Despite the routine use of systemic antibiotic prophylaxis, postoperative infection following fracture surgery remains a persistent issue with substantial morbidity. The use of additional local antibiotic prophylaxis may have a protective effect and some orthopaedic surgeons have adopted their use in recent years, despite limited evidence of its beneficial effect. The purpose of this systematic review and meta-analysis was to evaluate the current literature regarding the effect of prophylactic local antibiotics on the rate of infection in fracture surgery in both open and closed fractures. A comprehensive search of Medline, EMBASE, and PubMed was performed. Cohort studies were eligible if they investigated the effect on infection rate of additional local antibiotic prophylaxis compared with systemic prophylaxis alone following fracture surgery. The data were pooled in a meta-analysis. In total, four randomized controlled trials and 11 retrospective cohort studies with a total of 6161 fractures from various anatomical locations were eligible for inclusion. The majority of the included studies were Level 3 evidence and had a moderate risk of bias. When all fractures were pooled, the risk of infection was significantly reduced when local antibiotics were applied compared with the control group receiving systemic prophylaxis only (OR = 0.39; 95%CI: 0.26 to 0.53, P < 0.001). In particular, there was a significant reduction in deep infections (OR = 0.59; 95%CI: 0.38 to 0.91, P = 0.017). The beneficial effect of local antibiotics for preventing total infection was seen in both open fractures (OR = 0.35; 95%CI: 0.23 to 0.53, P < 0.001) and closed fractures (OR = 0.58; 95%CI: 0.35 to 0.95, P = 0.029) when analyzed separately. This meta-analysis suggests a significant risk reduction for postoperative infection following fracture surgery when local antibiotics were added to standard systemic prophylaxis, with a protective effect present in both open and closed fractures

Post-operative infection is a serious complication of spine surgery and can contribute to the strain on the healthcare system's resources. The purpose of this study is to determine what factors affect the risk of developing postoperative infection. We hypothesize that female gender, smoking, diabetes, having thoracolumbar procedures, having a neurological deficit, increased age, body mass index (BMI), American Society of Anaesthesiologists (ASA) score, blood loss, number of operative levels, operative time and undergoing non-elective surgery will increase the patients' risk of developing a post-operative infection. A retrospective review of prospectively collected data within the Canadian Spine Outcome and Research Network (CSORN) was conducted. Data was analyzed using IBM-SPSS. Multivariable logistical regression analysis was conducted (odds ratios) to determine any association between the outcome and independent factors. Significance level was p < 0.05. There were 7747 patients identified from the registry that had completed at least 12 weeks of follow up. There were 199 infections recorded representing a 2.6% risk of infection. There were no association found between the risk of developing a post operative infection and gender, smoking, diabetes, having thoracolumbar procedures, having a neurological deficit, ASA score, blood loss, number of operative levels and undergoing non-elective surgery. The following were associated with an increased risk of developing a post operative infection: Older age (adjusted OR=1.021, 95% CI=1.005–1.038, p < 0 .05), having an elevated BMI (adjusted OR=1.042, 95% CI=1.013–1.072, p < 0 .005), longer operative time (adjusted OR=1.002, 95% CI=1.001–1.004, p < 0 .001). There is a 2.6% overall rate of post-operative spine infection across 20 Canadian centres. The factors that were associated with an increased risk of developing a post operative-infection were older age, increased BMI and longer operative time. This study establishes a benchmark against which the effectiveness of future interventions to reduce infection can be compared

Our aim was to explore factors associated with early post operative infection for surgically managed base of 4th/5th metacarpal fractures. We hypothesised that K-wires crossing the 4th and 5th carpometacarpal joint (CMCJ) would be associated with an increased risk of post-operative infection.

Data from consecutive patients requiring surgical fixation for a base of 4th/5th metacarpal fracture from October 2016 to May 2021 were collected. Patient demographics, time to surgery, length of surgery, operator experience, use of tourniquet, intra-operative antibiotics, number and thickness of K-wire used, as well as whether or not the K-wires crossed CMCJ joints were recorded. Factors associated with post operative infection were assessed using Chi Squared test and univariable logistic regression using R studio.

Of 107 patients, 10 (9.3%) suffered post operative infection. Time to surgery (p 0.006) and length of operation (p=0.005) were higher in those experiencing infection. There was a trend towards higher risk of infection seen in those who had K-wires crossed (p=0.06). On univariable analysis, patients who had wires crossed were >7 times more likely to experience infection than those who didn't (OR 7.79 (95% CI, 1.39 - 146.0, p=0.056). Age, smoking, K-wire size, number of K-wires used, intraoperative antibiotics, tourniquet use and operator experience were not associated with infection.

In patients with a base of 4th/5th metacarpal fractures requiring surgical fixation, we find an increased risk of post-operative infection associated with K-wires crossing the CMCJ, which has implications for surgical technique. Larger prospective studies would be useful in further delineating these findings.

The April 2023 Spine Roundup. 360. looks at: Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy; Spine surgical site infections: a single debridement is not enough; Lenke type 5, anterior, or posterior: systematic review and meta-analysis; Epidural steroid injections and postoperative infection in lumbar decompression or fusion; Noninferiority of posterior cervical foraminotomy versus anterior cervical discectomy; Identifying delays to surgical treatment for metastatic disease; Cervical disc replacement and adjacent segment disease: the NECK trial; Predicting complication in adult spine deformity surgery

The June 2023 Wrist & Hand Roundup. 360. looks at: Residual flexion deformity after scaphoid nonunion surgery: a seven-year follow-up study; The effectiveness of cognitive behavioural therapy for patients with concurrent hand and psychological disorders; Bite injuries to the hand and forearm: analysis of hospital stay, treatment, and costs; Outcomes of acute perilunate injuries - a systematic review; Abnormal MRI signal intensity of the triangular fibrocartilage complex in asymptomatic wrists; Patient comprehension of operative instructions with a paper handout versus a video: a prospective, randomized controlled trial; Can common hand surgeries be undertaken in the office setting?; The effect of corticosteroid injections on postoperative infections in trigger finger release

Aims. The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing joint arthroplasty have a higher incidence of adverse outcomes than those without IBD. Methods. A comprehensive literature search was conducted to identify eligible studies reporting postoperative outcomes in IBD patients undergoing joint arthroplasty. The primary outcomes included postoperative complications, while the secondary outcomes included unplanned readmission, length of stay (LOS), joint reoperation/implant revision, and cost of care. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model when heterogeneity was substantial. Results. Eight retrospective studies involving 29,738 patients with IBD were included. Compared with non-IBD controls, patients with IBD were significantly more likely to have overall complications (OR 2.11 (95% CI 1.67 to 2.66), p < 0.001), medical complications (OR 2.15 (95% CI 1.73 to 2.68), p < 0.001), surgical complications (OR 1.43 (95% CI 1.21 to 1.70), p < 0.001), and 90-day readmissions (OR 1.42 (95% CI 1.23 to 1.65), p < 0.001). The presence of IBD was positively associated with the development of venous thromboembolism (OR 1.60 (95% CI 1.30 to 1.97), p < 0.001) and postoperative infection (OR 1.95 (95% CI 1.51 to 2.51), p < 0.001). In addition, patients with IBD tended to experience longer LOS and higher costs of care. Conclusion. The findings suggest that IBD is associated with an increased risk of postoperative complications and readmission after joint arthroplasty, resulting in longer hospital stay and greater financial burden. Surgeons should inform their patients of the possibility of adverse outcomes prior to surgery and make appropriate risk adjustments to minimize potential complications. Cite this article: Bone Joint Res 2023;12(6):362–371

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. Methods. A total of 60 patients (25 females, 35 males; mean age 39 years (SD 18)) undergoing iliosacral resection were reviewed. Most resections were performed for primary malignant tumours (n = 54; 90%). The mean follow-up for surviving patients was nine years (2 to 19). Results. Overall, 27 patients (45%) were reconstructed, while 33 (55%) had no formal reconstruction. There was no difference in the use of chemotherapy (p = 1.000) or radiotherapy (p = 0.292) between the groups. Patients with no reconstruction had a mean larger tumour (11 cm (SD 5) vs 8 cm (SD 4); p = 0.014), mean shorter operating times (664 mins (SD 195) vs 1,324 mins (SD 381); p = 0.012), and required fewer blood units (8 (SD 7) vs 14 (SD 11); p = 0.012). Patients undergoing a reconstruction were more likely to have a deep infection (48% vs 12%; p = 0.003). Nine reconstructed patients had a hardware failure, with five requiring revision. Postoperatively 55 (92%) patients were ambulatory, with no difference in the proportion of ambulatory patients (89% vs 94%; p = 0.649) or mean Musculoskeletal Tumor Society Score (59% vs 65%; p = 0.349) score between patients who did or did not have a reconstruction. The ten-year disease-specific survival was 69%, with no difference between patients who were reconstructed and those who were not (78% vs 45%; p = 0.316). There was no difference in the rate of metastasis between the two groups (hazard ratio (HR) 2.78; p = 0.102). Conclusion. Our results demonstrate that SIJ reconstruction is associated with longer operating times, greater need for blood transfusion, and more postoperative infections, without any improvement in functional outcomes when compared to patients who did not have formal SIJ reconstruction. Cite this article: Bone Joint J 2024;106-B(1):93–98

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

Over 13 months we prospectively monitored C-Reactive Protein (CRP) to assess surgical site infection (SSI) in 148 patients undergoing hip arthroplasty, including 34 hemiprostheses for femoral neck fracture, 35 hemiprostheses for osteosynthesis failure, 17 primary total hip arthroplasties (THAs) and 62 revisions of hemi-arthroplasty or THA. Ten patients who had probably had interaction with CRP were included.

In four out of seven patients with SSI, CRP values peaked three days after the operation, compared to eight out of 131 without SSI (p =0.0001). This gives a 60% sensitivity for detecting SSI by the CRP curve, with a specificity of 94%. The positive predictive value was 33%, and the negative predictive value 98%.

Previous studies have established the normal CRP curve after major joint replacement surgery. This study shows that a peak in CRP after day three may indicate SSI, or point to other deep infections such as pneumonia.

Methods. We conducted a single centre prospective observational study comparing post-operative infection rates in HIV positive and HIV negative patients presenting with tibial shaft fractures managed with surgical fixation. Results. Twenty eight patients were incorporated over a six month period and followed up for three months post operatively. 25 open fractures including 6 HIV positive patients and 3 closed fractures including 1 HIV positive patient were assessed for signs of wound sepsis assessed with the asepsis wound score. 21 patients treated with external fixation including 4 HIV positive patients were also assessed using Checkett's scoring system for pin site infection. There was no significant difference in post-operative wound infection rates between the HIV positive (mean wound score = 7.7) and HIV negative (mean = 3.7) patients (p=0.162). HIV positive patients were also found to be at no increased risk of pin site sepsis (p=0.520). No correlation was found between CD4 counts of HIV positive patients and wound infection rates. Conclusions. Our results show that HIV positive patients with tibial fractures are not significantly more at risk of wound infection postoperatively. External fixation has also been shown to be a safe effective treatment of open tibial fractures in HIV patients

Introduction: Infection after hip or knee replacement occurs with low frequency but shares high morbidity. Aim of this study was an evaluation of incidence and risk factors related to post operative infection after joint lower limb joint replacement in an orthopaedics unit.

Material and methods: This is a monocentric, retrospective, case control study over the years 2000 to 2002. All first intention Total Hip and Knee Replacement and revision cases for mechanical reasons that became infected were identified. Demographic, surgical and medical variables, potentially associated to prosthetic infection were compared for these patients to a control group of non ifected patients over the same time, matched for sex, age and surgery type.

