It is widely accepted by orthopaedic surgeons that antibiotics should be withheld until aspiration has been performed to increase the odds of identifying an organism in septic arthritis. Patients often present to other specialties that may not be as familiar with these principles. Twenty-five of forty-nine patients with septic arthritis of the native or prosthetic knee had received antibiotics prior to review by the orthopaedic service. Patients were significantly less likely to demonstrate an organism on initial microscopy (entire cohort p=0.001, native knees p=0.006, prosthetic knees p=0.033) or on subsequent culture (entire cohort p=0.001, native knees p=0.017, prosthetic knees p=0.012) of their aspirate if they had received antibiotics. The sensitivity of microscopy dropped from 0.58 to 0.12 when patients had received antibiotics (native knees 0.46 to 0, prosthetic knees 0.72 to 0.27). The sensitivity of the culture dropped from 0.79 to 0.28 when the patient had received antibiotics (native knees 0.69 to 0.21, prosthetic knees 0.91 to 0.36). Patients treated with empirical antibiotics are less likely to demonstrate an organism on microscopy and culture of their initial aspirate. There is a significantly high false negative rate associated with knee aspiration, particularly with prior administration of antibiotics

Aims. Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes. Methods. Patient identifiers for a consecutive cohort treated between 1 January 2003 and 31 December 2011 were linked to radiographs, surgical notes, clinic letters, and mortality data from a national dataset. This allowed charting of their postoperative course, complications, readmissions, returns to theatre, revisions, and deaths. We also identified all postoperative attendances at the Emergency and Outpatient Departments, and recorded any subsequent skeletal injuries. Results. In total, 1,312 Thompson’s hemiarthroplasties were analyzed (mean age at surgery 82.8 years); 125 complications were recorded, necessitating 82 returns to theatre. These included 14 patients undergoing aspiration or manipulation under anaesthesia, 68 reoperations (5.2%) for debridement and implant retention (n = 12), haematoma evacuation (n = 2), open reduction for dislocation (n = 1), fixation of periprosthetic fracture (n = 5), and 48 revised stems (3.7%), for infection (n = 13), dislocation (n = 12), aseptic loosening (n = 9), persistent pain (n = 6), periprosthetic fracture (n = 4), acetabular erosion (n = 3), and metastatic bone disease (n = 1). Their status at ten years is summarized as follows: 1,180 (89.9%) dead without revision, 34 (2.6%) dead having had revision, 84 (6.6%) alive with the stem unrevised, and 14 (1.1%) alive having had revision. Cumulative implant survivorship was 90.3% at ten years; patient survivorship was 7.4%. Conclusion. The Thompson’s stem demonstrates very low rates of complications requiring reoperation and revision, up to ten years after the index procedure. Fewer than one in ten patients live for ten years after fracture. This study supports the use of a cemented Thompson’s implant as a cost-effective option for frail hip fracture patients. Cite this article: Bone Jt Open 2022;3(9):710–715

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.

Background. Elderly patients with hip fractures are often malnourished and in a catabolic state upon admission to hospital. Waiting time for surgery is commonly unpredictable, and often more than 24 hours. Due to an assumed stress-induced delayed gastric emptying time with a possible associated risk of aspiration, fasting guidelines are the same as for other trauma patients. This leads to prolonged fasting time in these patients who are often metabolically compromised, with negative effects on post-operative recovery and prolonged hospital stay. The aim of this study was to investigate if 400 ml of a carbohydrate-rich beverage could be given to patients with a hip fracture 2–3 hours before surgery without carrying a risk of pulmonary aspiration. Methods. The gastric emptying rate of 400 ml 12.6 % carbohydrate rich drink was investigated in ten elderly women with a hip fracture awaiting surgery. The emptying rate was assessed by an indirect method, the paracetamol absorption technique. Results were compared with two control groups of healthy persons. Results. In the hip fracture patients, the mean gastric half-emptying time was 57 ± 5 minutes and displayed a normal emptying profile. The corresponding result in the control group was 58 ± 5 minutes. One hip fracture patient was excluded due to vomiting before finishing intake, i.e. before the anaesthesia procedure. Conclusions. In this pilot study, gastric emptying in nine elderly women with a hip fracture was not delayed. We suggest that it should be possible to give a carbohydrate-rich beverage 2–3 hours before surgery to most hip fracture patients. Patient selection is an issue

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The aim of this study was to evaluate the radiological outcome of patients with large bone defects in the femur and tibia who were treated according to the guidelines of the diamond concept in our department (Centre for Orthopedics, Trauma Surgery, and Paraplegiology).

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The aim of this study was to explore current use of the Global Fragility Fracture Network (FFN) Minimum Common Dataset (MCD) within established national hip fracture registries, and to propose a revised MCD to enable international benchmarking for hip fracture care.

