Aim. Sepsis is a life-threatening complication of periprosthetic joint infections (PJI) that requires early and effective therapy. This study aims to investigate the epidemiology, associated risk factors, and outcome of sepsis in the context of periprosthetic joint infections (PJI). Method. This single-center retrospective cohort study included patients treated for PJI from 2017 to 2020. Patients were classified based on the criteria of the European Bone and Joint Infection Society. The presence of sepsis was determined using the SOFA score and SIRS criteria. The cohort with PJI and sepsis (sepsis) was compared to patients with PJI without sepsis (non-sepsis). Risk factors considered were patient characteristics, affected joints, surgical therapy, microbiological findings, preexisting medical conditions, clinical symptoms, and symptom duration. Outcome parameters were mortality, length of hospital stay, and length of stay in the intensive care unit. Results. A total of 109 patients with PJI were identified, of whom 45 patients (41.3%) met the criteria for sepsis. Patients with sepsis had more severe preexisting diseases compared with the non-sepsis cohort (Charlson Comorbidity Index 3.8 vs. 2.8; p≤0.001). An increased odds ratio (OR) for a septic course was found for the comorbidities pneumonia (8.2; p=0.001), myocardial infarction (2.0; p=0.02), atrial fibrillation (3.3; p=0.01), diabetes mellitus (1.2; p=0.04), endocarditis (5.5; p=0.01), and renal disease (2.0; p≤0.001). Infection with Staphylococcus aureus (sepsis 20 vs. non-sepsis 10; p=0.002), Streptococcus dysgalactiae (sepsis 7 vs. non-sepsis 2; p=0.002) and Candida albicans (sepsis 5 vs. non-sepsis 0; p=0.01) were more prevalent in patients with sepsis. In the sepsis cohort, further infectious foci were present in addition to PJI in 57.8% of patients, compared to 18.8% in the non-sepsis cohort. The presence of sepsis was associated with a longer hospital stay (sepsis 68 days vs. non-sepsis 38 days; p=0.001) and longer intensive care unit stay (sepsis 12 days vs. non-sepsis 2 days; p=0.001). In-hospital mortality was ten times higher in the sepsis cohort compared to non-septic patients (sepsis 11/42 vs. non-sepsis 2/64; OR 10.3; p=0.01). Conclusions. In a relevant proportion of patients, PJI can lead to a septic course of disease associated with increased mortality. Particularly in patients with preexisting diseases, increased attention is required, and comprehensive screening for other foci of infection seems mandatory. In addition to highly virulent pathogens such as staphylococci and streptococci, fungal infections should be considered as causative pathogens in septic patients with PJI

Survival of sepsis has been documented worldwide, but little is documented about the long-term health outcomes of multifocal sepsis from acute musculoskeletal infection - the first study of its kind in New Zealand. Children admitted to the Paediatric Intensive Care Unit (PICU) from 1. st. January 2002 to 31. st. December 2017 with a musculoskeletal focus of infection were identified from hospital coding data. Notes review from discharge to present day determined survival and morbidity. Present-day clinical assessment of the musculoskeletal and respiratory systems along with questionnaires on health-related quality of life, mental health and sleep were performed. Seventy patients were studied. Seven children died acutely (five Pasifika and two Māori children) indicating 10% mortality. Long-term survival was favourable with no recorded deaths after discharge. Recurrence/chronic infection occurred in 23%, a mean of 1.1 year after discharge. Growth disturbance occurred in 18%, a mean of 3 years after discharge. The hip joint and proximal femur have the worst complications. Children under 2 years are most at risk of long-term disability. No patients had chronic respiratory illness beyond 90 days. Fifteen children had symptoms of acute neurological impairment, three of whom had permanent brain injury. Twenty-six survivors (41%) were assessed a mean of 8.2 years after discharge. Health-related quality of life scores were on par with normative data. Six patients and eight parents screened positive for moderate to severe post-traumatic stress disorder. Paediatric multifocal musculoskeletal sepsis can result in complex illness with long hospital stay and multi-organ complications. Māori and Pasifika children, those under two and those involving the proximal femur/or hip are most at risk. Other outcomes are favourable with no evidence of chronic lung disease or poor quality of life. A period of rehabilitation for children with identified acquired brain injury should be part of discharge planning

This study aimed to identify long-term physical and psychosocial health outcomes in children with overwhelming musculoskeletal sepsis. Children admitted to the Paediatric Intensive Care Unit (PICU) from 1st January 2002 to 31st December 2017 with a musculoskeletal focus of infection were identified. A medical notes review was completed to determine survival and morbidity. Present-day clinical assessment of the musculoskeletal and respiratory systems along with questionnaires on health-related quality of life, mental health and sleep were performed. 70 patients were identified over 15 years. Seven children died acutely (five Pasifika and two Māori children) indicating 10% mortality. Recurrence/chronic infection affected 23%. Growth disturbance affected 18%. The hip joint and proximal femur suffered the worst long-term complications. Children under 2 years most at risk of long-term disability. No patients had chronic respiratory illness beyond 90 days. Fifteen children had symptoms of acute neurological impairment, three of whom had permanent acquired brain injury. Twenty-six survivors (41%) were assessed a mean of 8.2 years (SD 4.5, range 2– 18 years) after discharge. Health-related quality of life scores were on par with normative data. All patients who underwent pulmonary function tests had normal results. Six patients and eight parents screened positive for moderate to severe post-traumatic stress disorder. Paediatric multifocal musculoskeletal sepsis can result in complex illness with multi-organ complications for some children. Māori and Pasifika children are most at risk. Children under 2 years and those with proximal femur and/or hip involvement are most likely to have chronic musculoskeletal sequelae and permanent disability. Other outcomes are favourable with no evidence of chronic lung disease or mean reduced quality of life. A period of rehabilitation for children with identified acquired brain injury should be part of discharge planning

A retrospective case control study of all rehabilitated patients who suffered amputations of the lower extremity by sepsis was performed in the HELIOS centre of rehabilitation for amputees, Bad Berleburg, Germany. This study examines patients who had undertaken an amputation of the lower extremity caused by severe sepsis and septic shock. Methods: Case control study. The clinical reports of 448 patients with amputations of the lower extremity clinically rehabilitated from 2010 to 2013 were systematically and statistically evaluated. Sepsis is classified in 4 categories: SIRS, sepsis, severe sepsis and septic shock. Epidemiology: The mean age of the amputees was 61.33 years, with 25 men and 11 women. Marital status: 16 patients are married (44.44%), 7 divorced, 5 widowed, 7 unmarried, 1 unknown. 24 patients are retired (66.67%). School-leaving qualifications: 22 elementary school (61.11%), 8 secondary school, 1 high school, 5 unknown. Health insurance: AOK 10 patients (27.77%), BEK 7 patients (19.44%), pension insurance 9 patients (25.0%). The medial time of hospitalization in the clinic for rehabilitation of the amputated patients suffering sepsis was 27.23 days. Results: 36 patients, – 8.03 % of all – with 39 amputations, suffered a loss of the lower extremity caused by severe sepsis and septic shock: 1 patient suffered an exarticulation of both hips, 20 patients suffered a transfemoral amputation (1 patient had a transfemoral amputation of both legs), 17 patients lost their leg by transtibial amputation (1 patient had a transtibial amputation of both legs). 13 patients presented a sepsis by MRSA (multiresistant Staph. aureus 36.11%), 8 patients with MSSA (multisensible Staph. aureus), 4 patients with multiresistant Acinetobacter (8.33%), 2 patients with MRSE (multiresistant Staph. epidermidis), 13 patients with other multiresistant germs (36.11%) such as Streptococcus B, Enterococcus faecalis, Enterobacteriaceae, Klebsiella. Mobility class of amputees at the beginning of hospitalization: class 0 (= non walkers) all 36 patients (100%). Mobility class of amputees at the end of hospitalization: class 0 (= non walkers) are 5 patients (27.78%), class 1 (= only inside walkers) are 5 patients (13.89%), class 2 (= inside and little outside walkers) are 18 patients (50.00%), class 3 (= inside and good outside walkers) are 3 patients (8.33%). Amputation of the lower extremity following severe sepsis and septic shock is not rare – in our group we found more than 8%