Results: Ten patients, all male, contracted post operative joint infection, out of 630 Total Hip or Knee Arthroplasties. This represented 1.2% after hip replacement and 3.1% after knee replacement. Bacteriological datas showed a majority of Staphylococal infection (5 aureus, 1 epidermidis), 2 among these being resistant to meticillin, but also evidence of ENT commensals (2 Streptococci milleri, 1 Actinomyces) and one epidermal commensal (Propionobacterium acnes). Univariate analysis: datas associated with increased risk of infection were diabetes melitus (OR 9.3; CI 95% 1.4–63), operating time exceeding 120 minutes (OR15.5 ; CI 95% 1,73–139,66), superficial wound infection (odds ratio 29; CI95% 2,77–303,32), coinfection outside the operation site (urinary tract , dental infection) (OR: 9,3 ; CI 95% 1,33–63,2). In our study an MNIS score higher than 1, autologous transfusion, locore-gional anaesthesia with or without the use of a catheter, antibioprophylaxis that did not comply with national recommendations could not be drawn as a risk factor.

Discussion: Incidence of infection and risk factors related to infection in our study were found similar tothe results of published datas. The small number of events (10 cases) did not allow us to realize multivariate analysis and could explain that some known risk factors such as non recommended antibioprophylaxis, could not be elicitated. However these results suggested the need to reevaluate the system of prevention of infection in our centre such as protocolization of antibioprophylaxis and screening for and treatement of perioperative coinfection.

The purpose of this randomized controlled trial is to evaluate the efficacy of using dilute betadine versus sterile saline lavage in aseptic revision total knee (TKA) and hip (THA) arthroplasty to prevent acute postoperative deep periprosthetic joint infection (PJI).

Of the 450 patients that were randomized, 5 did not have 90-day follow-up, 9 did not receive the correct treatment, and 4 were excluded for intraoperative findings consistent with PJI. 221 Patients (144 knees and 77 hips) received saline lavage only and 211 (136 knees and 75 hips) received a three-minute dilute betadine lavage (0.35%) prior to wound closure. Patients were observed for the incidence of acute postoperative deep PJI within 90 days of surgery. Statistical analysis was performed using t-tests or Fisher's exact test where appropriate. Power analysis determined that 285 patients per group are needed to detect a reduction in the rate of PJI from 5% to 1% (alpha=0.05, beta=0.20).

There were seven PJIs in the saline group and one in the betadine lavage group (3.2% vs. 0.5%, p=0.068). There were no significant differences in any baseline demographics between groups suggesting appropriate randomization.

Although we believe the observed difference between treatments is clinically relevant, it was not statistically significant with the sample size enrolled thus far and enrollment is ongoing. Nonetheless, we believe that these data suggests that dilute betadine lavage is a simple method to reduce the rate of acute postoperative PJI in patients undergoing aseptic revision procedures.

For one year (July 1999-July 2000), the rate of post-operative infection in patients undergoing joint arthroplasty was recorded (including wound, chest UTI etc). Standard precautions against infection used in most orthopaedic units in the UK were employed.

In July 2000 elective orthopaedic beds were ‘ring-fenced’. Only elective orthopaedic patients who had negative swabs for MRSA in the community were admitted. Eradication therapy was commenced in the community if appropriate. Trauma and other specialties’ patients were excluded.

In addition to standard precautions, nurses wore a disposable apron and gloves for each intervention. Antibacterial hand cleanser was installed by each bed, and staff expected to use it after each consultation. Doctors left jackets at the door and donned clean white coats for ward rounds. These were left on the ward and laundered daily. New cleaning regimes were adopted.

Pre ring-fencing, 417 joint replacements were performed and 60 patients were cancelled due to no bed. There were 43 post-op infections, 9 of which were MRSA. In the year post ring-fencing, 488 joint replacements were performed; there were no cancellations due to bed shortage. There were 15 post-op infections and no MRSA.

Eight patients swabbed positive for MRSA in the community, and were admitted after eradication therapy with no infections post-op.

We concluded that ‘ring-fencing’ of elective orthopaedic beds reduced cancellations, reduced the overall infection rate and abolished MRSA.

We have continued to ring-fence elective beds following this study, and recommend these precautions be employed in all units dealing with elective orthopaedic patients.

Aims

It remains difficult to diagnose early postoperative periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). We aimed to validate the optimal cutoff values of ESR, CRP, and synovial fluid analysis for detecting early postoperative PJI in a large series of primary TKAs.

Abstract

Aims. Wrist arthroscopy is a standard procedure in hand surgery for diagnosis and treatment of wrist injuries. Even though not generally recommended for similar procedures, general administration of perioperative antibiotic prophylaxis (PAP) is still widely used in wrist arthroscopy. Methods. A clinical ambispective dual-centre study was performed to determine whether PAP reduces postoperative infection rates after soft tissue-only wrist arthroscopies. Retrospective and prospective data was collected at two hospitals with departments specialized in hand surgery. During the study period, 464 wrist arthroscopies were performed, of these 178 soft-tissue-only interventions met the study criteria and were included. Signs of postoperative infection and possible adverse drug effects (ADEs) of PAP were monitored. Additionally, risk factors for surgical site infection (SSIs), such as diabetes mellitus and BMI, were obtained. Results. The overall infection rate of SSI was zero. Neither in the PAP group (n = 69) nor in the control group (n = 109) were signs of postoperative infection observed. Observed symptoms of ADEs were three-times higher in the PAP group when compared to the control-group (16.3 vs 5.5%; p = 0.043). No major ADEs were observed, but one in ten patients in the PAP group reported mild to severe intestinal or hypersensitivity symptoms. Conclusion. We demonstrate that the number needed to treat (NNT) with PAP to prevent one postoperative infection in soft-tissue arthroscopies of the wrist is > 109. Conversely, symptoms of ADEs were reported by one out of ten patients given PAP. Considering the high NNT to prevent postoperative infection and the large number of ADEs caused by PAP, we recommend not to use PAP routinely in soft-tissue arthroscopies of the wrist. Subsequent large-scale studies should be conducted to substantiate these results. Cite this article: Bone Jt Open 2023;4(4):219–225

Aims. There is conflicting evidence on the safety of intra-articular injections of hyaluronic acid (HA) or corticosteroids (CSs) before total knee arthroplasty (TKA). We performed a meta-analysis of the relationship between intra-articular injections and subsequent infection rates after TKA. Methods. We searched PubMed, EMBASE, and the Cochrane Library for cohort studies that assessed the effect of preoperative injection of drugs into the joint cavity on the infection rate after TKA. The outcomes analyzed included the total infection rate, as well as those for different preoperative injection time periods and different drugs. Results. Eight studies, including 73,880 in the injection group and 126,187 in the control group, met the inclusion criteria. The injection group had a significantly higher postoperative infection rate than the control group (risk ratio (RR) 1.16; 95% confidence interval (CI) 1.07 to 1.27; p < 0.001; I. 2. = 32%). For patients who received injections up to three months preoperatively, the postoperative infection risk was significantly higher than that in the control group (RR 1.26; 95% CI 1.18 to 1.35; p＜0.001; I. 2. = 0%). There was no significant difference in the infection rates between the four-to-six-month injection and control groups (RR 1.12; 95% CI 0.93 to 1.35; p = 0.240; I. 2. = 75%) or between the seven-to-12-month injection and control groups (RR 1.02; 95% CI 0.94 to 1.12; p = 0.600; I. 2. = 0%). Conclusion. Current evidence suggests that intra-articular injections of CSs or HA before TKA increase the risk of postoperative infection. Injections administered more than three months before TKA do not significantly increase the risk of infection. Cite this article: Bone Joint Res 2022;11(3):171–179

The routine use of intraoperative vancomycin powder to prevent postoperative wound infections has not been borne out in the literature in the pediatric spine population. The goal of this study is to determine the impact of vancomycin powder on postoperative wound infection rates and determine its potential impact on microbiology. A retrospective analysis of the Harms Study Group database of 1269 adolescent idiopathic scoliosis patients was performed. Patients that underwent a posterior fusion from 2004-2018 were analyzed. A comparative analysis of postoperative infection rates was done between patients that received vancomycin powder to those who did not. Statistical significance was determined using Chi-squared test. Additionally, the microbiology of infected patients was examined. In total, 765 patients in the vancomycin group (VG) were compared to 504 patients in the non-vancomycin group (NVG). NVG had a significantly higher rate of deep wound infection (p<0.0001) and associated reoperation rate compared to VG (p<0.0001). Both groups were compared for age, gender, race, weight, surgical time, blood loss, number of levels instrumented, and preop curve magnitude. There were significant differences between the groups for race (p<0.0001); surgical time (p=0.0033), and blood loss (p=0.0021). In terms of microbiology, VG grew p.acnes (n=2), and serratia (n=1), whereas NVG grew p.acnes (n=1) and gram positive bacilli (n=1). The remaining cultures were negative. The use of intraoperative vancomycin powder in adolescent idiopathic scoliosis appears to contribute significantly to deep wound infection prevention and reduction of associated reoperations. Based on this study's limited culture data, Vancomycin does not seem to alter the microbiology of deep wound infections

Aim. Mega-endoprosthesis over the last two decades have played a significant role in management of non-neoplastic cases for limb salvage for a variety of indications involving bone loss, infection, fracture and failed revision surgery. This is a retrospective case control study comparing outcomes of Mega-Endoprosthesis (MEP) in non-neoplastic cases with periprosthetic joint infections (PJI), with previous history of PJI and aseptic revision. Failure was defined as persistence/recurrence of infection, all cause revision, and antibiotic suppression during the follow up period. Secondary aims were identification of causative organisms, resistance profile and causative factors for revision surgery. Method. A total of 122 patients undergoing 133 MEPs were identified between January 2012 and December 2020. 60 procedures were categorised as group 1 (infection; 50%), 20 as group 2 (previous history of infection; 16.7%), and 53 controls (no infection; 44.2%). Mean age of the cohort was 70.97 years (37.16–94.17), with a mean follow-up of 44.5 months (0.2–179) including patients lost to follow up. Results. Overall failure rate was 71/133 53.3% (group 1 39/60 (55.56%), group 2 12/20 (60%) and controls 20/53 (37.7%)). Thirteen patients died in the first 2 years (five in group 1, one in group 2 & seven in controls). The most common postoperative infection was polymicrobial followed by Coagulase Negative Staphylococcus Species (CoNS) and Methicillin Sensitive Staphylococcus aureus (MSSA). Nineteen patients had polymicrobial PJI (Eighteen in group 1 and one in control). CoNS led to postoperative infection in Fifteen patients (six in group 1, five in group 2 and four in control group). MSSA was the pathogen in four patients (three in group-1 and one in the control group). The same organisms were responsible for recurrent infection in fourteen patients in group 1 and one patient in group 2. Limb salvage was achieved in 96.2% overall (95% group 1, 90% group 2, 100% control group). Conclusions. MEPs in the context of PJI have a significant risk of failure however they play an important role in limb salvage. Patients should be counselled appropriately prior to surgery

Postoperative surgical site infection in patients treated with lumbosacral fusion has been believed to be caused by perioperative contamination (Perioperative Inside-Out infections) in patients with comorbidities. With the proximity of these incisions to the perianal region and limited patient mobility in the early post-operative period, local contamination from gastrointestinal and/or urogenital flora (Postoperative Outside-In infections) should be considered as a major source of complication. A single center, retrospective review of adult patients treated with open posterior lumbosacral fusions between January 2014 and January 2021. We aimed to identify common factors in patients experiencing deep postoperative infections. Oncological, minimally invasive, primary infection, and index procedures carried out at other institutions were excluded. We identified 489 eligible patients, 20 of which required debridement deep to the fascia (4.1%). Mean age (62.9 vs 60.8), operative time (420 vs 390 minutes), estimated blood loss (1772 vs 1790 mL) and median levels fused (8.5 vs 9) were similar between the infected and non-infected groups. There was a higher percentage of deformity patients (75% vs 29%) and increased BMI (32.7 vs 28.4) in the infected group. The mean time from primary procedure to debridement was 40.8 days. Four patients showed no growth on culture. Three showed Staphylococcus species (Perioperative Inside-Out infections) requiring debridement at a mean of 100.3 days (95%CI 0- 225 days). Thirteen patients showed infection with intestinal or urogenital pathogens (Postoperative Outside-In infections) requiring debridement at a mean of 20.0 days (95%CI 9-31 days). Postoperative Outside-In infections led to debridement 80.3 days earlier than Perioperative Inside-Out infections (p= 0.007). In this series, 65% of deep infections were due to early local contamination by gastrointestinal and/or urogenital tracts pathogens. These infections were debrided significantly earlier than the Staphylococcus species infections. Due to the proximity of the incisions to the perianal region, there should be increased focus on post-operative local wound management to ensure these pathogens are away from the wound during the critical stages of wound healing

