Introduction: The prevalence of obesity continues to increase in the United Kingdom leading to a growing burden on the healthcare system. A significant percentage of patients who undergo total knee arthroplasty are obese. A review of the literature reveals that obese patients are at an increased risk of complications including wound problems. The aim of this study was to evaluate the rate of surgical site infection in all patients undergoing a primary total knee arthroplasty and to audit the outcomes for those who were obese. Methods: We retrospectively reviewed data for 839 primary total knee arthroplasties done at a National Arthroplasty Centre over one year (April 2007 – March 2008). BMI data was available for 824 (98%) of the patients and was obtained from the patients’ clinical records. Surgical site infection data had been collected prospectively by the Infection Control team for inpatient stays and up to 30 days post-operatively. Infection data was available for all patients. Patients were grouped based on their BMI and the WHO classifications (WHO Technical Report Series 894). The infection rates were analysed to establish if there were poorer outcomes for obese patients. Results: Based on the WHO classifications, 31.2% of the patients were obese class I (BMI 30 – 35), 19.0% were obese class II (BMI 35 – 40) and 8.6% were obese class III (BMI > 40). There were 23 patients with infections, 22 having superficial infection and only one patient with a deep infection. The overall superficial surgical site infection rate was 2.7%. The superficial surgical site infection rate for the normal weight group was 1.3%, for the overweight group was 2.3%, obese class I was 1.6%, obese class II was 3.2% but for obese class III was 8.5%. The Fisher’s Exact Test between all obese patients and those with BMI < 30 showed no statistically significant difference in superficial surgical site infection rates (p = 0.39). However, it did show a statistically significant difference between superficial surgical site infection rates in the obese class III patients and the rest of the cohort, p = 0.008. Conclusion: Obese class III (BMI > 40) patients are at an increase risk of superficial surgical site infection as compared to other patients undergoing primary total knee arthroplasty. However, obese class I and II patients do not appear to have an increased likelihood of superficial surgical site infection as compared to patients who have BMI < 30. It is therefore important that surgeons are aware of the higher risk of surgical site infection in obese class III patients and recommended that patients in this category should be informed of this by their surgeon when considering primary total knee arthroplasty

The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta. There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication. The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation. This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study. The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection. Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003). This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection

Objectives. The diagnosis of surgical site infection following endoprosthetic reconstruction for bone tumours is frequently a subjective diagnosis. Large clinical trials use blinded Central Adjudication Committees (CACs) to minimise the variability and bias associated with assessing a clinical outcome. The aim of this study was to determine the level of inter-rater and intra-rater agreement in the diagnosis of surgical site infection in the context of a clinical trial. Materials and Methods. The Prophylactic Antibiotic Regimens in Tumour Surgery (PARITY) trial CAC adjudicated 29 non-PARITY cases of lower extremity endoprosthetic reconstruction. The CAC members classified each case according to the Centers for Disease Control (CDC) criteria for surgical site infection (superficial, deep, or organ space). Combinatorial analysis was used to calculate the smallest CAC panel size required to maximise agreement. A final meeting was held to establish a consensus. Results. Full or near consensus was reached in 20 of the 29 cases. The Fleiss kappa value was calculated as 0.44 (95% confidence interval (CI) 0.35 to 0.53), or moderate agreement. The greatest statistical agreement was observed in the outcome of no infection, 0.61 (95% CI 0.49 to 0.72, substantial agreement). Panelists reached a full consensus in 12 of 29 cases and near consensus in five of 29 cases when CDC criteria were used (superficial, deep or organ space). A stable maximum Fleiss kappa of 0.46 (95% CI 0.50 to 0.35) at CAC sizes greater than three members was obtained. Conclusions. There is substantial agreement among the members of the PARITY CAC regarding the presence or absence of surgical site infection. Agreement on the level of infection, however, is more challenging. Additional clinical information routinely collected by the prospective PARITY trial may improve the discriminatory capacity of the CAC in the parent study for the diagnosis of infection. Cite this article: J. Nuttall, N. Evaniew, P. Thornley, A. Griffin, B. Deheshi, T. O’Shea, J. Wunder, P. Ferguson, R. L. Randall, R. Turcotte, P. Schneider, P. McKay, M. Bhandari, M. Ghert. The inter-rater reliability of the diagnosis of surgical site infection in the context of a clinical trial. Bone Joint Res 2016;5:347–352. DOI: 10.1302/2046-3758.58.BJR-2016-0036.R1

C. Difficile infections in elderly patients with hip fractures is associated with high morbidity and mortality. Antibiotic regimens with penicillin and its derivatives is a leading cause. Antibiotic prophylactic preferences vary across different hospitals within NHS. We compared two antibiotic prophylactic regimens - Cefuroxime only prophylaxis and Teicoplanin with Gentamicin prophylaxis in fracture neck of femur surgery, and evaluated the incidence of C. Difficile diarrhea and Surgical Site Infection (SSI). To assess the Surgical Site Infection and C. Difficile infection rate associated with different regimens of antibiotics prophylaxis in fracture neck of femur surgery. Data was analyzed retrospectively. Neck of femur fracture patients treated surgically from 2009 in our unit were included. Age, gender, co morbidities, type of fracture, operation, ASA grade was collected. 1242 patients received Cefuroxime only prophylaxis between January 2009 and December 2012 (Group 1) and 486 patients received Teicoplanin with Gentamicin between October 2015 and March 2017 (Group 2). There were 353 males and 889 female patients in Group 1 and 138 males and 348 female patients in Group 2. The co morbidities in both groups were comparable. Incidence of C. Difficile diarrhea and Surgical Site Infection (SSI) was noted. Statistical analysis with chi square test was performed to determine the ‘p’ value. C. Diff diarrhea rate in Group 2 was 0.41 % as compared to 1.29 % in Group 1. The Surgical Site Infection (SSI) rate in Group 2 was 0.41 % as compared to 3.06 % in Group 1. The comparative results were statistically significant (p = 0.0009). Prophylactic antibiotic regimen of Teicoplanin with Gentamicin showed significant reduction in C. Difficile diarrhea & Surgical Site Infection in fracture neck of femur patients undergoing surgery

Aims. This study explores the reported rate of surgical site infection (SSI) after hip fracture surgery in published studies concerning patients treated in the UK. Methods. Studies were included if they reported on SSI after any type of surgical treatment for hip fracture. Each study required a minimum of 30 days follow-up and 100 patients. Meta-analysis was undertaken using a random effects model. Heterogeneity was expressed using the I. 2. statistic. Risk of bias was assessed using a modified Newcastle-Ottawa Scale (NOS) system. Results. There were 20 studies reporting data from 88,615 patients. Most were retrospective cohort studies from single centres. The pooled incidence was 2.1% (95% confidence interval (CI) 1.54% to 2.62%) across ‘all types’ of hip fracture surgery. When analyzed by operation type, the SSI incidences were: hemiarthroplasty 2.87% (95% CI 1.99% to 3.75%) and sliding hip screw 1.35% (95% CI 0.78% to 1.93%). There was considerable variation in definition of infection used, as well as considerable risk of bias, particularly as few studies actively screened participants for SSI. Conclusion. Synthesis of published estimates of infection yield a rate higher than that seen in national surveillance procedures. Biases noted in all studies would trend towards an underestimate, largely due to inadequate follow-up

Corynebacterium Jeikeium is a pathogen rarely involved in orthopaedic infections. Till date only 14 cases of osteomyelitis are described in the literature, envolving the tibia, foot and prosthethic (hip and joint) infection. To our knowledge, Corynebacterium Jeikeium as not been reported as an infectious agent of the spine. Our goal is to describe a case of scoliosis surgical site infection by a Corynebacterium Jeikeium specimen. This is a retrospective and descriptive case report based on data from clinical records, patient observation and analysis of complementary exams. We present a 24 year old female with a history of premature birth, West syndrome, spastic cerebral palsy and spina bifida. She was sent to our consult for evaluation of dorsolombar scoliosis. In October of 2014, she was submitted to surgery – posterior spine arthrodesis and instrumentation (D10 to L5) with bilateral pedicle screws and two chromium-cobalt bars. The early post-operative period was without complications. She was discharge at the seventh day of internment and was seen, fifteen days postoperative, at the consultation office, where the dressings were changed, with no signs of surgical site infection. One month post-operative, she recurs to the office because of an apparent seroma at the surgical site wound. There was no reference to fever or other signs of local/systemic infection. A swabbing of the wound was done and the patient was medicated with Ciprofloxacine, 500mg 12/12 hours – the culture came back negative. Seven days later she was seen again, maintaining the seroma with purge of a serous-aspect fluid. Antibiotic therapy was maintained and another swabbing was collected – culture came back negative. Because of suspected surgical site infection, she was re-operated at December of 2014. Surgical wound debridement was performed; three tissue samples and one exudate were sent to the microbiological department. In all samples but one was identified a Corynebacterium Jeikeium. No sensitivity test was performed. Intravenous Vancomicine, 1 gram 12/12 hours was started and maintained during 8 days. Eleven days post-operative she was discharged with oral Vibramicin, 100 milligrams 12/12 hours for two weeks. She is currently being followed at the doctor's office, with no sign of reinfection of the surgical site. This is the first reported case describing an infection of the spine by a Corynebactereium Jeikeium. Isolation of the causative agent of infection and literature-based directed antibiotherapy are important for a successful outcome

Aims. Surgical site infection (SSI) after soft-tissue sarcoma (STS) resection is a serious complication. The purpose of this retrospective study was to investigate the risk factors for SSI after STS resection, and to develop a nomogram that allows patient-specific risk assessment. Methods. A total of 547 patients with STS who underwent tumour resection between 2005 and 2021 were divided into a development cohort and a validation cohort. In the development cohort of 402 patients, the least absolute shrinkage and selection operator (LASSO) regression model was used to screen possible risk factors of SSI. To select risk factors and construct the prediction nomogram, multivariate logistic regression was used. The predictive power of the nomogram was evaluated by receiver operating curve (ROC) analysis in the validation cohort of 145 patients. Results. LASSO regression analysis selected possible risk factors for SSI, including age, diabetes, operating time, skin graft or flap, resected tumour size, smoking, and radiation therapy. Multivariate analysis revealed that age, diabetes, smoking during the previous year, operating time, and radiation therapy were independent risk factors for SSI. A nomogram was developed based on the results of multivariate logistic regression analysis. In the development cohort, the incidence of SSI was 4.5% in the low-risk group (risk score < 6.89) and 26.6% in the high-risk group (risk score ≥ 6.89; p < 0.001). In the validation cohort, the incidence of SSI was 2.0% in the low-risk group and 15.9% in the high-risk group (p = 0.004). Conclusion. Our nomogram will enable surgeons to assess the risk of SSI in patients with STS. In patients with high risk of SSI, frequent monitoring and aggressive interventions should be considered to prevent this. Cite this article: Bone Joint J 2024;106-B(5):492–500

The aim of this study was to assess the impact of Covid-19 measures on the rate of surgical site infections (SSI) and subsequent readmissions in orthopaedic patients. Retrospective, observational study in a level 1 major trauma center comparing rates of SSI in orthopaedic patients who underwent surgery prior to the Covid-19 lockdown versus that of patients who underwent surgery during the lockdown period. A total of 1151 patients were identified using electronic clinical records over two different time periods; 3 months pre Covid-19 lockdown (n=680) and 3 months during the Covid-19 lockdown (n=470). Patients were followed up for 1 year following their initial procedure. Primary outcome was readmission for SSI. Secondary outcomes were treatment received and requirement for further surgeries. The most commonly performed procedures were arthroplasty and manipulation under anaesthesia with 119 in lockdown vs 101 non-lockdown (p=0.001). The readmission rate was higher in the lockdown group with 61 (13%) vs 44 (6.5%) in the non-lockdown group (p <0.001). However, the majority were due to other surgical complications such as dislocations. Interestingly, the SSI rates were very similar with 24 (5%) in lockdown vs 28 (4%) in non-lockdown (p=0.472). Twenty patients (4.2%) required a secondary procedure for their SSI in the lockdown group vs 24 (3.5%) in non-lockdown (p=0.381). Mortality rate was similar at 44 (9.3%) in lockdown vs 61 (9.0%; p=0.836). Whilst Covid-19 precautions were associated with higher readmission rates, there was no significant difference in rate of SSI between the two groups

Aims. Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery. Methods. Data from two large, UK-based multicentre randomized controlled major trauma trials investigating SSI and wound healing after surgical repair of open lower limb fractures that could not be primarily closed (UK WOLLF), and surgical incisions for fractures that were primarily closed (UK WHiST), were examined. Trial interventions were standard wound care management and negative pressure wound therapy after initial surgical debridement. Wound outcomes were collected from 30 days to six weeks. We compared the level of agreement between wound photography and clinical assessment of CDC-defined SSI. We are also assessed the level of agreement between blinded independent assessors of the photographs. Results. Rates of CDC-defined deep SSI were 7.6% (35/460) after open fracture and 6.3% (95/1519) after closed incisional repair. Photographs were obtained for 77% and 73% of WOLLF and WHiST cohorts respectively (all participants n = 1,478). Agreement between photographic-SSI and CDC-SSI was fair for open fracture wounds (83%; k = 0.27 (95% confidence interval (CI) 0.14 to 0.42)) and for closed incisional wounds (88%; k = 0.29 (95% CI 0.20 to 0.37)) although the rate of photographically detected deep SSIs was twice as high as CDC-SSI (12% vs 6%). Agreement between different assessors for photographic-SSI (WOLLF 88%, k = 0.63 (95% CI 0.52 to 0.72); WHiST 89%; k = 0.61 (95% CI 0.54 to 0.69)); and wound healing was good (WOLLF 90%; k = 0.80 (95% CI 0.73 to 0.86); WHiST 87%; k = 0.57 (95% CI 0.50 to 0.64)). Conclusion. Although wound photography was feasible within the research context and inter-rater assessor agreement substantial, digital photographs used in isolation overestimated deep SSI rates, when compared to CDC criteria. Wound photography should not replace clinical assessment in pragmatic trials but may be useful for screening purposes where surgical infection outcomes are paramount. Cite this article: Bone Joint J 2021;103-B(12):1802–1808

Aims. This study aims to estimate economic outcomes associated with 30-day deep surgical site infection (SSI) from closed surgical wounds in patients with lower limb fractures following major trauma. Methods. Data from the Wound Healing in Surgery for Trauma (WHiST) trial, which collected outcomes from 1,547 adult participants using self-completed questionnaires over a six-month period following major trauma, was used as the basis of this empirical investigation. Associations between deep SSI and NHS and personal social services (PSS) costs (£, 2017 to 2018 prices), and between deep SSI and quality-adjusted life years (QALYs), were estimated using descriptive and multivariable analyses. Sensitivity analyses assessed the impact of uncertainty surrounding components of the economic analyses. Results. Compared to participants without deep SSI, those with deep SSI had higher mean adjusted total NHS and PSS costs (adjusted mean difference £1,577 (95% confidence interval (CI) -951 to 4,105); p = 0.222), and lower mean adjusted QALYs (adjusted mean difference -0.015 (95% CI -0.032 to 0.002); p = 0.092) over six months post-injury, but this difference was not statistically significant. The results were robust to the sensitivity analyses performed. Conclusion. This study found worse economic outcomes during the first six months post-injury in participants who experience deep SSI following orthopaedic surgery for major trauma to the lower limb. However, the increase in cost associated with deep SSI was less than previously reported in the orthopaedic trauma literature. Cite this article: Bone Jt Open 2022;3(5):398–403

The aim of this study was to evaluate the rate of surgical site infection (SSI) in all patients undergoing a primary total knee arthroplasty (TKA) and to audit the outcomes for those who were obese. We retrospectively reviewed data for 839 primary TKAs done at a National Arthroplasty Centre over one year (April 2007 – March 2008). Body mass index (BMI) data was available for 824 (98%) of the patients. Surgical site infection (SSI) data had been collected prospectively by the Infection Control team for up to 30 days post-operatively and was available for all patients. There were 23 patients with SSIs, 22 having superficial SSI and only one patient with a deep SSI. The overall superficial SSI rate was 2.7%. For the BMI< 25 group (9.6% of patients) SSI rate was 1.3%. For BMI 25–30 (31.6% of patients) SSI rate was 2.3%. For BMI 30–35 (31.2% of patients) SSI rate was 1.6%. For BMI 35–40 (19.0% of patients) SSI rate was 3.2%. For BMI > (8.6% of patients) SSI rate was 8.5%. Fisher’s Exact Test between all obese patients (BMI< 30) and those with BMI< 30 showed no significant difference in superficial SSI rates (p = 0.39) but did show a significant difference between superficial SSI rates in the obese class III patients (BMI> 40) and the rest of the cohort (p = 0.008). Obese class III (BMI > 40) patients are at an increase risk of superficial SSI as compared to other patients undergoing primary TKA. However, obese class I and II patients (BMI 30–40) do not appear to have an increased likelihood of superficial SSI as compared to patients who have BMI< 30

