 1177 patients (41.8 ± 8.4 years). In total, 413 patients underwent early weightbearing and early mobilization (35%), 338 patients underwent early weightbearing and delayed mobilization (29%), 287 patients underwent delayed weightbearing and early mobilization (24%), and 139 patients underwent delayed weightbearing and delayed mobilization (12%). In total, 81 patients had a complication (7%), including 53 wound complications (5%), 11 deep vein thromboses (1%), and 2 failures/nonunions (0%). Early ankle mobilization resulted in statistically significant increases in OMAS scores compared to delayed mobilization (3 studies [222 patients], 12.65; 95% CI, 7.07-18.22; P < 0.00001, I2 = 49%). No significant differences were found between early and delayed weightbearing at a minimum of one-year follow-up (3 studies [377 patients], 1.91; 95% CI, −0.73-4.55, P = 0.16, I2 = 0%). Patients treated with early weightbearing and early mobilization were at higher odds of facing any complication (OR 3.6, 95%CI 1.05-12.1, p=0.041) or wound complications (OR 4.9, 95%CI 1.3-18.8, p=0.022) compared to those with delayed weightbearing and delayed mobilization. Early mobilization following surgical treatment for an ankle fracture resulted in improved ankle function scores compared to delayed mobilization regimens. There were no significant differences between early and delayed weightbearing with respect to patient reported outcomes. Patients who were treated with early mobilization and early weightbearing had an increased odds of postoperative complications

Aims. The purpose of this study was to assess total knee arthroplasty (TKA) volume and rates of early complications in morbidly obese patients over the last decade, where the introduction of quality models influencing perioperative care pathways occurred. Methods. Patients undergoing TKA between 2011 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI < 40 kg/m. 2. and ≥ 40 kg/m. 2. and evaluated by the number of cases per year. The 30-day rates of any complication, wound complications, readmissions, and reoperation were assessed. Trends in these endpoints over the study period were compared between groups using odds ratios (ORs) and multivariate analyses. Results. In total, 314,695 patients underwent TKA and 46,362 (15%) had BMI ≥ 40 kg/m. 2. The prevalence of morbid obesity among TKA patients did not change greatly, ranging between 14% and 16%. Reoperation rate decreased from 1.16% to 0.96% (odds ratio (OR) 0.81 (95% confidence interval (CI) 0.66 to 0.99)) for patients with BMI < 40 kg/m. 2. , as did rates of readmission (4.46% to 2.87%; OR 0.61 (0.55 to 0.69)). Patients with BMI ≥ 40 kg/m. 2. also had fewer readmissions over the study period (4.87% to 3.34%; OR 0.64 (0.49 to 0.83)); however, the rate of reoperation did not change (1.37% to 1.41%; OR 0.99 (0.62 to 1.56)). Significant improvements were not observed for infective complications over time for either group; patients with BMI ≥ 40 kg/m. 2. had increased risk of both deep infection and wound complications compared to non-morbidly obese patients. Rate of any complication decreased for all patients. Conclusion. The proportion of TKAs in morbidly obese patients has not significantly changed over the past decade. Although readmission rates improved for all patients, reductions in reoperation in non-morbidly obese patients were not experienced by the morbidly obese, resulting in a widening of the complication gap between these cohorts. Care improvements have not lowered the differential risk of infective complications in the morbidly obese. Cite this article: Bone Joint J 2021;103-B(6 Supple A):38–44

Aims. The aim of this study was to characterize the influence of social deprivation on the rate of complications, readmissions, and revisions following primary total shoulder arthroplasty (TSA), using the Social Deprivation Index (SDI). The SDI is a composite measurement, in percentages, of seven demographic characteristics: living in poverty, with < 12 years of education, single-parent households, living in rented or overcrowded housing, households without a car, and unemployed adults aged < 65 years. Methods. Patients aged ≥ 40 years, who underwent primary TSA between 2011 and 2017, were identified using International Classification of Diseases (ICD)-9 Clinical Modification and ICD-10 procedure codes for TSA in the New York Statewide Planning and Research Cooperative System database. Readmission, reoperation, and other complications were analyzed using multivariable Cox proportional hazards regression controlling for SDI, age, ethnicity, insurance status, and Charlson Comorbidity Index. Results. A total of 17,698 patients with a mean age of 69 years (SD 9.6), of whom 57.7% were female, underwent TSA during this time and 4,020 (22.7%) had at least one complication. A total of 8,113 patients (45.8%) had at least one comorbidity, and the median SDI in those who developed complications 12 months postoperatively was significantly greater than in those without a complication (33 vs 38; p < 0.001). Patients from areas with higher deprivation had increased one-, three-, and 12-month rates of readmission, dislocation, humeral fracture, urinary tract infection, deep vein thrombosis, and wound complications, as well as a higher three-month rate of pulmonary embolism (all p < 0.05). Conclusion. Beyond medical complications, we found that patients with increased social deprivation had higher rates of humeral fracture and dislocation following primary TSA. The large sample size of this study, and the outcomes that were measured, add to the literature greatly in comparison with other large database studies involving TSA. These findings allow orthopaedic surgeons practising in under-served or low-volume areas to identify patients who may be at greater risk of developing complications. Cite this article: Bone Joint J 2024;106-B(2):174–181

Aims. Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients. Methods. MEDLINE (PubMed), EMBASE (Ovid), Cochrane, and CINAHL databases were searched focusing on VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, or wound complication rates. Results. In all, 17 studies published from 1998 to 2018 met the inclusion criteria for the systematic review. The mean incidence of all VTE events in orthopaedic oncology patients was 10.7% (1.1% to 27.7%). The rate of PE was 2.4% (0.1% to 10.6%) while the rate of lethal PE was 0.6% (0.0% to 4.3%). The overall rate of DVT was 8.8% (1.1% to 22.3%) and the rate of symptomatic DVT was 2.9% (0.0% to 6.2%). From the studies that screened all patients prior to hospital discharge, the rate of asymptomatic DVT was 10.9% (2.0% to 20.2%). The most common risk factors identified for VTE were endoprosthetic replacements, hip and pelvic resections, presence of metastases, surgical procedures taking longer than three hours, and patients having chemotherapy. Mean incidence of VTE with and without chemical prophylaxis was 7.9% (1.1% to 21.8%) and 8.7% (2.0% to 23.4%; p = 0.11), respectively. No difference in the incidence of bleeding or wound complications between prophylaxis groups was reported. Conclusion. Current evidence is limited to guide clinicians. It is our consensus opinion, based upon logic and deduction, that all patients be considered for both mechanical and chemical VTE prophylaxis, particularly in high-risk patients (pelvic or hip resections, prosthetic reconstruction, malignant diagnosis, presence of metastases, or surgical procedures longer than three hours). Additionally, the surgeon must determine, in each patient, if the risk of haemorrhage outweighs the risk of VTE. No individual pharmacological agent has been identified as being superior in the prevention of VTE events. Cite this article: Bone Joint J 2020;102-B(12)1743:–1751

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

Aims. To compare results of institutional preferences with regard to treatment of soft tissues in the setting of open tibial shaft fractures. Methods. We present a retrospective review of open tibial shaft fractures at two high-volume level 1 trauma centres with differing practices with regard to the acute management of soft tissues. Site 1 attempts acute primary closure, while site 2 prefers delayed closure/coverage. Comparisons include percentage of primary closure, number of surgical procedures until definitive closure, percentage requiring soft tissue coverage, and percentage of 90-day wound complication. Results. Overall, there were 219 patients at site 1 and 282 patients at site 2. Differences in rates of acute wound closure were seen (168 (78%) at site 1 vs 101 (36%) at site 2). A mean of 1.5 procedures for definitive closure was seen at site 1 compared to 3.4 at site 2. No differences were seen in complication, nonunion, or amputation rates. Similar results were seen in a sub-analysis of type III injuries. Conclusion. Comparing outcomes of open tibial shaft fractures at two institutions with different rates initial wound management, no differences were seen in 90-day wound complications, nonunion rates, or need for amputation. Attempted acute closure resulted in a lower number of planned secondary procedures when compared with planned delayed closure. Providers should consider either acute closure or delayed coverage based on the injury characteristics, surgeon preference and institutional resources without concern that the decision at the time of index surgery will lead to an increased risk of complication. Cite this article: Bone Joint Open 2020;1-8:481–487

Abstract. Introduction. FHL transfer for management of chronic Achilles' tendon ruptures is done both open and endoscopically. But there are no published studies comparing open and endoscopic results. Our study aims to compare them and determine the suitability of these methods. Materials and methods. Fourteen patients were treated endoscopically while 26 with an open technique. Of the 26, fourteen had an open Achilles tendon repair and FHL transfer while 12 has only open FHL transfer. All the endoscopic patients had only an FHL transfer. We compared demographics, complications of the procedure, recovery times, return to work and strength after 1 year. We noted ATRS at 6 months and 1 year for all three groups. We also conducted an MRI scan of three patients each of the three groups to determine the state of Achilles tendon and FHL tendon after 1 year of surgery. Results. There were similar complication rates for both the only FHL groups but the open FHL + Achilles' repair had more complications both for wound complications and saphenous neuropraxia. The recovery time, return to work and ATRS at 6 months was better for the endoscopic group as compared to both open groups. The strength and ATRS at 1 year were similar for all three groups. Conclusion. Endoscopic FHL transfer is safe and provides earlier return to work and better 6 months patient satisfaction then the open method. It also has less post op complications than open FHL + Achilles tendon repair, while maintains the same strength after 1 year

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

Aims. Endoprosthetic reconstruction with a distal femoral arthroplasty (DFA) can be used to treat distal femoral bone loss from oncological and non-oncological causes. This study reports the short-term implant survivorship, complications, and risk factors for patients who underwent DFA for non-neoplastic indications. Methods. We performed a retrospective review of 75 patients from a single institution who underwent DFA for non-neoplastic indications, including aseptic loosening or mechanical failure of a previous prosthesis (n = 25), periprosthetic joint infection (PJI) (n = 23), and native or periprosthetic distal femur fracture or nonunion (n = 27). Patients with less than 24 months’ follow-up were excluded. We collected patient demographic data, complications, and reoperations. Reoperation for implant failure was used to calculate implant survivorship. Results. Overall one- and five-year implant survivorship was 87% and 76%, respectively. By indication for DFA, mechanical failure had one- and five-year implant survivorship of 92% and 68%, PJI of 91% and 72%, and distal femur fracture/nonunion of 78% and 70% (p = 0.618). A total of 37 patients (49%) experienced complications and 27 patients (36%) required one or more reoperation. PJI (n = 16, 21%), aseptic loosening (n = 9, 12%), and wound complications (n = 8, 11%) were the most common complications. Component revision (n = 10, 13.3%) and single-stage exchange for PJI (n = 9, 12.0 %) were the most common reoperations. Only younger age was significantly associated with increased complications (mean 67 years (SD 9.1)) with complication vs 71 years (SD 9.9) without complication; p = 0.048). Conclusion. DFA is a viable option for distal femoral bone loss from a range of non-oncological causes, demonstrating acceptable short-term survivorship but with high overall complication rates. Cite this article: Bone Jt Open 2022;3(3):173–181

Aim. Surgical options for management of a failed ankle arthroplasty are currently limited; typically conversion to fusion is recommended with only a few patients being considered for revision replacement surgery. This paper presents our experience of revision ankle replacements in a cohort of patients with failed primary replacements. Method. A total of 18 revision TAR in 17 patients were performed in patients with aseptic loosening. The technique was performed by a single surgeon (CSK) over a 4 year period between July 2014 and August 2018 using the Inbone total ankle replacement system. Patient demographics and clinical outcomes were collected retrospectively using - MOXFQ, EQ5D, VAS pain score and patient satisfaction questionnaires. Results. 12 right and 6 left ankle replacements were revised in 17 patients (11 male/ 6 female). The mean age at revision was 69.1 years (range 56–81 years) with a mean BMI of 31. The mean surgical time was 171 minutes with 22% of cases requiring bone grafting. 6 patients had early wound complications, all superficial and settled with dressings. There were no deep infections, 2 patients had further surgery for exploration for possible nerve injuries. At a mean follow up of 20.6 months, 4 patients had mild/moderate ongoing pain with the majority of patients being satisfied with the outcome of their surgery. Conclusion. This study represents one of the largest group of patients reported to have undergone revision total ankle arthroplasty. Our experience shows that this results in acceptable level of complications and provides satisfactory function in most patients. We feel revision TAR is a viable option in patients with failed primary arthroplasty who wish to continue to maintain mobility at the ankle joint

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

Total Joint Arthroplasty (TJA) is a successful orthopaedic procedure allowing dramatic clinical and functional improvements. Globally, there's been an increase in demand and performed cases associated with an increase in complications. Subsequently, focus on the prevention of complications has become important worldwide. The incidence of venous-thrombolic events (VTE) despite great attention has not diminished despite much investigation. A balance between efficacy and safety from the available agents is essential. Low molecular weight heparin (LMWH) has been commonly used, but oral anti-coagulants have become more popular. The aim of this study was to assess the adherence LMWH and the effectiveness and safety of preventing VTE in post-operative arthroplasty patients in a South African setting. We conducted a prospective cohort study that included hip and knee, primary and revision, arthroplasty patients who received thromboprophylaxis with one daily injection of LMWH for 14 days post discharge. Patients who omitted 1 or more doses during the follow up period were classified as “non adherent”. A questionnaire was used at follow up visits at least 6 weeks post-operatively. 100 consecutive patients were followed up. The mean age of patients was 63.45 years. There were 68 % female patients. There was a 92% compliance rate. 60 % of patients had the injection administered by a family member, 38 % administered it themselves and 2 % had the injection administered by health professionals. Venous thromboembolic events were confirmed in 5 % at 7.86 days after surgery. Three patients had persistent wound drainage after surgery, however, none required reoperation or readmission. Compliance with LMWH is high and is comparable with oral agents. It is effective in preventing VTE and safe with regards to bleeding and wound complications in a South African setting. Patient education regarding medications may improve compliance of the medication

