Aims. The use of local antibiotic carriers in the treatment of chronic osteomyelitis is an important adjunct in dead space management. We present the outcomes of two different biodegradable antibiotic carriers used in the management of chronic osteomyelitis. Method. A single centre series between 2006–2017. The initial cohort (2006–2010) of 137 cases, Group A, had Osteoset® T (calcium sulphate carrier containing tobramycin). The second cohort (2013–1017) of 160 cases, group B, had CeramentTM G (biphasic calcium sulphate, nano-crystalline hydroxyapatite carrier containing gentamicin). Only Cierny-Mader Grade III and IV cases were included with a minimum six-month radiographic follow-up. Infection recurrence rate, wound leakage, subsequent fracture involving the treated segment, and radiographic void filling were assessed at a minimum of 6 months following surgery. Results. Mean follow-up in Group A was 2.5 yrs (0.5–10.5) and in Group B it was 1.4 yrs (0.6–4.7). Group A had a significantly higher rate of infection recurrence (16/137 (11.7%) Vs. 7/160 (4.4%) p=0.0278), wound leakage (26/137 (19.0%) Vs. 16/160 (10.0%) p=0.0304) and subsequent fracture rate (11/137 (8.0%) Vs. 3/160 (1.9%) p=0.0143) compared to Group B. Average time to recurrence was 1.07 years (0.1–2.6) in Group A and 1.02 (0.2–2.1) in Group B. The mean bone void healing in Group B was significantly better than Group A (73.2% Vs. 40.0%, p <0.00001). Conclusions. Cerament™ G has significantly better bone healing compared to a calcium sulphate carrier and was associated with a lower rate of recurrent infection, wound leakage and subsequent fracture risk

We examined the incidence of infection with methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to the Leicester Royal Infirmary Trauma Unit between January 2004 and June 2006. The influence of MRSA status at the time of their admission was examined, together with age, gender and diagnosis, using multi-variant analysis. Of 2473 patients, 79 (3.2%) were MRSA carriers at the time of admission and 2394 (96.8%) were MRSA-negative. Those carrying MRSA at the time of admission were more likely to develop surgical site infection with MRSA (7 of 79 patients, 8.8%) than non-MRSA carriers (54 of 2394 patients, 2.2%, p < 0.001). Further analysis showed that hip fracture and increasing age were also risk factors with a linear increase in relative risk of 1.8% per year. MRSA carriage at admission, age and the pathology are all associated with an increased rate of developing MRSA wound infection. Identification of such risk factors at admission helps to target health-care resources, such the use of glycopeptide antibiotics at induction and the ‘building-in’ of increased vigilance for wound infection pre-operatively

Introduction

Calcium sulphate is a resorbable void filler that can be used for local antibiotic delivery.

Results from clinical studies on chronic osteomyelitis thus treated with local vancomycin have already been published. Despite significant exposure to this drug, there are no pharmacokinetic studies published so far. Based on observations in our patients, a model predicting vancomycin serum and wound fluid levels and toxicity potential is presented.

Between October 2001 and February 2002, 324 healthcare workers were screened for methicillin-resistant Staphylococcus aureus (MRSA) by nose and throat swabs. A positive finding led to activation of a standardised control programme for the affected person who was immediately excluded from work. Family members of those who were MRSA-positive were offered screening free of charge. An eradication programme was carried out in the permanent carriers. MRSA was found in 17 (5.3%) healthcare workers, 11 of whom proved to be permanent carriers, and six temporarily colonised. Three children of a positive healthcare worker showed nasopharyngeal MRSA, the acquisition of which occurred within the hospital. The standardised eradication programme for carriers was successful in most cases but failed in two individuals, whereupon systemic antibiotics were used successfully. The decolonised carriers, observed for more than one year, remained MRSA negative. Isolation precautions in hospitals do not always prevent hospital staff and their families from acquiring MRSA. The identification of affected employees is difficult because in most cases only asymptomatic colonisation occurs. Screening and eradication can be complicated and costly, and for the affected employees the occupational consequences can be far-reaching as they have no guaranteed legal protection

Posterolateral spinal fusion (PSLSF) in rabbits is a challenging model for bone substitutes because the transverse processes are extremely thin and the space to be filled with bone is greater than critical and meiopragic in terms of vascularity. Several investigators have shown beneficial effects of PRP in bone and soft-tissue healing processes. However, controversial results have been reported in clinical setting analysing the effectiveness of PRP. Aim of the present study was to test the effectiveness of PRP in experimental model of PLSF in rabbits. MATERIAL AND METHODS. 20 White females New Zeland Rabbits were used. Seven rabbits (Group 1) had PRP plus carrier on the right side (Group 1A) and plus carrier and fresh bone marrow on the left side (Group 1B). Seven rabbits (Group 2) had carrier alone on the right side (Group 2A) and carrier plus fresh bone marrow on the left side (Group 2B). Six rabbits (Group 3) had sham operation on both right and left sides. Animals were sacrificed 6 months after surgery and the lumbar spine submitted to radiolographic and histologic analysis. Vascular density (VD) was also assessed in the different zone of the grafted material. RESULTS. Radiographs showed a complete fusion in 83% of group 1A and in 83% of group 1B, and in 86% of group 2A and 2B. Pseudarthrosis or non union, was observed in 1 specimen of group 1B and 2A and in all specimens of group 3 (sham). In contrast to radiographic results, no specimen showed a complete bony bridge between the transverse processes on histologic analysis. VD was significantly greater in the periapophyseal compared to the interapophyseal region of the graft material. However, no significant difference was found in the VD between groups. CONCLUSIONS. In this study PRP alone, or augmented with fresh bone marrow, failed to induce a histologically proved bony fusion in the PLSF model. Factors which may influence the effectiveness of PRP should be further addressed before applying PRP in the clinical setting

