Background. Morton's neuroma (MN) is a common cause of metatarsalgia. Whilst there are a many treatment modalities available, studies looking at the long term effectiveness of most forms of treatment are scarce. The injection of MN with alcohol has gained popularity over the past ten years with widespread media coverage. Many surgeons have anecdotally questioned the long-term effectiveness. Sixty patients underwent alcohol injection for the treatment of MN by Radiologists at our institution. These results were originally published showing 92% (92/100) success rates and only 3% (3/100) requiring surgical excision at a mean follow up of 10.5 mths. The authors concluded that alcohol injection was comparable to results for surgical excision. Methods. We were able to review forty five of this original cohort with an average follow up of 61 (range, 33 to 73) months. The modified Johnson score and visual analogue scales were used to assess the patients and compare these results to five year results available in the literature for surgical management. Results. Our results indicated that by five years 36% (16/45) had undergone surgical treatment and a further 45% (13/29) had return of symptoms. Only 29% (13/45) remained symptom free. Results at five years showed statistically significant differences (P< 0.05) compared to surgical management, with 67.8% complete resolution of symptoms with surgery and 33% in the alcohol injection group. Conclusion. Injection with alcohol sclerosant for MN has been marketed as a definitive management option comparable to surgical excision. Our investigation illustrated that although short term results are encouraging; alcohol injection does not offer permanent resolution of symptoms for most patients, can be associated with considerable morbidity and that results are not comparable to surgery. Our investigation provides the only long term data for alcohol injection treatment of MN

Alcohol remains a significant cause of disease in the UK population. Yet the effect of alcohol on fractures remains conflicting. We present a prospective analysis of self-reported alcohol consumption and the epidemiology of fractures sustained. 1950 patients over 13 years of age were prospectively interviewed after sustaining a fracture with basic epidemiological data, fracture data and average alcohol consumption recorded. 1621 (83%) of interviewees provided information on alcohol consumption. 10% admitted to drinking in excess of Scottish Health guidelines. 18.1% of males drunk to excess, compared to 4.7% of females (p<0.001). The five most frequent fractures were distal radius (20%), metacarpals (12%), ankle fractures (12%), neck of femur (10%), phallanges (10%). 48% of fractures were falls from standing height. Excess drinkers were more likely to sustain an AO grade C fractures than safe drinkers (18.1% compared to 11.2%, p<0.05). Excess drinkers sustained more open fractures than safe drinkers (5% compared to 1%, p<0.001). Excess drinkers were on average 5.66 years younger than safe drinkers at the time of injury (44.57 years compared to 50.23 years, p<0.05). People reporting alcohol excess who have sustained a fracture are more likely to be younger and suffer more severe fractures than those drinking within current guidelines. Opportune targetting of patients consuming excess alcohol should be targetted at problem drinkers sustaining a fracture

The prevalence of alcohol and opioids in severely injured patients has been widely reported from 30-80%. However, despite the increasing global misuse of stimulant drugs, there is a paucity of literature regarding the presence of stimulant drugs in trauma patients. The primary aim of this study was to define the prevalence of stimulant drugs that were detected in patients who presented to Level One Trauma Centers throughout North America, and their effect on length of stay and mortality. Our triage criteria for admittance to the regional trauma centre are based on the recommendations by the American College of Surgeons Committee on Trauma, who now recommend toxicology screening on every patient. This was a retrospective analysis of data from the Trauma Quality Improvement Program, including all patients presenting emergently to participating Level 1 Trauma Centers from January 2017 to December 2018. A stimulant drug was defined as the detection of cocaine, amphetamine, or methamphetamine. Adults aged 18-64 years were included. Patient risk factors were included adjusted for in the analysis: age, sex, body mass index (BMI), alcohol screening results and smoking status. Univariate analysis was performed for all variables. Multivariable logistic regression and liner regression were used for mortality and length of stay, respectively. Of a total of 110,561 patients included in the study, 15,958 patients (14.4%) had positive screens for stimulants. The average age in the stimulants cohort was 40.8 years, with a 77.6% male preponderance, BMI of 26.9, blood alcohol content of 0.07, and ISS of 11.3. The control cohort was comparable, though 71.1% male (p<0.001) Patients who tested positive for stimulants had 1.79 times (95% CI, 1.09-2.93) the odds of dying in the emergency department as the control group (p=0.02). Following transfer from the emergency department, the odds ratio for deaths in hospital (OR=1.02, 95% CI 0.90-1.15) was comparable to the control group (p=0.78). The mean length of stay was significantly higher in the stimulant group (2.84 days) compared to the control group (1.79 days) (p<.001). In the Intensive Care Unit, length of stay was 0.64 days in the stimulant group versus 1.65 in the control (p=0.48). Stimulant misuse is a relevant issue in the trauma population, associated with a longer hospital stay and higher mortality in the emergency department. The continued routine drug screening of trauma patients may be beneficial in trauma centers, to implement preventative measures and optimise resource allocation