The aim of this investigation is to firstly quantify the burden of disease, and secondly qualify the organisms being cultured during debridement to establish their sensitivities to available antibiotics. This study will also look at the concomitant burden of Human Immunodeficiency Virus (HIV) and Diabetes Mellitus (DM) in cases of hand sepsis, to establish whether these two disease processes require special consideration and treatment tailoring. The method employed to collect the data will be retrospective collection of patient information, using random sampling. Included patients will be adult patients who undergo debridement and have a sample registered on the National Health Laboratory System (NHLS). The daily intake sheet will be used to collect patients details and these details will then be used to collect results of intra-operative specimens using the NHLS. These patient details will also be used to check patients’ HIV results and HBA1c (Glycated Haemoglobin A1c) results. Majority of the specimens revealed Methicillin Sensitive Staphylococcus Aureus (MSSA), with a reassuringly low rate of Methicillin Resistant Staphylococcus Aureus (MRSA) when compared to international data. The yield of patients tested for HIV or DM was lower than expected, despite this being the standard of care. The projected impact of this study will be assessment of the current burden of disease and then clarification of our current management strategy, in order to assess if it would be possible to change to a more cost-effective antibiotic with a narrower spectrum of bacteria coverage. The potential exists to not only implement cost saving measures, but also promote antibiotic stewardship by decreasing the practice of empiric broad-spectrum antibiotic use

Between September 2004 and December 2005 we carried out a prospective study of all cases of sepsis of the hip in childhood at a South African regional hospital with a large local population, and which also took referrals from nine rural hospitals. The clinical, radiological, ultrasound and bacteriological features were assessed. All the hips were drained by arthrotomy and the diagnosis was confirmed microbiologically and histologically. Hips with tuberculosis were excluded. The children were reviewed in a dedicated clinic at a mean follow-up of 8.1 months (3 to 18). There were 40 hips with sepsis in 38 patients. Two patients were lost to follow-up. Nine (24%) had multi-focal sepsis. Overall, 13 hips (34%) had a full and uncomplicated clinical and radiological recovery and 25 (66%) had complications. All patients treated by arthrotomy and appropriate antibiotics within five days of the onset of symptoms had an uncomplicated recovery. Initial misdiagnosis was associated with a delay to arthrotomy. However, ‘deprivation’, consultation with a traditional healer, maternal educational attainment and distance to a primary health-care facility were not associated with delay to arthrotomy. The early correct diagnosis of this condition, common in the developing world, remains a significant factor in improving the clinical outcome

In patients with hand sepsis does bedside debridement compared to operating theatre debridement have similar clinical outcomes, hospital cost and time to discharge in a District Hospital setting in South Africa?. A case series of 130 adult patients presenting to a district level orthopaedic unit over 1 year with hand sepsis requiring debridement. All included patients were debrided at the bedside (i.e. the emergency room, ward, OPD) under wrist or digital block. Patients excluded from the study included patients with necrotising soft tissue infections that required debridement in theatre. A cost analysis was done based on operating theatre (OT) costs saved as defined by Samuel1 et al. If an average theatre time of 45 min is taken then the cost saved per patient is approximately R1500 and approximately R300000 for the patients included in the case series. This excludes ward and other hospital costs related to a longer hospital admission. The mean time to discharge for the included patients was 24 hours. This study suggests that bedside debridement can be a viable and cost effective option for selected cases of hand sepsis that can avoid the high cost and time associated with operating theatre debridement with similar outcomes. This has implications for the future treatment of hand sepsis in resource constrained settings were operating theatre time is not only very expensive but also very scarce

Aim. Hospital systems have recently instituted early systemic sepsis recognition systems, where vital signs and laboratory findings are monitored and automatically alert providers to potential sepsis. Although there are very few reports evaluating the use of sepsis alert systems outside of the emergency room or intensive care unit, many hospital systems have made the decision to apply the sepsis alarm protocols to all inpatients. The purpose of this study was to evaluate if an alarm system using systemic inflammatory response syndrome (SIRS) criteria is a valuable tool to predict systemic sepsis in the immediate postoperative period (POD#0–4) after total joint arthroplasty (TJA). Method. 10,791 primary and revision TJA patients at one institution, from 2010–2014, were retrospectively reviewed for positive SIRS criteria on each hospital day from the date of surgery to postoperative day four (POD#4). SIRS criteria included temperature > 38°C or < 36°C, heart rate > 90 beats per minute, respiratory rate > 20 breaths per minute, and white blood cell (WBC) > 12,000/mm3 or < 4,000/mm3. Additionally, hospital coding data was cross-referenced to identify patients who were diagnosed with systemic sepsis within 10 days after having a TJA. Results. Of the 10,791 patients undergoing a primary or revision TJA, only 1 patient was diagnosed with sepsis within 10 days of TJA, yielding a prevalence of 0.00009. During POD#0–4, 1798 patients would have triggered at least a 2 criteria SIRS alarm, yielding a false positive rate of 16.7% and a positive predictive value for systemic sepsis of 0.06% (95%CI: 0 to 0.31%). 416 patients would have triggered at least 3 criteria SIRS alarm, yielding a false positive rate of 3.9% and positive predictive value of 0.24% (95%CI:0.01 to 1.33%). The SIRS criteria in the one septic patient in this study did become positive, but did so only after the clinical team had already initiated sepsis care. Conclusions. A SIRS based alarm system for sepsis does not appear to have any utility in the postoperative period after TJA. We are concerned that the high false positive rate of these alarms may result in unnecessary sepsis work-ups, extended hospital stays, and potentially degrade the perceived importance of the sepsis alarms in other cohorts of hospital patients. Further research is necessary to determine if TJA patients with a length of stay greater than normal may benefit from an automatic sepsis alarm system

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

The mechanism by which cells die is important in an immune response and its resolution. The role of apoptosis in sepsis and trauma, and its regulation by cytokines is unclear. During the systemic inflammatory response, rates of human neutrophil apoptosis are decreased. Peritoneal macrophage apoptosis has been induced by nitric oxide and Lipopolysaccharide (LPS) in vitro but this has not as yet been demonstrated in vivo. We examined the induction and effects of macrophage apoptosis in a model of trauma and sepsis. One hundred female CD-I mice were randomised into four groups: Control, Septic model, challenged with intraperitoneal LPS (1.Img/200ul/mouse), Traumatic model, received hind limb amputation (HLA) and a Combined trauma/septic model. After 24 hrs mice were sacrificed and peritoneal macrophages were assessed for apoptosis by morphology and DNA fragmentation by flow cytometry and DNA gel electrophoresis. Peritoneal lavage from septic models had a decreased percentage of macrophages in comparison to control and trauma groups. The septic model also had a significantly increased incidence of apoptosis in comparison to control and trauma levels. There was no significant difference between control and traumatic groups. These findings demonstrate that in a murine model of sepsis, lipopolysaccharide induces macrophages apoptosis. Modulation of this immune response may have important roles in the management of trauma patients