Aims. This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection. Methods. This is a retrospective population-based cohort study using prospectively collected patient-level data between 1 January 2013 and 1 March 2020. The diagnosis of deep SSI was defined as per the Centers for Disease Control/National Healthcare Safety Network criteria. The Mann-Kendall Trend test was used to detect monotonic trends in annual rates of early-onset deep SSI over time. Multiple logistic regression was used to analyze the effect of different patient, surgical, and healthcare setting factors on the risk of developing a deep SSI within 90 days from surgery for patients with complete data. We also report 90-day mortality. Results. A total of 39,038 patients underwent primary TKA for osteoarthritis during the study period. Of these, 275 patients developed a deep SSI within 90 days of surgery, representing a cumulative incidence of 0.7%. The annual infection rate did not significantly decrease over the seven-year study period (p = 0.162). Overall, 13,885 (35.5%) cases were excluded from the risk analysis due to missing data. Risk factors associated with early-onset deep SSI included male sex, American Society of Anesthesiologists grade ≥ 3, blood transfusion, acute length of stay, and surgeon volume < 30 TKAs/year. Early-onset deep SSI was not associated with increased 90-day mortality. Conclusion. This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis using robust Infection Prevention and Control surveillance data, and identifies several potentially modifiable risk factors. Cite this article: Bone Joint J 2023;105-B(9):971–976

Aims. In contrast to operations performed for other fractures, there is a high incidence rate of surgical site infection (SSI) post-open reduction and internal fixation (ORIF) done for tibial plateau fractures (TPFs). This study investigates the effect of induced membrane technique combined with internal fixation for managing SSI in TPF patients who underwent ORIF. Methods. From April 2013 to May 2017, 46 consecutive patients with SSI post-ORIF for TPFs were managed in our centre with an induced membrane technique. Of these, 35 patients were included for this study, with data analyzed in a retrospective manner. Results. All participants were monitored for a mean of 36 months (24 to 62). None were subjected to amputations. A total of 21 patients underwent two-stage surgeries (Group A), with 14 patients who did not receive second-stage surgery (Group B). Group A did not experience infection recurrence, and no implant or cement spacer loosening was noted in Group B for at least 24 months of follow-up. No significant difference was noted in the Lower Extremity Functional Scale (LEFS) and the Hospital for Special Surgery Knee Score (HSS) between the two groups. The clinical healing time was significantly shorter in Group B (p＜0.001). Those with longer duration of infection had poorer functional status (p＜0.001). Conclusion. Management of SSI post-ORIF for TPF with induced membrane technique combined with internal fixation represents a feasible mode of treatment with satisfactory outcomes in terms of infection control and functional recovery. Cite this article: Bone Joint Res 2021;10(7):380–387

Aim. To investigate the incidence and time-trend in reoperation due to deep Surgical Site Infection (SSI) following hip fracture surgery. Method. This was a population-based, nationwide, cohort study. We included 74,771 from the Danish Multidisciplinary Hip Fractures Register (1) consisting of patients 65 years of age or older, who underwent surgery between January 1. st. 2005 and December 31. st. 2016 for all types of hip fracture. Cross-linkage with the Danish National Patient Register and The Danish Civil Registration system was made. Demographic data extracted included vital status, civil status, gender, age, Body Mass Index (BMI), fracture classification (AO/OTA 31A-C) and surgical procedures binary registered as joint replacement or internal fixation, Charlson comorbidity index (CCI) and secondary diseases not included in CCI. Outcome was reoperations due to deep SSI in accordance with the definition from Centre for Disease Control (2). We computed cumulative incidence rates and risk ratios (RR) by calendar year periods and by different risk factors, considering death as competing risk and adjusting for age, gender, CCI, fracture type and surgery type. Results. Within 365 days of primary surgery 2.1% of all hip fractures had undergone reoperation due to deep SSI. During the period 2005–2016, the incidence of reoperation due to SSI decreased from 2.7% to 1.7%, We could not identify differences in reoperation due to SSI within one year regarding gender, BMI or CCI. Patients aged above 85 had about 50% lower risk of being reoperated compared with the youngest age group; 65–74 years (RR: 0.5; 95% CI: 0.4:0.6). The RR for reoperation due to deep SSI was lower for patients with pertrochanteric or subtrochanteric fractures (AO/OTA: 31A1-3) versus femoral neck fractures (AO/OTA: 31B1-3), RR was 0.7 (95%CI: 0.7:0.8). However, RR for surgery type (joint replacement vs internal fixation) at 365 days was significantly lower for joint replacement, RR: 0.6 (95% CI: 0.6:0.7). Conclusions. This study shows reoperation risk due to SSI for all types of hip fractures of 2.1%. There was a 45% decrease in reoperation over time from 2005 to 2016. However, the risk of revision is still high, and further action in avoidance of SSI should be taken

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

Objectives. To review the current best surgical practice and detail a multi-disciplinary approach that could further reduce joint replacement infection. Methods. Review of relevant literature indexed in PubMed. Results. Surgical site infection is a major complication following arthroplasty. Despite its rarity in contemporary orthopaedic practice, it remains difficult to treat and is costly in terms of both patient morbidity and long-term health care resources. Conclusions. Emphasis on education of patients and all members of the health-care team and raising awareness in how to participate in preventative efforts is imperative

Objective. To identify risk factors for surgical site infections and to quantify the contribution of independent risk factors to the probability of developing infection after definitive fixation of tibial plateau fractures. Methods. A retrospective analysis was performed at a Level I trauma center between 2004 and 2010. A total of 251 consecutive patients (256 cases) were divided into two groups, those with and those without a surgical site infection. Preoperative and perioperative variables were compared between these groups and risk factors were determined by univariate analyses and multivariate logistic regression. Results. The overall rate of surgical site infection after tibial plateau ORIF was 7.8% (20 of 256). The most common causative pathogens was Staphylococcus aureus (n=15, 75%). Independent predictors of surgical site infection identified by multivariate analyses were open tibial plateau fracture (odds ratio =3.9; 95% confidence interval=1.3–11.6, p =0.015) and operative time (odds ratio=2.7; 95% confidence interval=1.6 − 4.4; p < 0.001). Conclusions. Both open fracture and operative time are independent risks factors for post operative infection

Aim. To investigate the effect of intraoperative wound irrigation with povidone-iodine on surgical site infection. Methods. Data were collected prospectively for all cases of instrumented thoracic and lumbar spine surgery undertaken by the senior author (DB) from 01/10/2008 to 1/10/2010. Variables recorded included patient factors (age, co-morbidities, drug history) and operative factors (type of operation, duration of operation, elective/emergency, in hours/out of hours, consultant/junior, perioperative antibiotic administration). Routine povidone-iodine application commenced on 1/06/2009. Surgical site infection was defined as wound infection confirmed on wound swab or blood cultures. Comparison was made between patients receiving povidone-iodine intraoperative wound irrigation and those who did not using Fisher's exact test. Results. Data from 91 consecutive patients who had undergone instrumented thoracic or lumbar fusions under the care of the senior author were analysed. Mean age was 58.0±16.9 years. There was no difference in age (Mean±SD) between those receiving povidone-iodine (59.1 ±16.9y) and those without povidone-iodine administration (55.3 ±16.9) (p=0.33). The number of wound infections was significantly reduced from 19% (5/26) in those without povidone-iodine to 0% (0/65) in those with application of povidone-iodine (p=0.001, Fisher's exact). Conclusion. Intraoperative povidone-iodine irrigation appears to be an effective method of reducing SSIs in instrumented spinal fixation surgery

Aims. The aim of this study was to estimate economic outcomes associated with deep surgical site infection (SSI) in patients with an open fracture of the lower limb. Patients and Methods. A total of 460 patients were recruited from 24 specialist trauma hospitals in the United Kingdom Major Trauma Network. Preference-based health-related quality-of-life outcomes, assessed using the EuroQol EQ-5D-3L and the 6-Item Short-Form Health Survey questionnaire (SF-6D), and economic costs (£, 2014/2015 prices) were measured using participant-completed questionnaires over the 12 months following injury. Descriptive statistics and multivariate regression analysis were used to explore the relationship between deep SSI and health utility scores, quality-adjusted life-years (QALYs), and health and personal social service (PSS) costs. Results. Deep SSI was associated with lower EQ-5D-3L derived QALYs (adjusted mean difference -0.102, 95% confidence interval (CI) -0.202 to 0.001, p = 0.047) and increased health and social care costs (adjusted mean difference £1950; 95% CI £1383 to £5285, p = 0.250) versus patients without deep SSI over the 12 months following injury. Conclusion. Deep SSI may lead to significantly impaired health-related quality of life and increased economic costs. Our economic estimates can be used to inform clinical and budgetary service planning and can act as reference data for future economic evaluations of preventive or treatment interventions. Cite this article: Bone Joint J 2018;100-B:1506–10

Purpose: The aim of this study was to evaluate the rate of surgical site infection (SSI) in all patients undergoing a primary total knee arthroplasty (TKA) and to audit the outcomes for those who were obese. Methods/Results: We retrospectively reviewed data for 839 primary TKAs done at a National Arthroplasty Centre over one year (April 2007 – March 2008). BMI data was available for 824 (98%) of the patients. SSI data had been collected prospectively by the Infection Control team for up to 30 days post-operatively and was available for all patients. Patients were grouped based on their BMI and the WHO classifications (WHO Technical Report Series 894). 31.2% of the patients were obese class I (BMI 30 – 35), 19.0% were obese class II (BMI 35 – 40) and 8.6% were obese class III (BMI > 40). There were 23 patients with SSIs, 22 having superficial SSI and only one patient with a deep SSI. The overall superficial SSI rate was 2.7%. The superficial SSI rates for each group were as follows: normal (BMI < 25) = 1.3%; overweight (BMI 25 –30) = 2.3%; obese class I = 1.6%; obese class II = 3.2%; obese class III = 8.5%. The Fisher’s Exact Test between all obese patients and those with BMI < 30 showed no significant difference in superficial SSI rates (p = 0.39) but did show a significant difference between superficial SSI rates in the obese class III patients and the rest of the cohort (p = 0.008). Conclusions: Obese class III (BMI > 40) patients are at an increase risk of superficial SSI as compared to other patients undergoing primary TKA. However, obese class I and II patients do not appear to have an increased likelihood of superficial SSI as compared to patients who have BMI < 30

Introduction: Infection following TKR is a catastrophic complication. Few authors have highlighted the need for screening of patients (nose, axilla and groin) before TKR. Despite the fact that some of the centers in UK now routinely perform preoperative screening for TKR patients the overall incidence of surgical site infection in the year 2004 was 2.9%. Methods and Materials: We introduced a new admission policy and SSI surveillance protocol for TKR patients in the year 2004 at our center. According to the new admission policy all TKR patients who were preoperatively screened were admitted into a clean elective ward. Care was taken not to admit anybody with positive infection screening in that ward, irrespective of the diagnosis. Further we also introduced a new policy of SSI surveillance according toNINSS protocol carried out by dedicated trained nurses. Results and conclusions: Following the introduction of these policies our surgical site infection has come down to 0% in the year 2004–5 in contrast to 1.7% in the year 2002–3. These results showed that simple measures like having dedicated infection free clean wards and dedicated trained surveillance nurses can significantly reduce the infection rate following TKR

Introduction: Infection following THR is a catastrophic complication. Few authors have highlighted the need for screening of patients (nose, axilla and groin) before THR. Despite the fact that some of the centres in UK now routinely perform preoperative screening for THR patients the overall incidence of surgical site infection in the year 2004 was 2.9%. Methods and Materials: We introduced a new admission policy and SSI surveillance protocol for THR patients in the year 2004 at our centre. According to the new admission policy all THR patients who were preoperatively screened were admitted into a clean elective ward. Care was taken not to admit anybody with positive infection screening in that ward, irrespective of the diagnosis. Further we also introduced a new policy of SSI surveillance according to NINSS protocol carried out by dedicated trained nurses. Results and conclusions: Following the introduction of these policies our surgical site infection has come down to 0% in the year 2004–5 in contrast to 1.7% in the year 2002–3. These results showed that simple measures like having dedicated infection free clean wards and dedicated trained surveillance nurses can significantly reduce the infection rate following THR

Introduction: Surgical site infection following total hip replacement results in poorer outcomes, longer hospital stays, and increased costs. The aim of this study was to describe infective complications in a large series of total hip arthroplasty. Methods: Between January 1998 and March 2005, consecutive total hip arthroplasties were prospectively. The presence of deep infection was confirmed by culture from joint aspiration or a secondary procedure such as joint washout or component removal and replacement. Risk factors for development of surgical site infective complications were analysed. Results: 2029 consecutive total hip arthroplasties was carried out in 1539 patients. There were 22 deep infections (1.1%) and 118 superficial infections (5.8%). Staphylococcus aureus (MSSA) was isolated in 10/22 (45%) of deep infections and MRSA in 4 (18%). In patients undergoing unilateral replacement there were 11/1539 deep infections (0.7%) compared 5/172 (2.9%) in the bilateral simultaneous group. In patients who were current or exsmokers the deep infection rate was 11/880 (1.3%) compared to 7/864 (0.8%) in non-smokers. 3/120 (2.5%) diabetic patients developed deep infection. In patients who received a blood transfusion 9/502 (1.7%) developed deep infection compared to 13/1527 (1%) who did not. In patients with a BMI> 35kgm. −2. the overall rate of infective complications (superficial and deep) was 18.8%. In patients with a report of a perioperative complication the deep infection rate was 6/169 (3.6%) compared to 16/1860 (0.9%) without complication. Discussion: This study has the advantage of investigating infective complications in a typical case series of patient presenting for total hip replacement. The rate of deep infection was consistent with previous reports. Deep infection is associated with bilateral simultaneous replacement, smoking, diabetes, blood transfusion and perioperative complications. Obese patients are at higher risk of all surgical site infective complications

We have analysed the management and clinical outcome of a series of consecutive patients who had a total hip replacement and developed post-operative surgical site infection (SSI) with methicillin-resistant Staphylococcus aureus. The incidence of this infection was 1% over a period of five years. We studied SSI in 15 patients (16 infections) with a mean age of 72.7 years (53 to 81). In all, 12 of the infections occurred early and half of the infections involved the prosthesis, resulting in an increase of 11-fold in the cumulative hospital stay. Methicillin-resistant Staph. aureus was successfully eradicated in all the patients after a mean follow-up of 53.6 months (25 to 88). Superficial incisional infections resolved after antibiotic therapy alone while deep infections required multiple operative debridements. Attempted retention of the implant in early organ space infections was successful in only one of five patients. Only three patients with implant-level infections obtained a pain-free, functional prosthesis while a further three required excision arthroplasty. We have formulated a protocol of treatment which may serve as a guide in the management of these infections

Introduction. Hip fracture is a worldwide problem, not only as far as epidemiology is concerned but also regarding economical issues. Surgery is the current standard treatment. However owing to age, and patients co-morbidities complications are common. Surgical site infection is directly related to operative procedure, and surgeons' experience may be very important when making plans for outcome improvement. In this paper we study the role of hip surgeons versus general orthopaedic surgeons in relation to postoperative site infection. Operative hypothesis determines that hip surgeons have less infection rates than general orthopaedic surgeons. Null hypothesis that infection rates are rather the same. Material and Methods. In a prospective controlled cohort study 820 patients presenting with a hip fracture were randomizelly operated on by a group of orthopaedic surgeons of the same Hospital Department. Patients were then classified according to surgeons adscription either to a Hip Unit (Group A=215 cases) or not (Group B=605). Variables studied included age, gender, treatment (osteosynthesis or joint replacement), co-morbidities (according to Charlson, s index), and infection rate. Fisher, and Ranksum statistical tests, and simple and multiple logistic regression, for univariate and multivariate, analysis was performed. Results. 237 (28,93 %) patients were male, and 583 (71,06 %) females. Mean age for both groups was 77,58 years (r=16−105; group A=78, group B=81). 215 patients were included in group A, and 605 in group B. 534 (65.12%) underwent an osteosynthesis, and 272 (33,17%) a joint replacement. 14 patients were not operated. Both groups were homogeneous regarding gender, surgical technique, Charlson's index, and functional outcome (Fisher test p=0,777). 17 patients (2,073%) sustained a surgical site infection (group A=7 cases out of 215 [3,27%], and group B=10 cases out of 605 [1,65%]). Multivariate logistic regression showed that there was no relation between gender, surgical site infection, Charlson index, surgical technique, or groups (A or B). Only age was a determinant factor (Raksum test p=0,003; OR 95% CI=1,08, p=0,005). Conclusion. Since there are no differences in the outcomes between surgeons dedicated to a Hip Unit and general orthopaedic surgeons as far as postoperative surgical site infection is concerned, delaying operative treatment for hip fracture or creating a special Unit for that is unworthy. Only age appears as a significant variable