The Victorian state government introduced a trial electronic scooter sharing scheme on 1. st. February 2022 in inner city Melbourne. Despite epidemiological data from other jurisdictions that show these devices are associated with significant trauma. This is a descriptive study from the largest trauma centre in Victoria demonstrating the “scope of the problem” after introduction of this government-approved, ride sharing scheme. Retrospective case series. Our hospital orthopaedic department database was searched from 1/1/2021 to 30/6/22 to identify all presentations associated with electronic scooter trauma, the mechanism of injury and admission information was confirmed via chart review. Data collected included: mode of arrival, alcohol/drug involvement, hospital LOS, injury severity score, ICU admission, list of injuries, operations undertaken, surgical procedures, discharge destination, death. In the 12 months prior to and 5 months since introduction of the ride share scheme, 43 patients were identified. 18 patients (42% of our cohort) presented in the 5 months since ride sharing was introduced, and 25 patients in the preceding 12 months. 58% were found to be alcohol or drug affected. All patients were admitted to hospital, 14% of which included ICU admission. 44% were polytrauma admissions. Median hospital length of stay was 2 days. The longest individual hospital stay was 69 days. No patients in this series died. There were 49 surgical procedures in 35 patients including neurosurgical, plastics and maxillofacial operations. Mean Injury Severity Score was 10. Despite data demonstrating their danger in other jurisdictions, the Victorian state government approved a trial of an electronic scooter ride share scheme in inner Melbourne in February 2022. These devices are associated with a significant trauma burden and the rate has increased since the introduction of the ride-sharing scheme. This data may be combined with other hospital data and could be used to inform policy makers

Intimate partner violence (IPV) causes significant morbidity and its unlikely to be reported compared to other forms of gender-based violence (GBV). For early detection, understanding Orthopaedic injuries from GBV is vital. This study assesses the pattern of musculoskeletal injuries from GBV and determines the factors associated with it. It is a retrospective observational study of patients aged ≥18 years, with GBV-related acute Orthopaedic injuries. Data was reviewed from January 2021 to December 2021, including, demographic information, soft tissue and bony injuries, relationship to assailant, substance abuse and the day and time of injury. Frequencies and percentages for categorical data were analysed. Chi-square test was used to calculate association. T-test was used to compare groups for continuous & categorical variables. Multivariate analysis was conducted to find the odds ratio and a p-value <0.05 was statistically significant. 138 patients were included, the mean age at presentation being 35.02 years (SD=11). 92.75% of GBV victims were females. Most were unemployed (66.7%). 30.43% (n-42) had a soft tissue injury; superficial laceration being the most common (23.1%), flexor tendon injury (10.87%), hand abscess (5.8%), and extensor tendon injury (5.07%). 71.02 % (n=98) sustained appendicular fractures. 51.45% (n=71) sustained upper limb fractures; distal radius fractures (10.86%) and distal 3rd ulnar fractures (9,42%). 19.57% (n=27) had lower limb fractures; 7.25% (n=10) had lateral malleolus ankle fractures. 63.7% (n=80) of cases were by an intimate partner on weekends (50.73%). 62.31% occurred between 16h00 and 0h00. 41.1% (n=65) reported alcohol abuse. 63.04% had surgery. GBV likely occurs in early middle-aged females by intimate partners influenced by alcohol over the weekends between 16h00 to 0h00. Distal radius/distal 3rd ulnar fractures are the most common bony injuries. Superficial wrist laceration is the commonest soft tissue injury. These findings may assist with early detection and intervention to prevent adverse outcomes in GBV