Introduction. A previous study in South Africa showed the prevalence of HIV related osteo-articular sepsis in children to be around 20% with a high prevalence of Streptococcus pneumoniae (38%) in HIV positive patients. This initial study was conducted at the same time that the polyvalent S pneumoniae vaccine was introduced to the EPI in South Africa (2009). The aim of the current study was to review the epidemiology of osteo-articular infections at two hospitals after the introduction of this vaccine. Methods. A retrospective review of patients presenting to two hospitals, between July 2009 and January 2013, with acute osteo-articular sepsis and pus at arthrotomy. The NHLS laboratory results were reviewed for microscopy, culture and sensitivity as well as white cell count (WCC), C reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Results. A total of 100 cases of acute osteo-articular sepsis were identified during this period. The prevalence of HIV was 15%. The most common bacterial isolate was Staphylococcus aureus (22%). There were no Streptococcus pneumoniae isolates grown in either of the two groups. There was no difference in the WCC, CRP and ESR between the HIV negative and positive groups. Conclusion. We have seen a dramatic shift in the bacteriology in paediatric patients with osteo-articular sepsis since the original study in 2009. The incidence of HIV in our study population has declined. This may be due to the introduction of mother to child transmission programmes and increased use of anti-retrovirals. Staphylococcus aureus is now the most common isolated organism in patients with osteo-articular sepsis, regardless of HIV status. The empiric antibiotic therapy of choice in paediatric patients with osteo-articular sepsis remains Cloxacillin. NO DISCLOSURES

Purpose of study. Pin tract infection is a common complication with the use of circular external fixators. HIV infection itself is frequently quoted as a relative contra-indication for the use of circular external fixators for complex trauma and limb reconstruction in HIV seropositive individuals. Methods. Between July 2008 and December 2012, 286 patients were treated with circular external fixators at our tertiary level government hospital. A retrospective review was undertaken to compare the rate and severity of pin tract sepsis in HIV seropositive and seronegative patients. Results. Two-hundred and twenty-three patients met the inclusion and exclusion criteria. Pin tract sepsis was found in 51 patients overall (22.8%). The incidences of pin tract sepsis in the seropositive group, seronegative group, and the unknown group are 22.5%, 22.8% and 23.8% respectively, and the differences were not statistically significant. The severity of pin tract sepsis in the individual groups was also similar. Conclusion. Pin tract sepsis is a common complication with the use of circular external fixators. The incidence and severity of pin tract infection is not influenced by HIV infection, and should not in itself deter from the use of circular external fixators for complex trauma and limb reconstruction in HIV seropositive individuals. NO DISCLOSURES

Background:. There is limited evidence regarding HIV infection as a risk factor for delayed union and implants sepsis in patient with fractures treated with surgical fixation. Most studies have included patient with a variety of different fractures and hence very different risks regarding delayed union and implant sepsis. We have looked at a single fracture, closed femoral shaft fractures treated with intramedullary nailing, to see if HIV infection is a risk factor with for the development of delayed union and implant sepsis. We present a prospective study of 160 patients with closed femoral shaft fractures treated with intramedullary nailing. Primary outcomes were delayed union of more than 6 months and implant sepsis in the first 12 months. Methods:. From February 2011 until November 2012 all patient with closed femoral shaft fractures treated at our hospital were included in the study. Patients were tested for HIV infection and a number of clinical parameters were documented, including: AO fracture score, duration of surgery, level of training of surgeon, comorbidities, CD4 count, high energy injury and number of operations. Results:. Forty (25%) patients were HIV positive. Seven patients had CD4 counts below 350 cells/µL and 12 patients were on ARV's. Four (3%) patients developed implants sepsis and of these 1 (25%) was HIV positive. Two (1%) patients had a delayed union of more than 6 months and both these patients were HIV negative. Conclusion:. HIV is not a risk factor for delayed union and implant sepsis in the first 12 months after surgery. Intramedullary nailing is a safe and effective in the treatment of HIV positive patients with closed femur fractures

Deep vein thrombosis is uncommon in children but can occur given certain circumstances. Protein C deficiency has recently been described in a child with deep vein thrombosis complicating septic arthritis. We present four case reports of children who developed deep vein thrombosis in association with musculoskeletal sepsis. All had evidence of musculoskeletal sepsis and thrombosis. One child died. Prothrombotic screens were performed demonstrating normal haematological parameters in the three surviving children. The high mortality of deep vein thrombosis complicating musculoskeletal sepsis is emphasised, particularly the potential for septic embolic complications. Deep vein thrombosis should be considered in any child with musculoskeletal sepsis and generalised limb swelling. Early recognition and treatment can lead to favourable outcomes

HIV and musculoskeletal trauma have reached epidemic proportions in the developing world especially in sub Saharan Africa. The epidemic has adversely affected health care delivery in limited resource settings. We assessed the outcome of HIV+ patients following spinal surgery for fractures and dislocations. Forty seven HIV+ patients were treated surgically over the past three years. The mean age was 32 years (19–53 years) and included 39 males. The dorsolumbar region was affected in 28 patients and the cervical spine in 19. Motor vehicle collisions (34) accounted for 72% of the injuries. Neurology occurred in 49% of patients (23). The mean CD4 count was 426 (range 98–742). The albumen was 29 gm/d? (range 26–34) and the lymphocyte count was 1.6c/cumm range 1.4–1.9). Twenty eight patients had generalized lymphadenopathy and recent weight loss was noted in 11 patients. Fifteen patients were treated for pulmonary TB and seven patients were on ARVs. The dislocations at the cervical spine commonly occurred at C5/6 (8). Three patients required a posterior cervical release with facetectomy prior to anterior cervical plating which was performed in all patients. The dislocations and unstable burst fractures of the dorsolumbar spine were treated by a one/two level posterior fusion. Post-operative sepsis due to S. aureus occurred in 8 (17%) patients. In four patients with deep infection vacuum dressings were used to clear the sepsis. Post-operative sepsis is best avoided by optimization of patients and meticulous surgery

There are unfortunately many reasons a TSA can be painful after implantation, but the most common reason is sepsis. Making the diagnosis can be a major challenge, but the biggest challenge is to think of that as a diagnosis! The most important steps are to first obtain plain radiographs one week after surgery so that you can compare subsequent radiographs to the immediate post-operative films. Progressive radiolucent lines in the glenoid or especially around the humerus are important hints. A loose humeral component is infected until proven otherwise. Next blood work to include CRP and ESR are critical. Other markers of infection have not been used on a widespread basis. If there is concern that there might be rotator cuff pathology and not sepsis, then we obtain an arthrogram CT scan at the time of aspiration. A cell count is helpful but often there is a dry tap. It is important to create a “p. acnes protocol” at your hospital to take cultures out 15 days. If still not sure and revision is necessary then we aspirate the joint at the time of surgery for cell count. The WBC cell count at the time of surgery keeps changing but over 3000 is considered diagnostic. Multiple specimens are sent for frozen section, culture and permanent section. The more WBC per high powered field the more likely there is an infection. Gram stains are worthless and we do not rely on them. We have no experience with implant sonification or use of IL-6

With the rising prevalence of HIV, the number of immunocompromised patients is increasing. Higher rates of wound sepsis following implant surgery in seropositive patients have been anecdotally reported in Central and East Africa, but at any single institution experience with HIV and implant surgery is limited. This is a review of 21 patients, 18 of whom were seropositive, who had infected implants after undergoing elective operations for fractures that presented late (mean time 24 months). In 16 patients radiological union had occurred and the septic implants were removed. The organisms cultured in these patients were Staphylococcus aureus and Group-A Streptococcus. In 14 of the patients, implant removal and antibiotics produced excellent results. Two required a Girdlestone excision of the hip and gentamycin beads. Incision and drainage was performed in three patients who had superficial sepsis. The organism cultured was Group-A Streptococcus. All wounds healed. One patient died of AIDS: aspirate revealed Escherichia coli with mixed organisms. In one patient the organism was Pseudomonas aeruginosa and after the nail was removed the patient had a persistent draining sinus. The results suggest that HIV-positive patients are at increased risk of postoperative infection, and that early removal of implants may avoid future septic complications