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

The management of comminuted metaphyseal fractures is a technical challenge and satisfactory outcomes of such fixations often remain elusive. The small articular fragments and bone loss often make it difficult for standard fixation implants for proper fixation. We developed a novel technique to achieve anatomical reduction in multiple cases of comminuted metaphyseal fractures at different sites by employing the cantilever mechanism with the help of multiple thin Kirschner wires augmented by standard fixation implants. We performed a retrospective study of 10 patients with different metaphyseal fractures complicated by comminution and loss of bone stock. All patients were treated with the help of cantilever mechanism using multiple Kirschner wires augmented by compression plates. All the patients were operated by the same surgeon between November 2020 to March 2021 and followed up till March 2023. Surgical outcomes were evaluated according to the clinical and radiological criteria. A total of 10 patients were included in the study. Since we only included patients with highly unstable and comminuted fractures which were difficult to fix with traditional methods, the number of patients in the study were less. All 10 patients showed satisfactory clinical and radiological union at the end of the study with good range of motion. One of the patient in the study had post-operative wound complication which was managed conservatively with regular dressings and oral antibiotics. Comminuted metaphyseal fractures might differ in pattern and presentation with every patient and there can be no standard treatment for all. The cantilever technique of fracture fixation is based on the principle of cantilever mechanism used in bridges and helps achieve good anatomical reduction and fixation. It provides a decent alternative when standard modes of fixation don't give desired result owing to comminuted nature of fractures and deficiency of bone stock

Background. Optimal management of displaced intra-articular calcaneal fractures remains controversial. The aim of this prospective cohort study was to compare the clinical and radiological outcomes of minimally invasive surgery (MIS) versus non-operative treatment in displaced intra-articular calcaneal fracture up to 2-years. Methods. All displaced intra-articular calcaneal fractures between August 2014 and January 2019 that presented to a level 1 trauma centre were considered for inclusion. The decision to treat was made by a multidisciplinary meeting. Operative treatment protocol involved sinus tarsi approach or percutaneous reduction & internal fixation. Non-operative protocol involved symptomatic management with no attempt at closed reduction. All fractures were classified, and the MOXFQ/EQ-5D-5L scores were used to assess foot and ankle and general health-related quality of life outcomes respectively. Results. 101 patients were recruited at a level 1 major trauma centre, between August 2014 and January 2019. Our propensity score matched 44 patients in the surgical cohort to 44 patients in the non-surgical cohort. At 24 months, there was no significant difference in the MOXFQ Index score (p<0.05) however the patients in the surgical cohort had a significantly higher EQ-5D-5L Index score (p<0.05). There was also a higher return to work (91% vs 72%, p<0.05) and physical activity rate (46 vs. 35%, p<0.05) in the surgical cohort despite a higher proportion of more complex fractures in the surgical cohort. The wound complication rate following surgery was 16%. 14% of patients in the non-operative cohort subsequently underwent arthrodesis compared to none of the patients in the surgical cohort. Conclusion. In this study, we found operative treatments were associated with low rates of surgical complication at 2-years and long term pain improvement, facilitating earlier and better functional outcomes for complex injury patterns compared to nonoperative treatment

Introduction. The purpose of this study was to analyse the efficacy and complications associated with the use of Calcium Sulphate synthetic bone graft in a paediatric population. There are no published articles on the use in children. Materials & Methods. A retrospective review was undertaken of the notes, microbiology, and X-Rays of 17 cases (in 15 patients) of calcium sulphate use in paediatric patients. As well as patient demographic data, data collected included indication, use of additional agents (antibiotics), return to theatre, and wound complications. Major complications were also assessed for. Results. There were 17 cases, in 15 patients, in our case series where calcium sulphate synthetic bone graft was used. The average patient age was 12.0 years (range 5 years – 17 years). Indications for use included likely infection (12), possible infection (3), and 2 elective finger cases (enchondroma and osteotomy). The humerus was the most common target site (5), followed by the femur (4), tibia (3), calcaneum (2), finger (2) and metatarsal (1) also included. There were positive intra-operative microbiology samples for eleven cases (Staphylococcus aureus and Staphylococcus epidermidis). Antibiotics were used in all cases except the elective finger surgery, and choice ranged between vancomycin, gentamicin, or a combination of both. Two patients required return to theatre for management of ongoing deep infection, although one case was later deemed to be non-infective osteomyelitis. Seven patients had undergone debridements prior to the definitive one with calcium sulphate (5 without Calcium Sulphate, 2 with Calcium Sulphate). Three patients experienced wound issues in the form of discharge/leakage, all were managed with dressings and did not require return to theatre. Conclusions. Calcium Sulphate synthetic bone graft, with addition of antibiotics, is an efficacious treatment in the paediatric population and is not associated with any major complications. Wound discharge should be observed for, and patients/parents warned about this, but only as per the adult population

Aims. Management of intra-articular calcaneal fractures remains a debated topic in orthopaedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures and those in whom surgery was highly likely to produce an equivocal functional outcome with potential post-operative complications. Methods. All patients who underwent open reduction and internal fixation of calcaneal fractures utilizing the Sinus Tarsi approach between March 2014 and July 2018 were identified using theatre records. Patient imaging was used to assess pre- and post-operative fracture geometry with Computed Tomography (CT) used for pre-operative planning. Each patient's clinical presentation was established through retrospective analysis of medical records. Patients provided verbal consent to participation and patient reported outcome measures were recorded using the Maryland Foot Score. Results. Fifty-eight intra-articular calcaneal fractures (fifty-three patients including five bilateral, mean age = 46.91 years) were included. Forty-nine patients were injured as a result of a fall from a height (92.4%). Mean time from presentation to surgery was 3.23 days (range 0–21). Mean Maryland Foot score was found to be 77.6 (+/− 16.22) in forty-five patients. Five patients (9.4%) had wound complications; two superficial (3.7%) and three deep (5.6%). Conclusion. Intra-articular fractures of the calcaneus should be considered for surgical intervention in order to improve long-term functional outcomes. The Sinus Tarsi approach provides the potential to decrease the operative complication rate whilst maintaining adequate fixation, however, the decision to surgically manage these fractures should be carefully balanced against the risk of post-operative complications. This increased risk of complication associated with smoking may tip the balance against benefit from surgical management

Background. Ankle fractures associated with diabetes experience more complications following standard Open-Reduction-Internal-Fixation (ORIF) than those without diabetes. Augmented fixation strategies namely extended ORIF and hind-foot-nail (HFN) may offer better results, and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes including early post-operative weight bearing and surgical complications. Methods. A national-multicentre retrospective cohort study was conducted between January to June 2019 in 56 centres (10 Major- Trauma-Centres and 46 Trauma-Units) in the United Kingdom; 1360 specifically defined complex ankle-fractures were enrolled. Demographics, fixation choice, surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with/without diabetes. Results. There were 316 patients in the diabetes cohort with mean age 63.9yrs (vs. 49.3yrs in non-diabetes cohort), and greater frailty score >4 (24% vs.14% (non-diabetes cohort) (p<0.03); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% a HFN compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p<0.02) but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications to non-diabetes, even though early-weight- bearing rates were greater than standard-ORIF. Conclusion. Ankle fractures in diabetes occur in older, frailer patients; whilst lower than expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weight-bearing without increasing complications in keeping with modern guidelines in ankle fracture management

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

Background. Studies have compared open reduction internal fixation (ORIF) with fibular nail fixation (FNF) and shown reduced wound complications with minimal difference to PROMS in the short term. Our aim is to compare long-term outcomes for unstable ankle fractures at 10 year follow up. Methods. Patients from a previously conducted RCT were contacted at a minimum of 10 years post intervention at a single study centre. Case notes were reviewed, and patient reported outcome measures acquired at 10 years. Results. Ninety-nine patients were included (48 FNF and 51 ORIF). After 10 years 75% (33/44) of patients in the FNF group required no further follow up versus 81% (39/48) in the ORIF group. Radiographically at 2 years post-injury, there was no statistically significant difference between groups for development of osteoarthritis (p=0.851). There was one tibio-talar fusion in each group secondary to osteoarthritis, but no statistically significant difference in overall re-operation rate (p=0.518). Fifty-one percent (n=50) of patients have so far returned patient reported outcome measures at a minimum of 10 years (Fibular nail n=23, plate fixation n=27). No significant difference was found between groups for the mean scores of Olerud and Molander Ankle Score (FNF 84.78 vs ORIF 84.07; p=0.883), the Manchester-Oxford Foot Questionnaire (MOXFQ) (FNF 89.54 vs ORIF 96.47; p=0.112), Euroqol-5D Index (FNF 0.88 vs ORIF 0.87; p=0.701) and Euroqol-5D Visual Analogue Score (FNF 77.30 vs ORIF 77.52; p=0.859). Conclusion. The current study illustrates that both methods of treatment result in a satisfactory long-term outcome with no difference in late complications or PROM scores at up to 10 years in patients under 65 years old, although the study is currently under powered

Introduction. The management of open or unstable ankle and distal tibial fractures pose many challenges. In certain situations, hindfoot nailing (HFN) is indicated, however this depends on surgeon preference and regional variations exist. This study sought to establish the current management and outcomes of complex ankle fractures in the UK. Methods. A National collaborative study in affiliation with BOTA was conducted and data retrospectively collected between January 1. st. – June 30. th. 2019. Adult patients with open and closed complex ankle fractures (AO43/44) were included. Complex fractures included the following patient characteristics: diabetes ± neuropathy, rheumatoid arthritis, alcoholism, polytrauma and cognitive impairment. We obtained data on fixation choice and patient outcomes. Institutional approval was obtained by all centres, and statistical analysis was performed including propensity matching. Results. Fifty-six centres provided data for 1360 patients. The average age of the cohort was 53.9 years ±19 (SD) with a male/female ratio of 1:1.3. 920 patients were ASA 1/2, 440 were ASA 3/4; 316 had diabetes, and 275 were open fractures. Most fractures were AO44 (71.2%) and more commonly associated with diabetes (P<0.001), alcoholism (P<0.007), open (P<0.013), and advanced age (55.7 vs. 46.3). 1227 patients underwent primary-fixation (111 HFN), with the remainder treated with external-fixation (84 definitive). Of the 111 HFN, 35% underwent primary fusion. Wound complication and thromboembolic rates were greater in the HFN group compared to ORIF groups (P<0.003), being more evident in the HFN group with primary fusion even after propensity matching. However, 1081 patients were non-weightbearing post-op contrary to the BOAST guidance. Conclusion. This is the first National collaborative audit of complex ankle fractures. Hindfoot nails were used in 9% of patients and we observed more complications in this group when compared to other cohorts. Despite BOAST guidance, only 21% of patients undergoing operative management were instructed to fully weightbear post-operatively

Introduction. Osteochondral lesions (OCLs) of the talus are a challenging and increasingly recognized problem in chronic ankle pain. Many novel techniques exist to attempt to treat this challenging entity. Difficulties associated with treating OCLs include lesion location, size, chronicity, and problems associated with potential graft harvest sites. Matrix associated stem cell transplantation (MAST) is one such treatment described for larger lesions >15mm2 or failed alternative therapies. This cohort study describes a medium-term review of the outcomes of talar lesions treated with MAST. Methods. A review of all patients treated with MAST by a single surgeon was conducted. Preoperative radiographs, MRIs and FAOS outcome questionnaire scores were conducted. Intraoperative classification was undertaken to correlate with imaging. Postoperative outcomes included FAOS scores, return to sport, revision surgery/failure of treatment and progression to arthritis/fusion surgery. Results. 58 MAST procedures in 57 patients were identified in this cohort. The mean follow up was 5 years. There were 20 females and37males, with a mean age of 37 years (SD 9.1). 22 patients had lateral OCLS were and 35 patients had medial OCLs. Of this cohort 32patients had previous surgery and 25 had this procedure as a primary event. 15 patients had one failed previous surgery, 9 patients had two, four patients had three previous surgeries and three patients had four previous surgeries. 12 patients had corrective or realignment procedures at the time of surgery. In terms of complications 3 patients of this cohort went on to have an ankle fusion and two of these had medial malleolar metal work taken out prior to this, 5 patients had additional procedures for arthrofibrotic debridements, 1 patient had a repeat MAST procedure, 1 additional patients had removal of medial malleolar osteotomy screws for pain at the osteotomy site, there were 2 wound complications one related to the ankle and one related to pain at the iliac crest donor site. Conclusion. MAST has demonstrated positive results in lesions which prove challenging to treat, even in a “ failed microfracture” cohort. RCT still lacking in field of orthobiologics for MAST. Longer term follow up required to evaluate durability

Aim. The most frequent mechanical failure in the osteosynthesis of intertrochanteric fractures is the cut-out. Fracture pattern, reduction quality, tip-apex distance or the position of the cervico-cephalic screw are some of the factors that have been associated with higher cut-out rates. To date, it has not been established whether underlying bacterial colonization or concomitant infection may be the cause of osteosynthesis failure in proximal femur fractures (PFF). The primary objective of this study is to assess the incidence of infection in patients with cut-out after PFF osteosynthesis. Method. Retrospective cohort study on patients with cut-out after PFF osteosynthesis with endomedullary nail, from January 2007 to December 2020. Demographic data of patients (such as sex, age, ASA), fracture characteristics (pattern, laterality, causal mechanism) and initial surgery parameters were collected (time from fall to intervention, duration of surgery, intraoperative complications). Radiographic parameters were also analyzed (tip-apex distance and Chang criteria). In all cut-out cases, 5 microbiological cultures and 1 anatomopathological sample were taken and the osteosynthesis material was sent for sonication. Fracture-related infection (FRI) was diagnosed based on Metsemakers et al (2018) and McNally et al (2020) diagnostic criteria. Results. Of the 67 cut-out cases, 16 (23.9%) presented clinical, analytical or microbiological criteria of infection. Of these sixteen patients, only in 3 of them the presence of an underlying infection was suspected preoperatively. A new osteosynthesis was performed in 24 cases (35.8%) and a conversion to arthroplasty in the remaining 43 (64.2%). A comparative analysis was performed between cases with and without infection. The groups were comparable in terms of demographic data and postoperative radiological data (using Chang criteria and tip-apex distance). Patients with underlying infection had a higher rate of surgical wound complication (56.3% vs 22%, p = 0.014), higher rates of leukocytes counts (11.560 vs 7.890, p = 0.023) and time to surgery (5.88 vs 3.88 days, p = 0.072). Conclusions. One out of four osteosynthesis failure in PFF is due to underlying FRI and in almost 20% were not unsuspected before surgery. In PFF osteosynthesis failures, underlying infection should be taken into account as a possible etiological factor and thus a preoperative and intraoperative infection study should be always performed