Aim. Debridement, antibiotic, and implant retention (DAIR) is an accepted treatment of early and late acute Total Knee Arthroplasty (TKA) infections. DAIR failure may adversely affect the outcome of a subsequent two-stage exchange arthroplasty. Controversy exists on risk factors that can affect DAIR's results. The aim of the study is to review presurgical, intrasurgical and postsurgical variables that could affect DAIR's result. Method. A retrospective study of 27 DAIRs performed between 2015–2019 to treat late acute TKA infections was carried out. Patients were divided into two groups depending on DAIR's outcome [Healing (H) vs non-healing group (NH)] according on the Delphi-based multidisciplinary consensus criteria on success after treatment of periprosthetic joint infection. We reviewed presurgical variables, including epidemiological variables (Age, Sex, comorbidities, ASA, Charlson, BMI, alcohol dependency), prosthesis variables (prosthesis type, primary cause of operation, primary TKA surgery center), infection variables (concomitant infection, previous antibiotic treatment, c-reactive protein, synovial WBC count, synovial % PMN, pathogen), KLIC score and CRIME 80 score. Surgical variables such as surgery duration and type of surgery (elective vs urgent). Post-surgical variables like antibiotic treatment duration and destination at discharge. Normal distribution was assessed by Shapiro-Wilk test. Mann Whitney U test was used to compare the two independent sample variables. Chi-squared test was used for qualitative variables. P-value was established at 0.05 and statistical power at 80%. Results. Infection Healing was achieved in 63% of patients. In presurgical variables, alcohol dependency, hypertension, liver disease, previous surgery performed in another institution were more frequent in NH group (p< 0.05). KLIC score value equal or greater than 4 had a higher risk of surgical failure (p < 0.05). Regarding surgical variables, the healing group had more negative cultures than de non-healing one (p<0.05). Regarding post-surgical variables, long term antibiotic treatment (six months) achieved more healing after DAIR (p<0.05). Conclusions. Alcohol dependency, hypertension, liver disease and KLIC score values equal or greater than 4, may increases the risk of DAIR failure. Finally, we observed that the long-term antibiotic treatment (6 months) favors healing after DAIR

Abstract. Background. Alcohol has been associated with up to 40% trauma-related deaths globally. In response to the Covid-19 pandemic, the United Kingdom (UK) entered a state of ‘lockdown’ on 23. rd. March 2020. Restrictions were most significantly eased on 1. st. June 2020, when shops and schools re-opened. This study aimed to quantify the effect of lockdown on trauma admissions specifically regarding alcohol-related trauma. Methods. All adult patients admitted as ‘trauma calls’ to a London Major Trauma Centre (MTC) during April 2018 and April 2019 (pre-lockdown; N=316), and 1. st. April – 31. st. May 2020 (lockdown; N=191) had electronic patient records (EPR) analysed. Patients’ blood alcohol level (BAC) combined with records of intoxication were used to identify alcohol-related trauma. Multiple regression analyses were performed to compare pre- and post-lockdown alcohol-related trauma admissions. Results. Alcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.4%), versus pre-lockdown 62/316 (19.6%); Odds Ratio (OR 0.83, 95% CI 0.38 to 1.28, p<0.001). Lockdown was also associated with increased weekend admissions of trauma (lockdown 125/191 weekend (65.5%) vs pre-lockdown 179/316 (56.7%); OR -0.40, 95% CI -0.79 to -0.02, p=0.041). No significant difference existed between the age, gender, or mechanism between pre-lockdown and lockdown cohorts (p>0.05). Conclusion. UK lockdown was independently associated with an increased proportion of alcohol-related trauma. Furthermore, trauma admissions were increased during the weekend when staffing levels are reduced. With the possibility of multiple global ‘waves’ of Covid-19, the risk of long-term repercussions of dangerous alcohol-related behaviour must be addressed