Aims. Tibiotalocalcaneal (TTC) fusion is used to treat a variety of conditions affecting the ankle and subtalar joint, including osteoarthritis (OA), Charcot arthropathy, avascular necrosis (AVN) of the talus, failed total ankle arthroplasty, and severe deformity. The prevalence of postoperative complications remains high due to the complexity of hindfoot disease seen in these patients. The aim of this study was to analyze the relationship between preoperative conditions and postoperative complications in order to predict the outcome following primary TTC fusion. Methods. We retrospectively reviewed the medical records of 101 patients who underwent TTC fusion at the same institution between 2011 and 2019. Risk ratios (RRs) associated with age, sex, diabetes, cardiovascular disease, smoking, preoperative ankle deformity, and the use of bone graft during surgery were related to the postoperative complications. We determined from these data which pre- and perioperative factors significantly affected the outcome. Results. Out of the 101 patients included in the study, 29 (28.7%) had nonunion, five (4.9%) required below-knee amputation (BKA), 40 (39.6%) returned to the operating theatre, 16 (15.8%) had hardware failure, and 22 (21.8%) had a postoperative infection. Patients with a preoperative diagnosis of Charcot arthropathy and non-traumatic OA had significantly higher nonunion rates of 44.4% (12 patients) and 39.1% (18 patients) (p = 0.016) and infection rates of 29.6% (eight patients) and 37% (17 patients) compared to patients with traumatic arthritis, respectively (p = 0.002). There was a significantly increased rate of nonunion in diabetic patients (RR 2.22; p = 0.010). Patients with chronic kidney disease were 2.37-times more likely to have a nonunion (p = 0.006). Patients aged over 60 years had more than a three-fold increase in the rate of postoperative infection (RR 3.60; p = 0.006). The use of bone graft appeared to be significantly protective against postoperative infection (p = 0.019). Conclusion. We were able to confirm, in the largest series of TTC ankle fusions currently in the literature, that there remains a high rate of complications following this procedure. We found that patients with a Charcot or non-traumatic arthropathy had an increased risk of nonunion and postoperative infection compared to individuals with traumatic arthritis. Those with diabetes, chronic kidney disease, or aged over 60 years had an increased risk of nonunion. These findings help to confirm those of previous studies. Additionally, our study adds to the literature by showing that autologous bone graft may help in decreasing infection rates. These data can be useful to surgeons and patients when considering, discussing and planning TTC fusion. It helps surgeons further understand which patients are at a higher risk for postoperative complications when undergoing TTC fusion. Cite this article: Bone Joint J. 2020;102-B(3):345–351

Aims. The purpose of this study was to: review the efficacy of the induced membrane technique (IMT), also known as the Masquelet technique; and investigate the relationship between patient factors and technique variations on the outcomes of the IMT. Methods. A systematic search was performed in CINAHL, The Cochrane Library, Embase, Ovid MEDLINE, and PubMed. We included articles from 1 January 1980 to 30 September 2019. Studies with a minimum sample size of five cases, where the IMT was performed primarily in adult patients (≥ 18 years old), in a long bone were included. Multivariate regression models were performed on patient-level data to determine variables associated with nonunion, postoperative infection, and the need for additional procedures. Results. A total of 48 studies were included, with 1,386 cases treated with the IMT. Patients had a mean age of 40.7 years (4 to 88), and the mean defect size was 5.9 cm (0.5 to 26). In total, 82.3% of cases achieved union after the index second stage procedure. The mean time to union was 6.6 months (1.4 to 58.7) after the second stage. Our multivariate analysis of 450 individual patients showed that the odds of developing a nonunion were significantly increased in those with preoperative infection. Patients with tibial defects, and those with larger defects, were at significantly higher odds of developing a postoperative infection. Our analysis also demonstrated a trend towards the inclusion of antibiotics in the cement spacer having a protective effect against the need for additional procedures. Conclusion. The IMT is an effective management strategy for complex segmental bone defects. Standardized reporting of individual patient data or larger prospective trials is required to determine the optimal implementation of this technique. This is the most comprehensive review of the IMT, and the first to compile individual patient data and use regression models to determine predictors of outcomes. Cite this article: Bone Joint J 2020;102-B(12):1723–1734

Aims. The primary aim of this study was to determine if delayed clavicular fixation results in a greater risk of operative complications and revision surgery. Patients and Methods. A retrospective case series was undertaken of all displaced clavicular fractures that underwent plate fixation over a ten-year period (2007 to 2017). Patient demographics, time to surgery, complications, and mode of failure were collected. Logistic regression was used to identify independent risk factors contributing towards operative complications. Receiver operating characteristic (ROC) curve analysis was used to determine if a potential ‘safe window’ exists from injury to delayed surgery. Propensity score matching was used to construct a case control study for comparison of risk. Results. A total of 259 patients were included in the analysis. Postoperative infection occurred in 3.9% of all patients (n = 10); the only variable associated was a greater time interval from injury to fixation (p = 0.001). Failed primary surgery requiring revision fixation was required in 7.7% of the cohort (n = 20), with smoking (p < 0.001), presence of a postoperative infection (p < 0.001), increasing age (p = 0.018), and greater time delay from injury to surgery (p = 0.015) identified as significant independent predictors on regression analysis. ROC analysis revealed that surgery beyond 96 days from injury increased the rate of major complications and revision surgery. Using a matched case cohort of cases before (n = 67) and after (n = 77) the ‘safe window’, the risk of postoperative infection increased (odds ratio (OR) 7.7, 95% confidence interval (CI) 1.9 to 62.9; p = 0.028), fixation failure (OR 3.8, 95% CI 1.2 to 12.1; p = 0.017) and revision surgery (OR 4.8, 95% CI 1.5 to 15.0; p = 0.004). Conclusion. A delay to primary fixation of up to three months following injury may be acceptable, beyond which there is an increased risk of major operative complications and revision surgery. Cite this article: Bone Joint J 2019;101-B:1385–1391

Aim. Surgical treatment of ankle fractures comes with a substantial risk of complications, including infection. An unambiguously definition of fracture-related infections (FRI) has been missing. Recently, FRI has been defined by a consensus group with a diagnostic algorithm containing suggestive and confirmatory criteria. The aim of the current study was to report the prevalence of FRI in patients operated for ankle fractures and to assess the applicability of the diagnostic algorithm from the consensus group. Method. Records of all patients with surgically treated ankle fractures from 2015 to 2019 were retrospectively reviewed for signs of postoperative infections. Patients with suspected infection were stratified according to confirmatory or suggestive criteria of FRI. Rate of FRI among patients with confirmatory and suggestive criteria were calculated. Results. Suspected infection was found in 104 (10%) out of 1004 patients. Among those patients, confirmatory criteria were met in 76/104 (73%) patients and suggestive criteria were met in 28/104 (27%) at first evaluation. Patients with clinical confirmatory criteria (N= 76) were diagnosed with FRI. Patients with suggestive criteria were further examined with either bacterial sampling at the outpatient clinic, revision surgery including bacterial sampling, or a wait-and-see approach. Eleven (39%) of the 28 patients had positive cultures and were therefore diagnosed as having FRI at second evaluation. In total 87 (9%) patients were diagnosed with FRI according to the consensus definition. Only 73 (70%) of the 104 patients with suspected FRI had adequate bacterial sampling. Conclusions. The prevalence of FRI, applying the FRI-consensus criteria, for patients with surgically treated ankle fractures was 9%. Twenty-two percent of patients who met the confirmatory criteria had negative bacterial cultures. The current study shows that we did not have a systematic approach to patients with suspected FRI as recommended by the consensus group. A systematic approach to adequate bacterial sampling when FRI is suspected is paramount. The consensus definition of FRI and its diagnostic algorithm facilitates such an approach

Background. Surgical site infection following spine surgery is associated with increased morbidity, mortality and increased cost for the health care system. The reported pooled incidence is 3%. Perioperative antibiotic prophylaxis is a key factor in lowering the risk of acquiring an infection. Previous studies have assessed perioperative cefuroxime concentrations in the anterior column of the cervical spine with an anterior surgical approach. However, the majority of surgeries are performed in the posterior column and often involve the lumbar spine. Accordingly, the objective was to compare the perioperative tissue concentrations of cefuroxime in the anterior and posterior column of the same lumbar vertebra using microdialysis in an experimental porcine model. Method. The lumbar vertebral column was exposed in 8 female pigs. Microdialysis catheters were placed for sampling in the anterior column (vertebral body) and posterior column (posterior arch) within the same vertebra (L5). Cefuroxime (1.5 g) was administered intravenously over 10 min. Microdialysates and plasma samples were continuously obtained over 8 hours. Cefuroxime concentrations were quantified by Ultra High Performance Liquid Chromatography Tandem Mass Spectrometry. Microdialysis is a catheter-based pharmacokinetic tool, that allows dynamic sampling of unbound and pharmacologic active fraction of drugs e.g., cefuroxime. The primary endpoint was the time with cefuroxime above the clinical breakpoint minimal inhibitory concentration (T>MIC) for Staphylococcus aureus of 4 µg/mL as this has been suggested as the best predictor of efficacy for cefuroxime. The secondary endpoint was tissue penetration (AUC. tissue. /AUC. plasma. ). Results. Mean T>MIC 4 µg/mL (95% confidence interval) was 123 min (105–141) in plasma, 97 min (79–115) in the anterior column and 93 min (75–111) in the posterior column. Tissue penetration (95% confidence interval) was incomplete for both the anterior column 0.48 (0.40–0.56) and posterior column 0.40 (0.33–0.48). Conclusions. Open lumbar spine surgery often involves extensive soft tissue dissection, stripping and retraction of the paraspinal muscles which may impair the local blood flow exposing the lumbar vertebra to postoperative infections. A single intravenous administration of 1.5 g cefuroxime resulted in comparable T>MIC between the anterior and posterior column of the lumbar spine. Mean cefuroxime concentrations decreased below the clinical breakpoint MIC for S. aureus of 4 µg/mL after 123 min (plasma), 97 min (anterior column) and 93 min (posterior column). This is shorter than the duration of most lumbar spine surgeries, and therefore alternative dosing regimens should be considered in posterior open lumbar spine surgeries lasting more than 1.5 hours

After a hip fracture, infections are common, but signs of infection resemble those of systemic inflammatory response to trauma and surgery, and conventional infection markers lack specificity. Plasma-calprotectin, a novel marker of neutrophil activation, has shown potential as an infection marker in ER and ICU settings. To investigate if plasma-calprotectin is superior compared to conventional infection biomarkers after hip fracture. Prospective cohort study of hip fracture patients admitted to our department. Calprotectin, procalcitonin (PCT), C-reactive protein (CRP), and white blood cell (WBC) count were measured in blood plasma upon admission and on day 3 post-surgery. Patients with infection (pneumonia, UTI, sepsis, SSI, other soft tissue infections) pre- or post-surgery were compared to a control group without infection within 30 days. Statistics: Wilcoxon rank-sum test, medians with interquartile range, and area under the curve (AUC) with 95% confidence intervals. Pilot study comprises calprotectin obtained at least once for 60 patients at admission and 48 on day 3. Mean age 84 years (SD 8.4), 65% women. 9/60 patients (23%) were admitted with infections. They had higher levels of CRP (median 111 [73-149]) and PCT (0.35 [0.18–0.86]) compared to the control group (29 [16-64], p=0.037; 0.10 [0.07–0.17], p=0.007). Calprotectin (2.67 vs 2.51) and WBC (12.2 vs 9.3) did not differ significantly. AUC was highest for PCT (0.79 [CI 0.60–0.97]), followed by CRP (0.71 [0.46–0.96]), WBC (0.60 [0.35–0.84]), and calprotectin (0.58, [0.33–0.83]). Day 3, 6/48 (13%) had infections, without significant differences between groups in any marker. The median levels were: calprotectin 3.5 vs 3.1, CRP 172 vs 104, WBC 12 vs 9, PCT 0.16 vs 0.17. Calprotectin had highest AUC 0.68 (0.41–0.93, n.s.). AUC for WBC was 0.67 (0.31–1.00), CRP 0.66 (0.38–0.94), PCT 0.56 (0.29–0.82). Preliminary data show no significant associations with postoperative infection for any of the studied biomarkers. However, plasma-calprotectin might perform slightly better compared to conventional markers