Freezing cold injuries (Frostnip and Frostbite) (FCI) have become uncommon in UK military personnel relative to non-freezing cold injuries (NFCI, ‘trench foot’). However if unidentified or inappropriately treated they may lead to avoidable medical downgrading or discharge. JSP 539 recommends delay or avoidance of surgical debridement where possible. An anonymised retrospective audit was performed of FMED7 medical reports of cases seen in the Institute of Naval Medicine Cold Injury Clinic (CIC) between July 2002 and January 2014 inclusive. In all 149 FCI cases were identified, 71 affected hands only of which 34 were bilateral, and 58 affected feet only, 34 of those being bilateral. A total of 17 patients had injured both hands and feet, with 10 bilateral. Royal Marines accounted for half of these cases, with the Army making up a further third, and the Royal Navy and RAF making up the remainder. Most FCI were found to have occurred in Norway, with Marine ranks being most commonly affected. Ten cases underwent surgery: aspiration of blisters, debridement of tissue, or amputation. Seven of these procedures took place prematurely, which appeared detrimental to recovery. No patients required fasciotomy. FCI are uncommon, but in arctic conditions their risk rises dramatically. The best treatment is conservative where possible following JSP 539 guidelines and consultation with CIC should occur at the earliest possibility. The Potential benefits of surgery must be weighed against problems of injured tissue healing and expert opinion should be obtained

Introduction. Iliac crest bone marrow aspirate (ICBMA) is frequently cited as the ‘gold-standard’ source of MSCs. Mesenchymal stem cells have been shown to reside within the intramedullary (IM) cavities of long-bones and a comparative assessment with ICBMA has not yet been performed. Methods. Aspiration of the IM cavities of 6 patients' femurs with matched ICBMA was performed. The long-bone-fatty-bone-marrow (LBFBM) aspirated was filtered (70μm) and the solid fraction digested for 60min (37°C) with collagenase. Enumeration was performed via the colony-forming-unit-fibroblast (CFU-F) assay and using the CD45low CD271+ phenotype via flow-cytometry. Passaged (P2) cells were differentiated towards osteogenic, adipogenic and chondrogenic lineages with their phenotype assessed using flow-cytometry CD33 CD34 CD45 CD73 CD90 CD105. Results. MSCs were isolated from all fractions. Using the CFU-F assay median number of colonies: ICBMA=8 (2–21), LBFBM-liquid=14 (0–53), LBFBM-solid=116 (23–171) per 200μl of sample; MSC frequency, as percentage of total cells, using flow-cytometry, provided similar results. Mesenchymal stem cells isolated from the LBFBM phases appeared to not be inferior to ICBMA in terms of osteogenic, chondrogenic or adipogenic differentiation. Passaged cells from all fractions had a phenotype consistent with other reported sources. Discussion. Intra-medullary cavities of long-bones are frequently accessed by the orthopaedic/trauma surgeon. This represents a ‘low-tech’ method of harvesting large numbers of MSCs with a favourable differentiation profile for autologous/allogenous uses

In some centres, serial bedside aspirations, in association with intravenous antibiotics, are still an accepted treatment for septic arthritis (Mathews, Postgraduate Medical Journal, 2008). However, there is a risk that bacterial products remain in the joint, even when the bacteria have been destroyed. We have conducted a study to ascertain whether bacterial products alone have an effect on in situ chondrocyte viability. A hip aspirate (25μl), containing Staphylococcus aureus, from a patient with septic arthritis was added to 5ml culture medium and incubated (37°C) for 48hrs. The solution was then centrifuged (3400g for 10mins) and the supernatant removed. Cartilage explants were harvested from a bovine metacarpophalangeal joint, placed into the bacterial supernatant and incubated at 37°C. Explants were removed at hourly intervals over a 6-hour period and stained with the fluorescent probes chloromethylfluorescein di-acetate (10μM) and propidium iodide (10μM) to label living chondrocytes green and dead cells red respectively. Following imaging of cartilage by confocal microscopy, the percentage cell death at each time point was obtained using Volocity 4 software. Chondrocyte death increased markedly with time: 0.04% at 2hrs, 28% at 4hrs and 39% at 6hrs. This study shows that bacterial products rapidly penetrate the cartilage matrix and have a damaging effect on in situ chondrocyte viability. Further work will clarify the contributions made by the various toxic components in the culture supernatant, but these data support the need to remove the bacteria and their products aggressively as part of the treatment of septic arthritis

Aims

Patients who sustain neck of femur fractures are at high risk of malnutrition. Our intention was to assess to what extent malnutrition was associated with worse patient outcomes.