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

Aim. Chronic osteomyelitis (OM) is usually treated with surgical excision of infected bone and subsequent dead space management to prevent local recurrence. We report outcome after antibiotic loaded biocomposite (ALB). 1. for management of infected bone defects. Method. We report a consecutive series of 97 patients with chronic OM treated at one institution by a multidisciplinary team, using a single-stage revision protocol inspired by a recently published study. 2. . The treatment protocol includes surgical debridement, tissue sampling, dead-space management using the ALB, stabilization and empirical antibiotic therapy adjusted based on culturing. Closure was performed directly, with a local flap, a free flap or secondarily. This series includes all patients operated using the ALB at our institution, since its implementation 26 months ago. The senior author (HG) performed 65 (67%) of the operations. The remaining procedures were performed by 14 different surgeons. Results. Mean age was 66.2 years (26 to 92). In 41 patients, OM followed an overlying soft-tissue infection, 30 followed surgical management of a closed fracture in the affected bone, 18 followed elective surgical procedures in the area, 5 followed open fractures of the affected bone, 2 were spontaneous following bacteremia and 1 patient had previously been diagnosed with OM in the affected bone. Seventy one (73,2%) of the included patients had systemic comorbidities (Cierny-Mader Class B hosts), thirty eight were diabetics, twenty-three were active smokers and twenty-five had a past history of smoking, fourteen consumed alcohol in quantities constituting alcohol abuse and 9 had a previous history of alcohol abuse. Patients were followed-up by chart review for a mean of 5.8 months (0 to 25). Twelve patients required a soft-tissue revision after a mean time of 2.2 months (0 to 12). Eleven patients required bone revision after a mean time of 3.4 months (0 to 10) where the ALB was re-applied in nine cases. Six patients required amputation after a mean time of 3.2 months (0 to 12). Two patients died after a 1 and 5 months respectively. Seventy patients (73%) had no adverse advents following surgery. Conclusions. An acceptable outcome was obtained considering a heterogeneous population with a high comorbidity rate and considerable smoking and alcohol abuse

Aim. Recurrence of bone and joint infection, despite appropriate therapy, is well recognised and stimulates ongoing interest in identifying host factors that predict infection recurrence. Clinical prediction models exist for those treated with DAIR, but to date no models with a low risk of bias predict orthopaedic infection recurrence for people with surgically excised infection and removed metalwork. The aims of this study were to construct and internally validate a risk prediction model for infection recurrence at 12 months, and to identify factors that predict recurrence. Predictive factors must be easy to check in pre-operative assessment and relevant across patient groups. Methods. Four prospectively collected datasets including 1173 participants treated in European centres between 2003 and 2021, followed up to 12 months after surgery for orthopaedic infections, were included in logistic regression modelling [1–3]. The definition of infection recurrence was identical and ascertained separately from baseline factors in three contributing cohorts. Eight predictive factors were investigated following a priori sample size calculation: age, gender, BMI, ASA score, the number of prior operations, immunosuppressive medication, glycosylated haemoglobin (HbA1c), and smoking. Missing data, including systematically missing predictors, were imputed using Multiple Imputation by Chained Equations. Weekly alcohol intake was not included in modelling due to low inter-observer reliability (mean reported intake 12 units per week, 95% CI for mean inter-rater error −16.0 to +15.4 units per week). Results. Participants were 64% male, with a median age of 60 years (range 18–95). 86% of participants had lower limb orthopaedic infections. 732 participants were treated for osteomyelitis, including FRI, and 432 for PJI. 16% of participants experienced treatment failure by 12 months. The full prediction model had moderate apparent discrimination: AUROC (C statistic) 0.67, Brier score 0.13, and reasonable apparent calibration. Of the predictors of interest, associations with failure were seen with prior operations at the same anatomical site (odds ratio for failure 1.51 for each additional prior surgery; 95% CI 1.02 to 2.22, p=0.06), and the current use of immunosuppressive medications (odds ratio for failure 2.94; 95% CI 0.89 to 9.77, p=0.08). Conclusions. This association between number of prior surgeries and treatment failure supports the urgent need to streamline referral pathways for people with orthopaedic infection to specialist multidisciplinary units