Purpose. Surgical site infection (SSI) is an infrequent but serious complication of total joint arthroplasty (TJA). Orthopaedic SSI causes substantial morbidity, prolonging the hospital stay by a median of 2 weeks, doubling the rates of rehospitalization, and more than tripling overall healthcare costs. Colonization with methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) is known to be associated with an increased risk of subsequent SSI. Carriers are two to nine times more likely to acquire S. aureus SSIs than non-carriers. Screening of the nose and throat for MRSA colonization and preoperative patient decolonization have been shown to decrease the incidence of subsequent MRSA infection. The aim of this study was to investigate the association between the results of MRSA colonization screening and the incidence of SSI in our hospital. Materials and Methods. Between June 2007 and June 2010, 238 patients were admitted for TJA, among whom 235 underwent preoperative assessment that included screening of the nose and throat for MRSA colonization. Fifty-nine of these patients underwent total hip arthroplasty (THA), 69 underwent total knee arthroplasty (TKA), 6 underwent unilateral knee arthroplasty (UKA), and 101 underwent bipolar hip prosthesis arthroplasty (BPH). The mean age of the patients was 72.7 (49–95) years and the male to female ratio was 1:3.8. We analyzed these patients retrospectively, and determined the site of colonization, eradication prior to surgery, and subsequent development of SSI in the year after surgery. SSI was defined according to the criteria established by the Centers for Disease Control and Prevention. Results. MRSA colonization was positive in 12 patients (5.1%) at the initial preoperative assessment (Fig. 1). All except 2 of the positive patients underwent nasal eradication with mupirocin 2% three times daily for three days. Eight of 10 patients were confirmed to be MRSA-negative after re-swabbing. During surgery, all patients received perioperative antibiotic prophylaxis. The standard regimen was cefazolin 1 g administered 15 to 30 min before incision, followed by 1 g every 3 hours until skin closure. One hundred eighty-six patients were monitored for development of SSIs for 1 year after TJA. Among these patients, 1 in the MRSA-positive group and 1 in the negative group developed MRSA SSIs (P<0.01)(Fig. 2). Discussion. Bode et al. recently reported that rapid screening and decolonizing of nasal S. aureus carriers with intranasal mupirocin prevented SSIs after mixed surgery. However, several studies of the effect of screening and decolonization for such carriers have yielded paradoxical findings because of differences in study design or sample size. Conclusion. We conclude that MRSA-colonized patients undergoing TJA are at an increased risk of SSI, despite eradication therapy prior to surgery. Use of prophylactic antibiotics such as vancomycin or teicoplanin may be beneficial

Aims: Data collected on knee replacements from 93 hospitals in England were analysed to identify risk factors for surgical site infection. Methods: Prospective surveillance data collected from hospitals in England to calculate surgical site infection rates and potential risk factors Results: There were 242 (1.6%) infections in 15427 primary TKR, with a 0.11% joint infection rate, and 36 (3.6%) infections in 988 revisions, with a signiþcantly higher joint infection rate of 0.35%. There was considerable variation between hospitals. Multivariable logistic regression found signiþcant association between risk of SSI and type of procedure (p< 0.01), the hospital where the procedure was performed, male sex (p< 0.001), age (p< 0.001) and wound class (p< 0.05). The mean length of stay in primary TKRñs increased from 9 days to 18 days with an infection; and in revision procedures from 12 to 24 days. The median time to diagnosis for SSI was 7.5 days. Staphylococcus aureus accounted for 33%, 66% of which were methicillin resistant (MRSA). Conclusions: There is signiþcant inter-hospital variation in the incidence of SSI following knee replacements in England. Signiþcant risk factors include revision procedures. Male sex, age and wound class. SSIñs doubled the length of post-operative stay and MRSA accounted for 21% of organisms

Introduction. The purpose of this study was to introduce our perioperative prophylaxis method for infection and clarify surgical site infection rate in our patients performed total hip arthroplasty (THA). Method. Two hundred and eighty four THA (including revision 18 cases) performed by single surgeon between Oct. 2007 and Jan. 2013 were evaluated. The mean age of patients was 65.7 years old. The male to female ratio was 46 to 238. BMI was 23.6. Ninety patients (32%) were compromised host suffering from diabetes mellitus, rheumatoid arthritis, autoimmune disease, history of malignant tumor, hemodialysis or skin disease at surgical site respectively. At preoperative period, we checked decayed tooth, alveolar pyorrhea, hemorrhoids, and leg skin condition. In addition, we examined culture of nasal cavity. At the day of surgery, patient took a shower just before entering surgical room. All of THA was performed in clean room NASA class 100. Surgeons and assistant nurse put on nonwoven fabric gown, space suit and double rubber gloves. We wiped surgical site leg by gauze impregnated by 0.5% chlorhexidine alchohol to eliminate skin bacteria twice just before surgeons scrubbing hands. Surgical site was covered by povidone iodine containing drape. Surgeons or nurse changed gloves when glove was broken at each time. We cleaned surgical field by pulse washer whenever necessary. We did not use drain except for 5 revision THAs. Regarding to prophylactic antibiotics usage, we administered cefcapene pivoxil orally the day before surgery. Drip infusion antibiotics (PIPC: until Oct. 2008, CEZ: after Oct. 2008) was administered at the period of 30 min. before surgery and 4 hours after surgery in case of prolonged surgical time (4 hours >). Skin closure was performed by staple and covered by gauze until May 2010. After that, we used surgical tape and transparent water proof sheet. After finishing surgery, antibiotic was administered 8 hours interval at surgery day and 12 hours interval for additional two days. In case multi-drug resistant bacteria (MRSA, MRSE) was positive in nasal culture, we applied mupirocin ointment to nasal cavity for 3 days before surgery and administered vancomycin (from Aug. 2011) or linezolid (from 2012) for prophylactic antibiotics in perioperative period. Results. Multi-drug resistant bacteria was detected from nasal cavity in 23 patients (8%). The mean operation time was 194 min (due to education for young surgeon). Intraoperative bleeding was 598g. Length of skin incision was 13.6 cm. Intraoperative wash volume was 4500 ml. The infection rate were 0 % in early period and 0.7 % (two case) in late period respectively. One infected case was 75 years old female. Deep infection was occurred 3 years after surgery. She was administered steroid and immunosuppressive drug due to metal allergy after total knee arthroplasty. The other case was 64 years old female. Superficial infection happened 3 months after THA. The patient was suffered from collagen disease and diabetes. Conclusion. Our prophylaxis method for surgical site infection of THA achieved 0 % in early infection and 0.7% late chronic infection respectively

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

Background. Much effort has been aimed at strategies for patient optimization, perioperative standards of care, and postoperative risk stratification to reduce the incidence of SSI. Examples include, newer dressing modalities, antibiotic-impregnated bone cement, intra-wound powdered antibiotics, as well as novel suture types and techniques, all of which have shown great potential. However, the question remains as to whether these changes in practice have led to lower overall infections over the past few years. Therefore, the purpose of this study was to track the annual rates and trends of: 1) overall; 2) deep; and 3) superficial SSI following total hip arthroplasty (THA) using the most recent data (2012 to 2016) from a large nationwide database. Methods. The National Surgical Quality Improvement Program database was queried for all primary THAs (CPT code 27130) between 2012 and 2016, yielding 122,451 cases. Cases with reported superficial and/or deep SSIs were combined for an overall rate, and then independently analyzed as deep and superficial SSIs. The infection incidence for each year was calculated. After an overall 5-year correlation and trends, univariate analysis was also performed to compare the most recent year, 2016, with each of the preceding 4 years. Furthermore, a comparison of overall and deep SSI incidences from this study were compared to meta-analysis of pooled data from 2001 to 2011. Pearson correlation coefficients and chi-squared tests were used to determine correlation and statistical significance which was maintained at a p-value less than 0.05. Results. Over the 5-year period, 1,154 cases out of 122,451 (0.94% of all cases) were complicated by any SSI. The lowest incidence was in the latest year, 2016 (n=289, 0.81%), while the greatest was in the earliest year, 2012 (n=163, 1.12%). There was a significant inverse correlation between overall SSI rate and year (p<0.01). A 31% decrease in rate was found between 2016 and 2012 (0.81% vs. 1.12%, p<0.01). For deep SSI, the lowest incidence was in the most recent year, 2016 (n=82, 0.23%). The incidence over 5 years was 0.30% (364 out of 122,451 cases). The mean percent decrease in deep SSI incidence over the 5 years was 31%. There was a 49% decrease in deep SSI rate in 2016 compared to 2015 (0.23% vs. 0.38%, p>0.05). Additionally, there was an inverse correlation between deep SSI rate and year of surgery (p>0.05). The lowest superficial SSI incidence occurred in the most recent year, 2016 (n=204, 0.58%), while 2012 had the greatest incidence (n=121, 0.83%). There were a total of 796 cases out of 122,451 over 5 years, an incidence of 0.65%. A 31% decrease was observed between 2016 and 2012 (0.58% vs. 0.83%, p=0.001). There was a statistically significant inverse correlation between superficial SSI rate and year (p<0.01). A meta-analysis evaluating primary THA SSIs from 2001 to 2011 reported an overall SSI incidence of 2.5% (95% confidence interval [Cl], 1.4%-4.4%; P<.001; n=28,883), substantially higher (309%) than the 2016 incidence of 0.81% found in this study. Furthermore, the meta-analysis reported an incidence for deep SSIs to be 0.9% (95% Cl, 0.4%-2.2%; p<.001; n=28,883), also found to be markedly lower than the 2016 incidence noted here (0.23%), marking a 391% difference. Conclusion. The findings from this study suggest that the evolving standards of care have brought about improvements in SSI prevention following THA over time. Deep SSIs, which can pose substantial threats to implant survivorship, have decreased throughout the years. These results highlight the importance of following up-to-date clinical recommendations to reduce surgical site infections and substantially improve patient outcomes

We examined rates of MRSA wound infection in patients admitted to the Leicester Royal Infirmary Trauma Unit between January 2004 and June 2006. The influence of MRSA status at the time of their admission, together with age, sex and diagnosis were examined using multivariant analysis. 3.2%(79/2473)) were MRSA carriers at time of admission and 96.8%(2394/2473) were MRSA negative. Those carrying MRSA at the time of admission were more likely to develop MRSA surgical site infections [8.8% (7/79)] as compared to non MRSA carrier at the time of admission [2.2% (54/2394), p< 0.001]. Further analysis revealed that hip fracture and increasing age (linear increase in relative risk of 1.8% per year) were also risk factors. MRSA carriage at admission, age and pathology are all associated with an increased rate of developing MRSA wound infections. Identification of such risk factors at admission helps to target health care resources such as the use of glycopeptides at induction and increased vigilance for wound infection in the post operative phase

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

Introduction. Surgical site infections (SSI) are related to a surgical procedure and affect the surgical wound or deeper tissues. With continuing emphasis on clinical governance and quality control, there is increasing demand from both patients and government for methods of assessing surgical results. Rates of morbidity and mortality may play important roles in these assessments. When crude comparisons between hospitals in the incidence of SSI are made, these should at least be stratified by the type of procedure. The aim of this study is to fix SSI incidence in relation to surgical procedure. Methods. This report contains data of 19.948 procedures collected from 1996 to 2008 at a Specialist Orthopaedic Hospital and analyzed by a specific software designed for the study of infection in orthopaedic and trauma surgery. The SSI surveillance is focused on categories of surgical procedure (Hip Arthroplasty, Knee Arthroplasty, Spine Surgery and Hip Fracture Surgery) with each category containing a defined set of similar procedures. A basic of demographic data and details about operation itself are collected for each procedure. Patients are followed up throughout their hospital stay and after hospital discharge. We present the incidence of SSI by risk group and surgical procedure. SSI are categorized in type, moment of diagnosis and micro-organisms reported. Analysis of the data was performed (SPSSv15.0 ®). Statistical methods used to determine significance were the independent samples t test, Pearson X2 test, Odds ratio and Spearman correlation coefficient, with a significance level of p<0,05. Results. Rates of SSI are highest in hip hemiarthroplasty after fracture and in hip and knee revision procedures. Rates of SSI increase with the number of risk factors present in the patient, especially after fracture procedures. The most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. 38% of the infections arise after one year of surveillance. Conclusions. Our results confirm difference in rates of SSI depending of surgical procedure in orthopaedic and trauma surgery. We believe that our decision to monitor infection with a long term follow up it's the better way to avoid under-reporting of infection. Our study has also demonstrated the extent to which the emerging problem of infection due to MRSA has affected orthopaedic surgery. The risk of acquiring SSI caused by MRSA was particularly high in patients after hip fracture surgery. Rates of SSI increase with the number of risk factors present in the patient, especially after fracture procedures. Globally, the most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. 38% of the infections arise after one year of surveillance

Background. Growing of the geriatric population has brought about increase of lower extremity fractures. The purpose of this study was to investigate the occurrence of surgical site infection after the surgery for lower extremity fractures, except proximal femoral fracture, in over eighty years old patients. Methods. Patients with closed lower extremity fracture which were treated surgically in 2011 were divided into two groups (Group O; the equal or more than 80 years old, Group Y; from 20 to 65 years old), and the incidence of infection and the outcome after its treatment was compared between Group O and Group Y. Results. In group O, there were 35 fractures in 35 patients with average age of 86.7 years (range from 80 to 92). Five patients (14.3%) showed infection. Only one case recovered from infection, one died because of sepsis and the other three required amputation. The reasons for amputation were advanced sepsis in 2 and severe soft tissue damage in 1. In group Y with 110 fractures in 101 patients, there was no infection (p = 0.0007). Conclusions. The presented study showed that infection rate following lower extremity fracture surgery in group O had been significantly higher than that of group Y. Despite the application of minimum invasive surgery or intramedullary nail, infection occurred in Group O. Once, infection occurred after lower extremity fracture surgery in advanced age patients, it may be difficult to recover the infection without amputation

Aim. Reveal the rate of surgical site infection (SSI) after primary hip and knee arthroplasty in patients with inflammatory joint disease and analyse if the infection rate was correlated to the given anti-rheumatic treatment. The background is that since 2006 patients operated at the orthopaedic department at Skåne University hospital, Lund, Sweden, have continued treatment with TNF-alpha inhibitors during the perioperative period. Method. During 2006 to 2015 494 planned primary hip and knee arthroplasties were performed on 395 patients (236 hip arthroplasties and 239 knee arthroplasties). Data on age, sex, diagnosis, BMI, operation time, ASA-classification, treatment with cDMARDs (conventional disease modifying anti-rheumatic drugs) and bDMARDs (biological disease modifying antirheumatic drugs) and use of prednisolone was collected. The primary outcome variable was prosthetic joint infection (PJI) within 1 year from surgery with a secondary outcome variable being superficial SSI. Results. In 32% (n=159) of the cases the patient was treated with a TNF-alpha inhibitor. The rate of PJI was 1.4% (n=7). The overall rate of infection, including superficial infections, was 2.4% (n=12). All the PJIs occurred after a knee arthroplasty and only 1 patient was treated with a TNF-alpha inhibitor (etanercept). Conclusions. We could not find that continuing treatment with TNF-inhibitors perioperatively led to a higher incidence of PJI or SSI than generally would be expected in a group of patients with an inflammatory joint disease. Based on these results there is no need to discontinue treatment with TNF-inhibitors when performing arthroplasty surgery

There is mixed evidence in the literature regarding increasing age, ASA and BMI as risk factors for surgical site infection in orthopaedic surgery. To investigate the matter further, we examined 1055 wounds in 1008 patients in the Department of Trauma and Orthopaedic Surgery at University College London Hospital between 2000 and 2006. All patients with a minimum two-night stay were included. Data was collected by four designated research nurses. The age, height, weight and ASA status of each patient was recorded. All wounds were classified using ASEPSIS. This is a quantitative wound scoring method which is a summation of scores calculated from visual wound characteristics and the clinical consequences of infection. Our results showed a strong linear association between age and ASEPSIS scores. Single variable regression analysis showed a t value of 3.32 and p value of 0.001. A similar linear association was seen between ASA grading and ASEPSIS scores. Single variable regression analysis showed a t value of 2.75 and p value of 0.006. The association between BMI and ASEPSIS scores was markedly different from that seen with age and ASA. The graph was U-shaped with patients with a BMI of 25-30 having the lowest average ASEPSIS scores. Patients with a lower and a higher BMI had higher average ASEPSIS scores. Single variable regression analysis was not significant since the relationship between BMI and ASEPSIS scores is not linear. In conclusion, there are clearly defined patient groups who are at increased risk of developing a surgical site infection: older patients, patients with a higher ASA, and patients with both a low and high BMI. These patients should be targeted to reduce overall infection rates. This can be achieved by ensuring adequate antibiotic prophylaxis, having a low threshold to treat suspected infection and arranging regular follow-up