Abstract. Objectives. Diabetes has been associated with greater risk of complications and prolonged postoperative recovery following ankle trauma. Our cohort study seeks to review the operative management and outcomes of ankle fractures in diabetic adults relative to non-diabetic adults. Methods. Cases were identified using ICD-10 coding criteria. 572 patients from Jan 2016–2019 presented with ankle fractures; 34 in diabetic patients. Mechanism of injury and stability were determined from the index radiograph using a validated Lauge-Hansen classification algorithm. Admission, primary post-operative and discharge radiographs were reviewed independently by two foot and ankle reconstruction specialists to assess adequacy of fixation method. 32% of diabetic patients were managed non-operatively compared to 29% of the matched non-diabetic cohort. The distribution in Lauge-Hansen fracture pattern was comparable between cohorts. Non-diabetic controls were frequency age-matched 2:1. Results. Mean length of follow-up was significantly longer for diabetics (26 weeks) compared to non-diabetics (16 weeks). Post-operative wound complications (superficial wound infection, breakdown, dehiscence) occurred in 48% of the operated diabetic ankles, compared to 5% in non-diabetics (RR 8.1, 95% CI 2.5–26.4). Reoperation (RR 4.3, 95% CI 2.5–26.4, p=0.03) and non-wound complication rates (Charcot joint, mal/non-union, metalwork infection) were likewise significantly higher (RR 3.9, 95% CI 1.4–10.8, p=0.008) in diabetics. Amongst diabetics alone, those with an HbA1c >69 mmol/mol (n=14, 41%) demonstrated a significantly higher rate still of non-wound complications (RR 4.3, 95% CI 1.1–18., p=0.03) with a trend towards higher wound complication rates (RR 3, 95% CI 0.52–17, p=0.13). Conclusions. Poorly controlled diabetes is associated with substantially greater complication rates following ankle fracture than those with well controlled or normal blood sugar; high HbA1c > 69mmol/mol is a significant predictor of complicated follow-up. Locally we recommend management strategies that are influenced by the fracture pattern stability and the presence or absence of complicated or poorly managed diabetes. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Diabetes has been associated with greater risk of complications and prolonged postoperative recovery following ankle trauma. Our cohort study reviewed the operative management and outcomes of ankle fractures in diabetic adults relative to non-diabetic adults from Jan 2016–2019. Non-diabetic controls were frequency age-matched 2:1. 34 of 572 ankle fracture presentations were in diabetic patients, 32% managed non-operatively compared to 29% of the matched non-diabetic cohort. The distribution in Lauge-Hansen fracture pattern was comparable between cohorts. Mean length of follow-up was significantly longer for diabetics (26 weeks) compared to non-diabetics (16 weeks). Post-operative wound complications (superficial wound infection, breakdown, dehiscence) occurred in 48% of the operated diabetic ankles, compared to 5% in non-diabetics (RR 8.1, 95% CI 2.5–26.4). Reoperation (RR 4.3, 95% CI 2.5–26.4, p=0.03) and non-wound complication rates (Charcot joint, mal/non-union, metalware infection) were likewise significantly higher (RR 3.9, 95% CI 1.4–10.8, p=0.008) in diabetics. Amongst diabetics alone, those with an HbA1c >69 mmol/mol (n=14, 41%) demonstrated a significantly higher rate still of non-wound complications (RR 4.3, 95% CI 1.1–18., p=0.03) with a trend towards higher wound complication rates (RR 3, 95% CI 0.52–17, p=0.13). Poorly controlled diabetes is associated with substantially greater complication rates following ankle fracture than those with well controlled or normal blood sugar; high HbA1c > 69mmol/mol is a significant predictor of complicated follow-up. Locally we recommend management strategies that are influenced by the fracture pattern stability and the presence or absence of complicated or poorly managed diabetes

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

Introduction. Amputation or disarticulation is a reliable option for management of severe foot deformities and limb-length discrepancies, the surgical restoration of which are unpredictable or unfavourable. Of the various surgeries involving foot ablation, Syme's amputation is preferred for congenital deformities as it provides a growing, weight bearing stump with proprioception and cushioning. Materials and Methods. We reviewed data of all children who underwent Syme's amputation over the past 13 years at our institution. Surgical technique followed the same principles for Syme's but varied with surgeons. Results. Ten boys and ten girls, with an average age of 18 months and average follow up of 70 months were included in the study. The most common indication was fibular hemimelia. Wound complications were reported in three children, phantom pain in one, heel pad migration in two. None had wound dehiscence, flap necrosis, stump overgrowth, or calcaneal regrowth. None of this required surgical intervention. One child required an amputation at a higher-level secondary to a congenital malformation of nervous tissue in the affected leg. Prosthetic compatibility was 94.7 % and none used mobility aids. Six children participated in sports. Conclusions. Syme amputation is a safe and potentially advantageous procedure in children, with a low incidence of complications to offer patients with non-salvageable foot conditions. It offers good prosthetic use with minimal risk of complications and can offer patients a functional solution with only one surgical intervention throughout their childhood

Aims. Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method. Methods. We retrospectively reviewed all patients undergoing THA via the DAA between 2011 and 2017 at our institution. Primary outcome was dislocation at minimum two-year follow-up. Patients were stratified by demographic details and risk factors for dislocation, and an in-depth analysis of dislocations was performed. Results. A total of 2,831 hips in 2,205 patients were included. Mean age was 64.9 years (24 to 96), mean BMI was 29.2 kg/m. 2. (15.1 to 53.8), and 1,595 patients (56.3%) were female. There were 11 dislocations within one year (0.38%) and 13 total dislocations at terminal follow-up (0.46%). Five dislocations required revision. The dislocation rate for surgeons who had completed their learning curve was 0.15% compared to 1.14% in those who had not. The cumulative periprosthetic infection and fracture rates were 0.53% and 0.67%, respectively. Conclusion. In a non-selective, consecutive cohort of patients undergoing THA via the DAA, the risk of dislocation is low, even among patients with risk factors for instability. Our data further suggest that the DAA can be safely used in all hip arthroplasty patients without an increased risk of wound complications, fracture, infection, or revision. The inclusion of seven surgeons increases the generalizability of these results. Cite this article: Bone Joint J 2021;103-B(7 Supple B):38–45

Introduction. The incidence of periprosthetic fractures is increasing as the population ages. Wound complications and surgical site infections following surgery to treat periprosthetic fractures are a major source of patient morbidity and health care burden. This study evaluates the efficacy of closed-incision negative-pressure wound therapy (ciNPT) in decreasing wound complications and surgical site infections (SSIs) after periprosthetic fracture surgery about the hip and knee. Methods. An IRB-approved retrospective quality improvement analysis of sixty-five consecutive periprosthetic fracture surgeries performed by four surgeons at a single institution in a fifteen-year period was performed. ciNPT was selectively used on patients in the last 20 months of the study period. Rates of wound complications, surgical site infections, and reoperation were compared with those of a sterile antimicrobial dressing (AMD). Results. AMD was used on 44 patients, while ciNPT was used in 21 patients. Compared with those treated with AMD, patients treated with ciPNT developed fewer wound complications 5% (1/21) vs 25% (11/44) (p = 0.045), deep infections 0% (0/21) vs 20% (9/44) (p = 0.014), and underwent fewer reoperations 5% (1/21) vs 20% (9/44) (p = 0.045). All patients had at least thirty days of follow up. Conclusion. Our findings suggest that ciNPT decreases the incidence of wound complications, deep infections, and reoperations in patients requiring surgical management of periprosthetic fractures about the hip and knee

Aims. The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA. Methods. Data for patients who underwent arthroplasty of the shoulder in the USA between January 2011 and December 2015 were obtained from the National Readmission Database, and 90-day readmissions and complications were documented using validated coding methods. Multivariate regression analysis was performed to quantify the risk of smoking on the outcome after TSA, while controlling for patient demographics, comorbidities, and hospital-level confounding factors. Results. A total of 196,325 non-smokers (93.1%) and 14,461 smokers (6.9%) underwent TSA during the five-year study period. Smokers had significantly increased rates of 30- and 90-day readmission (p = 0.025 and 0.001, respectively), revision within 90 days (p < 0.001), infection (p < 0.001), wound complications (p < 0.001), and instability of the prosthesis (p < 0.001). They were also at significantly greater risk of suffering from pneumonia (p < 0.001), sepsis (p = 0.001), and myocardial infarction (p < 0.001), postoperatively. Conclusion. Smokers have an increased risk of readmission and medical and surgical complications after TSA. These risks are similar to those found for smokers after hip and knee arthroplasty. Many surgeons choose to avoid these elective procedures in patients who smoke. The increased risks should be considered when counselling patients who smoke before undertaking TSA. Cite this article: Bone Joint J 2020;102-B(11):1549–1554

Wound complications are common in patients with soft tissue sarcomas (STS) treated with surgical excision. Limited data is available on predictive factors for wound complications beyond the relationship to neo-adjuvant or adjuvant radiotherapy. Likewise, the association between blood transfusion, patient comorbidities and post-operative outcomes is not well described. In the present study we identified the predictive factors for blood transfusion and wound complications in patients undergoing surgical resection of soft tissue sarcoma from a national cohort. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent surgical resection of a STS from 2005 to 2013. Primary malignant soft tissue neoplasms were identified using the following ICD-9 codes: 171.2, 171.3 and 171.6. Patients treated with both wide excision and amputation were identified using the current procedural terminology (CPT) codes. Prolonged operative time was defined as greater than 90th percentile of time required per procedure. A multivariable logistic regression model was used to identify associations between patient factors and post-operative wound complications (superficial and deep surgical site infections (SSI), and wound dehiscence). A similar regression model sought to identify prognostic factors for blood transfusion and associations with post-operative outcomes. A total of 788 patients met our inclusion criteria. Of theses, 64.2% had tumours in the lower limb, 23.1% patients had tumours in the upper limb, and 12.7% patients had pelvic tumours. Six hundred and forty patients (81.2%) underwent surgical excision; 148 (18.8%) patients had an amputation. Multivariable logistic regression modeling identified American Society of Anaesthesiologist (ASA) class 3 and 4 (OR=2.3, P=0.03; OR=8.3, P=0.001, respectively), amputation (OR=14.0, P<0.001) and prolonged operative time (OR=4.6, P<0.001) as significant predictors of blood transfusion. Radiotherapy (OR=2.6, P=0.01) and amputation (OR=2.6, P=0.01) were identified as predictors of superficial SSI, whereas ASA class 4 (OR=6.2, P=0.03), prolonged operative time (OR=3.9, P=0.012) and return to the operating room (OR=10.5, P<0.001) were associated with deep SSI. Male gender (OR=1.8, P=0.03), diabetes (OR=2.3, P=0.03), ASA class 3 (OR=2.4, P=0.003), amputation (OR=3.8, P<0.001) and steroids (OR=4.5, P=0.03) were identified as predictors for wound dehiscence and open SSI. A national cohort demonstrates that male gender, diabetes, chronic steroid use, higher ASA score and radiotherapy are associated with an increased incidence of wound complications. One in twenty-three patients undergoing resection of an STS will require a blood transfusion, and this risk is correlated with amputation, prolonged operative time and increased ASA score. Strategies to decrease the risk of blood transfusion and wound complication should be considered for these patient groups

Previous work has demonstrated increased implant failure in patients with DDH compared to osteoarthritis with historic methods and implants. This study examines outcomes of modern total hip arthroplasty (THA) techniques using uncemented fixation and cross-linked PE (XLPE) bearings for DDH. A consecutive series of 879 patients with DDH who underwent primary THA with uncemented components and a XLPE bearing at a single institution between 1999 and 2016 were identified. Mean age at index arthroplasty was 51 years, with 78% females. Mean follow-up was 8 years. 5- and 10-year survivorships free of revision were 98.4% and 98%, respectively. 5- and 10-year survivorships free of reoperation for any reason were 97% and 96%, respectively. Survivorship free of acetabular revision for aseptic loosening was 99.8% at 5 and 10 years, while survivorships free of femoral revision for aseptic loosening were 99.7% at 5 years and 99.5% at 10 years. Survivorship free of reoperation for PE damage (2 liner fractures, 2 rim damage from impingement) was 99.3% at 10 years. There were no revisions for bearing surface wear or osteolysis. 13% of patients experienced complications (4% dislocation, 3.3% wound complication rate). Ten-year survivorship free of reoperation for instability was 99.2%. 8 patients developed infection requiring operation (<1%). 100 patients had a prior pelvic osteotomy (11%), which did not increase rate of complications (p=0.22) or reoperations (p=0.51). Fixation with modern uncemented implants has dramatically reduced implant loosening in patients with DDH, and the use of XLPE bearings has markedly reduced revision for PE wear/osteolysis in this young patient population, leading to dramatically improved mid/long-term survivorship compared to historic series

Purpose. Obesity has previously been demonstrated to be an independent risk factor for increased complications following total hip (THA) and total knee arthroplasty (TKA). The purpose of this study was to compare the effects of obesity and BMI to determine whether the magnitude of the effect was similar for both procedures. Materials & Methods. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients who underwent primary THA or TKA between 2010 and 2014. Patients were stratified by procedure and classified as non-obese, obese, or morbidly obese according to BMI. Thirty-day rates of wound complications, deep infection, total complications, and reoperation were compared using univariate and multivariate logistic regression analyses. Results. We identified 64,648 patients who underwent THA and 97,137 patients who underwent TKA. Obese THA patients had significantly higher rates of wound complications (1.53% vs 0.96%), deep infection (0.31% vs 0.17%), reoperation rate (2.11% vs 1.02%), and total complications (5.22% vs. 4.63%) compared to TKA patients. Morbidly obese patients undergoing THA were also found to have significantly higher rates of wound complications (3.25% vs 1.52%), deep infection (0.84% vs 0.23%), reoperation rate (3.65% vs 1.60%), and total complications (7.36% vs. 5.57%). Multivariate regression analysis identified increasingly higher odds of each outcome measure as BMI increased. Conclusions. This study demonstrates the impact of obesity on postoperative complications is more profound for THA than TKA. This emphasizes the importance of considering patient comorbidities in the context of the specific procedure (hips and knees should be analyzed independently) when assessing risks of surgery