Aim. In vivo biofilm models play major role to study biofilm development, morphology, and regulatory molecules involve in biofilm. Due to ethical restrictions, the use mammalian models are replaced with other alternative models in basic research. Recently, we have developed insect infection model G. mellonella larvae to study implant associated biofilm infections. This model organism is easy to handle, cheap and ethical restriction free and could be used for the high through put screening of antimicrobial compounds to treat biofilm. To promote the use of this model in basic research we aimed to validate this based on the typical biofilm features such as less susceptible to the antibiotics, complexity of the biofilm structure and gene expression profile of biofilms. Method. G. mellonella larvae are maintained at 30oC on artificial diet in an incubator. Titanium and Stainless steel K-wires were cut into small pieces with size of 4mm. After sterilization with 100% alcohol, these K-wires were pre-incubated in S. aureus bacterial suspension (5×10. 6. CFU/ml) for 30 min, washed in PBS and implanted inside the larva after with help of scalpel. The larvae were incubated at 37. o. C for two day for the survival analysis. To analyze the less susceptibility of the biofilms towards antibiotics, the larvae were treated with gentamicin and compared survival with planktonic infection in G. mellonella. To reveal the complex structure of biofilm, the implants were removed and processed for the MALDI analysis. Whole genome-based transcriptome of biofilm was performed to explore the changes in transcriptional landscapes. Results. The results are very promising to validate the use of G. mellonella as in vivo model to study the biofilm formation on implanted materials. The gentamicin treatment could rescue the larvae from the planktonic infection, but not from the biofilm infection on the implants. Further, the MALDI analysis could reveal the complex structure and components of S. aureus biofilm formed on the implant inside the larvae. Finally, the transcriptomic analysis revealed the gene expression changes that can be compared to normal biofilm expression profile. Conclusions. Further, comparison of these results with other in vivo models such as rat and mouse as well as acute and chronic clinical samples from patients with implant-associated bone infections could validate and relevant use of this model to study S. aureus biofilm infections

Aims. This study aims to define the epidemiology of trauma presenting to a single centre providing all orthopaedic trauma care for a population of ∼ 900,000 over the first 40 days of the COVID-19 pandemic compared to that presenting over the same period one year earlier. The secondary aim was to compare this with population mobility data obtained from Google. Methods. A cross-sectional study of consecutive adult (> 13 years) patients with musculoskeletal trauma referred as either in-patients or out-patients over a 40-day period beginning on 5 March 2020, the date of the first reported UK COVID-19 death, was performed. This time period encompassed social distancing measures. This group was compared to a group of patients referred over the same calendar period in 2019 and to publicly available mobility data from Google. Results. Orthopaedic trauma referrals reduced by 42% (1,056 compared to 1,820) during the study period, and by 58% (405 compared to 967) following national lockdown. Outpatient referrals reduced by 44%, and inpatient referrals by 36%, and the number of surgeries performed by 36%. The regional incidence of traumatic injury fell from 5.07 (95% confidence interval (CI) 4.79 to 5.35) to 2.94 (95% CI 2.52 to 3.32) per 100,000 population per day. Significant reductions were seen in injuries related to sports and alcohol consumption. No admissions occurred relating to major trauma (Injury Severity Score > 16) or violence against the person. Changes in population mobility and trauma volume from baseline correlated significantly (Pearson’s correlation 0.749, 95% CI 0.58 to 0.85, p < 0.001). However, admissions related to fragility fractures remained unchanged compared to the 2019 baseline. Conclusion. The profound changes in social behaviour and mobility during the early stages of the COVID-19 pandemic have directly correlated with a significant decrease in orthopaedic trauma referrals, but fragility fractures remained unaffected and provision for these patients should be maintained. Cite this article: Bone Joint Open 2020;1-6:182–189