Aims. Currently, the most common approach for the management of a chronic PJI is a Two-Stage Replacement; because of success rates exceeding 90% when using an antibiotic impregnated cement spacer. Reliable information regarding the etiologic microorganism and its sensitivities is essential to select the antimicrobial therapy that should be used locally in the bone cement spacer during the first stage surgery as well as to select the appropriate microbiological systemic agent. Diagnostic algorithms focus to the importance of joint aspiration cultures although in the modern literature, preoperative joint aspiration has a broad range of values of sensitivity and the proportion of “dry-aspirations” is not well assessed. This low sensitivity of aspiration fluid samples in chronic-PJI is partly attributable to the fact that the majority of the microorganisms in these infections grow in biofilms attached to the implant. We have developed this biopsy technique in an effort to improve the identification rates of the causative organism. Materials and methods. A sample is harvested through a 4 mm bone trephine and the target is the bone-prosthesis gap. We have compared the results of preoperative PIB with the results of cultures from intra-operative tissue collected during the first stage surgery. In both cases a prolonged culture protocol (10 days) in enrichment media was used. On the basis of this relation, sensitivity, specificity, positive and negative predictive values and accuracy were calculated. Results. Twenty-four PIB were done on the 24 patients (10 hips and 14 knees) who subsequently underwent two-stage revision surgery because of high suspicion of PJI between January 2007 and December 2009. A retrospective analysis was performed in these 24 patients (13 women and 11 men) in the mean age of 70 years (from 63 to 88 years old). Nineteen of the cases were primary and 5 were revision arthroplasty. Nineteen patients (79%) were positive for infection from operative tissue cultures. The sensitivity was 0.79 (95% CI, 0.54–0.93); the specificity was 0.80 (95% CI, 0,30–0.99), the positive predictive value was 0.94 (95% CI, 0.67–0.99), the negative predictive value was 0.50 (95% CI, 17.5–82.5) and the accuracy was 0.79. Conclusion. PIB is a useful test to, preoperatively, isolate the infecting bacteria. The values of sensitivity, specificity and accuracy are on the average of the currently published with joint aspiration or biopsy samples cultures. Although comparative study is necessary we believe that the PIB could be useful in cases with high suspicion of PJI and negative joint aspiration cultures and in cases where no fluid is aspired from the joint, in order to preoperatively isolate the infecting bacteria

Introduction. The combined incubation of a composite scaffold with bone marrow stromal cells in a perfusion bioreactor could make up a novel hybrid graft material with optimal properties for early fixation of implant to bone. The aim of this study was to create a bioreactor activated graft (BAG) material, which could induce early implant fixation similar to that of allograft. Two porous scaffold materials incubated with cells in a perfusion bioreactor were tested in this study. Methods and Materials. Two groups of 8 skeletally mature female sheep were anaesthetized before aspiration of bone marrow from the iliac crest. For both groups, mononuclear cells were isolated, and injected into a perfusion bioreactor (Millenium Biologix AG, Switzerland). Scaffold granules Ø∼900–1500 μm, ∼88% porosity) in group 1, consisted of hydroxyapatite (HA, 70%) with -tricalcium-phosphate (−TCP, 30%) (Danish Technological Institute, Denmark). The granules were coated with poly-lactic acid (PLA) 12%, in order to increase the mechanical strength of the material (Phusis, France). Scaffold granules Ø∼900–1400 μm, 80% porosity) in group 2 consisted of pure HA/-TCP (Fin Ceramica, Italy). For both groups, cells were incubated in the bioreactor for 2 weeks. Fresh culture medium supplemented with dexamethasone and ascorbic-acid was added every third or fourth day. Porous titanium alloy implants with diameter=length=10mm (Biomet, USA) were inserted bilaterally in each of the distal femurs of the sheep; thus 4 implants in each sheep. The concentric gap (2 mm) surrounding the implant was filled with 1) BAG (autogenous), 2) granules, 3) granules+bone marrow aspirate (BMA, autologous) or 4) allograft. The sheep were euthanized after 6 weeks. Distal femurs were removed and implant-bone samples were divided in two parts. The superficial part was used for mechanical testing and micro-CT scanning, and the profound part for histomorphometry. Push-out tests were performed on an 858 Bionix MTS hydraulic materials testing machine. Shear mechanical properties between implant and newly generated bone were calculated to assess implant fixation. Results were assessed by One-way ANOVA. P-values less than 0.05 were considered significant. Results. One sheep in group 1 had to be euthanized after 4 weeks (excluded). One implant in each group was loosened and could not undergo push-out test (excluded). Group 1: No significant differences regarding failure energy (kJ/m2, p=0.44) or ultimate shear strength (MPa, p=0.17) could be seen. Shear stiffness (MPa) was significantly higher for the allograft group (p=0.04). Group 2: No significant differences regarding failure energy (p=0.11) or shear stiffness (p=0.52) could be seen. Ultimate shear strength was significantly higher for allograft (p=0.04). Results from μ-CT scanning and histomorphometry are pending. Discussion and Conclusion. The present study shows a possible effect of bioreactor activated bone substitute on early implant fixation. We are currently working on bone microarchitecture surrounding implant and histomorphometry. These results will aid in determining if BAG could make up a promising alternative for allograft as bone graft material