Obesity has previously been demonstrated to be an independent risk factor for increased complications following total hip (THA) and total knee arthroplasty (TKA). The purpose of this study was to compare the effects of obesity and BMI to determine whether the magnitude of the effect was similar for both procedures. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients who underwent primary THA or TKA between 2010 and 2014. Patients were stratified by procedure and classified as non-obese, obese, or morbidly obese according to BMI. Thirty-day rates of wound complications, deep infection, total complications, and reoperation were compared using univariate and multivariate logistic regression analyses. We identified 64,648 patients who underwent THA and 97,137 patients who underwent TKA. Obese THA patients had significantly higher rates of wound complications (1.53% vs 0.96%), deep infection (0.31% vs 0.17%), reoperation rate (2.11% vs 1.02%), and total complications (5.22% vs. 4.63%) compared to TKA patients. Morbidly obese patients undergoing THA were also found to have significantly higher rates of wound complications (3.25% vs 1.52%), deep infection (0.84% vs 0.23%), reoperation rate (3.65% vs 1.60%), and total complications (7.36% vs. 5.57%). Multivariate regression analysis identified increasingly higher odds of each outcome measure as BMI increased. This study demonstrates the impact of obesity on postoperative complications is more profound for THA than TKA. This emphasizes the importance of considering patient comorbidities in the context of the specific procedure (hips and knees should be analyzed independently) when assessing risks of surgery

Background. Surgical management of calcaneus fractures is demanding and has a high risk of wound complications. Traditionally these fractures are managed with splinting until swelling has subsided. We describe a novel protocol for the management of displaced intra-articular calcaneus fractures utilising a temporizing external fixator and staged conversion to plate fixation through a sinus tarsi approach. The goal of this technique is to allow for earlier treatment with open reduction and internal fixation, minimise the amount of manipulation required at the time of definitive fixation and reduce the wound complication rate seen with the extensile approach. Methods. The records of patients with displaced calcaneus fractures from 2010–2014 were retrospectively reviewed. A total of 10 patients with 12 calcaneus fractures were treated with this protocol. All patients underwent ankle-spanning medial external fixation within 48 hours of injury. Patients underwent conversion to open plate fixation through a sinus tarsi approach when skin turgor had returned to normal. Time to surgery, infection rate, wound complications, radiographic alignment, and time to radiographic union were recorded. Results. The average Bohler's angle improved from 13.2 (range −2 to 34) degrees preoperatively to 34.3 (range 26 to 42) degrees postoperatively. The average time from external fixation to conversion to internal fixation was 4.8 (range 3 to 7) days. There were no immediate post-surgical complications. The average time to weight bearing was 8.5 weeks. The average time to radiographic union was 9.5 (range 8 to 12) weeks. There were no infections or wound complications at the time of last follow-up. Conclusions. Early temporizing external fixation for the acute management of displaced calcaneus fractures is a safe and effective method to reduce and stabilise the foot and may decrease the time to definitive fixation. In our series there were no complications related to the use of the external fixator. Level of Evidence. IV Retrospective case series

Introduction. Rivaroxaban, an oral factor Xa inhibitor, has been approved by USFDA for prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hip and knee arthroplasties. Its indication in hip fracture surgery has been recently recommended in Asian venous thromboembolism (VTE) guidelines. Phase II dose-ranging study demonstrated that 5 mg rivaroxaban is as effective as enoxaparin for VTE prophylaxis with lower incidence of bleeding complication than the recommended 10 mg dose. Rivaroxaban is recommended to be given 6–8 hours after operation. However, many surgeons are hesitated to follow this guideline since it might increase post-operative blood loss and wound complication. Elderly patients, such as hip fracture patients, are generally at more risk of bleeding and wound complications. These patients may benefit from using the delayed and reduced-dose regimen. Methods. Since July 2011, all eligible hip fracture patients treated by single group of surgeons were given 5mg daily dose of rivaroxaban for VTE prophylaxis. Initial dose of rivaroxaban was given after drain had been removed (24–36 hours post-operatively) and continued for 14 days. Inclusion criteria are femoral neck fracture or intertrochanteric fracture in patients age 60 and over. Exclusion criteria are pathologic fracture, reoperation for failed fixation, chronic anticoagulant therapy, and allergy to rivaroxaban. Criteria by Aniwan and Rojnackarin were used for clinical diagnosis of DVT and PE. Suspected case of DVT and PE were sent for confirmation with Doppler U/S and Pulmonary Artery CT scan, respectively. All bleeding and wound complications were recorded. Numbers of blood transfusion were also recorded. Patients were followed for at least 6 weeks, all complications were recorded. Results. There were 79 hip fracture patients matching our criteria. They were composed of 54 femoral neck fractures and 25 intertrochanteric fractures. Mean age of patients was 76.3 years. All femoral neck fractures were treated with bipolar hemiarthroplasty and intertrochanteric fractures were treated with short cephalomedullary nail. Two patients (2.6%) were compatible with clinical criteria of DVT. However, Doppler ultrasound examinations do not demonstrate thrombus or intraluminal filling defect. There was no suspected case of PE. There was no major hemorrhagic wound complication requiring reoperation. Minor wound complications include 7 (8.9%) cases of prolong serous oozing and 1 (1.3%) superficial wound infection. Extrasurgical site bleeding includes 1 (1.3%) upper GI bleeding and 2 (2.5%) hematuria. None of the patients received more than 2 units of blood transfusion. Discussion and Conclusion. Delayed and reduced-dose regimen of rivaroxaban is effective for VTE prophylaxis in hip fracture patients. There is no major hemorrhagic wound complication. Nonetheless, extrasurgical site bleeding is frequent. Further randomized comparative study with larger number of patients should be performed to demonstrate whether the benefits of the modified regimen existed or not

Introduction. Spine is a common site for haematological malignancies. Multiple myeloma affects the spine in 70% of cases. New guidelines were published in 2015 to help manage spinal haematological malignancies. Despite neural compression or spinal instability, instrumentation of the spine should be avoided. Surgery carries significant risks of wound complications and more importantly delaying the definitive chemotherapy and radiotherapy. Cement augmentation and bracing for pain and prevention of deformity is key to the new strategies. We aimed to evaluate the different treatment modalities adopted in the spine unit at St George's hospital for spinal haematological malignancies. We compared our practice to the current guidelines published in 2015. Methods. Retrospective review of all spinal haematological malignancy patients who were discussed in the spinal MDT and managed through the spine unit at St George's hospital in the period between April 2019 and February 2021. We analysed the demographics of the patients treated in this period and compared the management modalities adopted in the unit to the current British haematological guidelines. Results. 139 patients were included in this study, 61.9% of them were male. 70 cases came through the MSCC pathway. 15 patients had their spinal involvement in the lumbar spine only below the conus. The Bilsky Grades of the other 124 cases were B0: 35.97 % 1a: 4.31%%, 1b: 7.19%, 1c: 3.59%, 2: 5.75% 3: 32.37%. 43 patients (30.9 %) had neurological deficits on presentation. 70 cases were treated conservatively (50.35%), 21 were treated with brace only (15.1%), 25 had BKP (17.98%) and 23 were treated with instrumentation (16.54%). The number of instrumented cases was small and trending down and cement augmentation and bracing were more frequently chosen for these patients. This comes in accordance to the British haematological guidelines. Conclusion. Utilising BJH 2015 guidelines we have reduced our instrumented operative case load. There is a higher percentage of BKP and Bracing in accordance to the algorithm

Introduction:. In this cohort study, we present comprehensive injury specific and surgical outcome data from one of the largest reported series of distal tibial pilon fractures, treated in our tertiary referral centre. Methods:. A series of 76 pilon fractures were retrospectively reviewed from case notes, plain radiographs and computed tomography (CT) imaging. Patient demographics, injury and fracture patterns, methods and timing of fixation and clinical and radiological outcomes were assessed over a mean follow up period of 8.6 months (range 2–30). Results:. Definitive fixation was most commonly performed through an open technique with plate fixation. CT imaging was used to plan the most direct approach to access the fracture fragments. The majority of cases were classified as AO/OTA 43.C3. When definitive open fixation for closed fracture was performed within 48 hours, the rate of deep infection or wound complication was 0%. When performed on day 3–5, the deep infection rate was 0% but the superficial wound complication rate was 23.5%. From day six onwards, the deep infection rate was 4% and the superficial wound complication rate was 8%. The rate of wound complications after double plate fixation of the tibia using two separate incisions was 23.1%, compared to 11.7% after single incision and plating. The rate of non-union was 9.7%. Symptomatic post-traumatic arthritis requiring orthopaedic management occurred in 9.9%. Further surgery was required in 27.8% of all patients. Conclusion:. Outcomes from our unit compare favourably with those from large trauma centres worldwide. Our study supports the use of early definitive fixation, within 48 hours, to achieve low rates of wound complications. We support an “unsafe window” for definitive fixation of three to five days post injury due to the high rate of wound complications. The likelihood of developing post-traumatic arthritis and of requiring further surgery is high

The incidence of wound complications after a hip or a knee replacement is well established, but there is no such data about foot/ankle surgery. Without this data it is difficult to compare performance between different care-providers. It is also difficult to benchmark services that could potentially be provided by a wide range of care providers (chiropodists, podiatrists, podiatric surgeons, general orthopaedic surgeons with a small foot/ankle practice, etc). Our aim was to establish the incidence of wound complications after foot/ankle surgery and provide a baseline for future comparison. Our study was done in two parts. First part was to conduct an opinion-survey of BOFAS members with a substantial foot/ankle practice, on wound complications from foot/ankle surgery in their own practice. Second part was to conduct a prospective study on the incidence of wound complications from our own foot/ankle practice. The study was registered as an audit and did not require ethical approval. All wound complications (skin necrosis, wound dehiscence, superficial and deep infections) were recorded prospectively. Record of such data was obtained by an independent observer, and from multiple sources, to avoid under-reporting. 60 % of the responders to our survey had a predominant foot/ankle practice (exclusive or at least 75 % of their practice was foot/ankle surgery) and were included for further analysis of their responses. A large majority of these responders (64%) reported a rate of 2–5 % for superficial infection, and a significant majority (86 %) reported a deep infection rate of less than 2 %. Results from our own practice showed an incidence of superficial infection of 2.8 % and deep infection of 1.5 %. With increasing focus on clinical outcome measures as an indicator of quality, it is imperative to publish data on wound complications/ infection after foot/ankle surgery, and in the absence of such data, our two-armed study (survey-opinion and prospective audit) provides a useful benchmark for future comparisons

Wound complication including superficial infection is a concern after total knee arthroplasties (TKA) in diabetics. However, influence of glycoregulation before TKA has not been investigated in relationship to wound healing. Our hypothesis was that glycated hemoglobin (HbA1C), since it reflects long-term regulation of blood glucose, might be associated with incidence of wound complications after TKA in diabetic patients. We retrospectively reviewed 167 TKAs performed in 115 patients with diabetes mellitus between January 2001 and March 2007. All patients were diagnosed as type II DM and osteoarthritis. A wound complication was defined as a hematoma, bulla, drainage or superficial infection. Stepwise multivariate logistic regression was used to identify which variables had a significant effect on the risk of wound complications. Variables considered were age, gender, body mass index, histories of previous knee surgery, comorbidities, duration of diabetes, the methods of diabetes treatment, complications of diabetes, preoperative HbA1c level, operation time, antibiotics-impregnated cement use, the amount of blood transfusion, and postoperative blood glucose level. The overall incidence of wound complications was 6.6% (n=11) including superficial infection in 1.8% (n=3), hematoma or bullae in 3.6% (n=6), and drainage in 1.8% (n=3). There were seven cases (4.2%) of deep infection. A multivariate logistic regression revealed that independent risk factors for the development of wound complications were preoperative HbA1C ≥ 8% (odds ratio 6.074, 95% confidence interval 1.119–32.971) and operation time (odds ratio 1.013, 95% confidence interval 1.000–1.026). Poorly controlled hyperglycemia before surgery may increase the incidence of wound complications among diabetic patients receiving total knee arthroplasties. The correlation of glycemic control and wound complications may assist in the preoperative evaluation and selection of time for surgery

The incidence of total shoulder arthroplasty (TSA) in increasing. Evidence in primary hip and knee arthroplasty suggest that preoperative opioid use is a risk factor for postoperative complication. This relationship in TSA is unknown. The purpose of this study was to investigate this relationship. The Truven Marketscan claims database was used to identify patients who underwent a TSA and were enrolled for 1-year pre- and post-operatively. Preoperative opioid use status was used to divide patients into cohorts based on the number of preoperative prescriptions received. An ‘opioid holiday’ group (patients with a preoperative, 6-month opioid naïve period after chronic use) was also included. Patient information and complication data was collected. Univariate and multivariate logistic regression were then performed. Fifty-six percent of identified patients received preoperative opioids. Multivariate analysis demonstrated that patients on continuous preoperative opioids (compared to opioid naïve) had higher odds of: infection (OR 2.34, 95%CI 1.62–3.36, p<0.001), wound complication (OR 1.97, 95%CI 1.18–3.27, p=0.009), any prosthetic complication (OR 2.62, 95%CI 2.2–3.13, p<0.001), and thromboembolic event (OR 1.42, 95%CI 1.11–1.83, p=0.006). The same group had higher healthcare utilization including extended length of stay, non-home discharge, readmission, and emergency department visits (p<0.001). This risk was reduced by a preoperative opioid holiday. Opioid use prior to TSA is common and is associated with increased complications and healthcare utilization. This increased risk is modifiable, as a preoperative opioid holiday significantly reduced postoperative risk. Therefore, preoperative opioid use represents a modifiable risk factor

Objectives. The aim of this study was to compare the biomechanical stability and clinical outcome of external fixator combined with limited internal fixation (EFLIF) and open reduction and internal fixation (ORIF) in treating Sanders type 2 calcaneal fractures. Methods. Two types of fixation systems were selected for finite element analysis and a dual cohort study. Two fixation systems were simulated to fix the fracture in a finite element model. The relative displacement and stress distribution were analysed and compared. A total of 71 consecutive patients with closed Sanders type 2 calcaneal fractures were enrolled and divided into two groups according to the treatment to which they chose: the EFLIF group and the ORIF group. The radiological and clinical outcomes were evaluated and compared. Results. The relative displacement of the EFLIF was less than that of the plate (0.1363 mm to 0.1808 mm). The highest von Mises stress value on the plate was 33% higher than that on the EFLIF. A normal restoration of the Böhler angle was achieved in both groups. No significant difference was found in the clinical outcome on the American Orthopedic Foot and Ankle Society Ankle Hindfoot Scale, or on the Visual Analogue Scale between the two groups (p > 0.05). Wound complications were more common in those who were treated with ORIF (p = 0.028). Conclusions. Both EFLIF and ORIF systems were tested to 160 N without failure, showing the new construct to be mechanically safe to use. Both EFLIF and ORIF could be effective in treating Sanders type 2 calcaneal fractures. The EFLIF may be superior to ORIF in achieving biomechanical stability and less blood loss, shorter surgical time and hospital stay, and fewer wound complications. Cite this article: M. Pan, L. Chai, F. Xue, L. Ding, G. Tang, B. Lv. Comparisons of external fixator combined with limited internal fixation and open reduction and internal fixation for Sanders type 2 calcaneal fractures: Finite element analysis and clinical outcome. Bone Joint Res 2017;6:433–438. DOI: 10.1302/2046-3758.67.2000640