Introduction:. During the Christmas period a number of patients are admitted to the Chris Hani Baragwanath Academic Hospital (CHBAH) Hand Unit with explosive injuries to their hands caused by firecrackers. South African legislation restricts the sale and use of fireworks to adults, with a limitation being placed on the size of explosive and type of commercial outlet. Despite this an inordinate amount of explosive hand injuries are admitted over the festive season. Aim:. To evaluate the epidemiological pattern of firecracker injuries to the hand during the Christmas festive period and assess contributing factors. Comparison to a previous study in 2008 will also be evaluated. Method:. Patients with firecracker injuries to the hand were interviewed. Demographic information, events surrounding the incident including alcohol use, and origin of the explosive were recorded. Injuries were classified into minor, moderate and severe based on the amount of soft tissue and bony damage. Treatment and complications was recorded. The data is also compared to previous data obtained in 2008. Results:. 26 patients were admitted. 2 patients were injured with explosives from a legal source. Alcohol use was implicated in 10 of the injuries. 17 amputations were performed at various levels, 9 fractures and 2 dislocations were stabilised with K-wires. Sepsis was more common in severe injuries. The majority of patients were injured from mis-use with several patients suffering injuries following removal of explosives from children or from other people throwing explosives at them or their family. These results are similar to those obtained in 2008. Conclusion:. A large number of patients are injured by firecrackers during the festive period. Injuries are severe. Lack of law enforcement, alcohol and misuse are contributing factors in these injuries. No significant change has occurred in the pattern of injury between 2008 and 2011

Radial head fractures are common and mainly require a functional conservative treatment. About 20% of patients will present an unsatisfactory final functional result. There is, however, little data allowing us to predict which patients are at risk of bad evolve. This makes it difficult to optimize our therapeutic strategies in these patients. The aim of this study is to determine the personal and environmental factors that influence the functional prognosis of patients with a radial head fracture. We realized over a 1-year period a prospective observational longitudinal cohort study including 125 consecutive patients referred for a fracture of the radial head in a tertiary trauma center. We originally collected the factors believed to be prognostic indicators: age, sex, socioeconomic status, factors related to trauma or fracture, alcohol, tobacco, detection of depression scale, and financial compensation. A clinical and radiological follow-up took place at 6 weeks, 3 months, 6 months, and 1 year. The main functional measurement tool is the Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand (DASH). 123 patients were included in the study. 114 patients required nonsurgical management. 102 patients completed the 1-year follow-up for the main outcome (89 for the DASH score). Two patients required an unplanned surgery and were excluded from analyses. At 1 year, the average MEPS was 96.5 (range, 65–100) and 81% of subjects had an excellent result (MEPS ≥90). The most constant factor to predict an unsatisfactory functional outcome (MEPS <90 or DASH >17) is the presence of depressive symptoms at the initial time of the study (P = 0.03 and P = 0.0009, respectively). This factor is present throughout the follow-up. Other observed factors include a higher socioeconomic status (P = 0.009), the presence of financial compensation (P = 0.027), and a high-velocity trauma (P = 0.04). The severity of the fracture, advanced age, female sex, and the nature of the treatment does not influence the result at 1 year. No factor has been associated with a reduction in range of motion. Most of the radial head fractures heal successfully. We identified for the first time, with a valid tool, the presence of depressive symptoms at the time of the fracture as a significant factor for an unsatisfactory functional result. Early detection is simple and fast and would allow patients at risk to adopt complementary strategies to optimize the result

Introduction. Total knee arthroplasty is very successful although the clinical assessment and rated outcome does not always match the patients reported satisfaction. One reason for patient dissatisfaction is less than desired range of motion. Poor postoperative motion inhibits many functional activities and may create a perception of dysfunction. Early in the postoperative period when patients are having trouble regaining motion (usually 6–8 weeks), manipulation under anesthesia can be used to advance range of motion by manually lysing adhesions. Comorbidities have been used as predictors for outcome in total knee arthroplasty in population health studies. Likewise, predicting which patients are most susceptible to early postoperative stiffness/manipulation would be valuable for patient education and to predict outcome. Methods. Prospectively collected data was retrieved from the hospital's MARCQI database (Michigan Arthroplasty Collaborative Quality Initiative) for the years 2014–2018. There were 3098 primary total knees performed during the study period and 139 manipulations (4.44%). The registry specifically abstracts patients’ preoperative comorbidities, operative data, and 90-day postoperative complications. Results. There were 2118 Cruciate Retaining/Cruciate Stabilized knees (105 MUA), 801 Posterior Stabilized (33), and 41 Total Stabilized/Hinge (1), 2160 knees were cemented (91) and 799 uncemented (48). No differences were found between the manipulation and non-manipulation groups for gender, race, alcohol consumption, bleeding disorders, history of DVT or PE, Diabetes, or use of pre-op narcotics or anti-coagulents. Patients undergoing manipulation were younger (67.2 vs. 63.8, p= 0.00001), had a lower BMI (32.6 vs. 30.9 p= 0.0007), and were more likely to be non or former (quit) smokers. There were no differences noted for the constraint of the component (cr/ps), or whether the implants were cemented or uncemented (35% vs. 27%, p= 0.064). Conclusions. Understanding the risk for postoperative stiffness and the potential for manipulation is helpful in the preoperative period for patient education and outcome prediction. Assessing comorbidities and patient characteristics may help avoid the need for manipulations postoperatively. This patient cohort may be biased since the manipulations were not based on predetermined criteria. The cohort represents patients whose range of motion was poor enough to cause the surgeon to perform the procedure. The findings do however highlight a patient pool that was surprisingly at risk: younger, thinner, nonsmokers regardless the implant design or use of cement