Aims. The results of irrigation and debridement with component retention (IDCR) in the treatment of acutely infected total knee arthroplasties (TKAs) have been variable. The aim of this study was to assess the outcome after IDCR when combined with chronic antibiotic suppression. We also evaluated survivorship free from subsequent infection, removal of the components, and death, as well as the risk factors for failure. Patients and Methods. This was a single-centre retrospective review of 134 infected primary TKAs that were treated with IDCR. Infections within four weeks of the procedure were defined as acute postoperative infections, and those occurring more than four weeks after the procedure with symptoms for less than three weeks were defined as acute haematogenous infections. Patients were treated with intravenous antibiotics for four to six weeks, followed by chronic oral antibiotic suppression. Estimates of survival were made using a competing risk analysis. The mean follow-up was five years (2.1 to 13). Results. The infection was an acute postoperative infection in 23 TKAs and an acute haematogenous infection in 111 TKAs. The incidence of subsequent infection was 36% in those with an acute postoperative infection and 33% in those with a haematogenous infection, five years postoperatively (p = 0.40). Age < 60 years increased the risk of subsequent infection (hazard ratio (HR) 2.4; p = 0.009) and removal of the components (HR 2.8; p = 0.007). Infection with a staphylococcal species increased the risk of subsequent infection (HR 3.6; p < 0.001), and removal of the components (HR 3.2; p = 0.002). Musculoskeletal Infection Society host type and local extremity grade, body mass index (BMI), the duration of symptoms, gender, and the presence of a monoblock tibial component had no significant effect on the outcome. Conclusion. In a rigorously defined group of acute periprosthetic infections after TKA treated with IDCR and chronic antibiotic suppression, the infection-free survival at five years was 66%. The greatest risk factor for failure was an infection with a staphylococcal species, followed by age of < 60 years. Cite this article: Bone Joint J 2018;100-B:1471–76

Aim. Strenuous efforts to minimize postoperative infection rates have been made, including the Swedish nation-wide initiative Prosthesis Related Infections Shall be Stopped (PRISS). The aim of this study was to calculate the incidence rate of periprosthetic joint infections (PJI) following primary total knee arthroplasty (TKA) before and after PRISS. Method. All 45,438 primary TKAs registered in the Swedish knee arthroplasty register (SKAR) during 2007–2008 and 2012–2013 were included. Matched data on antibiotic prescriptions were obtained from the Swedish Prescribed Drug Register (SPDR). All patients with ≥28 days of continuous antibiotic treatment within 2 years of primary surgery had their medical charts reviewed to identify cases of PJI. Results. 644 PJIs were identified, equaling a 2-year cumulative incidence rate of 1.42% (95% CI: 1.31–1.53). The incidence rate was 1.41% before PRISS and 1.43% after. Diagnosis was made within 30 days of primary TKA in 52%, and within 90 days in 73% of the cases. 603 cases were reoperated. Debridement with exchange of the insert was performed in 32.1% and 62.5% of cases before and after PRISS respectively. Conclusions. No reduction in cumulative PJI incidence was seen after the PRISS initiative

The management of prosthetic joint infection (PJI) has been widely performed for total hip arthroplasties (THA), but none has compared it with hip resurfacing arthroplasty (RSA). We also carried out a retrospective case-control study comparing the surgical treatment of PJI by surgical debridement and implant retention between RSA and THA in order to clarify whether there was a difference in terms of (1) successful healing of PJI (2) functional scores after recovery (3) risk factors for recurrence of PJI. Our hypothesis was that simple debridement with prosthesis retention regardless of the timeframe allowed to obtain a higher success rate for RSA compared to THA. From 2010 to 2018, a single-center case-control study based on 3056 RSA found 13 PJI were age-matched (based on the 139 THA PJI treated) with 15 THA PJI (mean age of 53 years old (47–58) for THA and 59 (45–66) for RSA (p=0.34)). We compared their survival (absence of infectious recurrence) and the means differences between the 2 groups (demographical, clinical and biological data). There was no difference between the 2 groups concerning: age (p=0.3), BMI (p=0.4), initial diagnosis (p=0.4), operating time for primary surgery (p=0.3), the presence of a postoperative hematoma (p=0.4), the type of bacteria (p=0.5), the total duration of antibiotic therapy (p=0.9) and the type of antibiotic therapy (p=0.6). Early postoperative infections (less than 6 weeks) occurred in 7/13 RSA cases (54%) compared to 11/15 THA cases (73%). At the mean follow-up of 5 years (2–7), the success rate without recurrence was significantly higher in the RSA group 100% versus 66.7% (10/15) for the THA group (p=0.044). At the last follow-up, the Oxford Hip Score was higher in the RSA versus THA group's (14 versus 22 p=0.004). Simple surgical debridement an RSA without changing implants after PJI can be done regardless of the time to onset of infection. This is secondary to the absence of metaphyseal bone invasion and the low content of joint fluid

Introduction. Cheilectomy is a recommended procedure for the earlier stages of osteoarthritis of the 1. st. metatarsophalangeal joint. Although good improvement in symptoms have been reported in many studies, the long term performance of this procedure is not well understood. It is thought that a significant number of patients go onto have arthrodesis or joint replacement. We report on a large cohort of patients who received this procedure and report on the complications and mid-term outcome. Methods. This is a retrospective study looking at all patients who underwent cheilectomy for hallux rigidus between November 2007 and August 2018. Departmental database was used to access patient details and outcome measures recorded include: postoperative wound infection, patient reported improvement in pain and the incidence of further surgical interventions like revision cheilectomy and conversion to arthrodesis and arthroplasty. X-rays were studied using PACS to stage the osteoarthritis (Hattrup and Johnson classification). Results. A total of 240 feet in 220 patients (20 bilateral surgeries) were included in the study, there were 164 Females (75%) and 56 Males (25%), the median age was 55 years (range 22–90 years). Radiological assessment showed 89 Stage 1 arthritis(42%), 105 Stage 2 (50%), 17 Stage 3 (8%) and 9 patients were excluded due to unavailable X-rays. 5 patients (2%) had superficial wound infection. There were 16 further surgeries (7%) performed in this cohort, 12 arthrodesis (5%), 3 revision cheilectomy and 1conversion to arthroplasty. 157 patients were found to be pain-free at the latest post-operative visit (77%), 48 reported minimal pain (23%), 15 patients were excluded due to unavailable data. Conclusion. Cheilectomy appears to produce good improvement in pain with a low complication rate. The rate of conversion to arthrodesis/arthroplasty is lower than in many reported studies

Aims. Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP. Methods. This is a retrospective and observational study containing data from nine patients with a mean age of 14.1 years (9 to 25; three female, six male) with OP who were treated in our hospital between April 2008 and October 2018 with 20 surgical procedures due to 17 different fractures. Patient data included age, sex, operating time, length of stay, genetic type of the disease, previous surgery, fractures, complications, and comorbidity. Results. The mean follow-up period was 92.5 months (25 to 140). Bony union was observed in all of our patients. Osteomyelitis developed in two patients with femoral shaft fractures, and two patients had peri-implant stress fractures. Conclusion. Treatment of fractures in OP patients is difficult, healing is protracted, and the risk of postoperative infection is high. In children and young adults with OP who have open medullary canal and the epiphyses are not closed, fractures can be treated with surgical techniques such as intramedullary titanium elastic nail (TENS) technique or fixation with Kirschner (K)-wire. Cite this article: Bone Joint J 2020;102-B(8):1082–1087

Aims. To investigate the experience and emotional impact of prosthetic joint infection (PJI) on orthopaedic surgeons and identify holistic strategies to improve the management of PJI and protect surgeons’ wellbeing. Methods. In total, 18 prosthetic joint surgeons in Sweden were recruited using a purposive sampling strategy. Content analysis was performed on transcripts of individual in-person interviews conducted between December 2017 and February 2018. Results. PJI had a negative emotional impact on Swedish surgeons. Many felt guilt, stress, and a sense of failure, and several aspects of PJI management were associated with psychosocial challenges. Peer support was reported as the most important coping strategy as was collaborating with infectious disease specialists. Conclusion. Our study affirms that there is a negative emotional impact of PJI on surgeons which can be minimized by improved peer support and working in multidisciplinary teams. Based on the surgeons’ experiences we have identified desired improvements that may facilitate the management of PJI. These may also be applicable within other surgical specialties dealing with postoperative infections, but need to be evaluated for their efficacy. Cite this article: Bone Joint J 2020;102-B(6):736–743

Cheilectomy is a recommended procedure for early stage osteoarthritis of the 1st metatarsophalangeal joint. Although improvement in symptoms has been reported in many studies, long term performance is not well understood. It is thought that significant numbers of patients require subsequent arthrodesis or arthroplasty. We report on a large cohort of patients receiving this procedure and on complications, and mid-term outcome. This is a retrospective study looking at all patients undergoing cheilectomy for hallux rigidus between November 2007 and August 2018. Departmental database was used to record outcome measures including: postoperative wound infection, patient reported improvement in pain and incidence of further surgical interventions like revision cheilectomy, conversion to arthrodesis and arthroplasty. Osteoarthritis was staged radiographically using PACS (Hattrup and Johnson classification). A total of 240 feet in 220 patients (20 bilateral surgeries) were included with 164 females (75%) and 56 males (25%), the median age being 55 years (range 22–90 years). Radiological assessment showed 89 stage 1 arthritis (42%), 105 stage 2 (50%), 17 stage 3 (8%) and 9 patients were excluded due to unavailable radiographs. 5 patients (2%) had superficial wound infections. There were 16 further surgeries (7%); 12 arthrodesis (5%), 3 revision cheilectomy and 1 conversion to arthroplasty. 157 patients were found to be pain-free at the latest post-operative visit (77%), 48 reported minimal pain (23%), 15 patients were excluded due to incomplete data. Cheilectomy appears to effectively reduce pain with low complication rates. Rates of conversion to arthrodesis/arthroplasty are lower than in many reported studies

Aims. With resumption of elective spine surgery services in the UK following the first wave of the COVID-19 pandemic, we conducted a multicentre British Association of Spine Surgeons (BASS) collaborative study to examine the complications and deaths due to COVID-19 at the recovery phase of the pandemic. The aim was to analyze the safety of elective spinal surgery during the pandemic. Methods. A prospective observational study was conducted from eight spinal centres for the first month of operating following restoration of elective spine surgery in each individual unit. Primary outcome measure was the 30-day postoperative COVID-19 infection rate. Secondary outcomes analyzed were the 30-day mortality rate, surgical adverse events, medical complications, and length of inpatient stay. Results. In all, 257 patients (128 males) with a median age of 54 years (2 to 88) formed the study cohort. The mean number of procedures performed from each unit was 32 (16 to 101), with 118 procedures (46%) done as category three prioritization level. The majority of patients (87%) were low-medium “risk stratification” category and the mean length of hospital stay was 5.2 days. None of the patients were diagnosed with COVID-19 infection, nor was there any mortality related to COVID-19 during the 30-day follow-up period, with 25 patients (10%) having been tested for symptoms. Overall, 32 patients (12%) developed a total of 34 complications, with the majority (19/34) being grade 1 to 2 Clavien-Dindo classification of surgical complications. No patient required postoperative care in an intensive care setting for any unexpected complication. Conclusion. This study shows that safe and effective planned spinal surgical services can be restored avoiding viral transmission, with diligent adherence to national guidelines and COVID-19-secure pathways tailored according to the resources of the individual spinal units. Cite this article: Bone Jt Open 2021;2(12):1096–1101