Introduction: Surgical Site Infection (SSI) in spinal surgery at the James Cook University Hospital was investigated and compared with the published rates of 1 – 12%. Variables of instrumentation, laminar air flow, duration of operation, and blood units transfused in the first 48 hours were examined. Methods: 556 spinal operations were carried out in 2005–6. 147 of these involved the use of instrumentation. Infections were defined as positive wound or blood cultures. The duration of surgery, presence of laminar air flow and units of blood transfused were recorded. Statistical analysis was performed using Fishers exact test. Results: 9 cases of SSI were identified in the 147 instrumented spinal operations in comparison to zero in the 409 non-instrumented patients (p < 0.0001). The mean duration of surgery was 4 hours 19mins. The results for operation duration < 5hours vs. operation duration > 5hours (3/96 vs 6/51) were not statistically significant. (p=0.065). Of the 147 instrumented spinal operations, 8 of the infected were performed in a laminar air flow system and 1 without (not statistically significant, p=0.69). The results for blood transfusion < 2units vs. blood transfusion ≥2 units (4/85 vs 5/62) were not significant (P=0.49). Conclusion: The rate of SSI at the James Cook University Hospital in instrumented spinal surgery was 6%. SSI in spinal surgery was heavily influenced by instrumentation, but was not reduced by laminar airflow. Duration of operation and number of units of blood transfused were not significant factors

Surgical site infection (SSI) is an important outcome indicator. It is estimated that 70% of post-operative infections present after discharge. A reliable post-discharge surveillance (PDS) method is yet to be described. The aim of this prospective cohort study was to assess the reliability of patient self-diagnosis. Telephone questionnaires were used following hip and knee prosthetic surgery. A trained validation nurse checked the wounds of all patients reporting problems and a sample of those who did not. 376 elective hip and knee arthroplasty procedures from 363 patients were included. In-patient infection rate was 3.1% (13 of 422 procedures) and post-discharge infection rate was 5.2% (22 of 422 procedures). Results suggest that patients can reliably self diagnose SSI. The sensitivity of the procedure (the probability that the telephone surveillance will detect an infection given that the patients has an infection) was 90.9%. The specificity (the probability that the telephone surveillance will report no infection given that no infection is present) was 76.6%. Hence telephone PDS of SSI is a valuable means of identifying accurate rates of hospital acquired infection following surgery. In this study population, 41% of infections were diagnosed post discharge, which is lower than has previously been estimated. PDS of SSI is necessary if accurate rates of hospital acquired infection following surgery are to be available

Introduction: Surgical Site Infection (SSI) in spinal surgery at the James Cook University Hospital was investigated and compared with the published rates of 1–12%. Variables of instrumentation, laminar air flow, duration of operation, and blood units transfused in the first 48 hours were examined. Methods: 556 spinal operations were carried out in 2005–6. 147 of these involved the use of instrumentation. Infections were defined as positive wound or blood cultures. The duration of surgery, presence of laminar air flow and units of blood transfused were recorded. Statistical analysis was performed using the Fisher’s Exact Test. Results: Nine cases of SSI were identified in the 147 instrumented spinal operations in comparison to Zero in the 409 non-instrumented patients (p < 0.0001). The mean duration of instrumented surgery was 4 hours 19mins. The infection rates for operation duration < 5 h versus operation duration > 5 h (3/96 Vs 6/51) were not statistically significant (p = 0.065). Of the 147 instrumented spinal operations, 8 of 117 operations performed in a laminar air flow system and 1 of 30 performed without laminar air flow were infected (p = 0.69). Infection rates for those patients transfused < 2 units (4/85) were not significantly different to those in patients transfused > 2 units (5/62), p = 0.49. Conclusion: The rate of SSI at the James Cook University Hospital in instrumented spinal surgery was 6%. SSI in spinal surgery was heavily influenced by instrumentation, but was not reduced by laminar airflow. Duration of operation and number of units of blood transfused were not significant factors

Purpose of study: Evaluate our surgical site infection (SSI) rate in scoliosis surgery against nationally agreed standards, examine local practices to limit SSI and compare metalwork survivorship in the presence of infection. Methods and Results : Retrospective analysis of patients undergoing instrumented correction of scoliosis with or without fusion between September 2003 and January 2009. Clinical and laboratory records of 134 patients (age range 10 months to 22 years) were examined for any evidence of SSI. There were 14 (10.4%) SSI cases, of which 8 (5.9%) were clinically significant deep SSIs, which is slightly higher than a pooled SSI rate of 2.2% from a meta-analysis of infection in spinal surgery (range 1.2 to 8.5%). 1. Half of our deep SSIs occurred in neuromuscular scoliosis corrections with the most prevalent pathogen being E. Coli (28%) overall. All deep SSI patients underwent surgical debridement and iv antibiotics and we were able to retain the metalwork in all early (within 21 days) SSIs (6 of 8) but in neither late SSI (588 and 814 days). No single common variable was identified from our data-set as a risk factor for SSI although high staff numbers in theatre was noted. Infection rate increased toward the end of our series which coincided with a change in antibiotic prophylaxis protocol and paradoxically with a move to a laminar flow theatre. Conclusion : Our SSI rate in scoliosis surgery was not significantly higher than previously published pooled rates. No single common variable was identified as risk factor for SSI. An empirical return to previous antibiotic prophylaxis could be recommended along with limiting staff numbers and movements within the operating theatre. Ethics approval: Audit/service standard in trust. Conflict of Interest Statement: None

Fresh-frozen allograft bone is frequently used in orthopaedic surgery. We investigated the incidence of allograft-related infection and analysed the outcomes of recipients of bacterial culture-positive allografts from our single-institute bone bank during bone transplantation. The fresh-frozen allografts were harvested in a strict sterile environment during total joint arthroplasty surgery and immediately stored in a freezer at −78° to −68° C after packing. Between January 2007 and December 2012, 2024 patients received 2083 allografts with a minimum of 12 months of follow-up. The overall allograft-associated infection rate was 1.2% (24/2024). Swab cultures of 2083 allografts taken before implantation revealed 21 (1.0%) positive findings. The 21 recipients were given various antibiotics at the individual orthopaedic surgeon's discretion. At the latest follow-up, none of these 21 recipients displayed clinical signs of infection following treatment. Based on these findings, we conclude that an incidental positive culture finding for allografts does not correlate with subsequent surgical site infection. Additional prolonged post-operative antibiotic therapy may not be necessary for recipients of fresh-frozen bone allograft with positive culture findings. Chang Gung Medical Foundation

Aims. Surgical site infection (SSI) is a common complication of surgery with an incidence of about 1% in the United Kingdom. Sutures can lead to the development of a SSI, as micro-organisms can colonize the suture as it is implanted. Triclosan-coated sutures, being antimicrobical, were developed to reduce the rate of SSI. Our aim was to assess whether triclosan-coated sutures cause a reduction in SSIs following arthroplasty of the hip and knee. Patients and Methods. This two-arm, parallel, double-blinded study involved 2546 patients undergoing elective total hip (THA) and total knee arthroplasty (TKA) at three hospitals. A total of 1323 were quasi-randomized to a standard suture group, and 1223 being quasi-randomized to the triclosan-coated suture group. The primary endpoint was the rate of SSI at 30 days postoperatively. Results. The baseline characteristics of age, gender and comorbidities were well matched in the two groups. The rates of superficial SSI were 0.8% in the control group and 0.7% in the intervention group (p = 0.651), and when deep and superficial SSIs were combined the rates were 2.5% and 1.8 (p = 0.266). The length of stay in hospital and the rates of medical complications did not differ significantly between the groups (p = 1.000). Conclusion. This trial provided no evidence that the use of triclosan-coated sutures at THA and TKA leads to a reduction in the rate of SSI. Cite this article: Bone Joint J 2018;100-B:296–302

Introduction: More than 140,000 joint replacements are carried out in England and Wales per annum costing from £4000 to £7000 each (. 1. , . 2. ). Implant costs are relatively fixed but there are considerable variations in length of stay [LOS] following surgery. The National Audit office estimated that a reduction of two days per patient could save the NHS £15.5 million per year (. 2. ). A specialist orthopaedic ward for elective arthroplasty was opened in Bangor in 2008 in an attempt to address these issues. The staff per bed ratio remained the same as in the general orthopaedic wards but beds were “ring fenced” and strict infection control measures protocols were implemented. This audit aimed to assess the effect of the specialist ward on LOS following arthroplasty. Method: Retrospective data on length of stay, demographics and surgical site infections [SSI] were collected for the six months before and six months after the specialist ward was opened. Only primary lower limb arthroplasty data was evaluated and LOS was calculated from day of operation to the day of discharge. Statistical analysis was performed on the length of stay with SPSS software using the two-sample t-test and Mann-Whitley U test. Results: Patients were managed by the same surgical teams in the same theatres but nursed in different ward settings. Group 1 included 222 patients managed in general orthopaedic wards and group 2 included 191 patients, managed in the ring fenced ward. The mean age for total hip replacements was 70.8 in group 1 and 71.2 years in group 2. The mean age for total knee replacements was 70.9 years in group 1 and 69.2 years in group 2. The overall mean LOS for both procedures was 7.61 days (95% CI: 7.14 – 8.07) in group 1 compared with 5.67 days (95% CI: 5.28 – 6.06) group 2. This was statistically significant (p< 0.001). The mode was 7 days in group 1 compared with 4 days in group 2. Three SSIs were noted in group 1 and zero in group 2. Conclusions: This audit demonstrates a two day reduction in LOS for patients managed in a ring fenced ward. The reasons for the reduction are multi factorial but include a trend for reduced SSI. Overall reduced stay frees up resources for other use and may reduce costs. Other units may benefit from similar dedicated wards in response to growing demand for arthroplasty within a system of fixed resources

This trial aims to assess the effectiveness of quality improvement collaboratives as a technique to introduce large-scale change and improve outcomes for patients undergoing primary elective total hip or total knee arthroplasty. 41 NHS Trusts that did not have; a preoperative anaemia screening and optimisation pathways, or a methicillin sensitive Staphylococcus Aureus (MSSA) decolonisation pathway, in place were randomised to one of two parallel collaboratives in a two arm, cluster randomised controlled trial. Each collaborative focussed on implementing one of these two preoperative pathways. Collaboratives took place from May 2018 to November 2019. 27 Trusts completed the trial. Outcome data were collected for procedures between November 2018 and November 2019. Co-primary outcomes were perioperative blood transfusion (within 7 days of surgery) and deep surgical site infections (SSI) caused by MSSA (within 90 days) for the anaemia and MSSA arms respectively. Secondary outcomes include deep and superficial SSIs (any organism), length of stay, critical care admissions, and readmissions. Process measures include the proportion of patients receiving each preoperative initiative. 19,254 procedures from 27 Trusts are included. Process measures show both preoperative pathways were implemented to a high degree (75.3% compliance in MSSA arm; 61.2% anaemia arm), indicating that QICs can facilitate change in the NHS. However, there were no improvements in blood transfusions (2.9% v 2.3% adjusted-OR 1.20, 95% CI 0.52–2.75, p=0.67), MSSA deep SSIs (0.13% v 0.14% adjusted-OR 1.01, 95%CI 0.42–2.46, p=0.98), or any secondary outcome. Whilst no significant improvement in patient outcomes were seen, this trial shows quality improvement collaboratives can successfully support the implementation of new preoperative pathways in planned surgery in the NHS

Aims

The importance of accurate identification and reporting of surgical site infection (SSI) is well recognised but poorly defined. Public Health England (PHE) mandated collection of orthopaedic SSI data in 2004. Data submission is required in one of four categories (hip prosthesis, knee prosthesis, repair of neck of femur, reduction of long bone fracture) for one quarter per year. Trusts are encouraged to carry out post-discharge surveillance but this is not mandatory. Recent papers in the orthopaedic literature have highlighted the importance of SSI surveillance and the heterogeneity of surveillance methods. However, details of current orthopaedic SSI surveillance practice has not been described or quantified.

This study evaluated whether obese patients who lost weight before their total joint replacement and kept it off post-operatively were at lower risk of surgical site infection (SSI) and re-admission compared with those who remained the same weight. We reviewed 444 patients who underwent a total hip replacement and 937 with a total knee replacement who lost weight pre-operatively and sustained their weight loss after surgery. After adjustments, patients who lost weight before a total hip replacement and kept it off post-operatively had a 3.77 (95% confidence interval (CI) 1.59 to 8.95) greater likelihood of deep SSIs and those who lost weight before a total knee replacement had a 1.63 (95% CI 1.16 to 2.28) greater likelihood of re-admission compared with the reference group. These findings raise questions about the safety of weight management before total replacement of the hip and knee joints. Cite this article: Bone Joint J 2014;96-B:629–35

Background. Hospital acquired MRSA is globally endemic and is a leading cause of surgical site infection (SSI). Of great concern is the emergence of community acquired MRSA (CA MRSA) with its unique virulence characteristics. Infected hip or knee prostheses due to MRSA are associated with multiple reoperations and prolonged hospital stay. Few studies have been done to assess for risk of SSI in MRSA carriers undergoing elective orthopaedic surgery following decolonisation. However in these studies, the eradication status was not confirmed prior to proceeding for surgical intervention. Aim. The purpose of the study was to evaluate the incidence of SSI in MRSA carriers undergoing elective hip and knee arthroplasty, who had confirmed eradication of MRSA carrier status and to compare it with incidence of SSI in non MRSA carriers. Material and Methods. This is a retrospective analysis of 6613 patients who underwent elective hip (3347) and knee arthroplasty (3266) at our institution between January 2008 and August 2012. A cohort of patients who were preoperatively colonised with MRSA was identified. These patients were offered decolonisation protocol and successful eradication was ensured prior to surgery. The MRSA negative patients served as the control group and we looked into the incidence of SSI in both groups up to one year after surgery. Categorical variables were investigated between groups using chi-squared tests and p value of < 0.05 was taken as significant. Results. Out of 6613 patients, MRSA colonisation was observed in 83 patients (a mean age of 76 years with a M:F ratio of 1:1.2) pre-operatively with a colonisation rate of 1.3%. A total of 79 patients had confirmed eradication of carrier status prior to surgical intervention. Of these 38 were THRs and 41 were TKRs. Total number of MRSA negative patients were 6530 with 3307 THRs and 3223 TKRs in control group. Teicoplanin was used for antibiotic prophylaxis in these patients. 5 of 79 patients had “deep SSI” within 1 year of surgery giving an infection rate of 6.32%. There were 2 MRSA infections in hip replacements with an infection rate of 5.26%. There were 2 MRSA and 1 MSSA infection in TKR resulting in an infection rate of 7.31%. These patients did not belong to the “high-risk” group for MRSA colonisation. A significant statistical difference in infection rates from MRSA negative control group was noted, which had a deep sepsis rate of 1.17% (p value − 0.03) in THRs and 0.87% in TKRs (p value − 0.0016). Conclusions and Clinical Implication. In spite of a selective treatment program for carriers and confirmed eradication in terms of achieving a reduction in the rate of SSI, there is still a significantly increased risk of SSI in MRSA colonised patients undergoing hip and knee replacements. Also, should infection develop, MRSA is the most likely causative organism. Patients should be made aware of this higher risk of infection and the serious consequences of developing MRSA SSI

Purpose: There is very little evidence to guide treatment of patients with spinal surgical site infection (SSI) who require irrigation and debridement (I& D) with respect to need for single or multiple I& D’s. The purpose of this study is to build a predictive model which stratifies patients with spinal SSI to determine which patients will go on to need single versus multiple I& D. Method: A consecutive series of 128 patients from a tertiary spine center (collected from 1999–2005) who required I& D for spinal SSI, were studied based on data from a prospectively collected outcomes database. Over 30 variables were identified by extensive literature review as possible risk factors for SSI, and tested as possible predictors of risk for multiple I& D. Logistic regression was conducted to assess each variable’s predictability by a “bootstrap” statistical method. Logistic regression was applied using outcome of I& D – single or multiple as the “response”. Results: 24/128 patients required multiple I& D. Primary spine diagnosis was approximately represented by ¼ trauma, ¼ deformity, ¼ degenerative and ¼ oncology/inflammatory/other. Six predictors: spine location, medical comorbidities, microbiology of the SSI, presence of distant site infection (ie. UTI or bacteremia), presence of instrumentation and bone graft type, proved to be the most reliable predictors of need for multiple I& D. Internal validation of the predictive model yielded area under the curve (AUC) of .84. Conclusion: Infection factors played an important role in need for multiple I& D. Patients with +MRSA culture or those with distant site infection such as bacteremia with or without UTI or pneumonia, were strong predictors of need for multiple I& D. Presence of instrumentation, location of surgery in the posterior lumbar spine and use of non-autograft bone predicted multiple I& D. Diabetes also proved to be the most significant medical comorbidity for multiple I& D

Aims: To calculate SSI rates and potential risk factors for primary total hip replacements (THR), hip hemiarthroplasties (HH), revision THR’s, and revision HH’s in England. Methods: Demographic, operative, and infection data was collected prospectively from 104 hospitals in England over 4 years to calculate SSI rates and potential risk factors. Results: There were 353 (2.3%) infections in 15697 THR’s with a 0.2% joint infection rate; 248 (4.6%) infections in 5456 HH procedures (0.9% joint). For revision THRs there were 92 (3.6%) infections in 2563 procedures, and 11 (5.6%) infections in 197 revision HH’s. Staphylococcus Aureus was identified in 52%; 58% were MRSA. With multivariable analysis, only inter-hospital variation (p< 0.001) and ASA score (p< 0.001) remained significant. Mean time to detection of infection varied from 9.2 days (superficial) to 11.3 days (joint). Mean length of stay increased from 9 to 14 days in THR’s; from 14 to 30 days for revision THR’s; from 19 to 34 days for HH’s and from 20 to 28 days for revision HH’s with an infection.