The purpose of this study was to identify the prevalence of common mental disorders in patients undergoing complex limb reconstruction. Patients undergoing limb reconstruction are vulnerable to mental health problem as they must adapt to significant and prolonged physical disability. Treatment emphasis has been on restoration and rehabilitation of physical health with little or no attention given to spectrum of psychological consequences. IMPARTS (Integrating Mental and Physical healthcare: Research, Training and Services) is a King's Health Partners initiative aiming to develop informatics to improve detection and management of common mental disorders in medical settings. IMPARTS screening in the King's College Hospital limb reconstruction clinic commenced in April 2012. Outpatients attending between April 2012 and November 2013 were screened prior to their appointment. Patients were screened for symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), alcohol dependence and drug use. In total, 298 individual patients were screened. The prevalence of depression was found to be 21.8%, with 6.4% experiencing suicidal thoughts. Probable anxiety disorder was identified in 20.7% of patients. Symptoms of PTSD were reported by 29.2%, with 9.0% reporting severe symptoms. Probable alcohol dependence was identified in 2.7% of patients, and 3.0% screened positive for drug misuse. The consequences of undergoing limb reconstruction stretch beyond the physical problem to mental well-being, rendering patients vulnerable to mental health problems and substance misuse. Early detection and management of such problems may have a significant effect on physical treatment outcome and rehabilitation to productive social life. There is urgent need to integrate mental health care as part of early management of severely injured patients

Aim. Periprosthetic joint infections (PJI) are increasing due to our elderly population with the need of a joint prosthesis. These infections are difficult to treat, because bacteria form biofilms within one day on the orthopedic implant surface. Notably, most of the current available antibiotics do not penetrate the biofilm or are not active against the sessile forms of bacteria. Therefore, prevention is key. In the current paradigm, bacteria from the skin surface or dermis - such as Staphylococcus aureus, coagulase-negative staphylococci, or Cutibacterium sp. – contaminate the periimplant tissue during surgery. Cutibacterium avidum, which has increasingly been reported in hip PJIs, colonizes the skin in the groin area in 32.3%. We were wondering if standard skin antisepsis before hip arthroplasty is effective to eliminate C. avidum colonization in the surgical field. Method. In a single-center, prospective study, we preoperatively screened all patients undergoing a hip arthroplasty through a direct anterior approach for different skin bacteria in the groin area. Only in patients colonized with C. avidum, we intraoperatively searched for persistent bacterial growth during and after triple skin antisepsis with povidone-iodine/alcohol. For that, we collected skin scrapings after first and third antisepsis and biopsies from the dermis at the surgical incision and evaluated bacterial growth and species. In addition, thin sections of the dermis biopsies were submitted to Fluorescence in situ Hybridization (FISH) using pan-bacteria probe EUB338. Results. From October 2018 until March 2019, 53 patients (47.2% female) were screened. Patients were mainly colonized with coagulase-negative staphylococci (41, 77.4%; 41), C. avidum (12, 22.6%), and Cutibacterium acnes (8, 15.1%). Intraoperative skin antisepsis of patients colonized with C. avidum was ineffective to eliminate any bacteria in 75% (5 out of 7) after the first and 28.6% (2 out of 7) after the third antisepsis. Focusing on C. avidum, antisepsis was ineffective in 43% (3 out of 7) and 14% (1 out of 7), respectively. Dermis biopsies were all culture negative, but FISH showed positive ribosome-rich bacteria in 50%. Conclusions. We show in our ongoing study that the commensal C. avidum resists the standard skin antisepsis and bacteria visually persist in the dermis as demonstrated by FISH technique. Standard skin antisepsis is of limited effectiveness, resulting in a risk for intraoperatively acquired PJIs. Thus, new and more effective techniques to improve skin antisepsis are urgently needed