Aim. Acute postoperative infection is reported to occur in 0.3–2% after arthroscopic rotator cuff repair. Few reports have addressed this dreaded complication although the costs are high both for the patient and for society. The aim of this prospective study was to describe incidence, treatment and outcome after acute postoperative infections following arthroscopic rotator cuff repair. Method. Patients undergoing arthroscopic rotator cuff repair in our department have been prospectively registered since 2009. 11 out of 1072 patients undergoing surgery developed an acute postoperative infection. The patients were examined with an MRI scan and/or functional scores (Constant Murley (CM) and WORC) at final follow-up. Results. All 11 patients that developed acute postoperative infections were male. Mean age was 54 (41–68) years. Except for male gender, no common underlying predisposing risk factor for infection could be identified. 1/11 patient had diabetes mellitus and 2/11 smoked. Average BMI was 27 (21–36). 1/11 was categorized as ASA 3 and the rest of the patients were ASA 1 and 2. All patients underwent arthroscopic debridement and biopsies were collected 26 (14–50) days after primary surgery. In 10 patients Propionibacterium acnes was cultured, and 6 of these patients also had positive cultures for coagulase negative staphylococci. In the remaining patient only coagulase negative staphylococcus was cultured. 5/11 patients were treated with one arthroscopic debridement, 5/11 had two arthroscopic debridements, whereas 1/11 required arthroscopic debridement four times before the infection was eradicated. Only 2/11 patients had to have their implants removed during the reoperation due to loosening of the suture anchors. All 11 patients were treated with parenteral antibiotics for 7–28 days, followed by oral treatment for 1–5 weeks, and all infections had resolved at final follow-up. Median CM score was 84 and median WORC score was 81% at follow-up median 22(11–28) months. 10 patients had a postoperative MRI scan after median 23 (3–49) months, 8 of them showing a healed cuff repair. Conclusions. Acute postoperative infections after arthroscopic rotator cuff repair can be eradicated with arthroscopic debridement(s) and removal of implants may not be necessary if patency is adequate. Despite the postoperative acute infection our patients presented good functional results and were satisfied at last follow-up

Aims. The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice. Methods. This UK-based multicentre retrospective national audit studied foot and ankle patients who underwent surgery between 13 January and 31 July 2020, examining time periods pre-UK national lockdown, during lockdown (23 March to 11 May 2020), and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included. A total of 43 centres in England, Scotland, Wales, and Northern Ireland participated. Variables recorded included demographic data, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates. Results. A total of 6,644 patients were included. Of the operated patients, 0.52% (n = 35) contracted COVID-19. The overall all-cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n = 9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n = 3 deaths). Matching for age, American Society of Anesthesiologists (ASA) grade, and comorbidities, the odds ratio of mortality with COVID-19 infection was 11.71 (95% confidence interval 1.55 to 88.74; p = 0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and among patients with and without COVID-19 infection. After lockdown the COVID-19 infection rate was 0.15% and no patient died of COVID-19. Conclusion. COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and postoperative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions. Cite this article: Bone Joint Open 2021;2(4):216–226

Aims. Graft infection following anterior cruciate ligament reconstruction (ACLR) may lead to septic arthritis requiring multiple irrigation and debridement procedures, staged revision operations, and prolonged courses of antibiotics. To our knowledge, there are no previous studies reporting on how gentamicin pre-soaking of hamstring grafts influences infection rates following ACLR. We set out to examine this in our study accordingly. Methods. This retrospective study included 2,000 patients (1,156 males and 844 females) who underwent primary ACLR with hamstring autografts between 2007 to 2017. This included 1,063 patients who received pre-soaked saline hamstring grafts for ACLR followed by 937 patients who received pre-soaked gentamicin hamstring grafts for ACLR. All operative procedures were completed by a single surgeon using a standardized surgical technique. Medical notes were reviewed and data relating to the following outcomes recorded: postoperative infection, clinical progress, causative organisms, management received, and outcomes. Results. Superficial wound infection developed in 14 patients (1.31 %) receiving pre-saline soaked hamstring grafts compared to 13 patients (1.38 %) receiving pre-gentamicin soaked hamstring grafts, and this finding was not statistically significant (p = 0.692). All superficial wound infections were treated with oral antibiotics with no further complications. There were no recorded cases of septic arthritis in patients receiving pre-gentamicin soaked grafts compared to nine patients (0.85%) receiving pre-saline soaked grafts, which was statistically significant (p = 0.004). Conclusion. Pre-soaking hamstring autographs in gentamicin does not affect superficial infection rates but does reduce deep intra-articular infection rates compared to pre-soaking hamstring grafts in saline alone. These findings suggest that pre-soaking hamstring autografts in gentamicin provides an effective surgical technique for reducing intra-articular infection rates following ACLR. Cite this article: Bone Jt Open 2021;2(1):66–71

INTRODUCTION. In the United States, the Centers for Medicare and Medicaid Services consider rates of unplanned hospital readmissions to be indicators of provider quality. Understanding the common reasons for readmission following total joint arthroplasty will allow for improved standards of care and better outcomes for patients. The current study seeks to evaluate the rates, reasons, and Medicare costs for readmission after total hip and total knee arthroplasty. METHODS. This study used the Limited Data Set (LDS) from the Centers for Medicare and Medicaid Services (CMS) to identify all primary, elective Total Knee Arthroplasties (TKA) and Total Hip Arthroplasties (THA) performed from January 2013 through June 2016. The data were limited to Diagnosis-Related Group (DRG) 470, which is comprised of major joint replacements without major complications or comorbidities. Readmissions were classified by corresponding DRG. Readmission rates, causes, and associated Medicare Part A payments were aggregated over a ninety-day post-discharge period for 804,448 TKA and 409,844 THA. RESULTS. There were 31,172 readmissions in the ninety days following THA, for a readmission rate of 7.6%. There were 51,768 readmissions following TKA, for a readmission rate of 6.4%. The leading causes of readmission post-THA were revision of hip or knee replacement (17.66%); septicemia (4.76%); and postoperative infections (3.74%). The most common reasons for readmission post-TKA were postoperative infections (6.42%); septicemia (4.84%); and esophagitis (3.85%). In contrast to THA, implant revisions only accounted for 2.51% of readmissions after TKA. The mean cost of readmission post-THA was $11,682, while the mean cost of readmission post-TKA was $8,955. DISCUSSION AND CONCLUSION. Ninety-day readmission rates for both THA and TKA remained stable for the duration of the study period, suggesting the need for additional research on the efficacy of various programs intended to reduce the incidence of readmission

Aim. The incidence of prosthetic joint infections can be severe to monitor, as they are rare events. Recent publications from National registries points toward a significant underestimation of reported infections. The aim of this project was to develop a complication register that could report the “true” and momentaneous incidence of prosthetic infections after total knee and hip arthroplasty. Method. All patients operated with total hip arthroplasty (THA) or total knee arthroplasty (TKA) at our hospital were included in a local quality registry. All complications were reported at follow-up at 2 and 3 months for total knee and hip arthroplasties respectively, and at 1-year follow up. Both primary and revision surgeries were included. In order to monitor complications of special interest, such as deep postoperative infections, key variables were presented in a g-chart. This chart shows the number of uncomplicated surgeries between each complication (such as infection) in a bar diagram. This diagram is easily read as high bars indicate a low incidence of complications and low bars indicate a high incidence. The diagram is updated and distributed for information every month. Results. From September 2010 till December 2015 we included 2093 primary total hip arthroplasties and 272 hip revisions. The overall incidence for prosthetic infection after primary THA within 1 year after surgery was 1.8% and for hip revisions 3.4%. The momentaneous incidence in December 2015 was 3% for both primary and revision THA together. In the same period 1555 total knee arthroplasties and 155 knee revisions were included. The overall incidence of prosthetic infection after primary TKA within 1 year after surgery was 1.2% and for knee revisions 2.2%. The momentaneous incidence in December 2015 was 2.5% for primary and revision TKA together. Conclusions. Reporting the number of uncomplicated surgeries between every unwanted event or complication, such as postoperative infections, is a good method for describing rare events. This method will reveal changes in the trend at an earlier stage and can be an important tool in the work on preventing postoperative infections. A local quality register can be important in order to report a “true” incidence of postoperative infections, as the risk of underestimation is lower than in a national registry

Abstract. Aim. With resumption of elective spine surgery services following the first wave of COVID-19 pandemic, we conducted a multi-centre BASS collaborative study to examine the clinical outcomes of surgeries. Methods. Prospective data was collected from eight spinal centres in the first month of operating following restoration of elective spine surgery following the first wave. Primary outcomes measures were the 30-day mortality rate and postoperative Covid-19 infection rate. Secondary outcomes analysed were the surgical, medical adverse events and length of inpatient stay. Results. 257 patients (128 Male) with an age range of 2–88 years formed the study cohort. The average workload from each unit was 32(range 16–101) with 118 procedures (46%) done as category 3 prioritisation level (Procedures performed in < 3 month). 87% of patients were low-medium “risk stratification” category. 195 patients (75.8%) isolated for two weeks preoperatively and all but four patients had COVID-19 negative test prior to surgery. None of the patients were diagnosed with COVID-19 infection nor was any mortality related to COVID-19 in the 30 day follow up period, with 25 patients having been tested for symptoms. 32 patients (12%) developed a total of 34 complications with 19/34 being grade 1–2 Clavien-Dindo classification of surgical complications. Median LOS 5.2 days and 78.4 % patients stayed less than a week. Conclusions. As per our study safe and effective planned spinal surgical services can be restored avoiding viral transmission, with adherence to national guidelines and COVID-secure pathways tailored according to the resources of the individual spinal units

Aims. Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann’s kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion. Methods. A retrospective review of patients treated surgically for Scheuermann’s kyphosis between 2006 and 2014 was performed. A total of 62 patients were identified, with 31 in each group. Parameters were compared to evaluate postoperative outcomes using chi-squared tests, independent-samples t-tests, and z-tests of proportions analyses where applicable. Results. There were six postoperative infections in the two-stage anteroposterior group compared with three in the one-stage posterior-only group. A total of four patients in the anteroposterior group required revision surgery, compared with six in the posterior-only group. There was a significantly higher incidence of junctional failure associated with the one-stage posterior-only approach (12.9% vs 0%, p = 0.036). Proximal junction kyphosis (anteroposterior fusion (74.2%) vs posterior-only fusion (77.4%); p = 0.382) and distal junctional kyphosis (anteroposterior fusion (25.8%) vs posterior-only fusion (19.3%), p = 0.271) are common postoperative complications following both surgical approaches. Conclusion. A two-stage anteroposterior fusion was associated with a significantly greater correction of the kyphosis compared with a one-stage posterior-only fusion, with a reduced incidence of junctional failure (0 vs 3). There was a notably greater incidence of infection with two-stage anteroposterior fusion; however, all were medically managed. More patients in the posterior-only group required revision surgery. Cite this article: Bone Joint J 2020;102-B(10):1368–1374

Aims. Elective orthopaedic services have had to adapt to significant system-wide pressures since the emergence of COVID-19 in December 2019. Length of stay is often recognized as a key marker of quality of care in patients undergoing arthroplasty. Expeditious discharge is key in establishing early rehabilitation and in reducing infection risk, both procedure-related and from COVID-19. The primary aim was to determine the effects of the COVID-19 pandemic length of stay following hip and knee arthroplasty at a high-volume, elective orthopaedic centre. Methods. A retrospective cohort study was performed. Patients undergoing primary or revision hip or knee arthroplasty over a six-month period, from 1 July to 31 December 2020, were compared to the same period in 2019 before the COVID-19 pandemic. Demographic data, American Society of Anesthesiologists (ASA) grade, wait to surgery, COVID-19 status, and length of hospital stay were recorded. Results. A total of 1,311 patients underwent hip or knee arthroplasty in the six-month period following recommencement of elective services in 2020 compared to 1,527 patients the year before. Waiting time to surgery increased in post-COVID-19 group (137 days vs 78; p < 0.001). Length of stay also significantly increased (0.49 days; p < 0.001) despite no difference in age or ASA grade. There were no cases of postoperative COVID-19 infection. Conclusion. Time to surgery and length of hospital stay were significantly higher following recommencement of elective orthopaedic services in the latter part of 2020 in comparison to a similar patient cohort from the year before. Longer waiting times may have contributed to the clinical and radiological deterioration of arthritis and general musculoskeletal conditioning, which may in turn have affected immediate postoperative rehabilitation and mobilization, as well as increasing hospital stay. Cite this article: Bone Jt Open 2021;2(8):655–660

Aims

Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.