Conclusions: Infection rates are within acceptable levels, however there is a significant inter-hospital variation in infections following hip prosthesis in England. ASA score remains a significant risk factor and MRSA accounted for 30% of organisms.

The goals of the present study are to describe the prevalence of both methicillin sensitive and resistant S.aureus carriage among elective total hip and knee arthroplasty candidates and to evaluate the real impact of preoperatively treating carriers in preventing prosthetic joint infection.

Patients undergoing elective primary THA or TKA at a single institution were enrolled in a prospective randomized trial. S.aureus nasal carriage screening was performed in the outpatient setting and selected carriers underwent a 5-day preoperative treatment of nasal mupirocin and chlorhexidine bathing. All patients were followed regularly in the outpatient clinic. No patients were lost to follow-up at a minimum of one year after surgery. The main outcome of the study was the diagnosis of prosthetic joint infection occurring in the first year after surgery including all pathogens and a secondary outcome was defined as infections involving S.aureus bacteria only.

From January 2010 to December 2012, 1305 total joint arthroplasties were performed and 1028 of those were screened. We observed a 22.2% (228/1028) S.aureus colonization rate and only eight patients colonized with MRSA (0.8%). Twenty five cases of prosthetic joint infections were identified with an overall infection rate of 2.4%. S.aureus was involved in 14 cases. PJI rate in S.aureus carriers was 3.9% (9/228), which was not significantly higher than the 2.0% (16/800) found among non carriers. Treated and untreated carriers infection rate also showed no significant differences – 3.4% (3/89) vs. 4.3% (6/139). Multivariable analysis substantiates ASA≥ 3 (OR=3.42, 95% CI=1.51 – 7.74) and duration of surgery above the 75th percentile (OR=2.74, 95% CI=1.22 – 6.16) as independent predictors of PJI but not S.aureus carrier state. We obtained similar results when considering infection involving S.aureus bacteria only.

Of the 14 cases where S.aureus was present in PJI, only five were carriers preoperatively. Of those five cases, one was an untreated MSSA carrier that ultimately got an MRSA infection.

Our results show no clear benefit in screening and decolonizing S.aureus nasal carriers before total joint arthroplasty. There seems to be a lack of causal relation between nasal S.aureus and PJI pathogen as most of S.aureus PJI seems to have an exogenous source.

The cement used for hemiarthroplasties by the authors and many other surgeons in the UK is Palacos® (containing 0.5g Gentamicin). Similar cement, Copal® (containing 1g Gentamicin and 1g Clindamycin) has been used in revision arthroplasties. We aim to investigate the effect on SSI rates of doubling the gentamicin dose and adding a second antibiotic (clindamycin) to the bone cement in hip hemiarthroplasty.

We randomised 848 consecutive patients undergoing cemented hip hemiarthroplasty for fractured NOF into two groups: Group I, 464 patients, received standard cement (Palacos®) and Group II, 384 patients, received high dose, double antibiotic-impregnated cement (Copal®). We calculated the SSI rate for each group at 30 days post-surgery. The patients, reviewers and statistician were blinded as to treatment group.

The demographics and co-morbid conditions were statistically similar between the groups. The combined superficial and deep SSI rates were 5 % (20/394) and 1.7% (6/344) for groups I and II respectively (p=0.01). Group I had a deep infection rate 3.3 %(13/394) compared to 1.16% (4/344) in group II (p=0.082). Group I had a superficial infection rate 1.7 % (7/394) compared to 0.58% (2/344) in group II (p=0.1861). 33(4%) patients were lost to follow up, and 77 (9%) patients were deceased at the 30 day end point.

Using high dose double antibiotic-impregnated cement rather than standard low dose antibiotic-impregnated cement significantly reduced the SSI rate (1.7% vs 5%; p=0.01) after hip hemiarthroplasty for fractured neck of femur in this prospective randomised controlled trial.

Currently, the cement being used for hemiarthroplasties and total hip replacements by the authors and many other surgeons in the UK is Palacos® (containing 0.5g Gentamicin). Similar cement, Copal® (containing 1g Gentamicin and 1g Clindamycin) has been used in revision arthroplasties, and has shown to be better at inhibiting bacterial growth and biofilm formation. We aim to investigate the effect on SSI rates of doubling the gentamicin dose and adding a second antibiotic (clindamycin) to the bone cement in hip hemiarthroplasty.

We randomised 848 consecutive patients undergoing cemented hip hemiarthroplasty for fractured NOF at one NHS trust (two sites) into two groups: Group I, 464 patients, received standard cement (Palacos®) and Group II, 384 patients, received high dose, double antibiotic-impregnated cement (Copal®). We calculated the SSI rate for each group at 30 days post-surgery. The patients, reviewers and statistician were blinded as to treatment group.

The demographics and co-morbid conditions (known to increase risk of infection) were statistically similar between the groups. The combined superficial and deep SSI rates were 5 % (20/394) and 1.7% (6/344) for groups I and II respectively (p=0.01). Group I had a deep infection rate 3.3 %(13/394) compared to 1.16% (4/344) in group II (p=0.082). Group I had a superficial infection rate 1.7 % (7/394) compared to 0.58% (2/344) in group II (p=0.1861). 33(4%) patients were lost to follow up, and 77 (9%) patients were deceased at the 30 day end point. There was no statistical difference in the 30 day mortality, C. difficile infection, or the renal failure rates between the two groups.

Using high dose double antibiotic-impregnated cement rather than standard low dose antibiotic-impregnated cement significantly reduced the SSI rate (1.7% vs 5%; p=0.01) after hip hemiarthroplasty for fractured neck of femur in this prospective randomised controlled trial.

Aims. Hand trauma, consisting of injuries to both the hand and the wrist, are a common injury seen worldwide. The global age-standardized incidence of hand trauma exceeds 179 per 100,000. Hand trauma may require surgical management and therefore result in significant costs to both healthcare systems and society. Surgical site infections (SSIs) are common following all surgical interventions, and within hand surgery the risk of SSI is at least 5%. SSI following hand trauma surgery results in significant costs to healthcare systems with estimations of over £450 per patient. The World Health Organization (WHO) have produced international guidelines to help prevent SSIs. However, it is unclear what variability exists in the adherence to these guidelines within hand trauma. The aim is to assess compliance to the WHO global guidelines in prevention of SSI in hand trauma. Methods. This will be an international, multicentre audit comparing antimicrobial practices in hand trauma to the standards outlined by WHO. Through the Reconstructive Surgery Trials Network (RSTN), hand surgeons across the globe will be invited to participate in the study. Consultant surgeons/associate specialists managing hand trauma and members of the multidisciplinary team will be identified at participating sites. Teams will be asked to collect data prospectively on a minimum of 20 consecutive patients. The audit will run for eight months. Data collected will include injury details, initial management, hand trauma team management, operation details, postoperative care, and antimicrobial techniques used throughout. Adherence to WHO global guidelines for SSI will be summarized using descriptive statistics across each criteria. Discussion. The Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) will provide an understanding of the current antimicrobial practice in hand trauma surgery. This will then provide a basis to guide further research in the field. The findings of this study will be disseminated via conference presentations and a peer-reviewed publication. Cite this article: Bone Jt Open 2024;5(4):361–366

Aims. Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre. Methods. A retrospective review was performed of all gram-negative spinal infections (n = 32; median age 71 years; interquartile range 60 to 78), excluding surgical site infections, at a single centre between 2015 to 2020 with two- to six-year follow-up. Information regarding organism identification, antibiotic regime, and treatment outcomes (including clinical, radiological, and biochemical) were collected from clinical notes. Results. All patients had comorbidities and/or non-spinal procedures within the previous year. Most infections affected lumbar segments (20/32), with Escherichia coli the commonest organism (17/32). Causative organisms were identified by blood culture (23/32), biopsy/aspiration (7/32), or intraoperative samples (2/32). There were 56 different antibiotic regimes, with oral (PO) ciprofloxacin being the most prevalent (13/56; 17.6%). Multilevel, contiguous infections were common (8/32; 25%), usually resulting in bone destruction and collapse. Epidural collections were seen in 13/32 (40.6%). In total, five patients required surgery, three for neurological deterioration. Overall, 24 patients improved or recovered with a mean halving of CRP at 8.5 days (SD 6). At the time of review (two to six years post-diagnosis), 16 patients (50%) were deceased. Conclusion. This is the largest published cohort of gram-negative spinal infections. In older patients with comorbidities and/or previous interventions in the last year, a high level of suspicion must be given to gram-negative infection with blood cultures and biopsy essential. Early organism identification permits targeted treatment and good initial clinical outcomes; however, mortality is 50% in this cohort at a mean of 4.2 years (2 to 6) after diagnosis. Cite this article: Bone Jt Open 2024;5(5):435–443

Aims. There is increasing evidence to support the use of topical antibiotics to prevent surgical site infections. Although previous research suggests a minimal nephrotoxic risk with a single dose of vancomycin powder, fracture patients often require multiple procedures and receive additional doses of topical antibiotics. We aimed to determine if cumulative doses of intrawound vancomycin or tobramycin powder for infection prophylaxis increased the risk of drug-induced acute kidney injury (AKI) among fracture patients. Methods. This cohort study was a secondary analysis of single-centre Program of Randomized Trials to Evaluate Pre-operative Antiseptic Skin Solutions in Orthopaedic Trauma (PREP-IT) trial data. We included patients with a surgically treated appendicular fracture. The primary outcome was drug-induced AKI. The odds of AKI per gram of vancomycin or tobramycin powder were calculated using Bayesian regression models, which adjusted for measured confounders and accounted for the interactive effects of vancomycin and tobramycin. Results. Of the 782 included patients (mean age 48 years (SD 20); 59% male), 83% (n = 648) received at least one vancomycin dose (cumulative range 1 to 12 g). Overall, 45% of the sample received at least one tobramycin dose (cumulative range 1.2 to 9.6 g). Drug-induced AKI occurred in ten patients (1.2%). No association was found between the cumulative dose of vancomycin and drug-induced AKI (odds ratio (OR) 1.08 (95% credible interval (CrI) 0.52 to 2.14)). Additional doses of tobramycin were associated with a three-fold increase in the adjusted odds of drug-induced AKI (OR 3.66 (95% CrI 1.71 to 8.49)). Specifically, the risk of drug-induced AKI rose substantially after 4.8 g of tobramycin powder (7.5% (95% CrI 1.0 to 35.3)). Conclusion. Cumulative doses of vancomycin were not associated with an increased risk of drug-induced AKI among fracture patients. While the risk of drug-induced AKI remains less than 4% with three or fewer 1.2 g tobramycin doses, the estimated risk increases substantially to 8% after four cumulative doses. Level of evidence: Therapeutic Level III. Cite this article: Bone Jt Open 2022;3(4):284–290

Aims. Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures. Methods. A structured search of MEDLINE, EMBASE, the online archives of Bone & Joint Publishing, and CENTRAL databases from inception until 28 July 2021 was performed. Randomized, controlled, clinical trials that compared autologous and synthetic bone grafts in tibial plateau fractures were included. Preclinical studies, clinical studies in paediatric patients, pathological fractures, fracture nonunion, or chondral defects were excluded. Outcome data were assessed using the Risk of Bias 2 (ROB2) framework and synthesized in random-effect meta-analysis. The Preferred Reported Items for Systematic Review and Meta-Analyses guidance was followed throughout. Results. Six studies involving 353 fractures were identified from 3,078 records. Following ROB2 assessment, five studies (representing 338 fractures) were appropriate for meta-analysis. Primary outcomes showed non-significant reductions in articular depression at immediate postoperative (mean difference -0.45 mm, p = 0.25, 95%confidence interval (CI) -1.21 to 0.31, I. 2. = 0%) and long-term (> six months, standard mean difference -0.56, p = 0.09, 95% CI -1.20 to 0.08, I. 2. = 73%) follow-up in synthetic bone grafts. Secondary outcomes included mechanical alignment, limb functionality, and defect site pain at long-term follow-up, perioperative blood loss, duration of surgery, occurrence of surgical site infections, and secondary surgery. Mean blood loss was lower (90.08 ml, p < 0.001, 95% CI 41.49 to 138.67) and surgery was shorter (16.17 minutes, p = 0.04, 95% CI 0.39 to 31.94) in synthetic treatment groups. All other secondary measures were statistically comparable. Conclusion. All studies reported similar methodologies and patient populations; however, imprecision may have arisen through performance variation. These findings supersede previous literature and indicate that, despite perceived biological advantages, autologous bone grafting does not demonstrate superiority to synthetic grafts. When selecting a void filler, surgeons should consider patient comorbidity, environmental and societal factors in provision, and perioperative and postoperative care provision. Cite this article: Bone Jt Open 2022;3(3):218–228

Aims

The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs.