Purpose. Penetrating injuries of the hand and forearm may cause significant morbidity for a patient. Our aim was to evaluate the accuracy of initial examination of forearm lacerations and pre-operative examination and compare both to the actual findings on surgical exploration. We wanted to identify any factors which may influence the accuracy of the initial examination. Existing literature indicates that there are differences between initial and subsequent examination in terms of picking up injuries. Methods. 65 consecutive patients with penetrating injuries to the hand/forearm were studied. The admitting casualty doctor/s completed an admission form indicating their findings on examination. Factors which may have hampered history taking and examination were noted on the form. The same form was filled in prior to surgery by one of the hand registrars after re-examining the patient prior to surgery. A separate surgical form was filled in by the surgeon indicating the actual findings at surgery. Results. Our results show that as many as 40% of injuries are missed on examination initially by casualty officers but only 10% are missed on re-examination post admission. Factors such as alcohol intoxication and distracting injuries seem to play a role in the casualty examination being difficult. Conclusion. Underlying injuries to structures in the forearm and hand are often missed on initial examination of lacerations involving the forearm and hand. Re-examination post admission of the patient is essential to avoid underestimating the extent and time of surgery required to treat the patient. Factors identified as possibly contributing to this are alcohol intoxication, distracting injuries and language problems in the casualty setting. NO DISCLOSURES

Aims

In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.

Aim. Determine the incidence of surgical site infections (SSI) after intramedullary nailing (IN) of femoral and tibial diaphyseal fractures and evaluate possible risk factors. Method. Prospective observational cohort study. SSI was defined according to CDC-NHSN criteria and surveillance period for the occurrence of infection was 12 months instead of the 90 days currently recommended. Incidence was calculated as the ratio between the number of patients with SSI and total number of patients. Analysis of potential risk factors included patients-related factors (age, gender, body mass index, active foci of infection, immunosuppressive conditions, ASA score, alcohol or illicit drug abuse, smoking, polytrauma, etiology of fracture, type of fracture if closed or open, classification of fracture according to Müller AO, Tcherne classification for closed fractures, Gustilo-Anderson classification and duration of bone exposure for open fractures, previous stay in other healthcare services, use of external fixator, previous surgical manipulation at same topography of fracture, use of blood products); environmental and surgical-related factors (surgical wound classification, duration of surgery, hair removal, intraoperative contamination, antimicrobial use, presence of drains, hypothermia or hypoxia in the perioperative period, type of IN used, reaming, need for muscle or skin flap repair, use of negative pressure therapy) and microbiota-related factors (presence of preoperative colonization by Staphylococcus aureus or Acinetobacter baumannii). Results. 221 patients were included and completed the 12-month follow-up period. Incidence of SSI was 11.8% after 12-month follow-up, but would be 8.59% if used the 90-day vigilance period currently recommended. In the initial analysis by unadjusted logistic regression, following factors were associated SSI: Müller AO classification of the fracture morphology groups 2 or 3, previous use of external fixator, presence of drains, use of negative pressure therapy and need for muscle or skin flap repair. Preoperative colonization by S. aureus or A. baumannii was not associated with occurrence of infection. In the multiple logistic regression-adjusted analysis, only previous use of external fixator and need for muscle or skin flap repair remained associated with SSI. Conclusions. Incidence of SSI associated with IN for femoral and tibial diaphyseal fractures was 11.8%, but currently recommended vigilance period would be less sensitive for SSI detection after fracture fixation. Previous use of external fixators and need for muscle or skin flap repair were factors associated with occurrence of IN related infection