Revision total knee arthroplasty (TKA) procedures performed secondary to periprosthetic joint infection (PJI) are associated with significant morbidity and mortality. These poor outcomes may be further complicated by the development of postoperative infection requiring aggressive antibiotic treatment. However, this antibiotic overuse may suppress patients' native bacterial flora, leading to Clostridium difficile infection (CDI). With the increased demand for primary TKAs and expected rise in revision TKA due to PJI, it is important to identify factors contributing to CDI. Therefore, we aimed to study the: 1) incidence, 2) demographics, length of stay (LOS), and total costs, and 3) risk factors and mortality associated with CDI in revision TKA patients. The National Inpatient Sample database was queried for all individuals diagnosed with PJI and who underwent revision TKA between 2009 and 2013. Patients who developed CDI during their in-patient hospital stay were identified, yielding 83,806 patients (799 with CDI) with a mean age of 65 (S.D.=11.2). Logistic regression analysis was conducted to assess the association between hospital- and patient-specific characteristics and the development of CDI. During the study period, the overall incidence of CDI after revision TKA was 1%. These patients were significantly older (mean age 69.05 vs. 65.52 yrs), had greater LOS (median 11 vs. 5 days), had greater costs ($30,612.93 vs. 18,873.75), and had higher in-hospital mortality (3.6 vs. 0.5%, p < 0 .001 for all) compared to those without infection. Patients with CDI were more likely to be treated in urban, not-for-profit, medium or large bed-sized hospitals located in the Northeast or Midwest (p < 0 .05 for all). Patients with underlying depression (OR 4.267, p=0.007) or fluid/electrolyte disorders (OR 3.48, p=0.001) were more likely to develop infection. Although CDI is a rare event following revision TKA, it can have detrimental consequences. Our report demonstrates that CDI is associated with longer LOS, higher costs, and greater in-hospital mortality. With increased legislative pressure to lower healthcare expenditures, it is crucial to identify means of preventing costly complications

Aims

Implant-related postoperative spondylodiscitis (IPOS) is a severe complication in spine surgery and is associated with high morbidity and mortality. With growing knowledge in the field of periprosthetic joint infection (PJI), equivalent investigations towards the management of implant-related infections of the spine are indispensable. To our knowledge, this study provides the largest description of cases of IPOS to date.

Aims

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

Introduction. In the lower extremity, lymphedema is characterized by fluid buildup and swelling which can lead to fibrosis of the skin and recurring soft-tissue infections. Risk factors include obesity, older age, lower extremity surgery, and radiotherapy. There is currently a paucity of data examining the impact of lymphedema in primary total knee arthroplasty (TKA). The purpose of this study was to review outcomes following primary TKA performed in patients with lymphedema compared to a matched cohort with primary osteoarthritis. Methods. Over a 19-year period (1998–2016), 144 patients underwent primary TKA with a preceding diagnosis of ipsilateral lymphedema (Table 1). There were 114 (79%) females, a mean age of 69 years, and mean BMI of 37.1 kg/m2. Mean follow-up was 7-years (range 2–17 years). A blinded analyst completed a 1:2 match of patients with lymphedema to a group of patients without lymphedema undergoing primary TKA for osteoarthritis during the same period. Matching criteria included sex, age, date of surgery, and BMI. Matched controls included 228 (79%) females along with a mean age and BMI of 69 and 36.4 kg/m2. The mean follow-up for the comparison cohort was 8 years (range 2–18 years). There were no significant differences between groups on the evaluated baseline parameters. Results: Patients with a history of lymphedema were at a significantly increased risk of revision TKA (HR 7.60, P<0.001), reoperation for any cause (HR 2.87, P<0.001), and postoperative infection (HR 6.19, P<0.001). Patients with lymphedema were also at increased risk for periprosthetic fracture (p=0.04) and tibial component loosening (p=0.01). Morbid obesity increased the risk of reoperation (HR 2.11, p=0.02) and trended toward increased risk of revision TKA (HR 2.29, p=0.059) and infection (HR 2.37, p=0.06). Discussion: Patients with lymphedema are at significantly increased risk of revision, reoperation, and infection following primary TKA. This data highlights the need for appropriate patient counseling in this population and optimization of lymphedema management before and after TKA. Results. Patients with a history of lymphedema were at a significantly increased risk of revision TKA (HR 7.60, P<0.001), reoperation for any cause (HR 2.87, P<0.001), and postoperative infection (HR 6.19, P<0.001). Patients with lymphedema were also at increased risk for periprosthetic fracture (p=0.04) and tibial component loosening (p=0.01). Morbid obesity increased the risk of reoperation (HR 2.11, p=0.02) and trended toward increased risk of revision TKA (HR 2.29, p=0.059) and infection (HR 2.37, p=0.06). Discussion. Patients with lymphedema are at significantly increased risk of revision, reoperation, and infection following primary TKA. This data highlights the need for appropriate patient counseling in this population and optimization of lymphedema management before and after TKA. For any figures or tables, please contact authors directly

The February 2024 Shoulder & Elbow Roundup³⁶⁰ looks at: Does indomethacin prevent heterotopic ossification following elbow fracture fixation?; Arthroscopic capsular shift in atraumatic shoulder joint instability; Ultrasound-guided lavage with corticosteroid injection versus sham; Combined surgical and exercise-based interventions following primary traumatic anterior shoulder dislocation: a systematic review and meta-analysis; Are vascularized fibula autografts a long-lasting reconstruction after intercalary resection of the humerus for primary bone tumours?; Anatomical versus reverse total shoulder arthroplasty with limited forward elevation; Tension band or plate fixation for simple displaced olecranon fractures?; Is long-term follow-up and monitoring in shoulder and elbow arthroplasty needed?

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Hip fractures are a major cause of morbidity and mortality, and malnutrition is a crucial determinant of these outcomes. This meta-analysis aims to determine whether oral nutritional supplementation (ONS) improves postoperative outcomes in older patients with a hip fracture.

Malnutrition is an important consideration during the perioperative period and albumin is the most common laboratory surrogate for nutritional status. The purpose of this study is to identify if preoperative serum albumin measurements are predictive of infection following arthroscopic procedures. Patients undergoing knee, shoulder or hip arthroscopy between 2006–2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients with an arthroscopic current procedural terminology code and a preoperative serum albumin measurement were included. Patients with a history of prior infection, including a non-clean wound class, pre-existing wound infection or systemic sepsis were excluded. Independent t-tests where used to compare albumin values in patients with and without the occurrence of a postoperative infection. Pre-operative albumin levels were subsequently evaluated as predictors of infection with logistic regression models. There were 31,906 patients who met the inclusion criteria. The average age was 55.7 years (standard deviation (SD) 14.62) and average BMI was 31.7 (SD 7.21). The most prevalent comorbidities were hypertension (49.2%), diabetes (18.4%) and smoking history (16.9%). The average preoperative albumin was 4.18 (SD 0.42). There were 45 cases of superficial infection (0.14%), 10 cases of wound dehiscence (0.03%), 17 cases of deep infection (0.05%), 27 cases of septic arthritis or other organ space infection (0.08%) and 95 cases of any infection (0.30%). The preoperative albumin levels for patients who developed septic arthritis (mean difference (MD) 0.20, 95% CI, 0.038, 0.35, P = 0.015) or any infection (MD 0.14, 95% CI 0.05, 0.22, P = 0.002) were significantly lower than the normal population. Additionally, disseminated cancer, Hispanic race, inpatient status and smoking history were significant independent risk factors for infection, while female sex and increasing albumin were protective towards developing any infection. Rates of all infections were found to increase exponentially with decreasing albumin. The relative risk of infection with an albumin of 2 was 3.46 (95% CI, 2.74–4.38) when compared to a normal albumin of 4. For each albumin increase of 0.69, the odds of developing any infection decreases by a factor of 0.52. This study suggests that preoperative serum albumin is an independent predictor of septic arthritis and all infection following elective arthroscopic procedures. Although the effect of albumin on infection is modest, malnutrition may represent a modifiable risk factor with regard to preventing infection following arthroscopy

Aims

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

The April 2023 Oncology Roundup³⁶⁰ looks at: Complete tumour necrosis after neoadjuvant chemotherapy defines good responders in patients with Ewing’s sarcoma; Monitoring vascularized fibular autograft: are radiographs enough?; Examining patient perspectives on sarcoma surveillance; The management of sacral tumours; Venous thromboembolism and major bleeding in the clinical course of osteosarcoma and Ewing’s sarcoma; Secondary malignancies after Ewing’s sarcoma: what is the disease burden?; Outcomes of distal radial endoprostheses for tumour reconstruction: a single centre experience over 15 years; Is anaerobic coverage during soft-tissue sarcoma resection needed?; Is anaerobic coverage during soft-tissue sarcoma resection needed?

The August 2023 Shoulder & Elbow Roundup360 looks at: Motor control or strengthening exercises for rotator cuff-related shoulder pain? A multi-arm randomized controlled trial; Does the choice of antibiotic prophylaxis influence reoperation rate in primary shoulder arthroplasty?; Common shoulder injuries in sport: grading the evidence; The use of medial support screw was associated with axillary nerve injury after plate fixation of proximal humeral fracture using a minimally invasive deltoid-splitting approach; MRI predicts outcomes of conservative treatment in patients with lateral epicondylitis; Association between surgeon volume and patient outcomes after elective shoulder arthroplasty; Arthroscopic decompression of calcific tendinitis without cuff repair; Functional outcome after nonoperative management of minimally displaced greater tuberosity fractures and predictors of poorer patient experience.

Aims

Total femoral arthroplasty (TFA) is a rare procedure used in cases of significant femoral bone loss, commonly from cancer, infection, and trauma. Low patient numbers have resulted in limited published work on long-term outcomes, and even less regarding TFA undertaken for non-oncological indications. The aim of this study was to evaluate the long-term clinical outcomes of all TFAs in our unit.

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Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets.

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To investigate the optimal thresholds and diagnostic efficacy of commonly used serological and synovial fluid detection indexes for diagnosing periprosthetic joint infection (PJI) in patients who have rheumatoid arthritis (RA).