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

This study aims to determine the incidence of surgical site infection leading to reoperation for sepsis following minor hand procedures performed outside the main operating room using field sterility in the South African setting. The investigators retrospectively reviewed the records of 485 patients who had WALANT-assisted minor hand surgery outside a main operating theatre, a field sterility setting between March 2019 and April 2023. The primary outcome was the presence or absence of deep surgical site infection that required reoperation within four weeks. Cases included where elective WALANT minor hand procedures, a minimum age of 18 with complete clinical records. The patients were mostly female (54.8%), with a mean age of 56.35 years. The majority of cases were trigger finger and carpal tunnel release. An overall 485 cases were reviewed, the deep surgical site infection rate resulting in reoperation within 4 weeks post-operatively was 1.24% ((95% Confidence Interval (CI) 0.0034 to 0.0237); p = 0.009). Minor hand procedures performed under field sterility using WALANT have a low surgical site infection rate. The current study's infection rates are comparable to international surgical site infection rates for similar surgeries performed in main operating rooms using standard sterilisation procedures. Field sterility is a safe and acceptable clinical practice that may improve work efficiency in public sector

There is an increasing incidence of revision for periprosthetic joint infection. The addition of vancomycin to beta-lactam antimicrobial prophylaxis in joint arthroplasty may reduce surgical site infections, however, the efficacy and safety have not been established. This was a multicenter, double-blind, superiority, placebo-controlled trial. We randomized 4239 adult patients undergoing joint arthroplasty surgery to receive 1.5g vancomycin or normal saline placebo, in addition to standard cefazolin antimicrobial prophylaxis. The primary outcome was surgical site infection at 90-days from index surgery. Perioperative carriage of Staphylococcus species was also assessed. In the 4113 patients included in the modified intention-to-treat population, surgical site infections occurred in 72/2069 (3.5%) in the placebo group and 91/2044 (4. 5%) in the vancomycin group (risk ratio 1.28; 95% confidence interval 0.94 to 1.73; p value 0.11). No difference was observed between the two groups for primary hip arthroplasty procedures. A higher proportion of infections occurred in knee arthroplasty patients in the vancomycin group (63/1109 [4.7%]) compared with the placebo group (42/1124 [3.7%]; risk ratio 1.52; 95% confidence interval 1.04 to 2.23; p value 0.031). Hypersensitivity reactions occurred in 11 (0.5%) patients in the placebo group and 24 (1.2%) in the vancomycin group (risk ratio 2.20; 95% confidence interval 1.08, 4.49) and acute kidney injury in 74 (3.7%) patients in the placebo group and 42 (2.1%) in the vancomycin group (risk ratio 0.57; 95% confidence interval 0.39, 0.83). Perioperative Staphylococcus aureus carriage was detected in 1089/3748 (29.1%) of patients. This is the first randomized controlled trial examining the addition of a glycopeptide antimicrobial to standard beta-lactam surgical antimicrobial prophylaxis in joint arthroplasty. The addition of vancomycin to standard cefazolin prophylaxis was not superior to placebo for the prevention of surgical site infections in hip and knee arthroplasty surgery

Surgical site infections following spinal surgery profoundly influence continued treatment, significantly impacting psychological and economic dimensions and clinical outcomes. Its reported incidence varies up to 20%, with the highest incidence amongst neuromuscular scoliosis and metastatic cord compression patients. We describe the first reported biphasic osteoconductive scaffold (Cerament G) with a logarithmic elution profile as a cumulative strategic treatment modality for adjacent spinal surgery infections. All patients who developed surgical site infections following instrumented fusion (May 2021-December 2021) had their demographics (age, sex), type and number of procedures, isolated organism, antibiotics given, comorbidities, and WHO performance status analysed. The infected wound was debrided to healthy planes, samples taken, and Cerament g applied. Thirteen patients were treated for deep SSI following spinal instrumentation and fusion procedures with intraoperative Cerament G application. There were four males and nine females with an average age of 40 ranging between 12 and 87. Nine patients underwent initial surgery for spinal deformity, and four were treated for fractures as index procedure. 77% of infections were attributable to MSSA and Cutibacteriousm acnes; others included Klebsiella, Pseudomonas and Streptococcus and targeted with multimodal cumulative therapy. A WHO performance score improved in 11 patients. In addition, there was no wound leak, and infection was eradicated successfully in 12/13 with a single procedure. This series shows the successful eradication of the infection and improved functional outcomes with Cerament G. However, the low numbers of patients in our series are an essential consideration for the broader applicability of this device

Surgical site infections (SSIs) after spinal fusion surgery increase healthcare costs, morbidity and mortality. Routine measures of obesity fail to consider site specific fat distribution. We aimed to assess the association between the spine adipose index and deep surgical site infection and determine a threshold value for spine adipose index that can assist in preoperative risk stratification in patients undergoing posterior instrumented lumbar fusion (PILF). A multicentre retrospective case-control study was completed. We reviewed patients who underwent PILF from January 1, 2010 to December 31, 2018. All patients developing a deep primary incisional or organ-space SSI within 90 days of surgery as per US Centre for Disease Control and Prevention criteria were identified. We gathered potential pre-operative and intra-operative deep infection risk factors for each patient. Spine adipose index was measured on pre-operative mid-sagittal cuts of T2 weighted MRI scans. Each measurement was repeated twice by three authors in a blinded fashion, with each series of measurement separated by a period of at least six weeks. Forty-two patients were included in final analysis, with twenty-one cases and twenty-one matched controls. The spine adipose index was significantly greater in patients developing deep SSI (p =0.029), and this relationship was maintained after adjusting for confounders (p=0.046). Risk of developing deep SSI following PILF surgery was increased 2.0-fold when the spine adipose index was ≥0.51. The spine adipose index had excellent (ICC >0.9; p <0.001) inter- and intra-observer reliabilities. The spine adipose index is a novel radiographic measure and an independent risk factor for developing deep SSI, with 0.51 being the ideal threshold value for pre-operative risk stratification in patients undergoing PILF surgery

Malnutrition is considered a risk factor for postoperative complications in total hip and knee arthroplasty, though prospective studies investigating this assumption are lacking. The aim of this study was to prospectively analyse the 90-day postoperative complications, postoperative length of stay (LOS) and readmission rates of patients undergoing primary total hip and total kneearthroplasty using albumin, total lymphocyte count (TLC) and transferrin as serum markers of potential malnutrition. 603 primary hip and 823 primary knee arthroplasties over a 3-year period from a single centre wereprospectively analysed. BMI, demographic and comorbidity data were recorded. Complications werecategorised as surgical site infection, venous thromboembolism (deep vein thrombosis andpulmonary embolus), implant related (such as dislocation), and non-implant related (such aspneumonia). Outcomes were compared between groups, with malnutrition defined as serumalbumin <3.5g/dL, transferrin <200 mg/dL, or TLC <1,500 cells/mm³. Potential malnutrition was present in 9.3% of the study population. This group experienced a longeraverage LOS at 6.5 days compared to the normal albumin group at 5.0 days (p=0.003). Surgical siteinfection rate was higher in the malnourished group (12.5 vs 7.8%, p=0.02). There was no differencebetween the two groups in implant related complications (0.8 vs 1.0%, p=0.95) medicalcomplications (7.8 vs 13.3%, p=0.17), rate of venous thromboembolism (2.3 vs 2.7%) or 90-dayreadmission rate (14.1 vs 17.0%, p=0.56). TLC and transferrin were not predictive of any of theprimary outcomes measured (p<0.05). Pacific Island (p<0.001), Indian (p=0.02) and Asian (p=0.02) patients had lower albumin than NZ European. This study demonstrates an association between low albumin levels and increased postoperativeLOS and surgical site infection in total joint arthroplasty, providing rationale for consideration ofpreoperative nutritional screening and optimisation

The February 2023 Research Roundup. 360. looks at: Clinical and epidemiological features of scaphoid fracture nonunion; Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh); Characterization of genetic risk of end-stage knee osteoarthritis treated with total knee arthroplasty; Platelet-rich plasma or autologous blood injection for plantar fasciitis; Volume and outcomes of joint arthroplasty; The hazards of absolute belief in the p-value laid bare

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 December 2022 Spine Roundup. 360. looks at: Deep venous thrombosis prophylaxis protocol on a Level 1 trauma centre patient database; Non-specific spondylodiscitis: a new perspective for surgical treatment; Disc degeneration could be recovered after chemonucleolysis; Three-level anterior cervical discectomy and fusion versus corpectomy- anterior cervical discectomy and fusion “hybrid” procedures: how does the alignment look?; Rivaroxaban or enoxaparin for venous thromboembolism prophylaxis; Surgical site infection: when do we have to remove the implants?; Determination of a neurologic safe zone for bicortical S1 pedicle placement; Do you need to operate on unstable spine fractures in the elderly: outcomes and mortality; Degeneration to deformity: when does the patient need both?

The December 2023 Wrist & Hand Roundup. 360. looks at: Volar locking plate for distal radius fractures with patient-reported outcomes in older adults; Total joint replacement or trapeziectomy?; Replantation better than revision amputation in traumatic amputation?; What factors are associated with revision cubital tunnel release within three years?; Use of nerve conduction studies in carpal tunnel syndrome; Surgical site infection following surgery for hand trauma: a systematic review and meta-analysis; Association between radiological and clinical outcomes following distal radial fractures; Reducing the carbon footprint in carpal tunnel surgery inside the operating room with a lean and green model: a comparative study

The June 2024 Spine Roundup. 360. looks at: Intraoperative navigation increases the projected lifetime cancer risk in patients undergoing surgery for adolescent idiopathic scoliosis; Intrawound vancomycin powder reduces delayed deep surgical site infections following posterior spinal fusion for adolescent idiopathic scoliosis; Characterizing negative online reviews of spine surgeons; Proximal junctional failure after surgical instrumentation in adult spinal deformity: biomechanical assessment of proximal instrumentation stiffness; Nutritional supplementation and wound healing: a randomized controlled trial

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. Hand trauma accounts for one in five of emergency department attendances, with a UK incidence of over five million injuries/year and 250,000 operations/year. Surgical site infection (SSI) in hand trauma surgery leads to further interventions, poor outcomes, and prolonged recovery, but has been poorly researched. Antimicrobial sutures have been recognized by both the World Health Organization and the National Institute for Clinical Excellence as potentially effective for reducing SSI. They have never been studied in hand trauma surgery: a completely different patient group and clinical pathway to previous randomized clinical trials (RCTs) of these sutures. Antimicrobial sutures are expensive, and further research in hand trauma is warranted before they become standard of care. The aim of this protocol is to conduct a feasibility study of antimicrobial sutures in patients undergoing hand trauma surgery to establish acceptability, compliance, and retention for a definitive trial. Methods. A two-arm, multicentre feasibility RCT of 116 adult participants with hand and wrist injuries, randomized to either antimicrobial sutures or standard sutures. Study participants and outcome assessors will be blinded to treatment allocation. Outcome measures will be recorded at baseline (preoperatively), 30 days, 90 days, and six months, and will include SSI, patient-reported outcome measures, and return to work. Conclusion. This will inform a definitive trial of antimicrobial sutures in the hand and wrist, and will help to inform future upper limb trauma trials. The results of this research will be shared with the medical community through high impact publication and presentation. Cite this article: Bone Jt Open 2022;3(7):529–535

Aims. The aim of this study was to evaluate whether, after correction of an adolescent idiopathic scoliosis (AIS), leaving out the subfascial drain gives results that are no worse than using a drain in terms of total blood loss, drop in haemoglobin level, and opioid consumption. Methods. Adolescents (aged between 10 and 21 years) with an idiopathic scoliosis (major curve ≥ 45°) were eligible for inclusion in this randomized controlled noninferiority trial (n = 125). A total of 90 adolescents who had undergone segmental pedicle screw instrumentation were randomized into no-drain or drain groups at the time of wound closure using the sealed envelope technique (1:1). The primary outcome was a drop in the haemoglobin level during first three postoperative days. Secondary outcomes were 48-hour postoperative oxycodone consumption and surgical complications. Results. All 90 patients were included in the primary outcome analysis (no drain = 43; drain = 47). The mean total postoperative blood loss (intraoperative and drain output) was significantly higher in the group with a subfascial drain than in the no-drain group (1,008 ml (SD 520) vs 631 ml (SD 518); p < 0.001). The drop in haemoglobin level did not differ between the study groups over the postoperative timepoints (p = 0.290). The 48-hour opioid consumption was significantly higher in the no-drain group (2.0 mg/kg (SD 0.9) vs 1.4 (SD 0.6); p = 0.005). Two patients in the no-drain and one patient in the drain group developed a surgical site infection. Conclusion. Leaving the subfascial drain out after pedicle screw instrumentation for AIS is not associated with higher postoperative haemoglobin levels. Patients treated without a subfascial drain needed 30% more opioids during the first 48 hours than those who had a drain. Cite this article: Bone Joint J 2022;104-B(9):1067–1072

Rotator cuff repair (RCR) can be performed open or arthroscopically, with a recent dramatic increase in the latter. Despite controversy about the preferred technique, there has been an increase in the number of repairs performed arthroscopically. The purpose of this study was, therefore, to compare revision rates following open and arthroscopic RCR repair. Adult patients undergoing first-time, primary rotator cuff repair in Ontario, Canada (April 2003-March 2014) were identified using physician billing and hospital databases. Patients were followed for a minimum of two and up to 13 years for the primary outcome, revision rotator cuff repair, and secondary outcome, surgical site infection. The intervention considered was open versus arthroscopic technique. Patient factors (age, gender, residence, socioeconomic status, medical comorbidities) and provider factors (surgical volume, hospital setting, worked night before, year of surgery) were recorded. Standardized mean differences were used for covariate comparison. A Cox Proportional Hazards model was used to compare RCR survivorship between the two groups after adjustment for patient and provider factors, generating hazard ratios with 95% confidence intervals (HR, 95% CIs). Censoring occurred on the first of the primary outcome, death, shoulder arthroplasty or arthrodesis, or the end of the follow-up period (March 2016). A total of 37,255 patients were included. The overall revision RCR rate was 2.9% (1,096 patients) with a median time to revision of 23 months (IQR 12–52). Revision repair was more common in the arthroscopic group in comparison to the open group (3.2% vs 2.6%, NNT 166.7, p=0.004), with an adjusted HR of 0.72 (0.63–0.83 95% CI, p < 0 .0001). The surgical site infection rate was significantly higher in the open group compared with the arthroscopic group (0.5% vs 0.2%, NNT 333.3, p < 0 .001). Patient and provider covariates had no statistically significant effect on revision rates, aside from increasing age (per 10 year increase, HR 0.85, 0.81–0.90 95% CI, p < 0 .0001). Revision rotator cuff repair is approximately 30% more common in patients undergoing arthroscopic repair, in comparison to open repair, after adjustment. Surgical site infection is uncommon regardless of surgical technique, however, it is slightly more common following open repair. In the setting of an economic healthcare crisis, trends of increasing arthroscopic RCR may demand scrutiny, as the technique is associated with higher revision rates and higher costs

Aims. The aim of this study was to compare outcomes after growth-friendly treatment for early-onset scoliosis (EOS) between patients with skeletal dysplasias versus those with other syndromes. Methods. We retrospectively identified 20 patients with skeletal dysplasias and 292 with other syndromes (control group) who had completed surgical growth-friendly EOS treatment between 1 January 2000 and 31 December 2018. We compared radiological parameters, complications, and health-related quality of life (HRQoL) at mean follow-up of 8.6 years (SD 3.3) in the dysplasia group and 6.6 years (SD 2.6) in the control group. Results. Mean major curve correction per patient did not differ significantly between the dysplasia group (43%) and the control group (28%; p = 0.087). Mean annual spinal height increase was less in the dysplasia group (9.3 mm (SD 5.1) than in the control group (16 mm (SD 9.2); p < 0.001). Mean annual spinal growth adjusted to patient preoperative standing height during the distraction period was 11% in the dysplasia group and 14% in the control group (p = 0.070). The complication rate was 1.6 times higher (95% confidence interval (CI) 1.3 to 2.0) in the dysplasia group. The following complications were more frequent in the dysplasia group: neurological injury (rate ratio (RR) 5.1 (95% CI 2.3 to 11)), deep surgical site infection (RR 2.2 (95% CI 1.2 to 4.1)), implant-related complications (RR 2.0 (95% CI 1.5 to 2.7)), and unplanned revision (RR 1.8 (95% CI 1.3 to 2.5)). Final fusion did not provide additional spinal height compared with watchful waiting (p = 0.054). There were no significant differences in HRQoL scores between the groups. Conclusion. After growth-friendly EOS treatment, patients with skeletal dysplasias experienced a higher incidence of complications compared to those with other syndromes. Surgical growth-friendly treatment for skeletal dysplasia-associated EOS should be reserved for patients with severe, progressive deformities that are refractory to nonoperative treatment. Cite this article: Bone Joint J 2024;106-B(6):596–602

Aims. Prophylactic antibiotic regimens for elective primary total hip and knee arthroplasty vary widely across hospitals and trusts in the UK. This study aimed to identify antibiotic prophylaxis regimens currently in use for elective primary arthroplasty across the UK, establish variations in antibiotic prophylaxis regimens and their impact on the risk of periprosthetic joint infection (PJI) in the first-year post-index procedure, and evaluate adherence to current international consensus guidance. Methods. The guidelines for the primary and alternative recommended prophylactic antibiotic regimens in clean orthopaedic surgery (primary arthroplasty) for 109 hospitals and trusts across the UK were sought by searching each trust and hospital’s website (intranet webpages), and by using the MicroGuide app. The mean cost of each antibiotic regimen was calculated using price data from the British National Formulary (BNF). Regimens were then compared to the 2018 Philadelphia Consensus Guidance, to evaluate adherence to international guidance. Results. The primary choice and dosing of the prophylactic antimicrobial regimens varied widely. The two most used regimens were combined teicoplanin and gentamicin, and cefuroxime followed by two or three doses of cefuroxime eight-hourly, recommended by 24 centres (22.02%) each. The alternative choice and dosing of the prophylactic antimicrobial regimen also varied widely across the 83 centres with data available. Prophylaxis regimens across some centres fail to cover the likeliest causes of surgical site infection (SSI). Five centres (4.59%) recommend co-amoxiclav, which confers no Staphylococcus coverage, while 33 centres (30.28%) recommend cefuroxime, which confers no Enterococcus coverage. Limited adherence to 2018 Philadelphia Consensus Guidance was observed, with 67 centres (61.50%) not including a cephalosporin in their guidance. Conclusion. This analysis of guidance on antimicrobial prophylaxis in primary arthroplasty across 109 hospitals and trusts in the UK has identified widespread variation in primary and alternative antimicrobial regimens currently recommended. Cite this article: Bone Jt Open 2023;4(10):742–749