Introduction. Joint reconstruction remains a successful and popular surgery with advances in approaches, implants and techniques continually forthcoming. Various methods of skin closure exist to address issues in efficiency, aesthetics, and barrier to infection. While subcuticular skin closure techniques offer an aesthetic advantage to conventional skin stapling, no measurable differences have been reported. Furthermore, newer barbed sutures, such as the V-loc absorbable suture, theoretically distribute tension evenly through the wound and help decrease knot-related complications. To our knowledge, no literature exists on the rate of wound complications in joint arthroplasty with the use of V-loc suture for skin closure. We hypothesize that despite theoretical gains, skin closure with a V-loc (Covidien, Mansfield, MA) absorbable suture should be performed with caution. Methods & Materials. A retrospective chart review was conducted of 278 consecutive primary joint reconstruction cases performed by a single surgeon in 12 months from July 2009 through June 2010. Pre-operative history & physical reports were evaluated for co-morbidities (i.e diabetes mellitus), smoking status and body mass index (BMI). Operative dictations by the attending surgeon provided information on the surgical procedure, use of drain, wound closure technique and type of suture/staple used for skin closure. Skin was closed by the primary surgeon and his chief resident. Wounds were closed via staple gun or subcuticular stitch (3-0 Biosyn vs V-Loc) in a consecutive manner, depending on the surgeon's preference in that period. Post-operative clinic notes were reviewed to determine the occurrence of wound complications, issuance of antibiotic prescriptions, or return to the operating room. The cohort consisted of 106 males and 161 females at an average age of 63 years (range: 18–92). Overall, there were 153 procedures at the knee (including TKA, uni-compartmental arthroplasty, patello-femoral arthroplasty) and 125 procedures at the hip (including THA and hemi-arthroplasty). Results. In review of 278 consecutive primary joint reconstruction cases, there were 17 (6.1%) post-operative wound complications noted, including cellulitis, stitch abscesses, wound dehiscence, and deeper infections requiring OR irrigation and debridement. In 181 cases, staples were used for skin closure; in these cases, seven wound complications were noted (7/181, 3.9%). In 49 cases closed via a subcuticular Biosyn suture there were 4 wound complications noted (4/49, 8.1%). Six wound complications occurred in cases closed with a V-loc suture (6/45, 13.3%). Discussion. Aesthetics and efficiency often are the driving forces of innovation. We present the rate of wound complications in various superficial wound closure methods, including the V-loc, an innovative absorbable barbed suture. Based on our clinical experience, we promote consideration of wound and infectious complications when choosing a method of skin closure in joint reconstruction procedures

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

Objectives. Nylon sutures and skin staples are used commonly in total knee arthroplasty (TKA) surgical wound closure. However, there is no study that compares the wound healing efficacy and patient satisfaction scores of both techniques in the same knee. Methods. We randomised 70 patients who underwent primary TKA into two groups. In one group of 34 patients, the skin at the upper half of the wound was closed with skin staples and the lower half of the wound was closed with simple interrupted nylon sutures. In the other group of 36 patients, the skin at the upper half of the wound was closed with nylon stitches and the lower half of the wound was closed with skin staples. We recorded the wound closure time, pain score at the time of stitch removal, wound complication rate, patient satisfaction score, and the Hollander wound evaluation score at the post-operative periods of five days, 14 days, six weeks, three months, and six months. Each half wound was analysed separately. Results. The mean patient body mass index was 26.8 kg/m. 2. (standard deviation 6.3). A total of 70 nylon stitched wounds and 70 skin stapled wounds were analysed. There were no significant differences in wound complication rates, patient satisfaction score, and the Hollander wound evaluation score between both types of wounds (p > 0.05). The wound closure time for skin stapled wounds was significantly lower than the nylon stitched wounds (p < 0.001). However, the skin stapled wounds had a significantly higher pain score at the time of stitch removal (p < 0.001). Conclusion. Skin staples and nylon stitches had comparable results with respect to wound healing and patient satisfaction in TKA wound closure in non-obese patients. The benefit of skin staples over nylon stitches was a decrease in operative time, but was more painful upon removal. Cite this article: V. Yuenyongviwat. A randomised controlled trial comparing skin closure in total knee arthroplasty in the same knee: nylon sutures versus skin staples. Bone Joint Res 2016;5:185–190. DOI: 10.1302/2046-3758.55.2000629

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

The introduction of direct thrombin inhibitors in arthroplasty surgery has reignited the debate on the risk of wound complications when using chemical thromboprophylaxis. It has been suggested that direct thrombin inhibitors might lead to an increased risk of systemic and operative site bleeding and wound sepsis when compared to low molecular weight heparin. In July 2009, departmental thromboprophylaxis policy for patients undergoing hip and knee replacement surgery (including revision) was changed from subcutaneous enoxaparin for the duration of inpatient stay to dabigatran for 10 days (knees) or 28 days (hips) unless contraindicated. In the 2 years prior to policy change, 1091 patients underwent hip or knee arthroplasty (Group A), with 1150 patients undergoing the same procedures in the 2 years following July 2009 (Group B). A minority of patients were already on warfarin (2% in group 1, 3% in group 2). This study presents a retrospective analysis of all patients who returned to theatre within 30 days of joint replacement surgery to assess whether the change in unit policy caused any discernible increase in bleeding-related complications. In group A, 20 / 1091 patients (1.8%) returned to theatre within 30 days. 9 were for reasons unrelated to thromboprophylaxis (mainly dislocated hips), 4 for gastrointestinal bleeding and 7 for wound complications (haematoma, wound breakdown, or infection). In group B, 22 / 1150 patients (1.9%) returned to theatre within 30 days. 13 were for unrelated reasons, 4 for gastrointestinal bleeding, and 5 for wound complications. One patient with a wound complication was on warfarin and therefore did not receive dabigatran. The lower wound complication rate in group B was not statistically different. This study, in a large heterogeneous group of patients, suggests that a change from enoxaparin to dabigatran does not increase the incidence of early infection, or the risk of bleeding at the operative site or the gastrointestinal tract

The introduction of direct thrombin inhibitors in arthroplasty surgery has reignited the debate on the risk of wound complications when using chemical thromboprophylaxis. It has been suggested that direct thrombin inhibitors might lead to an increased risk of systemic and operative site bleeding and wound sepsis when compared to low molecular weight heparin. In July 2009, departmental thromboprophylaxis policy for patients undergoing hip and knee replacement surgery (including revision) was changed from subcutaneous enoxaparin for the duration of inpatient stay to dabigatran for 10 days (knees) or 28 days (hips) unless contraindicated. In the 2 years prior to policy change, 1091 patients underwent hip or knee arthroplasty (Group A), with1150 patients undergoing the same procedures in the 2 years following July 2009 (Group B). A minority of patients were already on warfarin (2% in group 1, 3% in group 2). This study presents a retrospective analysis of all patients who returned to theatre within 30 days of joint replacement surgery to assess whether the change in unit policy caused any discernible increase in bleeding-related complications. In group A, 20/1091 patients (1.8%) returned to theatre within 30 days. 9 were for reasons unrelated to thromboprophylaxis (mainly dislocated hips), 4 for gastrointestinal bleeding and 7 for wound complications (haematoma, wound breakdown, or infection). In group B, 22/1150 patients (1.9%) returned to theatre within 30 days. 13 were for unrelated reasons, 4 for gastrointestinal bleeding, and 5 for wound complications. One patient with a wound complication was on warfarin and therefore did not receive dabigatran. The lower wound complication rate in group B was not statistically different. This study, in a large heterogeneous group of patients, suggests that a change from enoxaparin to dabigatran does not increase the incidence of local or systemic complications of sufficient severity to warrant return to theatre

Introduction. We describe a novel single incision approach and its safety in the largest reported series of Lisfranc injuries to date. Via separate subcutaneous windows it is possible to access the medial three rays of the foot for bridge plating, without the concern of narrow skin bridges between multiple incisions. Methods. A retrospective review identified all 150 patients who underwent a Lisfranc ORIF via the modified dorsal approach at the Royal Melbourne Hospital between January 2011 and June 2016. All patients were operated by a single surgeon. Removal of metalwork (ROM) was routinely undertaken at six months post-operatively via the same incision. Medical recored were reviewed to record patient demographics, mechanism of injury and surgical details. Outpatient notes were reviewed to identify wound-related complications including; delayed wound healing, superficial infection, wound dehiscence, deep infection, complex regional pain syndrome (CRPS), neuroma and impaired sensation. Median follow-up was 1012 days (range 188–2141). Results. Median age was 37 years (19–78). 110 (73%) patients were male. Mechanism of injury was: motor vehicle accident (37%), motor bike accident (19%) and fall (18%). 24 (16%) injuries were open, 5 of which required soft tissue reconstruction at the primary surgery. A total of 34 wound related complications occurred (22%); superficial infection (14), delayed wound healing (7), wound dehiscence (5), CRPS (4), impaired sensation (3), neuroma (1). Re-operation was necessary in the 5 patients who experienced wound dehiscence; 4 requiring split skin grafts and 1 requiring a free flap. Crush injuries were 10 times more likely to have wound complications than those sustained in motor vehicle accidents. Patients undergoing ROM were more likely to have wound complications than those who did not. Conclusion. The modified dorsal approach using subcutaneous windows to access the midfoot joints offers a viable alternative to existing approaches

The anterolateral surgical exposure to the distal tibia for pilon fractures has become more popular. One of the potential benefits over the commonly used anteromedial approach is a reduction in wound complications due to the improved soft tissue coverage of the anterolateral tibia. Minimal data exists regarding the rate of complications with the anterolateral approach. The purpose of this study was to evaluate wound complications in the early postoperative period associated with the use of the anterolateral approach for pilon fractures. Methods: A retrospective review was conducted to identify all operatively treated pilon fractures at our university level 1 trauma center from September 2005 through July 2007. Sixty-eight pilon fractures were identified. All patients were treated with a staged protocol utilizing immediate external fixation followed by delayed open reduction and internal fixation based upon the condition of the soft tissue envelope. Patients who had an anterolateral surgical approach were identified and their medical records were reviewed for the first six weeks postoperatively to determine the rate of wound complications. The endpoint of six weeks was chosen to identify complications related to the surgical exposure alone. Results: Thirty-six of the sixty-eight patients with pilon fractures had an anterolateral surgical exposure. One additional patient had an anterolateral incision performed for revision of a previously treated pilon fracture. 97% of these fractures were AO/OTA 43-C (three C1, nine C2, and twenty-three C3). The median time delay to definitive fixation was 19 days (10–38 days). Sixteen (44.4%) of the fractures were open, ten of which were Gustilo type III (five IIIA, four IIIB, and one IIIC). Eight of the thirty-seven patients had wound complications related to the anterolateral incision within the first six weeks of definitive fixation. Six patients (16%) had minor complications which were successfully treated with dressing changes and oral antibiotics, and two (5%) had major complications, with evidence of deep wound infection that required formal irrigation and debridement. Conclusion: In a case series with a high rate of complex open pilon fractures, open reduction and internal fixation utilizing an anterolateral approach provided good exposure of the distal tibia with a low incidence of early wound complications. Significance: Pilon fractures, especially high energy complex open ones, have a high risk of wound complications. Avoiding complications is the key in managing high energy pilon fractures. This case series provides evidence that the anterolateral approach has a low rate of wound complications in the most complex pilon fractures

Rapid discharge pathways (RDP) have been implemented throughout most areas of orthopaedics. The primary goal of these pathways is to standardize the post-surgical hospital course for patients in order to decrease hospital length-of-stay (LOS). Surgical treatment of adolescent idiopathic scoliosis (AIS) remains one of the most invasive pediatric orthopaedic procedure and is routinely associated with a prolonged hospital stay. The implementation of RDPs following surgery for AIS has shown to be successful; however, all of these studies have been conducted within the United States and it has been shown previously that there exists major differences in hospital LOS and in post-operative complications between Canada and the United States. Therefore, the objective of this study was to determine if the implementation of a RDP at a single children's tertiary-referral centre in Canada could decrease hospital LOS without increasing post-operative complications. A retrospective chart review was completed for all patients who underwent posterior spinal instrumentation and fusion (PSIF) between March 1st, 2010 and February 28th, 2019, with date of implementation being March 1st, 2015. Patient pre-operative, operative, and post-operative information was collected from the charts along with the primary outcome variables: LOS, wound complication, 30-day return to the OR, 30-day emergency department admission, and 30-day hospital readmission. An interrupted time series analysis with a robust linear regression model was utilized to assess for any differences in outcomes following implementation of the RDP. Ninety days before and after the implementation of the RDP was not included in this analysis due to variances in practice that were occurring at this time. A total of 244 participants were identified, with 113 patients in the conventional pathway and 131 patients in the RDP cohort. No significant differences in pre-operative or operative characteristics existed between the groups, except for the RDP group having approximately a 50 larger pre-operative curve and the conventional pathway having on average 200mL greater intra-operative blood loss (p<0.05). Hospital LOS was found to be significantly shorter in the RDP group, with the median LOS being 5.2 [95% IQR 4.3–6.1] days in the conventional group and 3.4 [95% IQR 3.3–3.5] days in the RDP group (p<0.05). Patients in the RDP group were also found to stand 0.9 days earlier, walk 1.1 days earlier, their Foley catheter was discontinued 0.5 days earlier and their personal controlled analgesia was discontinued 12 hours sooner (p<0.05). There were no differences in post-operative complications between the two groups (p>0.05). This study demonstrates that implementing a RDP following PSIF for AIS can successfully decrease hospital LOS without increasing post-operative complications in a single payer universal healthcare system. The associated decrease in LOS could correlate with decreasing costs for both the healthcare system and for the patient's family