Aims. With an ageing population of patients who are infected with hepatitis C virus (HCV), the demand for total knee arthroplasty (TKA) in this high-risk group continues to grow. It has previously been shown that HCV infection predisposes to poor outcomes following TKA. However, there is little information about the outcome of TKA in patients with HCV who have been treated successfully. The purpose of this study was to compare the outcomes of TKA in untreated HCV patients and those with HCV who have been successfully treated and have a serologically confirmed remission. Patients and Methods. A retrospective review of all patients diagnosed with HCV who underwent primary TKA between November 2011 and April 2018 was conducted. HCV patients were divided into two groups: 1) those whose HCV was cured (HCV-C); and 2) those in whom it was untreated (HCV-UT). All variables including demographics, HCV infection characteristics, surgical details, and postoperative medical and surgical outcomes were evaluated. There were 64 patients (70 TKAs) in the HCV-C group and 63 patients (71 TKAs) in the HCV-UT cohort. The mean age at the time of surgery was 63.0 years (. sd. 7.5; 44 to 79) in the HCV-C group and 61.7 years (. sd. 6.9; 47 to 88) in the HCV-UT group. Results. HCV-UT patients had a significantly longer mean hospital stay (3.4 days vs 2.9 days; p = 0.04), were more likely to be transferred to the intensive care unit (14.1% vs 4.3%; p = 0.04), and were significantly more often discharged to a post-acute care facility (39.4% vs 14.3%; p < 0.01). HCV-UT patients had significantly more postoperative infections (15.5% vs 4.3%; p = 0.03), surgical complications (21.1% vs 7.1%; p = 0.02), and revision TKA (12.7% vs 1.4%; p < 0.01) than HCV-C patients. Conclusion. The preoperative treatment of HCV can reduce the risk of complications, including prosthetic joint infection and revision TKA. We recommend that HCV treatment regimens should be integrated into the preoperative optimization protocol for this high-risk group of patients. Cite this article: Bone Joint J 2019;101-B:667–674

The December 2022 Oncology Roundup³⁶⁰ looks at: Is high-dose radiation therapy associated with early revision with a cemented endoprosthesis?; Neoadjuvant chemotherapy and endoprosthetic reconstruction for lower extremity sarcomas: does timing impact complication rates?; Late amputation after treatment for lower extremity sarcoma; Osteosarcoma prediagnosed as another tumour: a report from the Cooperative Osteosarcoma Study Group; The influence of site on the incidence and diagnosis of solitary central cartilage tumours of the femur: a 21st century perspective.

Introduction. Hypoalbuminemia has previously been identified as an independent predictor of postoperative complications following total knee arthroplasty (TKA). Given the morbidity and financial burden associated with TKA complications, significant effort has gone into identifying patients at increased risk for perioperative complications. The American Society of Anesthesiologists (ASA) physical status score has been utilized for risk stratification of surgical patients for many years and is a measure of overall health. However, it is unclear how measures like albumin compare to the prognostic ability of this type of global health measure. This study aims to elucidate the utility of preoperative albumin compared with that of the ASA score in predicting complications following TKA. Methods. Patients undergoing TKA between 2005 and 2015 were identified using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were stratified based on preoperative hypoalbuminemia (<3.5 g/dL) and ASA score (≤ 2 vs. > 2). Multivariable regression analysis adjusted for age, sex, BMI, and smoking status was utilized to determine predictive potential of hypoalbuminemia and ASA score on each postoperative complication. Results. Of the 79,661 patients included in the cohort, 4.3% had preoperative hypoalbuminemia. Univariate regression analysis found significant predictive abilities of both serum albumin and ASA score on numerous postoperative complications, such as superficial infection, deep infection, MI, pneumonia, renal insufficiency, reintubation, transfusion, readmission, reoperation, and death. Interestingly, multivariable regression analysis demonstrated that hypoalbuminemia more robustly predicted postoperative deep infection than ASA. Discussion and Conclusion. Hypoalbuminemia and ASA each individually predict numerous postoperative complications following TKA. However, this study suggests that while ASA score more accurately predicts post-operative medical complications, hypoalbuminemia may be a more accurate predictor of periprosthetic infection following TKA. Ultimately, preoperative albumin should be incorporated in the pre-operative work-up routine to stratify patient risk, especially regarding postoperative infection

The August 2023 Research Roundup³⁶⁰ looks at: Can artificial intelligence improve the readability of patient education materials?; What is the value of radiology input during a multidisciplinary orthopaedic oncology conference?; Periprosthetic joint infection in patients with multiple arthroplasties; Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies Project - Phase III outcomes; Knot tying in arthroplasty and arthroscopy causes lesions to surgical gloves: a potential risk of infection; Vascular calcification of the ankle in plain radiographs equals diabetes mellitus?

The June 2023 Spine Roundup³⁶⁰ looks at: Characteristics and comparative study of thoracolumbar spine injury and dislocation fracture due to tertiary trauma; Sublingual sufentanil for postoperative pain management after lumbar spinal fusion surgery; Minimally invasive bipolar technique for adult neuromuscular scoliosis; Predictive factors for degenerative lumbar spinal stenosis; Lumbosacral transitional vertebrae and lumbar fusion surgery at level L4/5; Does recall of preoperative scores contaminate trial outcomes? A randomized controlled trial; Vancomycin in fibrin glue for prevention of SSI; Perioperative nutritional supplementation decreases wound healing complications following elective lumbar spine surgery: a randomized controlled trial.

In Denmark the most common postoperative pathogen is S. aureus (1), sensitive to dicloxacillin. These bacteria can cause a postoperative infection despite using prophylactic antibiotics. Whether the tissue concentration reached is above the minimal inhibitory concentration (MIC) for the pathogens is unknown, and if lower than expected could result in a postoperative infection. Thus a trial was conducted, measuring the actual tissue concentration of dicloxacillin in human muscle and adipose tissue and compared these to the plasma concentration. MIC for dicloxacillin against S. aureus was determined using the broth macrodilution method. Six healthy male volunteers aging 25 to 27 years (body-mass-index; 20–28), were recruited. A CMA63 (Mdialysis, Stockholm, Sweden) catheter was placed in the subcutaneous tissue of the abdomen and in the rectus muscle of the thigh and the volunteers given 2 g dicloxacillin intravenously over 5 minutes. In 10 min intervals for the following 6 hours, samples from blood and Microdialysis fluid (flowrate 5 ml/min) were collected. Recovery was determined in vitro. Plasma was isolated from blood samples. The unbound dicloxacillin was isolated from plasma using filter plates (AcroPrep 30K Omega, Pall Corporation, US) centrifuged for 30 minutes at 1000 × g and 37°C. All samples were analyzed with High Performance Liquid Chromatography. MIC was determined to be 0.125 µg/ml. Average recovery was 73,7 % Maximum concentrations were reached in muscle tissue after a median of 0.5 hours and adipose tissue after 0.8 hours. The geometric mean ration (GMR) of AUC0-6h for adipose tissue compared to plasma was 0.32 [0.15–0.71]. GMR of AUC0-6h for muscle tissue compared to plasma and adipose tissue compared to muscle showed no statistically significant differences. The tissue concentrations were above MIC for 3.4 hours for adipose tissue and 4.1 hours for muscle tissue. The administration of prophylactic dicloxacillin should be given at least 30 minutes prior to incision to ensure maximum tissue concentrations at the onset of surgery. A second dose should be given after 3.4 hours in case of long surgery time. Since the dicloxacillin concentration reached in the adipose tissue is lower than in plasma, it should be investigated whether this difference is more prominent in adipose patients or patients with impaired peripheral circulation, since these patients are at a greater risk of postoperative infections

Introduction. The management of patients with open leg fracture in Ivory Coast does not meet the standards of developed countries due to socio-economic conditions, accessibility and organization of care. However, is this care problematic? Is it associated with more post-traumatic infection or mechanical complications and are these correlated with the delay for treatment and the method of treatment?. Material and Methods. This is a single-center prospective study conducted on between January 2018 and May 2018 at Bouaké University Hospital. The observed parameters included factors related to patient, fracture and treatment conditions and were correlated with the rates of complications by multivariate analysis. Results. Fractures, mostly comminuted (69.8%), occurred following a road accident (93%). The series has 30 Gustilo 1 and 2 fractures and 13 Gustilo 3 fractures. The average delay before surgery was 26.6 ± 8.1 hours. Fracture stabilization required the use of a cast, an external fixator or an unlocked nail in 27, 10 and 6 cases, respectively. Complications developed in 28 patients (65%), including 17 malunions and 22 postoperative infections. 11 infections were controlled but 8 developed chronic osteomyelitis and 3 septic non-unions. Uncomplicated union was observed in only 15 cases and an acceptable functional outcome in only 16 cases. Gustilo Grade 3 fractures were associated with an increased risk of complication (p=0.02). The delay of management was not correlated with the appearance of a complication. In contrast, the use of plaster immobilization was significantly associated with an increased risk of complications and infection (p = 0.001). Conclusion. The management of open fractures in our conditions is associated with a high rate of complications and a satisfactory result in a small number of patients. More than the delay of management, the immobilization modalities by plaster and the insufficiency of this method of contention are correlated to the complications. The development of a National Health Care system covering the expenses for emergent treatment, including rapid transportation to hospitals and availability of external fixators at a lower cost would most probably contribute to a reduction of complications and infection. Keywords. Open fractures, developing countries, fixation, operative time

Aim. The primary aim of this study was to examine whether the use of iodine impregnated incision drape (IIID) decreased the risk of periprosthetic joint infections (PJIs). The secondary aim was to investigate whether intraoperative contamination could predict postoperative infection. PJI is a devastating incident for the patients and in a population that is getting older and the incidence of arthroplasty surgery is rising it is vital to keep the infection rate as low as possible. Despite prophylactic measures as pre-operative decontamination, antisepsis and prophylactic antibiotics the infection rate has been constant at 1–2%. Method. We performed a transregional, prospective, randomized two arm study (IIID vs control group) of 1187 patients undergoing primary knee arthroplasty surgery. A database with patient demographics and surgical observations was established with the purpose of following the patients for ten years. Patients, who developed an infection within the first year of surgery were analyzed for correlation with the intraoperative bacterial findings and the use of IIID. Results. 31/1187 (3.6%) patients were re-operated during the follow-up period. 18/1187 (1.5%) patients were deemed infected and received antibiotic treatment. 9/18 patients deemed infected were male. Of the 18 infected patients 2 were contaminated at the primary surgery. Chi square test showed no correlation between contamination and infection (OR 0.97, 95% CI 0.38–2.46, p=0.95). 9 of the 18 infected patients were operated with IIID at the primary surgery. No correlation was found between the use of IIID at primary surgery and subsequent infection (OR 0.86, 95% CI 0.20–3.79, p=1). Conclusions. We found no effect of the use of IIID and subsequent development of PJI. Nor did we find a correlation between the intraoperative contamination and development of PJI within the first year of follow-up. Acknowledgements. University of Copenhagen and 3M Health Care (St. Paul, Minnesota) funded the study. 3M did not participate in the design of the study, data collection, data analysis or data interpretation

Aims

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

The April 2024 Wrist & Hand Roundup³⁶⁰ looks at: Lunocapitate versus four-corner fusion in scapholunate or scaphoid nonunion advanced collapse: a randomized controlled trial; Postoperative scaphoid alignment, smoking, and avascular necrosis determine outcomes; Grip strength signals broader health concerns in females with distal radius fractures; Clearing the smoke: how smoking status influences recovery from open carpal tunnel release surgery; Age matters: assessing the likelihood of corrective surgery after distal radius fractures; Is pronator quadratus muscle repair required after anterior plate fixation for distal radius fractures?; Efficacy of total wrist arthroplasty: a comparative analysis of inflammatory and non-inflammatory arthritis outcomes; A comprehensive review of the one-bone forearm as a salvage technique.

Aims

Instability is a common cause of failure after total hip arthroplasty. A novel reverse total hip has been developed, with a femoral cup and acetabular ball, creating enhanced mechanical stability. The purpose of this study was to assess the implant fixation using radiostereometric analysis (RSA), and the clinical safety and efficacy of this novel design.

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

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

Aims

Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications.

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The aim of this study was to analyze how proximal radial neck resorption (PRNR) starts and progresses radiologically in two types of press-fit radial head arthroplasties (RHAs), and to investigate its clinical relevance.

The recently published Prophylactic Antibiotic Regimens In Tumor Surgery (PARITY) trial found no benefit in extending antibiotic prophylaxis from 24 hours to five days after endoprosthetic reconstruction for lower limb bone tumours. PARITY is the first randomized controlled trial in orthopaedic oncology and is a huge step forward in understanding antibiotic prophylaxis. However, significant gaps remain, including questions around antibiotic choice, particularly in the UK, where cephalosporins are avoided due to concerns of Clostridioides difficile infection. We present a review of the evidence for antibiotic choice, dosing, and timing, and a brief description of PARITY, its implication for practice, and the remaining gaps in our understanding.