Background. Previous data from our institution show that more than half of all prosthetic joint infections are due to S. aureus. A significant proportion of these bacteria may have an endogenous source. Detecting and treating asymptomatic S. aureus nasal carriers preoperatively has been shown to reduce the risk of infection. Material and Methods. This is an ongoing prospective study that started in March/2009 and involves primary total knee or hip arthroplasties candidates. So far preoperative nasal swab cultures were performed in 211(61%) out of 347 patients operated until April/2010. Carriers are identified and randomly chosen for preoperative treatment consisting of nasal mupirocin twice a day and daily cloro-hexidine baths in the 5 days that precede surgery. Antibiotic prophylaxis is cefazolin 24hours adding a single vancomycin dose in MRSA carriers. Results. Around 30% (64/211) of patients presented Saureus nasal carriage and 6 of them (9.4%) were methicilin-resistant. Infection rate was lower in the non-carriers: 1.36% (2/147). The group of 33 untreated carriers so far has the higher prevalence of infection (6.06%; Odds ratio=4.677; p=0.098). In the 31 treated carriers there was only one infection to date (3.23%; Odds ratio=2.371; p=0.463). The 136 patients control group in which no preoperative nasal culture was made registered 4 infections (2.94%; Odds ratio=2.197; p=0.356). Five out of the nine infections involved S. aureus. We further isolated 3 S. epidermidis, 1 enterococcus and 2 gram-negatives. Discussion. It seems that two S. aureus infections were due to endogenous contamination as the infecting bacteria possesses the exact same phenotype as the colonizing preoperative one (one untreated and one treated carrier). In other two S. aureus cases the seeding appears exogenous (a preoperative negative culture and a infecting bacteria different than the preoperative screening). One infection was registered in a non-studied patient. Accordingly, exogenous contamination seems responsible for at least 6 out of 9 infections. Conclusion. These preliminary results suggest that S. aureus colonization may be an endogenous risk factor for prosthetic joint infection that can be influenced. However exogenous contamination is still a major risk factor in our institution

Nasal carriers of methicillin sensitive Staphylococcus aureus (MSSA) have an increased risk for health-care associated infections. There is currently no national screening policy for the detection of MSSA in the UK. This study aimed to: evaluate the diagnostic performance of molecular and culture techniques in MSSA screening, determine the cause of any discrepancy between the diagnostic techniques, and model the potential effect of different diagnostic techniques on MSSA detection in orthopaedic patients. Paired nasal swabs for PCR assay and culture of S. aureus were collected from a study population of 273 orthopaedic outpatients due to undergo joint replacement surgery. The prevalence of MSSA nasal colonisation was found to be between 22.4–35.6%. The current standard direct culturing methods for detecting S. aureus significantly underestimated the prevalence (p=0.005), failing to identify its presence in ∼1/3 of patients undergoing joint replacement surgery. Modelling these results to national surveillance data, it was estimated that 800–1200 MSSA surgical site infections could be prevented annually in the UK by using alternative diagnostic methods to direct culture in pre-operative MSSA screening and eradication programmes

Aim. Previous studies of primary internal fixation of infected non-unions have reported high failure rates. Local antibiotic carriers and coatings have been advocated to reduce infection around implants and allow bone healing. We evaluated the effect of a calcium sulphate/hydroxyapatite antibiotic-loaded composite on bone healing and the eradication of infection in combination with internal fixation. Method. Twelve cases of established infected non-union, with segmental bone loss of up to 1cm were treated using a multidisciplinary protocol. This included; excision, deep sampling, stabilisation, local and systemic antibiotics, and soft-tissue closure. We treated 5 femurs, 4 humeri, 1 tibia and 2 periarticular non-unions at the ankle. Mean age was 59.8 years (34–75) and 9 patients had systemic co-morbidities (C-M Type B hosts). 9 patients had single stage surgery, with 5 IM Nails and 4 plates. Three patients had planned second stage internal fixation after external fixation to correct deformity. Staph. aureus was the commonest pathogen (5 cases) with polymicrobial infection in 3 cases. Results. All 12 patients were infection-free at a mean follow-up of 23 months (range 13–34 months). Union was achieved in 11/12 (92%) with the primary surgery alone. The single failure was the tibial case, who remains with an infection-free, stiff non-union. Conclusion. This protocol offered good results, mainly with a single stage treatment. Primary internal fixation was possible in 9 cases, without recurrent infection. The combination of excision of infected dead bone and a high level of local antibiotics above the Minimum Inhibitory Concentration and Minimum Biofilm Eradication Concentration levels for common bacteria, allowed a high success rate in these difficult cases