Aims. Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections. Methods. Between January 2019 and December 2022, 106 patients with bone and joint infections were treated by five surgeons in five hospitals. Surgical debridement and calcium sulphate bead insertion was performed for local elution of antibiotics in high concentration. In all, 100 patients were available for follow-up at regular intervals. Choice of antibiotic was tailor made for each patient in consultation with microbiologist based on the organism grown on culture and the sensitivity. In majority of our cases, we used a combination of vancomycin and culture sensitive heat stable antibiotic after a thorough debridement of the site. Primary wound closure was achieved in 99 patients and a split skin graft closure was done in one patient. Mean follow-up was 20 months (12 to 30). Results. Overall, six out of 106 patients (5.6%) presented with sepsis and poorly controlled comorbid conditions, and died in the hospital within few days of index surgery. Out of the remaining 100 patients, control of infection was achieved in 95 patients (95%). Persistence of infection was noted in five (5%) patients. Out of these 95 patients that had good control of infection, four patients (4.2%) with gap nonunion needed Masquelet procedure to achieve union. Conclusion. Our multicentre experience confirmed that surgical debridement along with calcium sulphate bead insertion was effective in treating bone and joint infections without any side effects and complications. Cite this article: Bone Jt Open 2023;4(7):516–522

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

Purpose: Approximately, 10% of two-stage TKA revisions for deep sepsis become re-infected. The purpose of this study was to determine the success in terms of sepsis eradication and factors associated with failure of repeat two-stage revision TKA. Method: Between 1991 and 2006, 129 two-stage revision TKRs for deep sepsis were performed. Ten cases which became re-infected were identified. These unfortunate patients, representing 8% of all the two-stage TKA revisions performed during this time period, are the focus of this study. Their progress and treatment interventions were followed for the purposes of this study. Results: Ten patients were identified with a two-stage revision TKA which became re-infected. Mean patient age was 72 with 40 % being female. Following recurrent sepsis all patients went on to require more than one further two-stage revision (mean 3.67 further revision surgeries). Infection was only successfully eradicated in 28.7% of cases, the remaining require chronic suppressive therapy or have ongoing active infection. Two patients went on to have an arthrodesis (both remain on suppressive anti-biotics) and one patient had trans-femoral amputation. Staph Aureus and Coagulase neg Staph accounted for 80% of primary infective organisms with only one primary infection with methicillin resistant staph aureus (MRSA). Cultures at subsequent revisions were the same organism in 67% cases. Additional organism cultured included Pseudomonas and Propionibacterium. These patients had an increased incidence of multiple medical co-morbidities including Type-2 Diabetes Mellitus and Rheumatoid Arthritis. Conclusion: Patients with recurrent sepsis after a two-stage revision for infection in TKR all required multiple further surgeries. Eradication of infection was only achieved in 28.7% cases. Risk factors for recurrent sepsis include Rheumatoid Arthritis and Type-2 Diabetes Mellitus

Aims. The aim of this study was to identify variables associated with time to revision, demographic details associated with revision indication, and type of prosthesis employed, and to describe the survival of hinge knee arthroplasty (HKA) when used for first-time knee revision surgery and factors that were associated with re-revision. Methods. Patient demographic details, BMI, American Society of Anesthesiologists (ASA) grade, indication for revision, surgical approach, surgeon grade, implant type (fixed and rotating), time of revision from primary implantation, and re-revision if undertaken were obtained from the National Joint Registry data for England, Wales, Northern Ireland, and the Isle of Man over an 18-year period (2003 to 2021). Results. There were 3,855 patient episodes analyzed with a median age of 73 years (interquartile range (IQR) 66 to 80), and the majority were female (n = 2,480, 64.3%). The median time to revision from primary knee arthroplasty was 1,219 days (IQR 579 to 2,422). Younger age (p < 0.001), decreasing ASA grade (p < 0.001), and indications for revision of sepsis (p < 0.001), unexplained pain (p < 0.001), non-polyethylene wear (p < 0.001), and malalignment (p < 0.001) were all associated with an earlier time to revision from primary implantation. The median follow-up was 4.56 years (range 0.00 to 17.52), during which there were 410 re-revisions. The overall unadjusted probability of re-revision for all revision HKAs at one, five, and ten years after surgery were 2.7% (95% confidence interval (CI) 2.2 to 3.3), 10.7% (95% CI 9.6 to 11.9), and 16.2% (95% CI 14.5 to 17.9), respectively. Male sex (p < 0.001), younger age (p < 0.001), revision for septic indications (p < 0.001) or implant fracture (p = 0.010), a fixed hinge (p < 0.001), or surgery performed by a non-consultant grade (p = 0.023) were independently associated with an increased risk of re-revision. Conclusion. There were several factors associated with time to first revision. The re-revision rate was 16.2% at ten years; however, the risk factors associated with an increased risk of re-revision could be used to counsel patients regarding their outcome. Cite this article: Bone Joint J 2023;105-B(1):47–55

In a retrospective study, we examine the occurrence and management of sepsis in total knee arthroplasty. Histological examination and MCS play important roles

Infection after total hip arthroplasty is a rare but potentially devastating complication. The most common pathogens responsible for these infections are gram positive bacteria. Infection caused by fungi is uncommon. There are few reports of prosthetic joint infection caused by Candida species, and there has no report of implant preservation. We experienced the case of a patient with Candida arthritis who underwent total hip arthroplasty for hip arthrosis, and successfully could preserved prosthetic joint. A 60 year-old woman underwent total hip arthroplasty in September 2014. She had had the past of sepsis by the Candida after surgery of the duodenal cancer. After four weeks in total hip arthroplasty, she made clinic visits. Her chief complaints were low-grade fever of 1 week's duration and discharge from operative scar for THA. The patient underwent arthrocentesis of the left hip. The culture was positive for Candida tropicalis. Operation of surgical debridement and liner change was performed as soon as possible. After operation, the patient was treated with fluconazole intravenously for 28 days. She has continued to taken fluconazole by mouth. Reactivation of infection have not been in her left hip. We reported the case of a patient with Candida arthritis who underwent total hip arthroplasty. Prosthetic joint could have preserved because of early detection for infection. This is the first report of preservating implant after Candida infection in total hip arthroplasty

Introduction: The limping child poses a diagnostic challenge. The purpose of this study was to create a clinically useful algorithm of presenting variables to allow the exclusion of ‘musculoskeletal sepsis’ as a differential diagnosis in the child presenting with a limp. Materials & Methods: This study represents the data collected on all limping children admitted to our centre over a 3-year period. Analysis was based on 229 admissions. Comparison was made between the group with septic arthritis or osteomyelitis and the group without infection, using univariate analysis. With logistic regression analysis, a model consisting of three independent multivariate predictors was constructed, to exclude infection. Results: Patients with septic arthritis or osteomyelitis differed significantly from patients without infection with regard to duration of symptoms, presence of constitutional symptoms, temperature, white cell count and erythrocyte sedimentation rate (ESR), (p-values < 0.05). Multivariate analysis demonstrated that the best model to describe our patient population was based on three variables: duration of symptoms between 1 and 5 days, temperature > 37.0°C and ESR > 35mm/hr. When all three variables were present, the predicted probability of musculoskeletal infection was 0.66. When none of the three were present, the predicted probability of infection was 0.01. Discussion: Diagnosis of septic arthritis or osteomyelitis is especially difficult in the early phase and there is no single variable that can serve as a definitive test. The significance of constitutional symptoms and duration of symptoms on univariate analysis emphasises the importance of careful history taking. C-reactive protein, while considered for inclusion, was excluded due to its limited availability at our institution. Conclusion: The multivariate model enables us to rule out musculoskeletal infection with 99% certainty in limping children with none of these three presenting variables