Aims

Acetabular fractures in older adults lead to a high risk of mortality and morbidity. However, only limited data have been published documenting functional outcomes in such patients. The aims of this study were to describe outcomes in patients aged 60 years and older with operatively managed acetabular fractures, and to establish predictors of conversion to total hip arthroplasty (THA).

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The aim of this study was to describe implant and patient-reported outcome in patients with a unilateral transfemoral amputation (TFA) treated with a bone-anchored, transcutaneous prosthesis.

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Hip hemiarthroplasty is a standard treatment for intracapsular proximal femoral fractures in the frail elderly. In this study we have explored the implications of early return to theatre, within 30 days, on patient outcome following hip hemiarthroplasty.

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To evaluate the outcomes of cemented total hip arthroplasty (THA) following a fracture of the acetabulum, with evaluation of risk factors and comparison with a patient group with no history of fracture.

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A fracture of the hip is the most common serious orthopaedic injury, and surgical site infection (SSI) is one of the most significant complications, resulting in increased mortality, prolonged hospital stay and often the need for further surgery. Our aim was to determine whether high dose dual antibiotic impregnated bone cement decreases the rate of infection.

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred.

This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence.

Cite this article: Bone Joint J 2013;95-B:151–9.

We report the outcome of 84 nonunions involving long bones which were treated with rhBMP-7, in 84 patients (60 men: 24 women) with a mean age 46 years (18 to 81) between 2003 and 2011. The patients had undergone a mean of three previous operations (one to 11) for nonunion which had been present for a mean of 17 months (4 months to 20 years). The nonunions involved the lower limb in 71 patients and the remainder involved the upper limb. A total of 30 nonunions were septic. Treatment was considered successful when the nonunion healed without additional procedures. The relationship between successful union and the time to union was investigated and various factors including age and gender, the nature of the nonunion (location, size, type, chronicity, previous procedures, infection, the condition of the soft tissues) and type of index procedure (revision of fixation, type of graft, amount of rhBMP-7) were analysed. The improvement of the patients’ quality of life was estimated using the Short Form (SF) 12 score.

A total of 68 nonunions (80.9%) healed with no need for further procedures at a mean of 5.4 months (3 to 10) post-operatively. Multivariate logistic regression analysis of the factors affecting union suggested that only infection significantly affected the rate of union (p = 0.004).Time to union was only affected by the number of previous failed procedures (p = 0.006). An improvement of 79% and 32.2% in SF-12 physical and mental score, respectively, was noted within the first post-operative year.

Rh-BMP-7 combined with bone grafts, enabled healing of the nonunion and improved quality of life in about 80% of patients. Aseptic nonunions were much more likely to unite than septic ones. The number of previous failed operations significantly delayed the time to union.

Cite this article: Bone Joint J 2015;97-B:997–1003.

We hypothesised that cells obtained via a Reamer–Irrigator–Aspirator (RIA) system retain substantial osteogenic potential and are at least equivalent to graft harvested from the iliac crest. Graft was harvested using the RIA in 25 patients (mean age 37.6 years (18 to 68)) and from the iliac crest in 21 patients (mean age 44.6 years (24 to 78)), after which ≥ 1 g of bony particulate graft material was processed from each. Initial cell viability was assessed using Trypan blue exclusion, and initial fluorescence-activated cell sorting (FACS) analysis for cell lineage was performed. After culturing the cells, repeat FACS analysis for cell lineage was performed and enzyme-linked immunosorbent assay (ELISA) for osteocalcin, and Alizarin red staining to determine osteogenic potential. Cells obtained via RIA or from the iliac crest were viable and matured into mesenchymal stem cells, as shown by staining for the specific mesenchymal antigens CD90 and CD105. For samples from both RIA and the iliac crest there was a statistically significant increase in bone production (both p < 0.001), as demonstrated by osteocalcin production after induction.

Medullary autograft cells harvested using RIA are viable and osteogenic. Cell viability and osteogenic potential were similar between bone grafts obtained from both the RIA system and the iliac crest.

Cite this article: Bone Joint J 2013;95-B:1269–74.