Aim. Simultaneous application of Ilizarov frames and free muscle flaps to treat osteomyelitis or infected non-unions is currently not standard practice in the UK, in part related to logistical issues, surgical duration and challenging access for microvascular anastomosis. We present the outcomes for 56 such patients. Methods. Retrospective single centre consecutive series between 2005–2017. We recorded comorbidities, Cierny-Mader and Weber-Cech classification, the Ilizarov method used, flap and anastomosis used, follow-up duration, time to union and complications. Results. 56 patients (55 tibiae and 1 forearm) were included (mean age 48 years). Thirty-four cases had osteomyelitis (20/34 Cierny-Mader Stage IV) and 22 had an infected non-union (14/22 Weber-Cech Type E or F). Forty-six patients had a segmental defect after resection. Monofocal compression was used in 14, monofocal distraction in 15, bifocal compression/distraction in 8, bone transport in 9 and a protective frame in 10. 8/56 had an ankle fusion, 7/56 had an angular deformity corrected at the same time and 32 also had local antibiotic carrier inserted. Forty-six gracilis, 9 latissimus dorsi and 1 rectus abdominus flaps were used. Six cases required urgent flap re-exploration (5 anastomotic revisions and 1 haematoma washout) with 4/6 successfully salvaged. Two cases suffered total flap failure (3.6%). Both had successful revision free muscle flaps with the frame in situ at 10 and 16 days respectively. There were no partial flap failures and no failures in bone transport frames. Mean follow-up was 22 months (4–89). Excluding three cases that still have a frame on, 42/43 (97.7%) achieved bony union. Recurrence of infection occurred in 8.9%. All were infection free at final follow-up after further surgery. Conclusions. With the right expertise, simultaneous Ilizarov frame and free muscle flap is safe and effective in treating complex limb infection, and is not associated with an increased flap failure rate. Level of evidence. III

Aims

Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England.

Aims

COVID-19 necessitated abrupt changes in trauma service delivery. We compare the demographics and outcomes of patients treated during lockdown to a matched period from 2019. Findings have important implications for service development.

Aims

The primary aim was to assess the independent influence of coronavirus disease (COVID-19) on 30-day mortality for patients with a hip fracture. The secondary aims were to determine whether: 1) there were clinical predictors of COVID-19 status; and 2) whether social lockdown influenced the incidence and epidemiology of hip fractures.

Objectives

Deep bone and joint infections (DBJI) are directly intertwined with health, demographic change towards an elderly population, and wellbeing.

The elderly human population is more prone to acquire infections, and the consequences such as pain, reduced quality of life, morbidity, absence from work and premature retirement due to disability place significant burdens on already strained healthcare systems and societal budgets.

DBJIs are less responsive to systemic antibiotics because of poor vascular perfusion in necrotic bone, large bone defects and persistent biofilm-based infection. Emerging bacterial resistance poses a major threat and new innovative treatment modalities are urgently needed to curb its current trajectory.

Objectives

The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery.

Aims

This study aimed to investigate the role of quantitative histological analysis in the diagnosis of fracture-related infection (FRI).

Systemic antibiotics reduce infection in open fractures. Local delivery of antibiotics can provide higher doses to wounds without toxic systemic effects. This study investigated the effect on infection of combining systemic with local antibiotics via polymethylmethacrylate (PMMA) beads or gel delivery.

An established Staphylococcus aureus contaminated fracture model in rats was used. Wounds were debrided and irrigated six hours after contamination and animals assigned to one of three groups, all of which received systemic antibiotics. One group had local delivery via antibiotic gel, another PMMA beads and the control group received no local antibiotics. After two weeks, bacterial levels were quantified.

Combined local and systemic antibiotics were superior to systemic antibiotics alone at reducing the quantity of bacteria recoverable from each group (p = 0.002 for gel; p = 0.032 for beads). There was no difference in the bacterial counts between bead and gel delivery (p = 0.62).

These results suggest that local antibiotics augment the antimicrobial effect of systemic antibiotics. Although no significant difference was found between vehicles, gel delivery offers technical advantages with its biodegradable nature, ability to conform to wound shape and to deliver increased doses. Further study is required to see if the gel delivery system has a clinical role.

Cite this article: Bone Joint J 2015;97-B:1423–7.

We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.

Cite this article: Bone Joint J 2013;95-B:583–97.

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders’ classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale.

There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler’s angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders’ classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler’s angle.