Sixty-five total hip arthroplastics were reinserted after sepsis around the hip, positive cultures being obtained from fifty-six. Although 65 per cent of patients still have their implant in position, only sixteen of sixty-five (25 per cent) show an excellent or good result on a Harris rating. Twenty-three of sixty-five (35 per cent) subsequently required an excision arthroplasty. The indications and contraindications for this procedure are given

Panton-Valentine leukocidin secreted by Staphylococcus aureus is known to cause severe skin, soft tissue and lung infections. However, until recently it has not been described as causing life-threatening musculoskeletal infection. We present four patients suffering from osteomyelitis, septic arthritis, widespread intravascular thrombosis and overwhelming sepsis from proven Panton-Valentine leukocidin-secreting Staphylococcus aureus. Aggressive, early and repeated surgical intervention is required in the treatment of these patients. The Panton-Valentine leukocidin toxin not only destroys host neutrophils, immunocompromising the patient, but also increases the risk of intravascular coagulopathy. This combination leads to widespread involvement of bone with glutinous pus which is difficult to drain, and makes the delivery of antibiotics and eradication of infection very difficult without surgical intervention

The purpose of this study is to present the preliminary results after treatment of shoulder sepsis with prolonged implantation of an antibiotic-loaded cement spacer in a selected group of compromised patients. The current study included 11 patients (9 males and 2 females) with a mean age of 64 years (range: 36–79 years). All patients were treated with radical debridement, implantation of an antibiotic-impregnated polymethylmethacrylate spacer, and 6 weeks of antibiotic therapy. The subjective complaints, range of motion of the shoulder, functional outcome (mini-DASH score), and radiographic findings were evaluated. Nine patients at a mean follow-up time of 21 months (range: 13–18 months) were free of infection with pain relief and adequate shoulder function for activities of daily living. Radiographic evaluation revealed no loosening or fracture of the spacer and no progressive degenerative changes involving the glenoid. Prolonged implantation of the spacer may be a useful alternative in selected patients with poor general condition

Aim. We describe a case series using adjuvant calcium sulphate bio composites with antibiotics in treating infected metalwork in the foot and ankle. Method. 11 patients aged 22–81 (9 males, 2 females) were treated with clinical evidence of infected limb metal work from previous orthopaedic surgery. Metal work removal with intra osseous application of either cerement in 8 cases (10–20ml including 175mg–350mg gentamycin) or stimulan in 3 cases (5–12ml including 1g vancomycin) into the site was performed. Supplemental systemic antibiotic therapy (oral/intravenous) was instituted based on intraoperative tissue culture and sensitivity. Results. 7 patients had infected ankle metalwork, 2 had infected foot metalwork and 2 had infected external fixators. Metal work was removed in all cases. Mean pre operative CRP was 25.4 mg/l (range 1–137mg/l). Mean postoperative CRP at 1 week was 15.4mg/l (range 2–36mg/l) and at 1 month was 16.1mg/l (range 2–63mg/l). Mean pre op WCC was 8.5×10. 9. (range 6.2–10.6×10. 9. ). Mean post op WCC at 1 week was 8.8×10. 9. (range 5.1–12.7×10. 9. ) and 1 month was 7.1×10. 9. (range 3.7–10.4×10. 9. ). Organisms cultured included enterobacter, staphylococcus species, stenotrophomonas, acinetobacter, group B streptococcus, enterococcus, escherichia coli, pseudomonas, morganella morganii and finegoldia magna. Infection eradication as a single stage procedure with primary would closure and healing was achieved in 10 out of 11 cases (90.9%). No additional procedures were required in these cases. Conclusions. Our results support the use of a calcium sulphate bio composite with antibiotic as an adjuvant for effective local infection control in cases with implant related bone sepsis. The technique is well tolerated with no systemic or local side effects. Our results show that a single stage implant removal, debridement and local antibiotic delivery can achieve over 90% success rates. We theorise that it could minimise the need for prolonged systemic antibiotic therapy in such cases

Introduction and Aims: To compare the results of patients treated with articulating versus static antibiotic-impregnated spacers for infected knee arthroplasty. Method: All patients undergoing two-stage revision knee arthroplasty for sepsis in the last five years were reviewed. Twenty-six patients had been treated with articulating spacers. This group was compared to 36 patients treated with static spacers. The articulating spacer technique had been adopted more recently than the static technique. Minimum follow-up was 12 months from second stage re-implantation (average 22 months articulating, 40 months static). Patients were compared in terms of the need for extensile exposures required for re-implantation, range of motion at most recent review, eradication of infection and augmentation required on revision implants. Results: In the articulating group, fewer extensile exposure methods were required at second-stage prosthesis re-implantation (19% vs 36%). No tibial tuberosity osteotomies have been required since using the articulating spacer. The articulating group demonstrated a significantly improved range of flexion compared to the static group (106 vs 97 degrees – p=0.045) and had fewer patients with significant loss of extension or quadriceps lag. Eradication of infection was improved in the articulating group (92% vs 82%) but at shorter average follow-up. The need for augments and stabilised prostheses at revision surgery as a measure of bone loss was no different between the groups but was related to the number of prior surgical procedures. Conclusion: Articulating cement spacers facilitate reimplantation surgery by maintaining tissue planes and joint mobility without compromising joint stability or eradication rate of infection. Patients demonstrate better range of motion and less complications related to the extensor mechanism with the articulated spacer

In recent years articulating cement spacers have been used to treat infected knee arthroplasty. The aim has been to better maintain tissue planes and joint mobility thereby improving second stage re-implantation surgery. Two groups of patients treated for infected knee arthroplasty were reviewed. Twenty-six patients with articulating and forty patients with static antibiotic-impregnated methyl-methacrylate spacers were compared. The articulating spacers demonstrated easier surgical exposure at second stage and improved range of knee motion after re-implantation. There was no compromise in the rate of infection eradication with articulating spacers. Bone loss at revision was independent of spacer type. To compare the results of patients treated with articulating versus static antibiotic-impregnated spacers for infected knee arthroplasty. Articulating cement spacers facilitate re-implantation surgery by maintaining tissue planes and joint mobility without compromising joint stability or eradication rate of infection. Patients demonstrate better range of motion and less complications related to the extensor mechanism with the articulated spacer. Antibiotic impregnated methyl-methacrylate spacers have become a mainstay in two-stage revision arthroplasty for sepsis. It is thought that articulating cement spacers facilitate prosthesis re-insertion by better maintaining tissue planes and joint mobility between stages. In the articulating group fewer extensile exposure methods were required at second stage prosthesis reimplantation (19% vs 36 %). No tibial tuberosity osteotomies have been required since using the articulating spacer. The articulating group demonstrated a significantly improved range of flexion compared to the static group(106 vs 97 degrees- p=0.045) and had fewer patients with significant loss of extension or quadriceps lag. Eradication of infection was improved in the articulating group (92% vs 82%) but at shorter average follow-up. The need for augments and stabilized prostheses at revision surgery as a measure of bone loss was no different between the groups but was related to the number of prior surgical procedures. Twenty-six patients treated with articulating spacers were compared to a matched consecutive group of forty patients treated with static spacers. Minimum follow-up was twelve months from second stage re-implantation (average twenty-two months articulating, forty months static). Funding: No direct funding from any commercial source has been received for this study. The primary author’s fellowship position is partially funded by Smith and Nephew Richards Inc