Aims. The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery. Methods. A retrospective cohort study was conducted in Japan using a nationwide multicentre database from April 2010 to March 2018, including 572,181 patients who had received hip fracture surgery. Propensity score matching was performed to compare patients who received additional weekend rehabilitation at the weekend in addition to rehabilitation on weekdays after the surgery (plus-weekends group), as well as those who did not receive additional rehabilitation at the weekend but did receive weekday rehabilitation (weekdays-only group). After the propensity score matching of 259,168 cases, in-hospital mortality as the primary outcome and systemic and surgical complications as the secondary outcomes were compared between the two groups. Results. The plus-weekends group was significantly associated with lower in-hospital mortality rates compared with the weekdays-only group (hazard ratio 0.86; 95% confidence interval 0.8 to 0.92; p < 0.001). Systemic complications such as acute coronary syndrome, heart failure, renal failure, and sepsis were significantly lower in the plus-weekends group, whereas urinary tract infection (UTI) and surgical complications such as surgical site infection and haematoma were significantly higher in the plus-weekends group. Conclusion. Additional weekend rehabilitation was significantly associated with lower in-hospital mortality, as well as acute coronary syndrome, heart failure, renal failure, and sepsis, but was also significantly associated with a higher risk of UTI and surgical complications. This result can facilitate the effective use of the limited rehabilitation resources at the weekend and improve the clinical awareness of specific complications. To establish more robust causal associations between additional rehabilitation over the weekend and clinical outcomes, further prospective studies or randomized controlled trials with larger sample sizes are warranted. Cite this article: Bone Joint J 2023;105-B(8):872–879

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. Methods. We identified 33 patients who underwent treatment for PJIs of the hip between January 2010 and December 2019 using our institutional joint registry. Mean age was 82 years (80 to 90), with 19 females (57%) and a mean BMI of 26 kg/m. 2. (17 to 41). Mean American Society of Anesthesiologists (ASA) grade was 3 (1 to 4) and mean Charlson Comorbidity Index was 6 (4 to 10). Leading pathogens included coagulase-negative Staphylococci (45%) and Enterococcus faecalis (9%). Two-stage exchange was performed in 30 joints and permanent resection arthroplasty in three. Kaplan-Meier survivorship analyses were performed. Mean follow-up was five years (3 to 7). Results. The two-year survivorship free of any recurrent PJI was 72% (95% confidence interval (CI) 56 to 89; 18 patients at risk). There were a total of nine recurrent PJIs at a mean of one year (16 days to eight years), one for the same pathogen as at index infection. One additional surgical site infection was noted at two weeks, resulting in a 69% (95% CI 52 to 86; 17 patients at risk) survivorship free of any infection at two years. There were two additional revisions for dislocations at one month each. As such, the two-year survivorship free of any revision was 61% (95% CI 42 to 80; 12 patients at risk). In addition to the aforementioned revisions, there was one additional skin grafting for a decubitus ulcer, resulting in a survivorship free of any reoperation of 54% (95% CI 35 to 73; ten patients at risk) at two years. Mean Clavien-Dindo score of perioperative complications was two out of five, with one case of perioperative death noted at six days. Conclusion. Octogenarians undergoing surgery for PJI of the hip are at low risk of acute mortality, but are at moderate risk of other perioperative complications. One in two patients will undergo a reoperation within two years, with 70% attributable to recurrent infections. Cite this article: Bone Joint J 2023;105-B(2):135–139

Aims. Antibiotic prophylaxis involving timely administration of appropriately dosed antibiotic is considered effective to reduce the risk of surgical site infection (SSI) after total hip and total knee arthroplasty (THA/TKA). Cephalosporins provide effective prophylaxis, although evidence regarding the optimal timing and dosage of prophylactic antibiotics is inconclusive. The aim of this study is to examine the association between cephalosporin prophylaxis dose, timing, and duration, and the risk of SSI after THA/TKA. Methods. A prospective multicentre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKA/THA at one of 19 high-volume Australian public/private hospitals. Data were collected prior to and for one-year post surgery. Logistic regression was undertaken to explore associations between dose, timing, and duration of cephalosporin prophylaxis and SSI. Data were analyzed for 1,838 participants. There were 264 SSI comprising 63 deep SSI (defined as requiring intravenous antibiotics, readmission, or reoperation) and 161 superficial SSI (defined as requiring oral antibiotics) experienced by 249 (13.6%) participants within 365 days of surgery. Results. In adjusted modelling, factors associated with a significant reduction in any SSI and deep SSI included: correct weight-adjusted dose (any SSI; adjusted odds ratio (aOR) 0.68 (95% confidence interval (CI) 0.47 to 0.99); p = 0.045); commencing preoperative cephalosporin within 60 minutes (any SSI, aOR 0.56 (95% CI 0.36 to 0.89); p = 0.012; deep SSI, aOR 0.29 (95% CI 0.15 to 0.59); p < 0.001) or 60 minutes or longer prior to skin incision (aOR 0.35 (95% CI 0.17 to 0.70); p = 0.004; deep SSI, AOR 0.27 (95% CI 0.09 to 0.83); p = 0.022), compared to at or after skin incision. Other factors significantly associated with an increased risk of any SSI, but not deep SSI alone, were receiving a non-cephalosporin antibiotic preoperatively (aOR 1.35 (95% CI 1.01 to 1.81); p = 0.044) and changing cephalosporin dose (aOR 1.76 (95% CI 1.22 to 2.57); p = 0.002). There was no difference in risk of any or deep SSI between the duration of prophylaxis less than or in excess of 24 hours. Conclusion. Ensuring adequate, weight-adjusted dosing and early, preoperative delivery of prophylactic antibiotics may reduce the risk of SSI in THA/TKA, whereas the duration of prophylaxis beyond 24 hours is unnecessary. Cite this article: Bone Jt Open 2022;3(3):252–260

Patients with Paget's Disease of Bone (PDB) more frequently require total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, controversy remains regarding their outcome. This project aims to evaluate the current literature regarding outcomes following THA and TKA in PDB patients. MEDLINE, EMBASE and Cochrane databases were searched on February 15th, 2022. Inclusion criteria comprised studies evaluating outcomes following THA/TKA in PDB patients. Quality of included studies was assessed using the Newcastle-Ottawa Scale. 19 articles (published between 1976–2022) were included, comprising 58,695 patients (48,766 controls and 10,018 PDB patients), from 209 potentially relevant titles. No study was of high quality. PDB patient pooled mortality was 32.5% at mean 7.8(0.1-20) years following THA and 31.0% at mean 8.5(2-20) years following TKA. PDB patient revision rate was 4.4% at mean 7.2(0-20) years following THA and 2.2% at mean 7.4(2-20) years following TKA. Renal complications, respiratory complications, heterotopic ossification, and surgical site infection were the most common medical and surgical complications. The largest systematic review, to date, evaluating outcomes following THA and TKA in PDB patients. All functional outcome scores improved. PDB patient revision rate was comparable to UK National Joint Registry. However, there is a significant need for prospective matched case-control studies to robustly compare outcomes in PDB patients with unaffected counterparts

One of the most important sequelae to ageing is osteoporosis and subsequently hip fractures. Hip fractures are associated with major morbidity, mortality and costs. Most patients require surgery to restore mobility. Provision of surgery and its complications is poorly understood in South Africa. Our aim was to collect and report current hip fracture care at four centres in South Africa, as well as reporting surgical and general patient outcomes. A three year retrospective cohort at four centres will be described, focussing on provision of surgical care, mortality, types of surgery and complications. We identified 562 patients who had surgical intervention for fragility fractures, 66% were females. Forty nine percent had open reduction and internal fixation, 28% had hemi-arthroplasty replacement whilst 23% had total hip replacements. Twenty percent of patients had operative intervention within 36 hours of presentation to the emergency department. Mortality was 9% at 30 days. The most common complications were lower respiratory infections (29%), urinary tract infections (21%) and surgical site infections (9%). This is the largest cohort of surgically treated hip fracture from South Africa. Proportions of patients receiving different surgical interventions such as THR are comparable to the broader literature. However a number of key performance indicators such as surgery within 36 hours are challenging to meet. Given the changing demographics of South Africa, this study provides an early insight to contemporary care and may help provide direction for broader national strategies for reporting and improving hip fracture care

Aims. To determine the value of scoliosis surgery, it is necessary to evaluate outcomes in domains that matter to patients. Since randomized trials on adolescent idiopathic scoliosis (AIS) are scarce, prospective cohort studies with comparable outcome measures are important. To enhance comparison, a core set of patient-related outcome measures is available. The aim of this study was to evaluate the outcomes of AIS fusion surgery at two-year follow-up using the core outcomes set. Methods. AIS patients were systematically enrolled in an institutional registry. In all, 144 AIS patients aged ≤ 25 years undergoing primary surgery (median age 15 years (interquartile range 14 to 17) were included. Patient-reported (condition-specific and health-related quality of life (QoL); functional status; back and leg pain intensity) and clinician-reported outcomes (complications, revision surgery) were recorded. Changes in patient-reported outcome measures (PROMs) were analyzed using Friedman’s analysis of variance. Clinical relevancy was determined using minimally important changes (Scoliosis Research Society (SRS)-22r), cut-off values for relevant effect on functioning (pain scores) and a patient-acceptable symptom state (PASS; Oswestry Disability Index). Results. At baseline, 65 out of 144 patients (45%) reported numerical rating scale (NRS) back pain scores > 5. All PROMs significantly improved at two-year follow-up. Mean improvements in SRS-22r function (+ 1.2 (SD 0.6)), pain (+ 0.6 (SD 0.8)), and self-image (+ 1.1 (SD 0.7)) domain scores, and the SRS-22r total score (+ 0.5 (SD 0.5)), were clinically relevant. At two-year follow-up, 14 out of 144 patients (10%) reported NRS back pain > 5. Surgical site infections did not occur. Only one patient (0.7%) underwent revision surgery. Conclusion. Relevant improvement in functioning, condition-specific and health-related QoL, self-image, and a relevant decrease in pain is shown at two-year follow-up after fusion surgery for AIS, with few adverse events. Contrary to the general perception that AIS is a largely asymptomatic condition, nearly half of patients report significant preoperative back pain, which reduced to 10% at two-year follow-up. Cite this article: Bone Joint J 2022;104-B(2):265–273

Aim. Treatment recommendations for periprosthetic joint infections (PJI) include surgical debridement, antibiotic therapy or staged revision. In surgical related foot and ankle infections (SR-FAI), implant removal will lead to instability. Debridement is difficult because the implant is outside the joint. Recommendations regarding PJI treatment can therefore not be extrapolated to the treatment of SR-FAI. Method. We searched PubMed for the etiology and treatment of SR-FAI, taken into account the time of occurrence, causative microorganisms and surgical treatment options. We integrated this knowledge into a treatment algorithm for SR-FAI. Results. Within the first 6 weeks after surgery, it is difficult to distinguish acute osteomyelitis from surgical site infection in which infection is limited to the soft tissue. The predominantly causative microorganism is Staphylococcus aureus. No debridement can be performed, because of the diffuse soft tissue inflammation and the absence of a joint space. If early SR- FAI is suspected without signs of systemic symptoms, fistula or abscess, empirical antibiotic treatment covering Staphylococcus aureus is recommended. If there is suspicion of ongoing SR-FAI after 2 weeks of empirical treatment, samples for culture after an antibiotic free window should be obtained to identify the causative microorganisms. If SR-FAI is confirmed, but there is no consolidation yet, targeted antibiotic treatment is given for 12 weeks without initial implant removal. In all other cases, debridement and samples for culture should be obtained after an antibiotic free window. Staged revision surgery will be performed if there is still a nonunion. Conclusions. Treatment algorithm regarding PJI cannot be extrapolated to the treatment of SR-FAI. Until now, no treatment guideline for SR-FAI is available. We have introduced a treatment algorithm for the treatment of SR-FAI. The guideline will be validated during the next 2 years

Complex acetabular reconstruction for oncology and bone loss are challenging for surgeons due to their often hostile biological and mechanical environments. Titrating concentrations of silver ions on implants and alternative modes of delivery allow surgeons to exploit anti-infective properties without compromising bone on growth and thus providing a long-term stable fixation. We present a case series of 12 custom acetabular tri-flange and custom hemipelvis reconstructions (Ossis, Christchurch, New Zealand), with an ultrathin plasma coating of silver particles embedded between layers of siloxane (BioGate HyProtect™, Nuremberg, Germany). At the time of reporting no implant has been revised and no patient has required a hospital admission or debridement for a deep surgical site infection. Routine follow up x-rays were reviewed and found 2 cases with loosening, both at their respective anterior fixation. Radiographs of both cases show remodelling at the ilium indicative of stable fixation posteriorly. Both patients remain asymptomatic. 3 patients were readmitted for dislocations, 1 of whom had 5 dislocations within 3 weeks post-operatively and was immobilised in an abduction brace to address a lack of muscle tone and has not had a revision of their components. Utilising navigation with meticulous implant design and construction; augmented with an ultrathin plasma coating of silver particles embedded between layers of siloxane with controlled and long-term generation of silver ion diffusion has led to outstanding outcomes in this series of 12 custom acetabular and hemipelvis reconstructions. No patients were revised for infection and no patients show signs of failure of bone on growth and incorporation. Hip instability remains a problem in these challenging mechanical environments and we continue to reassess our approach to this multifaceted problem

Infections represent a devastating complication in orthopedic and traumatological surgery, with high rates of morbidity and mortality. An early intervention is essential, and it includes a radical surgical approach supported by targeted intravenous antimicrobial therapy. The availability of parenteral antibiotics at the site of infection is usually poor, so it is crucial to maximize local antibiotic concentration using local carriers. Our work aims to describe the uses of one of these systems, Stimulan®, for the management and prevention of infections at our Institution. Analysing the reported uses of Stimulan®, we identified two major groups: bone substitute and carrier material for local antibiotic therapy. The first group includes its application as a filler of dead spaces within bone or soft tissues resulting from traumatic events or previous surgery. The second group comprehends the use of Stimulan® for the treatment of osteomyelitis, post-traumatic septic events, periprosthetic joint infections, arthroplasty revision surgery, prevention in open fractures, surgery of the diabetic foot, oncological surgery and for all those patients susceptible to a high risk of infection. We used Stimulan® in several complex clinical situations: in PJIs, in DAPRI procedure and both during the first and the second stage of a 2-stage revision surgery; furthermore, we started to exploit this antibiotic carrier also in prophylaxis of surgical site infections, as it happens in open fractures, and when a surgical site remediation is required, like in osteomyelitis following ORIF. Stimulan® is an extremely versatile and polyhedric material, available in the form of beads or paste, and can be mixed to a very broad range of antibiotics to better adapt to different bacteria and their antibiograms, and to surgeon's needs. These properties make it a very useful adjuvant for the management of complex cases of infection, and for their prevention, as well

Infections in spine surgery are relatively common and devastating complications, a significant burden to the patient and the healthcare system. Usually, the treatment of SSIs consists of aggressive and prolonged antibiotic therapy, multiple debridements, and in chronic cases, hardware removal. Infections are correlated with worse subjective outcomes and even higher mortality. Depending on the type of spine surgery, the infection rate has been reported to be as higher as 20%. Recently silver-coated implants have been introduced in spine surgery to reduce the incidence of post-operative infections and to improve implant survivorship. The aim of the present study is to evaluate complications and outcomes in patients treated with silver-coated implants because of spine infection. All consecutive patients who had spine stabilization with a silver-coated implant from 2018 to 2021 were screened for inclusion in the study. Inclusion criteria were: (1) six months of minimum follow-up; (2) previous surgical site infection; hematogenous spondylodiscitis requiring surgical stabilization. Demographic and surgical information were obtained via chart review, all the device-related complications and the reoperation rate were also reported. A total of 57 patients were included in the present study. The mean age was 63.4 years, and there were 36 (63%) males and 21 (37%) females. Among the included cases, 57% were SSIs, 33% were spondylodiscitis, and 9% were hardware mobilization. Comorbidities such as diabetes mellitus, obesity, smoke, and oncological history were significant risk factors. In addition, the organisms cultured were Staphylococcus species in most of the cases. At six months of follow-up, 40% of patients were considered free from infection, while 20% needed multiple surgeries. The present research showed satisfactory results of silver-coated implants for the treatment of spine infection