The Achilles tendon is commonly operated on, but has associated wound complications, ranging from 7–14% in previously reported series larger than 100 cases. We report a retrospective review of one surgeon’s practice conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon. The study evaluated the incidence of infection, and other wound complications such as suture reactions, scar revision, hematoma, incisional neuromas and granuloma formation. A total of 219 surgical cases were available for review (140 males, 70 females; average age at the time of surgery: 46.5 ± 12.6 years, range 16–75). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, with an overall complication rate of 22 of 219 surgeries (10.1%). There were no hematomas. Seven patients had additional surgery following their wound complications; some had simple granuloma excision, while one necessitated a flap. Patients with risk factors such as diabetes, smoking and Rheumatoid arthritis necessitating steroids were more likely to have a wound complication, (Fisher’s Exact Test, P=.03). Complications with Achilles tendon surgery may be unavoidable. Suture granulomas may appear in a delayed fashion. Absorbable and non-absorbable suture can be implicated

Aims. The best marker for assessing glycaemic control prior to total knee arthroplasty (TKA) remains unknown. The purpose of this study was to assess the utility of fructosamine compared with glycated haemoglobin (HbA1c) in predicting early complications following TKA, and to determine the threshold above which the risk of complications increased markedly. Patients and Methods. This prospective multi-institutional study evaluated primary TKA patients from four academic institutions. Patients (both diabetics and non-diabetics) were assessed using fructosamine and HbA1c levels within 30 days of surgery. Complications were assessed for 12 weeks from surgery and included prosthetic joint infection (PJI), wound complication, re-admission, re-operation, and death. The Youden’s index was used to determine the cut-off for fructosamine and HbA1c associated with complications. Two additional cut-offs for HbA1c were examined: 7% and 7.5% and compared with fructosamine as a predictor for complications. Results. Overall, 1119 patients (441 men, 678 women) were included in the study. Fructosamine level of 293 µmol/l was identified as the optimal cut-off associated with complications. Patients with high fructosamine (> 293 µmol/l) were 11.2 times more likely to develop PJI compared with patients with low fructosamine (p = 0.001). Re-admission and re-operation rates were 4.2 and 4.5 times higher in patients with fructosamine above the threshold (p = 0.005 and p = 0.019, respectively). One patient (1.7%) from the elevated fructosamine group died compared with one patient (0.1%) in the normal fructosamine group (p = 0.10). These complications remained statistically significant in multiple regression analysis. Unlike fructosamine, all three cut-offs for HbA1c failed to show a significant association with complications. Conclusion. Fructosamine is a valid and an excellent predictor of complications following TKA. It better reflects the glycaemic control, has greater predictive power for adverse events, and responds quicker to treatment compared with HbA1c. These findings support the screening of all patients undergoing TKA using fructosamine and in those with a level above 293 µmol/l, the risk of surgery should be carefully weighed against its benefit. Cite this article: Bone Joint J 2019;101-B(7 Supple C):3–9

Introduction. Superficial wound complications can occur in up to 10% of total knee arthroplasty (TKA) patients and have been associated with deep infection. The ideal material for TKA closure should fulfill the following requirements: 1) fast intraoperative application, 2) minimal wound complications and discomfort, and 3) can be removed by patients without a home care visit. We present our experience with a novel, non-invasive, removable skin closure system compared to conventional staple closure. Methods. We prospectively evaluated 105 consecutive patients who underwent unilateral or bilateral primary TKA and received skin closure consisting of the Zip 16 Surgical Skin Closure System (Zipline) for skin. All procedures were performed a by single surgeon (SBH) using a mini-midvastus approach. All patients were mobilized on the day of surgery and received 2 weeks of Rivaroxaban thromboprophylaxis. Patient demographics, medical comorbidities, in-hospital complications and wound healing and complications during the first 6-week post-operatively were recorded. Data was compared to a previous TKA cohort of 1,001 patients from the same surgeon who received staples for closure and warfarin for thromboprophylaxis. Results. Zip and staple patient groups had similar age, gender and BMI. There was a higher percentage of diabetic patients in the Zip closure group (12% vs. 10%). All 105 patients with Zip closure removed dressings themselves and had healed wounds with no noted drainage or blistering at six-weeks. Two patients had protruding subcutaneous vicryl stitches that were removed. In the staple group there were six knees (0.6%) that had wound drainage with 2 (0.2%) requiring reoperation for debridement and reclosure. Discussion. In our experience, the Zip 16 Surgical Skin Closure System is easy to apply, avoids the need for home care or office visit and had fewer wound complications compared to staples. Results have been positive despite the study cohort having a higher number of diabetic patients and using an anticoagulant which may be associated with higher risk of wound problems

Introduction. Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower limb arthroplasty. Trials supporting its use have not fully evaluated the risks of wound complications related to rivaroxaban. Method. A retrospective cohort analysis of 1558 consecutive patients who underwent total hip or knee replacements within the same hospital during a 19 month period (2009–2010) was performed. The first 489 patients (Group 1) were given tinzaparin postoperatively as per NICE guidance. The following 559 patients (Group 2) were given rivaroxaban. Concerns regarding wound complications prompted a change back to tinzaparin for the next 510 patients (Group 3.) Other than the thromboprophylactic agent used there were no other differences in the pre and postoperative treatments of all these patients. Results. Nine of the 489 patients in Group 1 (tinzaparin) (1.8%, 95% CI 0.9–3.5%) returned to theatre with wound complications within 30 days compared with 22 out of 559 patients in Group 2 (rivaroxaban) (3.94%, 95% CI 2.6–5.9%.) This increase in RTT rate was statistically significant (p=0.046.) After reverting back to tinzaparin 8 out of 510 patients in Group 3 (tinzaparin) (1.6% 95% CI 0.74–3.1%) returned to theatre. This reduction in RTT rate was statistically significant (p=0.02.) Combining the tinzaparin groups (1 and 3) and comparing with the rivaroxaban group (2) further increases the significance of our observations. Tinzaparin RTT was 1.7% (95% CI 1.0–2.7%) compared with rivaroxaban RTT of 3.94% (95% CI 2.6–5.9%) (p=0.01.). Discussion. We observed a significant rise in wound complication necessitating further surgery after a change in thromboprophylactic agent from tinzaparin to rivaroxaban, followed by a significant reduction after reverting back to tinzaparin. We call for further independent randomised controlled clinical trials examining wound related complications with respect to new pharmacological treatments

Wound closure is not often an area that is discussed by orthopaedic surgeons. We commonly attend meetings and talks related to different types of implants and surgical technique but in reality the wound and how we close it maybe one of the most important aspects of a surgical procedure. The avoidance of wound complications such as unplanned clinic visits, readmissions, reoperations and deep infections are very important as we move into a world of bundled payments and public reporting of complications. Not to mention the poor results for the patients when wound complications occur. Often there is little thought about how wound closure and surgical dressings could affect surgical site healing. We all have a common belief that blisters, drainage and surgical site infections are rare. In the literature it has been shown that the method of wound closure can influence skin and soft tissue perfusion. Which closure techniques can achieve physiologic blood flow, which may improve wound healing? This talk will cover topics related to reducing the dead space, avoidance of hematoma formation and what the literature says regarding different types of wound closure materials

Introduction. Manipulation under anesthesia (MUA) remains the gold standard to address restricted range of motion (ROM) within 3–6 months after primary total knee arthroplasty (TKA). However, there is little data on the outcomes of MUA with different types of anesthesia. We sought to compare the outcomes of patients undergoing MUA with intravenous (IV) sedation and neuraxial anesthesia. Methods. We identified 548 MUAs after primary TKA (136 IV sedation, 413 neuraxial anesthesia) at a single institution from 2016–2019. Mean age was 62 years and 349 patients (64%) were female. Mean body mass index was 32 kg/m. 2. The mean time from primary TKA to MUA was 10 weeks. Mean pre-MUA ROM was similar between each group; mean pre-MUA extension was 4.2° (p=0.35) and mean pre-MUA flexion was 77° (p=0.56). Patient demographics were statistically similar between both groups. We compared immediate complications, including fracture, extensor mechanism disruptions, and wound complications, Visual analogue pain scores (VAS), length of stay (LOS), and immediate and 3 month follow-up ROM between these groups. Results. No patients in either group sustained an immediate post-MUA complication. Patients undergoing MUA with IV sedation had significantly higher day of MUA average VAS of 5.1 compared to 4.1 in the neuraxial group (p<0.001). The average LOS was shorter in patients that received IV sedation (9 hours) compared to neuraxial anesthesia (12 hours) (p=0.009). Immediate-post MUA ROM was 1° – 121° in the IV sedation group and 0.9° – 123° in the neuraxial anesthesia group (p=0.21). Three month follow-up ROM was 2° – 108° in the IV sedation group and 1.9° – 110° in the neuraxial anesthesia group. Conclusion. IV sedation and neuraxial anesthesia are both effective anesthetic methods for patients undergoing MUA after primary TKA with minimal perioperative differences. Surgeons and anesthesiologists should cater anesthetic technique to patient specific needs as the orthopedic outcomes are similar for both methods; however, IV sedation resulted in a shorter LOS

Introduction. Perioperative optimization efforts have improved outcomes following primary total knee arthroplasty (TKA). However, morbidly obese patients continue to have increased rates of complications. The purpose of this study was to assess if rates of early complications after TKA have similarly improved for both morbidly obese and non-morbidly obese patients. Methods. Elective, primary TKA patients from 2011–2018 were identified in the National Surgical Quality Improvement Program database. Patients were stratified by body mass index (BMI) <40 kg/m. 2. and ≥40 kg/m. 2. Thirty-day rates of infectious complications, readmissions, and reoperation were assessed. Trends in these endpoints over the study period were compared between BMI groups utilizing odds ratios (OR) and multivariate analyses. Results. In total, 314,719 patients underwent TKA and 46,386 (15%) had BMI ≥40 kg/m. 2. From 2011–2018, the reoperation rate significantly improved from 1.2% to 1.0% (OR: 0.6 [0.6–0.7]) for patients with BMI <40 kg/m. 2. , as did rates of readmission (4.5% to 2.9%, OR: 0.8 [0.7–0.99]). Patients with BMI ≥40 kg/m. 2. also had a significant decrease in the rate of readmission over the study period (4.9% to 3.3%, OR: 0.6 [0.5–0.8]); however, the rate of reoperation did not significantly change (1.4% to 1.4%, OR: 1.0 [0.6–1.6]). Significant improvements were not observed for infectious complications over time for either group. However, patients with BMI ≥40 kg/m. 2. consistently had increased risk of both deep infection from 2014–2018 (2014 OR: 2.2 [1.4–3.4], 2018: 2.2 [1.6–3.0]) and wound complications from 2011–2018 (2011 OR: 1.7 [1.2–2.6], 2018 OR: 2.0 [1.7–2.4]) compared to non-morbidly obese patients. Conclusion. Although readmission rates significantly decreased for all patients, improvements in reoperation rates observed in non-morbidly obese patients were not experienced by the morbidly obese – resulting in a widening of the complication gap between these cohorts. Care improvements have not lowered the differential risk of infectious complications compared to non-morbidly obese

The posterior midline approach used in spinal surgery has been associated with a significant rate of wound dehiscence. This study investigates anatomical study of the arterial supply of the cervical and thoracic spinal muscles and overlying skin at each vertebral level. It aimed to provide possible anatomical basis for such wound complications. A dissection and angiographic study was undertaken on 8 cadaveric neck and posterior torso from 6 embalmed and 2 fresh human cadavers. Harvested cadavers were warmed and hydrogen peroxide was injected into the major arteries. Lead oxide contrast mixture was injected in stepwise manner into the subclavian and posterior intercostal arteries of each specimen. Specimens were subsequently cross-sectioned at each vertebral level and bones elevated from the soft tissue. Radiographs were taken at each stage of this process and analysed. The cervical paraspinal muscles were supplied by the deep cervical arteries, transverse cervical arteries and vertebral arteries. The thoracic paraspinal muscles were supplied by the superior intercostal arteries, transverse cervical arteries and posterior intercostal arteries. In the thoracic region, two small vessels provide the longitudinal connection between the segmental arteries and in the cervical region, deep cervical arteries provide such connection from C3 to C6. The arterial vessels supplying the paraspinal muscles on the left and right side anastomose with each other, posterior to the spinous processes in all vertebral levels. At cervical vertebral levels, source arteries travel near the surgical field and are not routinely cauterised; Haematoma is postulated to be the cause of wound complications. At thoracic levels, source arteries travel in the surgical field and tissue ischemia is a contributing factor to wound complications, especially in operations over extensive levels. Post-operative wound complications is a multi-factorial clinical problem, the anatomical findings in this study provide possible explanations for wound dehiscence in the posterior midline approach. It is postulated that drain tubes may reduce the incidence of haematoma in the cervical level

Background:. Calcaneal osteotomy is an established technique in correcting hind foot deformity. Patients have traditionally received an open osteotomy through Atkins lateral approach. In order to reduce the rate of wound complications associated with the Atkins approach, a minimally invasive surgical (MIS) technique has been adopted since 2011. This uses a low-speed, high-torque burr to perform the same osteotomy under radiographic guidance. The results of the new MIS technique, including post-operative complication rates, are compared to the standard open approach. Methods:. The safety of the new MIS technique was investigated by conducting a case controlled study on all patients who underwent displacement calcaneal osteotomy at the Nuffield Orthopaedic Centre, Oxford from 2008 to 2014. The primary outcome measure was 30 day post-operative complication rate. Secondary outcome measures included operating time, duration of stay, fusion rates and amount of displacement achieved. Results:. 82 patients underwent calcaneal osteotomy as part of their corrective surgery; 50 patients in the Open approach group and 32 patients in MIS group. The average age at the time of surgery was 47.7 years (range 16–77) for the Open group and 48.5 (range 21–77) in the MIS group. A mean calcaneal displacement of 8.0mm (s.d. 1.32, 7 to 11 mm) and 8.33mm (s.d.1.53, 6 to 10 mm) was achieved through the MIS and open approaches respectively. There were significantly fewer wound complications in the MIS group (6.25%) compared to the Open group (28%, P=0.021) and the MIS group was associated with significantly lower rates of wound infection (3% versus 20%, P = 0.043). Three patients in the Open group experienced sural peripheral neuropathy. Conclusions:. MIS calcaneal osteotomy was found to be a safe technique. It was as effective as calcaneal osteotomy performed through an open lateral approach but was associated with significantly fewer wound complications and fewer nerve complications

A national quality improvement initiative identified potentially avoidable complications, including venous thromboembolism (VTE) as “never events.” While the intent of this designation was to improve system-wide performance and to decrease medical costs, its value in total joint arthroplasty has not been defined. We performed this study to assess the relative incidence of VTE related admissions following TKA, the relative costs associated with care directed towards this complication, and compliance with SCIP VTE prophylaxis guidelines. From a total of 2,221 TKA procedures accomplished over a 5 year interval, we identified 121 hospital readmissions (5.4 percent). Primary readmission diagnoses were obtained from hospital coding and physician medical record documentation. Readmissions were categorised into five major complication types: 1) limited motion, 2) noninfectious wound complications, 3) bleeding complications, 4) deep infections, and 5) VTE events. VTE chemoprophylaxis was reviewed to determine the agent utilised, therapeutic level, and duration. Hospital records were assessed to determine whether additional surgeries or other procedures were accomplished and whether patients received allogeneic transfusions during their readmission. Direct costs of readmission care were obtained from hospital reimbursement records. Limited motion (18%), non-infectious wound complication (14%), surgical site infection (10%), and bleeding (10%) were the most common reasons for readmission. VTE events were less frequent (3%) and all occurred despite standard of care prophylaxis. The cost to manage bleeding, wound complications, infection, and limited motion each exceeded the cost of VTE. These results challenge the identification of VTE as a “never event.”

Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. However, trials supporting its use have not fully evaluated the risks of wound complications. This study of 1048 total hip/knee replacements records the rates of return to theatre and infection before and after the change from a low molecular weight heparin (tinzaparin) to rivaroxaban as the agent of chemical thromboprophylaxis in patients undergoing lower-limb arthroplasty. During a period of 13 months, 489 consecutive patients undergoing lower-limb arthroplasty received tinzaparin and the next 559 consecutive patients received rivaroxaban as thromboprophylaxis. Nine patients in the control (tinzaparin) group (1.8%, 95% confidence interval 0.9 to 3.5) returned to theatre with wound complications within 30 days, compared with 22 patients in the rivaroxaban group (3.94%, 95% confidence interval 2.6 to 5.9). This increase was statistically significant (p = 0.046). The proportion of patients who returned to theatre and became infected remained similar (p = 0.10). Our study demonstrates the need for further randomised controlled clinical trials to be conducted to assess the safety and efficacy of rivaroxaban in clinical practice, focusing on the surgical complications as well as the potential prevention of venous thromboembolism

Purpose: Resection of pelvic sarcoma with limb preservation (internal hemipelvectomy) is a major undertaking. Resection requires large areas of soft-tissue to be removed. Because of wound complications, we manage these defects with immediate tissue transfer (ITT) at the time of resection when a large defect is anticipated. This study compares the outcomes of ITT with primary wound closure (PWC). Method: Twenty patients undergoing 22 separate procedures (1995–2007) were identified in our prospectively maintained database. Demographics, tumour type, operative data and complications, and functional scores (MSTS-1993, TESS) were collected. Results: Twelve defects were managed with ITT, nine with pedicled myocutaneous vertical rectus abdominis (VRAM) flaps (one received double VRAM flaps due to the large defect), two with tensor fascia lata (TFL) rotation flaps (one augmented by local V-Y advancement, the other with gluteus maximus rotation flap) and one received latissimus dorsi free tissue transfer. Four wound complications necessitated operative intervention in this group: two debrided VRAM flaps went on to heal and the two TFL flaps required revision: one to VRAM flap and the other to a latissimus dorsi free flap which ultimately suffered chronic infection and hindquarter amputation was performed. Ten defects were managed with PWC, and 5 wound complications occurred, all five suffered infection, one developed hematoma and one dehisced. One wound resolved with debridement, two healed after revision to pedicled gracilis and gluteus maximus myocutaneous flaps. Two patients were converted to hindquarter amputation due to chronic infection. Functional scores were collected on 8 of 12 living patients, at time of writing. The mean TESS scores were 83 and 73 in the ITT and PWC groups. Five patients in the ITT and 3 in the PWC group were deceased. Conclusion: Soft-tissue closure following pelvic sarcoma resection remains a difficult challenge, and our experience reflects that. There were fewer wound complications (33% v 50%) and slightly better function with ITT than PWC, but this was not statistically significant due to the small size of our study. Although small, this study suggests ITT should be considered whenever a large soft tissue defect is anticipated

Background: The Achilles tendon is commonly operated on, but has associated wound complications, ranging from 7–14% in previously reported series larger than 100 cases. Methods: A retrospective review of one surgeon’s practice was conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon. The study evaluated the incidence of infection, and other wound complications such as suture reactions, scar revision, hematoma, incisional neuromas and granuloma formation. Results: A total of 219 surgical cases were available for review (140 males, 70 females; average age at the time of surgery: 46.5 ± 12.6 years, range 16–75). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, with an overall complication rate of 22 of 219 surgeries (10.1%). There were no hematomas. Seven patients had additional surgery following their wound complications; some had simple granuloma excision, while one necessitated a flap. Conclusion: Knowledge of suture materials, proper incision placement and possibly avoiding tourniquet usage can keep complications low when performing Achilles tendon surgery. Regardless, some complications with Achilles tendon surgery may be unavoidable

Purpose. Infections in orthopaedic surgery are costly, debilitating complications. The search for new treatments and prevention strategies has led to the use of antibiotic-filled calcium sulfate (CaS) as a bone void filler that is both safe and effective. The purpose of this study was to examine the available data on the efficacy of this technology. Methods. A literature search was performed for studies that evaluated the use of antibiotic-loaded CaS cement in orthopaedics published between inception of the databases to 2017. Selected studies included randomized controlled trials (RCTs) and observational studies published in the English language that met the following criteria: 1) patients underwent an orthopaedic procedure; 2) CaS cement with an antibiotic was used; and 3) at least one of our outcomes were mentioned. Outcomes included resolution of infection, complications related to treatment, subsequent surgeries, overall infection rate, fracture union rate, clinical outcomes, and wound complications. A total of 17 studies were included. Results. Ten studies examined the use of antibiotic-eluting CaS cement with surgical debridement to treat osteomyelitis and reported resolution rates ranging from 80–100%. Two studies examined CaS for prophylaxis of infection after open fracture, with subsequent infection rates ranging from 0–22%. Two studies examined infected non-unions with CaS used as an adjunct to surgery with an 87.5% infection clearance rate. Finally, three studies examined the use of local antibiotic release from CaS in the repair of infected TKAs or THAs, with success rates ranging from 52–93.3%. Conclusion. Initial results support the use of CaS with surgical debridement for osteomyelitis and infected non-unions. Results are mixed for CaS use in the prophylaxis of infection after open fractures and for PJIs, thereby necessitating further research. Overall the studies were small, retrospective, and lacked controls. Further research should focus on RCTs to minimize bias and investigate for non-inferiority. For any figures or tables, please contact authors directly

113 consecutive patients with soft tissue sarcoma treated by excision and reconstructive flaps were studied to assess the risk of complications and to compare local tumour control with those in whom primary wound closure was possible. Minimum follow-up was 24 months and mean age was 55 years (16–95). The sarcoma was located in the lower extremity in 83 and upper extremity 30 patients. Significant wound complications developed in 37 patients (33%). The most common complications were wound infections or partial necrosis occurring in 16% (18/113) and 13% (15/113) respectively. Complete flap necrosis requiring flap removal occurred in 6 patients (5%). Three patients (2.3%) required amputation as a result of complications. Significant risk factors for development of wound complications include location of tumour in the lower limb compared to upper limb (relative risk 2.3, p=0.02) and use of pre-operative radiotherapy compared to no or post-operative radiotherapy (relative risk 2.05, p=0.02). There was no difference in rates of complications in patients with free or pedicled flaps, tumours < or > 5cm, distal or proximal location of tumour. The rates of negative excision margins (80%) and wound complications in patients who required reconstructive flaps were not different from that for the other patients treated at our centre who did not require reconstructive flaps. The use of soft tissue reconstructive flaps did not reduce the risk of positive excision margins or the rates of wound complications. The risk of amputation secondary to flap complication or failure is low

Introduction: Thromboprophylaxis in Orthopaedic practice has long been a debated issue. The recent NICE guidelines have recommended low molecular weight heparins (LMWH) for all orthopaedic patients, although a number of authors have highlighted the low risk of thromboembolism in foot and ankle practice. We looked at our series of total ankle replacements (TAR) to identify the incidence of thromboembolism and any complications associated with chemical thromboprophylaxis. Methods: All patients who had undergone TAR were reviewed retrospectively. Risk factors according to the NICE guidelines were identified as was the type of chemical thromboprophylaxis, if given. Complications including thromboembolism, wound ooze, swelling and delay in discharge were recorded. Results: There were 45 TAR’s in 45 patients. 20 patients (44%) had been given some form of chemical thromboprophylaxis. There were no cases of thromboembolism in either group. In the group receiving chemical thromboprophylaxis, nine patients (45%) had a wound complication. In the group receiving no chemical thromboprophylaxis only one patient (4%) had a wound complication. Discussion: Thromboprophylaxis in total ankle replacement may significantly increase the risk of wound complications. We would recommend caution when prescribing chemical prophylaxis for patients undergoing total ankle replacement

The introduction of direct thrombin inhibitors in arthroplasty surgery has reignited the debate on the risk of wound complications when using chemical thromboprophylaxis. It has been suggested that direct thrombin inhibitors might lead to an increased risk of systemic and operative site bleeding and wound sepsis when compared to low molecular weight heparin. In July 2009, departmental thromboprophylaxis policy for patients undergoing hip and knee replacement surgery (including revision) was changed from subcutaneous enoxaparin for the duration of inpatient stay to dabigatran for 10 days (knees) or 28 days (hips) unless contraindidated. In the 2 years prior to policy change, 1091 patients underwent hip or knee arthroplasty (Group 1), with1150 patients undergoing the same procedures in the 2 years following July 2009 (Group 2). A minority of patients were already on warfarin (2% in group 1, 3% in group 2). This study presents a retrospective analysis of all patients who returned to theatre within 30 days of joint replacement surgery to assess whether the change in unit policy caused any discernible increase in bleeding-related complications. In group 1, 23/1091 patients (2.1%) returned to theatre within 30 days. 8 were for reasons unrelated to thromboprophylaxis (mainly dislocated hips), 5 for gastrointestinal bleeding (mainly upper GI endoscopy) and 10 for wound complications (haematoma, wound breakdown, or washout of early infection). In group 2, 22 / 1150 patients (1.9%) returned to theatre within 30 days. 12 were for unrelated reasons, 5 for GI bleeding, and 5 for wound complications. The lower return to theatre rate in the second group was not statistically different. This study, in a large heterogeneous group of patients, suggests that a change from enoxaparin to dabigatran does not increase the incidence of early infection, or the risk of bleeding at the operative site or the gastrointestinal tract

Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. Starting January 2011, our unit has converted from aspirin to Rivaroxaban use routinely following lower-limb arthroplasty for venous thromboembolism (VTE) prophylaxis. The aim of this audit was to retrospectively review its efficacy and the morbidity associated with its use. All patients undergoing primary and revision lower-limb arthroplasty between February 2011 and July 2011 were reviewed. All patients undergoing total knee replacement surgery and total hip replacement surgery received oral rivaroxaban 10 mg daily post-operatively for 14 days and 35 days respectively. Outcome measures recorded were; investigation for DVT/PE, rate of DVT/PE, wound complications (infection, dehiscence, leaking, bleeding), blood transfusion rate and readmission rate within 6 weeks of surgery. Of the 162 patients identified, 19 were excluded due to insufficient information or because they did not receive rivaroxaban as VTE prophylaxis. 141 patients (mean age 71.7 years) were included. 69 primary and 5 revision total knee replacements were performed. 60 primary and 7 revision total hip replacements were performed. 9 patients (6.4%) underwent Doppler USS for a painful swollen leg with 1 (0.7%) DVT diagnosed. None were investigated for a pulmonary embolus. 25 (17.7%) patients developed wound complications: 10 superficial infections requiring oral antibiotics, 2 deep infections requiring theatre washout, 1 wound dehiscence, 5 continuously leaking wounds, 5 bleeding wounds/haematomas. 26 (18.4%) patients required post-operative blood transfusion (average 2.2 units). 12 (8.5%) patients were re-admitted within 6 weeks with post-op complications (6 wound complications, 5 painful/swollen limbs, 1 large per-vaginal bleed). In keeping with previous literature, the rate of VTE following lower-limb arthroplasty using rivaroxaban as prophylaxis is low. However, the rate of morbidity was higher when compared with the use of aspirin in our centre between April and September 2010

British national guidelines recommend agents which antagonise factor Xa or warfarin as prophylaxis of venous thromboembolism (VTE) in lower limb arthroplasty. However, they discourage the use of aspirin prophylaxis. We conducted a prospective, multi-centre audit between two national centres, Ninewells Hospital in Dundee and the Royal Infirmary in Edinburgh to compare bleeding and VTE risk. Only Edinburgh routinely uses aspirin as VTE prophylaxis. The study comprises a number of cycles from 2013 to 2015. Consecutive groups of patients were identified prospectively using elective theatre data and information extracted from their case-notes on type of VTE prophylaxis, VTE occurrence, wound complications and length of hospital stay for a period of nine weeks post-operatively. 262 Edinburgh patients and 92 Dundee patients were included. Most Edinburgh patients were prescribed aspirin in hospital and on discharge (188/262, 71.8%), in line with local protocol. In Dundee, dalteparin was most commonly prescribed in hospital (68/92, 73.9%) and rivaroxaban on discharge (57/92, 62.0%). The Edinburgh group had a 1.5% incidence of pulmonary embolus (PE) and a 1% rate of deep venous thrombosis (DVT), 2% had problems with wound haematoma and one patient (0.4%) required a transfusion; no wound washouts were required. In Dundee there was 0% PE, 2% DVT, 5% had problems with haematoma, 3% required transfusion and 2% required washout. There was no difference in length of hospital stay, with a mode of 4 days for both centres. Non-fatal PE was prevented in Dundee patients but possibly at the cost of greater incidence of wound complications