In recent years articulating cement spacers have been used to treat infected knee arthroplasty. The aim has been to better maintain tissue planes and joint mobility thereby improving second stage re-implantation surgery. Two groups of patients treated for infected knee arthroplasty were reviewed. Twenty-six patients with articulating and forty patients with static antibiotic-impregnated methyl-methacrylate spacers were compared. The articulating spacers demonstrated easier surgical exposure at second stage and improved range of knee motion after re-implantation. There was no compromise in the rate of infection eradication with articulating spacers. Bone loss at revision was independent of spacer type. To compare the results of patients treated with articulating versus static antibiotic-impregnated spacers for infected knee arthroplasty. Articulating cement spacers facilitate re-implantation surgery by maintaining tissue planes and joint mobility without compromising joint stability or eradication rate of infection. Patients demonstrate better range of motion and less complications related to the extensor mechanism with the articulated spacer. Antibiotic impregnated methyl-methacrylate spacers have become a mainstay in two-stage revision arthroplasty for sepsis. It is thought that articulating cement spacers facilitate prosthesis re-insertion by better maintaining tissue planes and joint mobility between stages. In the articulating group fewer extensile exposure methods were required at second stage prosthesis reimplantation (19% vs 36 %). No tibial tuberosity osteotomies have been required since using the articulating spacer. The articulating group demonstrated a significantly improved range of flexion compared to the static group(106 vs 97 degrees- p=0.045) and had fewer patients with significant loss of extension or quadriceps lag. Eradication of infection was improved in the articulating group (92% vs 82%) but at shorter average follow-up. The need for augments and stabilized prostheses at revision surgery as a measure of bone loss was no different between the groups but was related to the number of prior surgical procedures. Twenty-six patients treated with articulating spacers were compared to a matched consecutive group of forty patients treated with static spacers. Minimum follow-up was twelve months from second stage re-implantation (average twenty-two months articulating, forty months static). Funding: No direct funding from any commercial source has been received for this study. The primary author’s fellowship position is partially funded by Smith and Nephew Richards Inc

Purpose: The role of hip aspiration as a preoperative investigation for the painful hip remains controversial. Since 1999, we have performed hip aspiration under local anaesthetics in the X-ray department. This paper reviews our experience with this technique. Results: Hip aspirations were carried out subsequently on 182 patients from November 1999 to November 2002. Out of 68 patients that underwent revision hip surgery, 63 were included in the study. Three of the five patients excluded had received antibiotics at induction prior to obtaining the operative samples and two did not have any operative samples taken at the time of surgery. Fifteen (23.8%) of the 63 hips were found to be infected based on operative tissue cultures. The sensitivity and specificity of the test were 80% and 87.5%, respectively. Positive and negative predictive values were 66.6% and 93.3% respectively and the accuracy was 85.7%. Conclusion: Hip aspiration in the Radiology department is a simple, cost effective and reliable preoperative test when used selectively. When used in combination with other laboratory and radiological investigation it can act as an important preoperative investigation in the diagnosis of sepsis. There is an added advantage of identifying the microorganism along with its antibiotic sensitivities. This can guide clinicians in choosing the correct antibiotic for the cement and also for the postoperative antibiotic therapy

Despite the vast quantities of published artificial intelligence (AI) algorithms that target trauma and orthopaedic applications, very few progress to inform clinical practice. One key reason for this is the lack of a clear pathway from development to deployment. In order to assist with this process, we have developed the Clinical Practice Integration of Artificial Intelligence (CPI-AI) framework – a five-stage approach to the clinical practice adoption of AI in the setting of trauma and orthopaedics, based on the IDEAL principles (https://www.ideal-collaboration.net/). Adherence to the framework would provide a robust evidence-based mechanism for developing trust in AI applications, where the underlying algorithms are unlikely to be fully understood by clinical teams.

Cite this article: Bone Joint Res 2024;13(9):507–512.

Spinal epidural sepsis is more widely recognised with MRI. Treatment includes antibiotics, multisystem support and drainage of pus. Neurological loss will often be stabilised but dramatic recovery is infrequent, explaining the importance of early intervention. This series highlights a very sinister spectrum of spinal infective disease despite ideal traditional treatment for spinal skeletal infection. This is a retrospective case series review of five patients. All patients presented with regional spinal pain, fever and regional musculoskeletal infective foci (e.g. discitis). Mild neurological abnormality existed in three patients. Rapid multisystem collapse occurred with the need for ventilatory support, despite institution of appropriate antibiotic treatment for all patients. All had grown Staphylococcus Aureus from blood cultures. Subsequent extensive quadriparesis/plegia developed, and repeat imaging demonstrated wide spread epidural pus in the cervical spine. Surgical treatment was considered but not performed when the prognosis was so poor neurologically and medically, and when the widespread epidural pus was so inaccessible. All patients died rapidly upon withdrawal of supportive treatment. This paper describes a sinister spectrum of spinal infection with catastrophic complications despite “appropriate” treatment for previously diagnosed spinal foci infection. Positive blood cultures and fever alert to these dangers, and multisystem collapse heralded the development of cervical epidural infection. Possible interventions include early MRI scanning of the whole spine, more aggressive (than traditionally accepted) surgical treatment of infective foci in the spine in these circumstances, and minimally invasive cervical canal decompression procedures with multiple laminotomies

Total hip arthroplasty was performed in 45 hips of 44 patients who had pyogenic arthritis of the hip during childhood. The average age of the patients was 36.4 years (range 19 to 50). The interval between active infection and arthroplasty ranged from 11 to 40 years, and average follow-up was 65.4 months (range 58 to 80). Specimens of tissue taken before and during operation gave negative cultures in all hips, and no patient had reactivation of infection. The mean functional rating of the hips was 58 points before operation and 90 at the final review. Complications were seen in 11 cases (24%), loosening of components occurred in six (13%) and one hip had to be revised for acetabular component migration. Acetabular allografts were required in 27 hips (60%). All allografts united but there was partial resorption of the graft in the non-weight-bearing area in all.

Purpose: Prevention of post-trauma infections is basically aimed at streptococcal, staphylococcal and anaerobic germs. An increasing number of open fractures are however contaminated with Bacillus cereus leading to a multidisciplinary discussion involving infectious disease specialists, orthopaedic surgeons, and bacteriologists concerning the appropriate management. Bacillus is an ubiquitous genus of sporulated telluric Gram positive germs found in soil and plants. B. cereus can lead to local wound infection. This environmental (including hospital) bacterium is often a temporary host of the skin flora and its isolation can be taken as a simple contamination with no therapeutic consequence. B. cereus is sensitive to fluoroquinolones.

Material and methods: Between August 1995 and December 2000, B. cereus was isolated in 41 patients from surgical specimens taken from deep muscle and bone tissues. Ordinary medium was used for culture. Genomic analysis was used to type the Bacillus. Statistical analysis was conducted in cooperation with the epidemiology unit.

Results: In our unit, isolation of B. cereus was significantly associated with severe open leg fractures (Gustilo grades IIA and IIIB) with soil contamination. Samples were taken due to fever, wound discharge, elevation of C reactive protein despite antibiotic prophylaxis beyond 48 hours using the standard protocol of aminopenicillin + betalactamase inhibitor, constantly inactive against B. cereus. The strains identified presented different genomic types ruling out nosocomial contramination. One amputation, one chronic osteitis and one anteriolateral leg compartment necrosis resulted from B. cereus infection in this series.