The role that fomites have to play in surgical site infection (SSI) and periprostheitic joint infection (PJI) has been observed and researched in the past. However the role that cellphones play in the transfer of microorganisms from hands to surgical sites and the indiscriminate use of cellphones within the Orthopaedics, could increase the risk of infection. This study aimed to measure the contamination of cellphones of health care workers (HCW's) in a South African tertiary hospital. Secondarily was to investigate the cellphone hygiene behaviour of HCW's. A prospective cross-sectional study was conducted in June 2022. Samples were taken from the the participant's cellphones under an aseptic technique and sent for microbiology. The participants also filled out a questionnaire on cellphone behaviour. The inclusion criteria was orthopaedic HCW's working in the institution; This included nurses and doctors in the orthopaedic theatres and main orthopaedic wards. Sixty-two participants were included; 54 from Orthopaedics and 7 from Anaesthesia. From the samples, 71% grew pathogens while 30,64% grew two or more colonies. This is slightly lower than other studies which showed contamination up to 100%. Micro-organisms cultured included Staphylococcus species; S.Epidermidis, Methycillin sensitive S.aureas; and E.Coli. Cellphone hygiene behaviour was also better than most other studies in terms of frequency of cleaning the devices and hand hygiene around cellphone usage. This which may be a contributing factor to the lower micro-organism contamination. This study should be the first of many as we have identified that there are indeed pathogens on cellphones transferable to patients; causing sepsis. Though cellphones have become vital in patients management in the hospital setting, factors such as improvement in cellphone hygiene through education and frequent cleaning of cellphones will aid in disabling the negative impact of cellphones in the orthopaedic environment

Introduction. Infections in total joint arthroplasty (TJA) are a burden to the healthcare system. An infection in total joint arthroplasty costs nearly $60,000–80,000 to the system. 3 major tenets to decrease surgical site infections, focus on patient preoperative optimization, intraoperative techniques, and postoperative care. Intraoperative vancomycin powder been successful in lowering infection rates in other areas of orthopaedics. The purpose of our study was to investigate whether topical intraoperative vancomycin powder had any effect on surgical site infection, complication rate, or reoperation rate. Our hypothesis was vancomycin powder may decrease the rate of surgical site infections without any effect on wound complications. Materials & Methods. 208 consecutive patients undergoing either total hip or total knee arthroplasty (THA or TKA) were given intraoperative vancomycin powder or none. 64 patients received vancomycin poweder compared to 164 patients who did not. All preoperative, intraoperative and postoperative management was similar. Preoperative data including age, sex, BMI, diabetes status and comorbidities were recorded. Surgical techniques included medial parapatellar or subvastus for TKA, posterolateral for THA. 90-day culture positive infection and reoperation rates were recorded. Results. Preoperative variables between the two groups were similar. Average age, ASA, BMI, diabetes status and other preoperative patient variables were not significantly different (p=0.31, 0.19, 0.65, 0.31). 5/64 patients (7.8%) in the vancomycin group underwent reoperation, compared with 13/164 (9.0%) in the no vancomycin group. There was no difference in the rate of reoperations (p=0.777). Of these patients, 3/64 (4.69%) patients in the vancomycin group had a positive infection compared with 8/164 (5.55%) in the no vancomycin group. There was no significant differences between the two infection rates (p=0.807). Discussion. Surprisingly, vancomycin powder did not have any effect on reoperation nor infection rates in our study group. Although other studies may have shown a decrease in infection, ours failed to do so. Due to low study numbers, we could not differentiate deep versus superficial surgical site infections. Based on our study, we are unable to recommend the use of intraoperative vancomycin powder for total joint arthroplasty

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

Aims. Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited. Methods. Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year. Results. A total of 3,966 patients were identified. The overall rate of SSI was 1.7% (51 patients (1.3%) with deep SSI, and 18 (0.45%) with superficial SSI). In all, 50 patients underwent revision surgery for infection (43 with DAIR, and seven with excision arthroplasty). After adjustment for other variables, only concurrent urinary tract infection (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.57 to 4.92; p < 0.001) and increasing delay to theatre for treatment of the fracture (OR 1.31 per day, 95% CI 1.12 to 1.52; p < 0.001) were predictors of developing a SSI, while a cemented arthroplasty was protective (OR 0.54, 95% CI 0.31 to 0.96; p = 0.031). In all, nine patients (20.9%) were alive at one year with a functioning hemiarthroplasty following DAIR, 20 (46.5%) required multiple surgical debridements after an initial DAIR, and 18 were converted to an excision arthroplasty due to persistent infection, with six were alive at one year. The culture of any gram-negative organism reduced success rates to 12.5% (no cases were successful with methicillin-resistant Staphylococcus aureus or Pseudomonas infection). Favourable organisms included Citrobacter and Proteus (100% cure rate). The all-cause mortality at one year after deep SSI was 55.87% versus 24.9% without deep infection. Conclusion. Deep infection remains a devastating complication regardless of the treatment strategy employed. Success rates of DAIR are poor compared to total hip arthroplasty, and should be reserved for favourable organisms in patients able to tolerate multiple surgical procedures. Cite this article: Bone Jt Open 2021;2(11):958–965

Standard fixation for intra-articular distal humerus fracture is open reduction and internal fixation (ORIF). However, high energy fractures of the distal humerus are often accompanied with soft tissue injuries and or vascular injuries which limits the use of internal fixation. In our report, we describe a highly complex distal humerus fracture that showed promising healing via a ring external fixator. A 26-year-old man sustained a Gustillo Anderson Grade IIIB intra-articular distal humerus fracture of the non-dominant limb with bone loss at the lateral column. The injury was managed with aggressive wound debridement and cross elbow stabilization via a hinged ring external fixator. Post operative wound managed with foam dressing. Post-operatively, early controlled mobilization of elbow commenced. Fracture union achieved by 9 weeks and frame removed once fracture united. No surgical site infection or non-union observed throughout follow up. At 2 years follow up, flexion - extension of elbow is 20°- 100°, forearm supination 65°, forearm pronation 60° with no significant valgus or varus deformity. The extent of normal anatomic restoration in elbow fracture fixation determines the quality of elbow function with most common complication being elbow stiffness. Ring fixator is a non-invasive external device which provides firm stabilization of fracture while allowing for adequate soft tissue management. It provides continuous axial micro-movements in the frame which promotes callus formation while avoiding translation or angulation between the fragments. In appropriate frame design, they allow for early rehabilitation of joint where normal range of motion can be allowed in controlled manner immediately post-fixation. Functional outcome of elbow fracture from ring external fixation is comparable to ORIF due to better rehabilitation and lower complications. Ring external fixator in our patient achieved acceptable functional outcome and fracture alignment meanwhile the fracture was not complicated with common complications seen in ORIF. In conclusion, ring external fixator is as effective as ORIF in treating complex distal humeral fractures and should be considered for definitive fixation in such fractures

Aim. The aim of our study was to analyze putative genes for virulence factors of Cutibacterium isolates obtained from implant-associated infections. Methods. We analyzed 64 isolates of Cutibacterium spp. (C. acnes (53/64), C. avidum (6/64), C. granulosum (4/64), C. namnetense (1/64)) using NextSeq 550 (Illumina, San Diego, CA, USA) and performed genomic analysis of 24 genes associated with virulence factors (VFs) of C. acnes previously reported in the literature. Most isolates were obtained from implant-associated infections (IAI) between 2012–2021 at the Institute of Microbiology and Immunology, Faculty of Medicine, Ljubljana. Additionally, we included the first C. namnetense isolated in our laboratory from surgical site infection. Results. C. acnes and C. namnetense have the highest number of VFs among those examined. The VFs gntK (shikimate kinase) and HYL-IB / II (hyaluronate lyase) are absent in phylotype IA. 1. (sequence types (ST) A, C, D according to the SLST scheme). Repressor gene of porphyrin synthesis, deoR is present in all Cutibacterium spp. isolates. The phylotypes II and IB show a similar distribution of VFs, with the presence of the VFs rcsB (compound for biofilm formation) and HYL-IA (hyaluronate lyase), which are absent in other C. acnes phylotypes and other Cutibacterium spp. In phylotypes IA. 1. and IB, the sequence of genes encoding VFs dsA1 and dsA2 does not have 100% genomic coverage, possibly indicating homologs between species. The isolates of C. acnes and C. namnetense possess all three CAMP (1,2,4) factors, which are not detected in other Cutibacterium spp. However, further analysis revealed species-specific CAMP factors in C. avidum and C. granulosum. Both species also have similar other genes for VFs, mainly encoding heat shock proteins and lipases, while VFs related to biofilm production are mostly absent (rcsB, ytpA). Conclusion. We found several differences in the distribution of VFs among Cutibacterium spp. isolated from IAI

We aimed to use data from a randomized controlled trial (RCT) comparing the sliding hip screw vs. intramedullary nailing (IMN) for trochanteric fractures to examine complication rates between those managed with a short vs. long IMN. This is a secondary analysis using one arm of an RCT of patients ≥18 years with trochanteric fractures. We examined differences in fracture-related (femoral shaft fracture, implant failure, surgical site infection (SSI), nonunion, limb shortening, and pain) and medical (organ failure, respiratory distress, stroke, deep vein thrombosis [DVT] gastrointestinal upset, pneumonia, myocardial infarction, sepsis, or urinary tract infection) adverse events (AE), and readmission between short vs. long IMNs. We included 412 trochanteric fracture patients, 339 (82.2%) of whom received a short (170mm–200mm) nail, while 73 (17.7%) received a long (260mm–460 mm) nail. Patients in the long group were more likely to be admitted from home (vs. an institution), and have comorbidities, or more complex fracture types. Patients in the long group had higher rates of fracture-related AE (12.3%) vs. the short group (3.5%). Specifically, SSI (5.5% vs. 0.3%) and pain (2.7% vs. 0.0%) were significantly higher in the long group. Patients in the long group were also more likely to develop DVT (2.7% vs. 0.3%), and be readmitted to the hospital (28.8% vs. 20.7%). Following covariable adjustment, long nails remained associated with a higher odds of fracture-related AE (5.11, 1.96–13.33) compared to short nails. We found no association between the adjusted odds of readmission and nail length (1.00, 0.52–1.94). Our analyses revealed that trochanteric fracture patients managed with long IMN nails may have a higher odds of fracture-related AE compared to short nails. Future research is required to validate these findings with larger event rates, and further optimize IMN for trochanteric fracture patients

Surgical site infections after total hip arthroplasty result in decreased quality of life, increased morbidity and increased health care cost. We hypothesized that the implementation of a bundle of care for total hip arthroplasty decreases the amount of surgical site infections. In this retrospective cohort study we investigated the implementation of this bundle in a University Medical Centre and its effect on perioperative surgical site infections after total hip arthroplasty and on incidence of hypothermia. In 2009 the bundle of care consisting of four elements was implemented in total hip arthroplasty in our hospital; (I) perioperative normothermia, (II) hair removal before surgery, (III) the use of preoperative antibiotic prophylaxis and (IV) discipline on the operation room measured by door movements. For this study we used data from January 2010 – October 2013. We measured all parameters prospectively including surgical site infections within 6 weeks postoperatively. In the study period a total of 585 patients received a primary total hip arthroplasty. Bundle compliance improved significantly in 3.5 years from 71.7% in 2010 to 91.6% in 2013. Postoperative hypothermia decreased from 10.5% to 8.4% (non-significant) and SSI rate from 0.9% to 0.0% (non-significant). Implementation of this bundle of care is possible in an academic tertiary referral center. A relatively cheap solution can increase patient safety in a surgical environment. Introduction of a bundle of care resulted in a non-significant reduction of hypothermia and rate of surgical site infections in total hip arthroplasty

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

The aim of this study was to determine the incidence, annual trend, perioperative outcomes, and identify risk factors of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis. Risk factors for early-onset deep SSI were assessed. We performed a retrospective population-based cohort study using prospectively collected patient-level data from several provincial administrative data repositories between January 2013, and March 2020. The diagnosis of early-onset deep SSI was based on published Centre for Disease Control/National Healthcare Safety Network (CDC/NHSN) definitions. The Mann-Kendall Trend Test was used to detect monotonic trends in early-onset deep SSI rates over time. The effects of various patient and surgical risk factors for early-onset deep SSI were analyzed using multiple logistic regression. Secondary outcomes were 90-day mortality and 90-day readmission. A total of 20,580 patients underwent primary TKA for osteoarthritis. Forty patients had a confirmed deep SSI within 90-days of surgery representing a cumulative incidence of 0.19%. The annual infection rate did not change over the 7-year study period (p = 0.879). Risk factors associated with early-onset deep SSI included blood transfusions (OR, 3.93 [95% CI 1.34-9.20]; p=0.004), drug or alcohol abuse (OR, 4.91 [95% CI 1.85-10.93]; p<0.001), and surgeon volume less than 30 TKA per year (OR, 4.45 [1.07-12.43]; p=0.013). Early-onset deep SSI was not associated with 90-days mortality (OR, 11.68 [0.09-90-58]; p=0.217), but was associated with an increased chance of 90-day readmission (OR, 50.78 [26.47-102.02]; p<0.001). This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis through the use of a robust methodological process. Several risk factors for early-onset deep SSI are potentially modifiable or can be optimized prior to surgery and be effective in reducing the incidence of early-onset SSI. This could guide the formulation of provincial screening programs and identify patients at high risk for SSI

Laminar flow theatres were first introduced in the United Kingdom in the 1960s and 1970s and have become standard in orthopaedic surgery involving implants. A study from 1982 showed a 50% reduction in infections with joint arthroplasties when compared to conventional theatres and laminar flow became standard in the following decades. Recent evidence including a meta-analysis from 2017 questions the effectiveness of these theatre systems. Most of the evidence for Laminar flow use is based on arthroplasty surgery. We aimed to determine the effect of using non-laminar flow theatres on our trauma patients. A total of 1809 patients who had trauma surgery were identified from 2019 to 2021. 917 patients were operated on in a laminar theatre and 892 in a non-laminar theatre across two operating sites. We identified the surgical site infections as reported through our surveillance program within the first 90 days of infection. Patient co-morbidities were noted through patient records and procedure length was also noted. Of the 1809 trauma patients identified between the years of 2019 and 2021, 917 patients had operations in a laminar flow theatre and 892 in a non-laminar theatre. Of the 892 operated in non-laminar flow theatres, 543 were operated in the University Hospital of Wales (UHW) and 349 at the University Hospital of Llandough (UHL). An analysis of soft tissue infections and hospital acquired infections post-operatively demonstrated 15/543 and 71/543 respectively for non-laminar UHW infections and 4/349 and 21/349 for non-laminar UHL infections. A look at laminar flow patients showed 25/917 with soft tissue infections and 86/917 hospital acquired infections. There was no difference between laminar and non-laminar flow theatre infection rates showing rates of 12.1% and 12.2% respectively. In our trauma patients we noticed no significant advantage of using laminar flow theatres when compared to non-laminar flow theatres. This is in keeping with some recently published literature. Laminar flow theatres have been shown to decrease airborne pathogen counts under controlled conditions, but we conclude in the day to day environment of trauma theatres these conditions are either not met or that the theoretical advantage of laminar flow does not translate to a direct advantage of reduction of infections which may be achieved by standard prophylactic antibiotics

Our objective was to conduct a systematic review and meta-analysis, comparing differences in clinical outcomes between either autologous or synthetic bone grafts in the operative management of tibial plateau fractures: a traumatic pattern of injury, associated with poor long-term functional prognosis. A structured search of MEDLINE, EMBASE, The Bone & Joint and CENTRAL databases from inception until 07/28/2021 was performed. Randomised, controlled, clinical trials that compared autologous and synthetic bone grafts in tibial plateau fractures were included. Preclinical studies, clinical studies in paediatric patients, pathological fractures, fracture non-union or chondral defects were excluded. Outcome data was assessed using the Risk of Bias 2 (ROB2) framework and synthesised in random-effect meta-analysis. Preferred Reported Items for Systematic Review and Meta-Analysis guidance was followed throughout. Six comparable studies involving 352 patients were identified from 3,078 records. Following ROB2 assessment, five studies (337 patients) were eligible for meta-analysis. Within these studies, more complex tibia plateau fracture patterns (Schatzker IV-VI) were predominant. Primary outcomes showed non-significant reductions in articular depression at immediate postoperative (mean difference −0.45mm, p=0.25, 95% confidence interval (95%CI): −1.21-0.31mm, I. 2. =0%) and long-term (>6 months, standard mean difference −0.56, p=0.09, 95%CI: −1.20-0.08, I. 2. =73%) follow-up in synthetic bone grafts. Secondary outcomes included mechanical alignment, limb functionality, defect site pain, occurrence of surgical site infections, secondary surgery, perioperative blood loss, and duration of surgery. Blood loss was lower (90.08ml, p<0.001, 95%CI: 41.49-138.67ml, I. 2. =0%) and surgery was shorter (16.17minutes, p=0.04, 95%CI: 0.39-31.94minutes, I. 2. =63%) in synthetic treatment groups. All other secondary measures were statistically comparable. Our findings supersede previous literature, demonstrating that synthetic bone grafts are non-inferior to autologous bone grafts, despite their perceived disadvantages (e.g. being biologically inert). In conclusion, surgeons should consider synthetic bone grafts when optimising peri-operative patient morbidity, particularly in complex tibial plateau fractures, where this work is most applicable