Introduction. Readmission after Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA) places a great burden on the health care system. As reimbursement systems place increased emphasis on quality measures such as readmission rates, understanding the causes for readmission becomes increasingly important. Methods. We queried an electronic database for all patients who underwent THA or TKA at our institution from 2006 through 2010. We identified those who had been readmitted within 90 days of discharge from the initial admission. We then collected clinical and demographic data as well as readmission diagnoses by ICD-9 code. We compared rates of readmission using chi-squared test. Results. 6436 patients underwent THA or TKA during the study period. Readmission rates were as follows: unilateral THA, 190 of 2546 (7.5%); bilateral THA, 0 of 13 (0%); unilateral TKA, 288 of 3553 (8.1%); bilateral TKA, 32 of 337 (9.5%), for a combined rate of 7.9%. There was no significant difference in the rate of readmission among procedures: unilateral THA, unilateral TKA and bilateral TKA (p=0.36). There were no significant differences overall by year of procedure (p=0.44). While there was a wide variety of readmission diagnoses, the top three were wound complications (ICD-9 Group 998, 18.5%), procedure-related complications (ICD-9 Group 996, 15.5%), and cellulitis (ICD-9 Group 682, 5%). Conclusions. Readmission after THA or TKA occurs with substantial frequency. Postoperative stiffness requiring manipulation (within ICD-9 Group 996) and wound complications (within ICD-9 Group 998) are the most common reasons for readmission. Procedure-related complications and wound complications accounted for more readmissions than medical complications. A clearer understanding of the factors related to these complications, along with accurate diagnosis and coding, should make a reduction in their occurrence possible

Introduction. Many surgeons are reluctant to use a constrained liner at the time of acetabular component revision given concerns this might result in early acetabular component loosening. We hypothesized that with appropriate initial implant stabilization of highly porous acetabular components with supplemental screw fixation, constrained liners could be safely used at the time of acetabular revision. Methods. We retrospectively identified 148 revision total hip arthroplasties (THAs) where a constrained liner of one design was cemented into a newly placed highly porous acetabular component fixed with supplemental screws (mean 5 screws). Mean age at revision THA was 69 years, with 68% being female. The most common indications for revision were two-stage re-implantation (33%), recurrent dislocation (30%), and aseptic loosening (22% acetabular; 9% acetabular/femoral component). Mean follow-up was 8 years. Results. There were no failures at the bone-implant interface, and there were no revisions for aseptic loosening of the acetabular component. Furthermore, all acetabular components were bone ingrown on radiographic analysis. The 10-year survivorships free from any acetabular revision and free from any reoperation were 75% and 67%, respectively. Overall, 33 hips (22%) required revision or reoperation for infection/wound complications (n=12), dislocation (n=11), periprosthetic femur fracture (n=4), femoral loosening (n=3), and other (n=3). The 10-year survivorship free from dislocation was 84% overall, which was similar to the 85% 10-year survivorship free from dislocation for those specifically revised for instability (p=0.9). Conclusions. Implanting a constrained liner at the time of acetabular revision in high-risk patients resulted in no cases of aseptic acetabular component loosening in this large series. This is likely related to the fact that a highly porous acetabular component was utilized with a large number of supplemental screws in each case. Such information is valuable as these data favor a paradigm shift when compared to some traditionally-held tenets. For any tables or figures, please contact the authors directly

Soft tissue sarcomas (STS) arising in the adductor compartment of the thigh are frequently large before clinical detection, posing particular challenges with surgical resection and associated with a high risk of wound complications. This study compares oncological and functional outcomes and complications following treatment of adductor compartment soft tissue sarcomas from three international centres with different treatment philosophies. 184 patients with new primary, non-metastatic, deep STS in the adductor compartment diagnosed between 1990 and 2001 were identified from the centres' local databases. The Toronto Extremity Salvage Score (TESS) was used to assess function in patients. There were 94 male and 90 female patients, with ages ranging from 13 to 88 years (median age 57 years). The period of follow-up ranged from 1 to 162 months. The overall survival was 65% at 5 years and related to grade and size of the tumour. There was no difference in overall survival or systemic relapse between the three centres. There was however a significant difference in local control (28% LR in centre 1 compared to 10% in centre 2 and 5% in centre 3, which appeared to be principally related to the use of radiotherapy and surgical margins.). 66 patients (36%) from the three centres developed wound complications post-operatively and it was shown to be associated with high grade and large tumours (>10cm). Functional scores averaged 78% but were significantly worse for patients with wound complications or high-grade tumours; however, they were not affected by timing of radiotherapy or use of prophylactic free muscle flaps. Conclusion. This large series of adductor compartment STS has shown that survival factors do not vary across international boundaries but that treatment factors affect complications, local recurrence and function. Centralisation of adjuvant treatment like radiotherapy may have an important role in improving local control

Aims. To evaluate the place of the massive prostheses in the most complex periprosthetic infections cases (PJis). Method. Between 2011 and 2017, 516 hip and knee revisions for periprosthetic infections had been performed in our hospital by the same senior surgeon. We report a prospective series of 58 patients treated between 2011 and the end of 2017. 26 males and 32 females with on average 69,4 years old (38–86). Infection involved TKA in 39 cases (26 TKA revisions, 11 primary TKA), THA in 18 cases (10 revisions, 7 primary THA), a femoral pseudoarthrosis with posttraumatic gonarthrosis in one case and a septic humeral pseudoarthrosis in one case. We used one stage procedures in 38 cases (14 hips, 23 knees, 1 shoulder) and 20 two stages surgeries (16 knees and 4 hips). Additional technics used with massive prostheses, all for TKA PJis: 4 massive extensor systemallografts performed two times in a one stage procedure, two local flaps (medial gastronecmienmuscle). Two perioperative hyperbaric procedures used to limit the risks of wound complications. Results. The average follow-up is 38 months (12–62 months). The rate of sucess to treat the infection at this follow-up is 89,7 %. We report our feedback of the different massive components uses and the qualities/defaults we noted. The most frequent complication was skin events like wound swelling and delayed cicatrisations in 13 cases. 3 cases of one stages needed a complementary debridement in the three weeks after the surgery with always a good local and infectious evolution. This series report 5 failures of two stages TKA revisions. In 4 cases, the initial local soft tissues conditions were compromised. Conclusions. The use of massive prostheses to treat PJIs is a good option for the complex cases. It can be a good alternative of knee arthrodesis. These components must be used, preferentially for oldest patients, in cases of extreme bone loss or extensed osteitis to secure the bone debridement and the quality of the reconstruction. In our series, the one stage procedure is a validated option even by using complementary technics as bone allografts, extensor system allografts or flaps. The two stages procedure is a secondary option, particularly when softtissues status is compromised before or after the debridement, and mostly for the knees

Aims

Surgical site infection (SSI) after soft-tissue sarcoma (STS) resection is a serious complication. The purpose of this retrospective study was to investigate the risk factors for SSI after STS resection, and to develop a nomogram that allows patient-specific risk assessment.

Surgical site infections constitute the cause of 13% to 18% of readmissions within 90 days of a total hip arthroplasty and are a leading cause of failure of revision total knee arthroplasty. The goals of wound closure are to enhance healing potential, prevent infection, and provide a cosmetic appearance. Traditionally, this has been achieved with the use of interrupted sutures. However, recently “barbed” sutures have been introduced which consist of a solid core with peripheral etched barbs in a helical array. These sutures have been used for both the deep and superficial layers of wound closure in a running fashion with the barbs intended to be self-retaining in the event that the suture is cut or pulls out of the tissue. Proposed advantages include the avoidance of knots, less needles required, improved efficiency, and creation of a “watertight” seal. Numerous studies have shown decreased times for wound closure with the use of barbed vs. interrupted sutures with no difference in infection or complication rates. With less needles and improved efficiency, there is the potential for cost savings with the use of barbed sutures. However, there have been two studies raising concerns of arthrotomy failure with their use in total knee arthroplasty. In addition, several reports have noted the potential for increased superficial wound complications when barbed sutures are used for a subcutaneous closure. Therefore, what remains clear is that there is no proven, optimal method of wound closure in total joint arthroplasty and that every closure method remains technique dependent

Aims

The sacroiliac joint (SIJ) is the only mechanical connection between the axial skeleton and lower limbs. Following iliosacral resection, there is debate on whether reconstruction of the joint is necessary. There is a paucity of data comparing the outcomes of patients undergoing reconstruction and those who are not formally reconstructed.

Background: A subcuticular suture is an ideal closure method of a surgical wound, in patients undergoing foot & ankle surgery, when the aim is healing by primary intention. However, the addition of adhesive strips over the subcuticular suture has become an accepted method of closure despite being based on anecdotal, rather than experimental evidence. Methods: We performed a prospective study to compare the postoperative wound complications of combination closure (3/0 Monocryl & steri strips) with subcuticular closure alone (3/0 Monocryl). Patients undergoing foot & ankle surgery were allocated to either group on an alternate basis. The wounds of sixty consecutive patients were assessed clinically for wound complications at one-week post op. Results: Patients who had a combined closure were more likely to develop a wound discharge (23% vs 7%), friable skin (53% vs 3%) and were more likely to have non-opposed wound edges (60% vs 23%). They were also twice as likely to return to clinic for a further wound check (20% vs 10%). Discussion: Adhesive strips were originally developed as wound dressings and offer no improvement in the tensile strength of the subcuticular closure. Instead their addition exposes the surgical wound to the possibility of epidermal injury from the adhesive in the tape and increases the likelihood of developing wound complications. We recommend meticulous closure of surgical wounds of the foot and ankle with continuous, absorbable, subcuticular suture without adhesive strips, for an optimal outcome

Background: The timing of surgery for closed ankle fracture is controversial. Conventional teaching recommends either immediate surgery or a delay of 5–7 days in order to minimise soft tissue complications. However, there have been no large studies to produce clear guidelines and the literature is conflicting. Some authors suggest that delayed surgery results in increased risk of wound complications, less satisfactory rate of anatomical reduction, increased hospital stay and health service cost. Objective: We aimed to determine whether surgery can be safely performed in an intermediate time frame with respect to soft tissues complications. Method: We performed retrospective analysis of case notes and plain radiographs of 85 patients undergoing open reduction and internal fixation for closed ankle fractures at our unit in 2004. Data was analysed using the StatView statistical analysis program. Continuous variables were assessed for association with wound complication by means of an unpaired t-test. Nominal variables were assessed using Fisher’s exact test. Results: The overall rate of infection in our population of 85 patients was 9.4%. This comprised 7 superficial wound infections and one deep infection. Patients were classified into early (within 1 day), intermediate (between 2–6 days) and delayed (after 6 days) groups according to the time delay prior to surgery. Only 1 patient in the intermediate surgery group developed infection compared to 6 in the delayed group and this was statistically significant (p = 0.046). Conclusion: We suggest that with experience, meticulous soft tissue handling and good operative technique, delaying surgery until swelling has subsided is unnecessary in the majority of patients and is associated with a higher risk of wound complication

The aim of the study was to find out the relationship between delay in fixation of ankle fractures and incidence of wound complications like wound dehiscence, necrosis of margins, infection. Ankle fractures are fixed either on the day of injury or delayed for up to 7 days in view of the swelling. We reviewed 51 patients with ankle fractures retrospectively (exclusions- children, open fractures, co-morbid conditions like diabetes, steroid use) looking for delay in surgical fixation and wound complications. Out of 19 patients operated within 24 hours of injury, only one had a wound complication. This was 8 out of 20 for patients operated anywhere between 24 hours and 7 days. 12 patients had their fractures fixed after 7days, out of which 4 developed wound problems. (p value- < 0.05). This suggests that delay in ankle fracture fixation increases the rate of wound related problems. Review of case notes suggested that most patients in the second group (24 hours to 7 days) were waiting for the available slot in the trauma list. Based on these observations we suggest that ankle fractures should be prioritized in trauma lists and fixed within 24 hours of injury

The December 2022 Foot & Ankle Roundup³⁶⁰ looks at: Evans calcaneal osteotomy and multiplanar correction in flat foot deformity; Inflammatory biomarkers in tibialis posterior tendon dysfunction; Takedown of ankle fusions and conversion to total ankle arthroplasty; Surgical incision closure with three different materials; Absorbable sutures are not inferior to nonabsorbable sutures for tendo Achilles repair; Zadek’s osteotomy is a reliable technique for treating Haglund’s syndrome; How to best assess patient limitations after acute Achilles tendon injury; Advances in the management of infected nonunion of the foot and ankle.

Early and/or prolonged wound discharge after total knee arthroplasty often raises the question whether this is a sign of an early infection or if the prolonged discharge leads to a secondary deep wound infection from migrating skin bacteria. Confronted with the dilemma of what to do with early PWC our department implemented a new treatment protocol in 2002 to deal with early PWC after TKA in order to standardize decision-making. The aim of this study was to report our long-term results using this protocol on a prospective cohort primary TKA and revision TKA performed for other reasons than infection. This report focuses on the results of DAIR (debridement, antibiotics and implant retention) performed for early PPJI and/or early wound complications without clinical signs of infection. After implementing our treatment algorithm regarding postoperative wound complications in early 2002, we initiated a quality registration including every primary and non infected revision TKA performed. Between January 2002 and August 2012 1439 consecutive primary knee arthroplasties were performed at our institution. During the same period a total of 120 knee revisions for reasons not related to infection were performed. All patients undergoing DAIR within three months of the index procedure where divided into two groups: successful and unsuccessful. Successful DAIR didn't require any more surgery and the implant could be retained with a minimum follow up time of two years. Unsuccessful DAIR required at least one more surgical intervention. Treatment with DAIR was successful in 47 of 62 patients operated with primary and revision TKA as index operation. Those patients had no signs of infection and no antimicrobial therapy after a minimum of one year follow up time. The remaining 15 patients were in need of further surgery. Positive cultures could be obtained in 41 of 62 patients including those operated for aseptic revision arthroplasty. Staphylococcus aureus was by far the most common isolated organism with 24 isolations and the sole causative pathogen in 15 cases. When looking at all patients even including those with aseptic revision TKA we could see that the algorithm resulted in 57 of 62 patients (91,9%) ending up with a working knee prosthesis at the final follow up. In 47 (75,8%) cases prosthesis retention could be achieved with only a single DAIR procedure. We therefore conclude that the algorithm applied at our centre leads to satisfactory results