Conclusion: Arguments developed here allow us to recall the importance of careful surgical debridement of open fractures and to emphasise the requirement for bacteriological samples and appropriate antibiotic therapy for 48 hours, combining, in agreement with the 1998 Consensus Conference, aminopenicillin + betalactamase inhibitor and gentamycin which is active against B. cereus. Severe open leg fractures which follow an unfavourable course should suggest possible B. cereus infection requiring early antibiotic therapy using a regimen with good bone diffusion including a fluoroquinolone which is always active against B. cereus.

Aims. We present the clinical and radiological results at a minimum follow-up of 20 years using a second-generation uncemented total hip arthroplasty (THA). These results are compared to our previously published results using a first-generation hip arthroplasty followed for 20 years. Methods. A total of 62 uncemented THAs in 60 patients were performed between 1993 and 1994. The titanium femoral component used in all cases was a Taperloc with a reduced distal stem. The acetabular component was a fully porous coated threaded hemispheric titanium shell (T-Tap ST). The outcome of every femoral and acetabular component with regard to retention or revision was determined for all 62 THAs. Complete clinical follow-up at a minimum of 20 years was obtained on every living patient. Radiological follow-up was obtained on all but one. Results. Two femoral components (3.2%) required revision. One stem was revised secondary to a periprosthetic fracture one year postoperatively and one was revised for late sepsis. No femoral component was revised for aseptic loosening. Six acetabular components had required revision, five for aseptic loosening. One additional acetabular component was revised for sepsis. Radiologically, all femoral components remained well fixed. One acetabular was judged loose by radiological criteria. The mean Harris Hip Score improved from 46 points (30 to 67) preoperatively to 89 points (78 to 100) at final follow-up. With revision for aseptic loosening as the endpoint, survival of the acetabular component was 95% (95% confidence interval (CI) 90 to 98) at 25 years. Femoral component survival was 100%. Conclusion. The most significant finding of this report was the low prevalence of aseptic loosening and revision of the femoral component at a mean follow-up of 22 years. A second important finding was the survival of over 90% of the hemispheric threaded ring acetabular components. While these shells remain controversial, in this series they performed well. Cite this article: Bone Jt Open 2021;2(1):33–39

Since 1977 we did implant ceramic on ceramic THR in younger and active population. In 1991 we published (JBJS B N°4) data's in a consecutive group of patients under 50 years of age. What about the same patients for more than 30 years? Eighty-six hips in 75 patients, 41 males 34 females, mean age 43 (18 to 50), mean weight 68 kg (36 to 100), Charnley class: 38 A, 28 (38 hips) B, 9 patients (10 hips) C. Sixty-six primary procedures, 20 revisions (18 failed arthroplasties: 6 THR, 5 resurfacing, four single cup, two hemiarthroplasty, one bipolar), one after acetabular fractures. Four hips previously infected. Eight Patients deceased (8 hips) prosthesis still in place, ten lost to follow-up before 2 years, eight hips in 8 patients were revised before the review, partially followed: from 2 to 20 years: 35, completely followed: 25 hips in 23 patients resuming in: No pain in 20, slight pain in 2, severe disability in 3 not related to the hip, no radiolucent lines in 22, radiolucent lines in 3, no osteolysis in 25. Revision for: early sepsis in one, socket loosening in 8 (3 revisions cases), femoral head fractures in 2: one extra small head (22mm) for Crowe 3 DDH, one fractured at 24 years. Inertness, stability related to fibrous tissue generation, no noise

Introduction. The reconstruction of segmental long bone defects remains one of the holy grails of orthopaedic surgery. The optimal treatment of which remains a topic of great debate. This study aimed to evaluate the outcomes following the management of critical-sized bone defects using a classification-based treatment algorithm. Materials & Methods. A retrospective review of all patients undergoing treatment for segmental diaphyseal defects of long bones at a tertiary-level limb reconstruction unit was performed. The management of the bone defect was standardised as per the classification by Ferreira and Tanwar (2020). Results. A total of 96 patients (mean age 39.8, SD 15.2) with a minimum six months follow-up were included. Most bone defects were the result of open fractures (75/96) with 67% associated with Gustilo-Anderson IIIB injuries. There was a statistical difference in the likelihood of union between treatment strategies with more than 90% of cases undergoing acute shortening and bone transport achieving union and only 72% of cases undergoing the induced membrane technique consolidating (p=0.049). Of those defects that consolidated, there was no difference in the time to bone union between strategies (p=0.308) with an overall median time to union 8.33 months (95% CI 7.4 — 9.2 months). The induced membrane technique was associated with a 40% risk of sepsis. Conclusions. This study reported the outcomes of a standardised approach to the management of critical-sized bone defects. Whilst overall results were supportive of this approach, the outcomes associated with the induced membrane technique require further refinement of its indications in the management of critical-sized bone defects

In reverse shoulder arthroplasty (RSA), a high complication rate is noted in the international literature (24.7%), and limited local literature is available. The complications in our developing health system, with high HIV, tuberculosis and metabolic syndrome prevalence may be different from that in developed health systems where the literature largely emanates from. The aim of this study is to describe the complications and complication rate following RSA in a South African cohort. An analytical, cross-sectional study was done where all patients’ who received RSA over an 11 year period at a tertiary hospital were evaluated. One-hundred-and-twenty-six primary RSA patients met the inclusion criteria and a detailed retrospective evaluation of their demographics, clinical variables and complication associated with their shoulder arthroplasty were assessed. All fracture, revision and tumour resection arthroplasties were excluded, and a minimum of 6 months follow up was required. A primary RSA complication rate of 19.0% (24/126) was noted, with the most complications occurring after 90 days at 54.2% (13/24). Instability was the predominant delayed complication at 61.5% (8/13) and sepsis being the most common in the early days at 45.5% (5/11). Haematoma formation, hardware failure and axillary nerve injury were also noted at 4.2% each (1/24). Keeping in mind the immense difference in socioeconomical status and patient demographics in a third world country the RSA complication rate in this study correlates with the known international consensus. This also proves that RSA is still a suitable option for rotator cuff arthropathy and glenohumeral osteoarthritis even in an economically constrained environment like South Africa

Osteoarticular infections (OAI) are a common cause of morbidity in children, and as opposed to adults is usually caused by haematogenous spread. The bacteriology of OAI in children is not well described in the South African context, therefore this study was designed to determine the bacteriology of OAI in our population. All patients that underwent surgery for the treatment of OAI over a 3-year period were identified and those with positive cultures where organisms were identified from tissue, pus, fluid or blood were included. Duplicate cultures from the same patient were excluded if the organism and antibiotic susceptibility profile was the same. Patients were categorised according to age and class of infection (Septic arthritis, acute osteomyelitis, fracture related infection, post-operative sepsis and chronic osteomyelitis) and organisms were stratified according to these categories. We identified 132 organisms from 123 samples collected from 86 patients. Most cultured organisms were from children older than 3-years with acute haematogenous septic arthritis, osteomyelitis, or both. Methicillin sensitive Staphylococcus aureus accounted for 56% (74/132) of organisms cultured. There were no cases of MRSA. The Enterobacterales accounted for 17% (22/132) of organisms cultured, mostly in the fracture related and post-operative infection groups. Of these, 6 each were extended spectrum B-lactamase producers and AmpC producers. There were no carbapenemase producing Enterobacterales. Kingella kingae was not isolated in any patient. Methicillin sensitive S. aureus is the most common infecting organism in paediatric OAI and an anti-staphylococcal penicillin such as cloxacillin or flucloxacillin is the most appropriate empiric treatment for haematogenous OAI in our environment. In fracture related or post-operative infections, Enterobacterales were more frequently cultured, and treatment should be guided by culture and susceptibility results