Cite this article: Bone Joint J 2023;105-B(8):850–856.

Aims

The gold standard for percutaneous Achilles tendon tenotomy during the Ponseti treatment for idiopathic clubfoot is a tenotomy with a No. 15 blade. This trial aims to establish the technique where the tenotomy is performed with a large-bore needle as noninferior to the gold standard.

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This study aimed to evaluate the clinical application of the PJI-TNM classification for periprosthetic joint infection (PJI) by determining intraobserver and interobserver reliability. To facilitate its use in clinical practice, an educational app was subsequently developed and evaluated.

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This scoping review aims to identify patient-related factors associated with a poorer outcome following total ankle arthroplasty (TAA).

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The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes.

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The optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition.

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The aim of this study was to perform a systematic review and bias evaluation of the current literature to create an overview of risk factors for re-revision following revision total knee arthroplasty (rTKA).

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CRP is an acute-phase protein that is used as a biomarker to follow severity and progression in infectious and inflammatory diseases. Its pathophysiological mechanisms of action are still poorly defined. CRP in its pentameric form exhibits weak anti-inflammatory activity. The monomeric isoform (mCRP) exerts potent proinflammatory properties in chondrocytes, endothelial cells, and leucocytes. No data exist regarding mCRP effects in human intervertebral disc (IVD) cells. This work aimed to verify the pathophysiological relevance of mCRP in the aetiology and/or progression of IVD degeneration.

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Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures.

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

Artificial intelligence (AI) is, in essence, the concept of ‘computer thinking’, encompassing methods that train computers to perform and learn from executing certain tasks, called machine learning, and methods to build intricate computer models that both learn and adapt, called complex neural networks. Computer vision is a function of AI by which machine learning and complex neural networks can be applied to enable computers to capture, analyze, and interpret information from clinical images and visual inputs. This annotation summarizes key considerations and future perspectives concerning computer vision, questioning the need for this technology (the ‘why’), the current applications (the ‘what’), and the approach to unlocking its full potential (the ‘how’).

Cite this article: Bone Joint J 2022;104-B(8):911–914.

Aims

Achievement of accurate microbiological diagnosis prior to revision is key to reducing the high rates of persistent infection after revision knee surgery. The effect of change in the microorganism between the first- and second-stage revision of total knee arthroplasty for periprosthetic joint infection (PJI) on the success of management is not clear.

To compare usual practices against published guidelines of Perioperative Antimicrobial Prophylaxis (AP), which is an established method to reduce the risk of postoperative infection in TJR. We prospectively evaluated AP in 616 patients, who underwent TJR of the hip and the knee in an ongoing cohort study. Teicoplanin was administered once perioperatively (10mg/kg iv) in one group A (n=278), while in the other group B (n=338) AP was administered according to the usual practice (various antibiotic combinations, including hemisynthetic penicillins/penicillinase inhibitors, cephalosporins, aminoglycosides and quinolones for 2–10 days). An evaluation form and personal examination were used for data collection and monitoring. Patients were followed up for 2 years minimum. The two groups did not statistically differ (p> 0.05) regarding overall postoperative infections. Superficial soft tissue infection developed in 9/616 pts. 1/278 in group A (0.4%) vs 8/338 in group B (2.4%) (p< 0.05). Deep SSI was rarely seen, 4/616 pts (0.6%). 2/278 in group A (0.7%) vs 2/338 in group B (0.6%) (p=NS). Mean duration of AP was significant higher in group B [6(IQR: 5–8.25)], p< 0.001 Mann-Whitney test. Only in group B, MRSA-MRCNS postoperative infections did appear. The duration (days) of glycopeptide antibiotic usage, therapeutic (group B) or prophylactic (group A), was comparable in both groups (p> 0.05). Glycopeptide antibiotic prophylaxis for TJR leads to less postoperative infections compared to other antibiotic prophylaxis, but similar duration of overall glycopeptide usage (prophylactic and therapeutic) in both groups

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The aim of this study was to assess the accuracy of pedicle screw placement, as well as intraoperative factors, radiation exposure, and complication rates in adult patients with degenerative disorders of the thoracic and lumbar spines who have undergone robotic-navigated spinal surgery using a contemporary system.

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The open Latarjet procedure is a widely used treatment for recurrent anterior instability of the shoulder. Although satisfactory outcomes are reported, factors which influence a patient’s experience are poorly quantified. The aim of this study was to evaluate the effect of a range of demographic factors and measures of the severity of instability on patient-reported outcome measures in patients who underwent an open Latarjet procedure at a minimum follow-up of two years.

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This study evaluated the definitions developed by the European Bone and Joint Infection Society (EBJIS) 2021, the International Consensus Meeting (ICM) 2018, and the Infectious Diseases Society of America (IDSA) 2013, for the diagnosis of periprosthetic joint infection (PJI).

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Tranexamic acid (TXA) is now commonly used in major surgical operations including orthopaedics. The TRAC-24 randomized control trial (RCT) aimed to assess if an additional 24 hours of TXA postoperatively in primary total hip (THA) and total knee arthroplasty (TKA) reduced blood loss. Contrary to other orthopaedic studies to date, this trial included high-risk patients. This paper presents the results of a cost analysis undertaken alongside this RCT.

Minimizing the risk of periprosthetic joint infection (PJI) is of interest to all surgeons performing hip and knee arthroplasty. Among the most critical factors to reducing the risk of infection include the use of pre-incisional antibiotics, appropriate skin preparation with clippers (as opposed to a razor for hair removal) and the use of an alcohol-based skin preparation. Host factors are also likewise critically important including obesity, diabetes, inflammatory arthritis, renal insufficiency, skin disorders and patients who are otherwise immune-compromised. If modifiable risk factors are identified, it would seem reasonable to delay elective surgery until these can be optimised. One other factor to consider is the nutritional status of the patient. In a study of 501 consecutive revisions, we found that serological markers suggestive of malnutrition (albumin, transferrin or total lymphocyte count) were extremely common in the revision population. Specifically, among patients who presented for treatment of a chronic infection, 53% (67 of 126) had at least one marker for malnutrition. The prevalence of serological markers of malnutrition was lower (33%) in the group of patients undergoing revision for an aseptic reason suggesting that malnutrition was a risk factor for septic failure (p < 0.001 and OR 2.1). Interestingly, malnutrition was most common among patients of normal weight but was also common among obese patients (so-called “paradoxical” malnutrition). What was more disturbing, however, that of those patients undergoing an aseptic revision, serum markers of malnutrition were associated with a 6x risk of acute postoperative infection complicating the patient's aseptic revision. At our center, we also have studied the use of dilute betadine at the end of the case, prior to wound closure, in an attempt to decrease the load of bacteria in the wound. In a retrospective review the prevalence of acute postoperative infection was reduced from just under 1% (18/1862) to 0.15% (1 of 688; p = 0.04). It is critical that the betadine utilised be STERILE and the dilution we use is 0.35% made by diluting 17.5cc of 10% povidone-iodine paint in 500cc of normal saline. Although this is a retrospective review, it does suggest a benefit and we have not seen any problems associated with its use

Purpose: The purpose of this work was to define clinical and microbiological criteria allowing the distinction of postoperative infections of joint implants from secondary infections and to propose a probability score. Material and methods: This retrospective multicentric study was conducted on 134 cases of infections of hip and knee prostheses. The first step was to distinguish three populations of infections (postoperative, secondary, unknown) based on the germ isolated at diagnosis of prosthesis infection (coagulase-negative Staphylococus, other germs, and Staphylococcus aureus respectively). The second step was to analyse clinical features in the group of postoperative infections and in the group of secondary infections in order to evaluate the predictive value of each of the following parameters: infection-free period, time to infection, distant focus. Results: Fifty-seven cases of secondary infections were identified. There were 34 cases of postoperative infection and 43 cases of infection of unknown category (Staphylococcus aureus infections). The diagnosis of prosthesis infection was retained on the basis of intraoperative samples in 81% of the cases. The infection-free period was less than 1 year (time between implantation and first joint signs) in 69% of the cases of postoperative infection and in 36% of the cases of secondary infection. The difference was significant (p=0.003). A distant focus of infection was found in 44% of the cases (and documented by a bacteriological sample in 13%, 18/134). An invasive therapeutic procedure was identified in 12% (4/34) of the postoperative infections and in 56% (32/57) of the secondary infections. The difference was significant. Discussion: The duration of the infection-free period and the notion of a distant focus of infection (documented or not) are significant criteria enabling a distinction between postoperative and secondary infections after prosthesis implantation. The notion of time to infection (time between the infectious episode and diagnosis of infected prosthesis) is not a significant criteria for identifying secondary infection (p > 0.005). Staphylococcus aureus infection remains difficult to classify. Conclusion: Analysis of clinical features as a function of the microbiological findings enabled identification of significant criteria of secondary infection of joint prostheses. This enables proposing a probability score to be evaluated on a larger scale

Aims

With increasing burden of revision hip arthroplasty (THA), one of the major challenges is the management of proximal femoral bone loss associated with previous multiple surgeries. Proximal femoral arthroplasty (PFA) has already been popularized for tumour surgeries. Our aim was to describe the outcome of using PFA in these demanding non-neoplastic cases.

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Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA.

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To identify the responsiveness, minimal clinically important difference (MCID), minimal clinical important change (MIC), and patient-acceptable symptom state (PASS) thresholds in the 36-item Short Form Health Survey questionnaire (SF-36) (v2) for each of the eight dimensions and the total score following total knee arthroplasty (TKA).

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Developmental dysplasia of the hip (DDH) describes a pathological relationship between the femoral head and acetabulum. Periacetabular osteotomy (PAO) may be used to treat this condition. The aim of this study was to evaluate the results of PAO in adolescents and adults with persistent DDH.

Aim. Spinal infection is the most frequent complication of spine surgery. Its incidence varies between 1% and 14% in the literature, depending on various studied populations and surgical procedures. The aim of this study was to describe a consecutive 2706 case series. Method. We analyzed a prospective cohort of 2706 patients operated for spine disease between 2013 and 2016 in a University Hospital. The infection rates, germs, time between surgery and infection and outcomes after surgical revision were assessed with a minimum follow-up of 7 months. We developed a mathematical model to analyze risk factors in this difficult-to-treat population. Results. Among 2706 patient who underwent spinal surgery during the three-year study period, 106 developed a postoperative spine infection. Clinical indicators for infection were the sudden onset of local pain and swelling without fever after an initial pain-free interval. We observed a masculine predominance (68%); the median age was 56 years. The rate of infection was comprised between 0,3% (discal herniation surgery) to over 20% in posterior cervical instrumented surgery (acute cervical fractures), with a global rate of 4%. Polymicrobial infections with more than 3 germs were found in only 2 case, with 3 germs in 8 cases, 2 germs in 27 cases and 1 germ in 69 cases. Staphylococcus aureus, Propionibacterium acnes and Staphylococcus epidermidis were the three main germs identified (53, 36 and 22 respectively). Propionibacterium acnes was involved with a higher rate in instrumented surgery but also in 8% of conventional non-instrumented surgery, with a median relapse time of 24 days (12 days to 4 years). Staphylococcus aureus was involved at a higher rate in posterior non-instrumented surgery with a median relapse time of 18 days (8–66 days). The rate of infection per month was globally stable along the year except an increased rate in February-March. All patients with a suspicion of post-op infection were initially treated with wound/deep tissues revision within the first month after surgery and associated with implant removal after one-month post-op. Pejorative outcomes were associated with incomplete revision surgery, several surgeries and polymicrobial infection. Conclusions. In this study, the rate of postoperative infection is comparable to the literature. In contrast, Propionibacterium incidence is high, especially for acute infections. This unexpected rate can be linked to technical improvements in culture detection but this should also lead us to further discuss the natural process of spine/disk colonization of this germ