Nitric oxide is a free radical which in vivo is solely produced during the conversion of the amino acid arginine into citrulline by nitric oxide synthase enzymes. Recently, the importance of nitric oxide on inflammation and bone metabolism has been investigated. However, the knowledge regarding possible in vitro effects of arginine supplementation on chondrogenic differentiation is limited. ATDC5, a cell line which is derived from mouse teratocarcinoma cells and which is characterized as chondrogenic cell line, were proliferated in Dulbecco's Modified Eagle Medium (DMEM)/F12 and subsequently differentiated in proliferation medium supplemented with insulin, transferrin and sodium-selenite and where arginine was added in four different concentrations (0, 7.5, 15 and 30 mM). Samples were harvested after 7 or 10 days and were stored at −80 °C for subsequent RNA isolation for qPCR analysis. To determine chondrogenic differentiation, Alcian Blue staining was performed to stain the proteoglycan aggrecan, which is secreted by differentiated ATDC5 cells. All measurements were performed in triplo. Alcian Blue staining showed a qualitative increase of proteoglycan aggrecan secretion in differentiated ATDC5 cells after treatment with 7 and 15 mM arginine, with additional increased expression of ColII, ColX, Bmp4 and Bmp6. Treatment with 30 mM arginine inhibited chondrogenic differentiation and expression of aforementioned genes, however, Cox-2 and Vegfa gene expression were increased in these samples. Bmp7 was not significantly expressed in any experimental condition. The obtained results are suggestive for a dose-dependent effect of arginine supplementation on chondrogenic differentiation and associated gene expression, with 7.5 and 15 mM as most optimal concentrations and implications for apoptosis after incubation with 30 mM arginine. A future recommendation would be to investigate the effects of citrulline in a similar experiment, as this shows even more promising results to enhance the nitric oxide metabolism in sepsis and bone healing

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

Aim. Pelvic osteomyelitis following pressure ulceration results in substantial patient morbidity. Previous studies have reported a heterogenous approach to diagnosis and medical management by physicians, suggesting equipoise on key clinical questions. This study hypothesised that the same equipoise exists amongst Orthopaedic surgeons. Method. An 18-question multiple-choice questionnaire was designed through an iterative feedback process until the final version was agreed by all authors. Likert-type scale responses were used with graded responses (e.g., never/fewer than half of patients/around half of patients/more than half of patients/every patient). The online survey was sent to members of the Musculoskeletal Infection Society (MSIS), the European Bone and Joint Infection Society (EBJIS), and the ESCMID Study Group for Implant-Associated Infections (ESGIAI). No incentive for participation was provided. Results. Amongst respondents, 22/41 were based in Europe and 10/41 from the USA. The majority (29/41) had been in clinical practice between 5—24 years. There was a high priority placed on bone biopsy histology, culture-positive bone sampling, and palpable bone without periosteal covering for diagnosis. Multidisciplinary team approach with plastic surgery involvement at the index procedure was advocated. The strongest indications for surgical intervention were source control for sepsis, presence of an abscess/collection, and prevention of local osteomyelitis progression. Physiological/psychological optimisation and control of acute infection were the primary determinants of surgical timing. There was low utilisation of adjunctive surgical therapies. Local/regional primary tissue transfer or secondary healing with/without VAC were the preferred techniques for wound closure. Recurrent osteomyelitis was the most common reason for prolonged antimicrobial therapy. The majority received bedside advice from an infectious disease-specialist but a quarter of respondents preferred telephone advice. Conclusions. Amongst an international cohort of Orthopaedic Surgeons there was a heterogenous diagnostic and therapeutic approach to pressure-related pelvic osteomyelitis

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

Aim. Melioidosis is a significant public health problem in endemic regions such as India. Lack of awareness, predominant empiric antibiotic use reducing culture yields, morphotypic variability of cultures and frequent misidentification by automated blood culture systems, pose myriad challenges in diagnosis and treatment. Through this series, we present our experience of Hematogenous Osteomyelitis with Burkholderia pseudomallei. Method. This was a single centre, retrospective, observational study performed at a tertiary case hospital in Mumbai, India from June 2011 to June 2021. Results. The study comprised of 7 cases (6:1, M: F). Mean age was 53.7 years (5 to 75). All had an underlying co- morbidity or were immunosuppressed. 3 patients were misidentified by automated systems prior to presentation (e coli, burkholderia cepacieae, acinetobacter). Most common site of infection was femur (n= 3), followed by tibia and foot and ankle (n= 2, each). One had disseminated meliodosis involving the spleen, lymph nodes, pulmonary) in addition to involvement of bilateral feet and ankles. B. pseudomallei was identified in all following surgical debridement at our institute. Each patient underwent mean 2 procedures. 3 needed local rotation flap surgeries for wound cover. All were treated with ceftazidime along with trimethoprim- sulfamethoxazole (TMP- SMX) during the 6 week induction phase. TMP- SMX was continued for a further 6 months in the consolidation phase. All patients had infection remission at a mean 19.3 months follow up. There were no mortalities in our series. Conclusions. Clinically Burkholderia infections mimic other pyogenic infections, Gram-negative sepsis, tuberculosis and has been referred to as the “remarkable imitator” and the “mimicker of maladies”. Diabetes and alcoholism are risk factors. The need for diagnosing this entity is due to the fact that the septicemic form has a mortality rate that exceeds 90%. Melioidosis is frequently misidentified. A high clinical suspicion, communication with microbiologist, knowledge about the biochemical, cultural and phenotypic susceptibility patterns may help in optimising diagnosis. Adequate debridement coupled with targeted prolonged antibiotics help achieve good outcomes

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

Fracture related infections (FRI) are debilitating complications of musculoskeletal trauma surgery that can result in permanent functional loss or amputation. This study aims to determine risk factors associated with FRI treatment failure, allowing clinicians to optimise them prior to treatment and identify patients at higher risk. A major trauma centre database was retrospectively reviewed over a six-year period. Of the 102 patients identified with a FRI (66 male, 36 female), 29.4% (n=30) had acute infections (onset <6 weeks post-injury), 34.3% (n=35) had an open fracture. Open fractures were classified using Gustilo-Anderson (GA) classification (type 2:n=6, type 3A:n=16, type 3B:n=10, type 3C:n=3). Patients with periprosthetic infections of the hip and knee joint, those without prior fracture fixation, soft tissue infections, diabetic foot ulcers, pressure sore infections, patients who died within one month of injury, <12 months follow-up were excluded. FRI treatment failure was defined as either infection recurrence, non-union, or amputation. Lifestyle, clinical, and intra-operative data were documented via retrospective review of medical records. Factors with a P-value of p<0.05 in univariate analysis were included in a stepwise multivariate logistic regression model. FRI treatment failure was encountered in 35.3% (n=36). The most common FRI site was the femoral shaft (16.7%; n=17), and 15.7% (n=16) presented with signs of systemic sepsis. 20.6% (n=21) had recurrent infection, 9.8% (n=10) had non-union, and 4.9% (n=5) required an amputation. The mean age at injury was 49.71 years old. Regarding cardiovascular risk factors, 37 patients were current smokers (36.3%), 31 patients were diabetics (30.4%), and 32 patients (31.4%) were obese (BMI≥30.0). Average follow-up time was 2.37 (range: 1.04-5.14) years. Risk factors for FRI treatment failure were BMI>30, GA type 3c, and implant retention. Given that FRI treatment in 35.3% (36/102) ended up in failure, clinicians need to take into account the predictive variables analysed in this study, and implement a multidisciplinary team approach to optimise these factors. This study could aid clinicians to redirect efforts to improve high risk patient management, and prompt future studies to trial adjuvant technologies for patients at higher risk of failure