Aim. Although non-unions being one of the most common complication after long-bone fracture fixation, the definition of this entity remains controversial and varies widely among authors. A clear definition is crucial, not only for the evaluation of published research data but also for the establishment of uniform treatment concepts. The aim of this systematic review was to identify the definitions and different criteria used in the scientific literature to describe non-unions after long bone fractures. Method. A comprehensive literature search was performed in PubMed, Cochrane Library, Web of Science, and Embase. according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Prospective therapeutic and diagnostic clinical studies in which adult long-bone fracture non-unions were investigated as main subject were included in this analysis. Results. One hundred fifty-two studies investigating 6432 long-bone non-unions met inclusion criteria for this analysis. In total 49% (75/152) of included studies did not define non-union at all, even though non-union was their main study subject. A definition of non-union on either clinical, radiologic or time criteria could be found in 51% (77/152) of the included studies. Non-union was defined based on time criteria in 83% (64/77), on radiographic criteria in 65% (50/77), and on clinical criteria in 43% (33/77). A combination of clinical, radiologic and time criteria for definition was only found in 35% (27/77) of all the included studies that defined non-union. The time point when authors defined an unhealed fracture as a nonunion showed a considerable heterogeneity, ranging from four to 24 months. Conclusions. In the current orthopaedic trauma literature, we found a lack of consensus with regard to the definition of long bones non-unions. Therefore, a standardized definition of non-union remains unclear. Without valid and reliable definition criteria of non-unions, the establishment of standardized diagnostic and treatment algorithms as well as the comparison of studies remain difficult. The lack of a clear definition emphasizes the need for consensus-based definition of fracture non-unions based on clinical, radiographic and time criteria

Aim. Surgical treatment of ankle fractures comes with a substantial risk of complications, including infection. An unambiguously definition of fracture-related infections (FRI) has been missing. Recently, FRI has been defined by a consensus group with a diagnostic algorithm containing suggestive and confirmatory criteria. The aim of the current study was to report the prevalence of FRI in patients operated for ankle fractures and to assess the applicability of the diagnostic algorithm from the consensus group. Method. Records of all patients with surgically treated ankle fractures from 2015 to 2019 were retrospectively reviewed for signs of postoperative infections. Patients with suspected infection were stratified according to confirmatory or suggestive criteria of FRI. Rate of FRI among patients with confirmatory and suggestive criteria were calculated. Results. Suspected infection was found in 104 (10%) out of 1004 patients. Among those patients, confirmatory criteria were met in 76/104 (73%) patients and suggestive criteria were met in 28/104 (27%) at first evaluation. Patients with clinical confirmatory criteria (N= 76) were diagnosed with FRI. Patients with suggestive criteria were further examined with either bacterial sampling at the outpatient clinic, revision surgery including bacterial sampling, or a wait-and-see approach. Eleven (39%) of the 28 patients had positive cultures and were therefore diagnosed as having FRI at second evaluation. In total 87 (9%) patients were diagnosed with FRI according to the consensus definition. Only 73 (70%) of the 104 patients with suspected FRI had adequate bacterial sampling. Conclusions. The prevalence of FRI, applying the FRI-consensus criteria, for patients with surgically treated ankle fractures was 9%. Twenty-two percent of patients who met the confirmatory criteria had negative bacterial cultures. The current study shows that we did not have a systematic approach to patients with suspected FRI as recommended by the consensus group. A systematic approach to adequate bacterial sampling when FRI is suspected is paramount. The consensus definition of FRI and its diagnostic algorithm facilitates such an approach

Aim. There have been many attempts to define the criteria by which prosthetic joint infection (PJI) is diagnosed. Our aim is to validate the 2021 European Bone and Joint Infection Society (EBJIS) definition of PJI. Method. This is a multicenter retrospective study of patients who have undergone total hip or knee revision surgery in four different European institutions between 2013–2018. Cases with less than four intraoperative microbiology samples; no preoperative/intraoperative synovial fluid differential leukocyte count or intraoperative histology were excluded. Minimum follow-up of at least two years after revision surgery if no subsequent infection and/or the need for implant removal was also required. All cases were classified using the 2021 EBJIS, the 2018 International Consensus Meeting (ICM) and the 2013 Musculoskeletal Infection Society (MSIS) PJI definitions. Results. Definitive PJI classification according to the different definitions of the 507 patients included are presented in table 1. The EBJIS definition classifies 40.4%(205/507) of the cases as confirmed infections compared to 33.9%(p=0.038) and 29.4%(p<0.001) in 2018 ICM and 2013 MSIS classifications respectively. Compared to 2018 ICM classification it also offers significantly less undetermined cases – 5.0% vs. 11.4%(p<0.001). Free from infection Kaplan-Meyer survival curve shows significantly better outcome for EBJIS unlikely compared to confirmed subgroup(p=0.031). EBJIS likely subgroup survival is not significantly different from unlikely(p=0.529) or confirmed(p=0.717) cohorts. Among the MSIS not infected cohort the newly classified EBJIS confirmed/likely cases present higher subsequent infection rate (albeit not statistically significant) when compared to EBJIS infection unlikely cases − 16.0%(13/81) vs. 10.1%(28/277). This subsequent PJI rate is similar to the MSIS infected cohort. A similar trend is not obvious within ICM 2018 not infected subgroup. Conclusions. The EBJIS 2021 definition is shown to be the most sensitive definition while also offering a smaller number of undetermined cases. Newly diagnosed infections seem to have a similar prognosis as “classically” infected cases. For any tables or figures, please contact the authors directly

Aim. Accurate diagnosis is key in correctly managing prosthetic joint infection (PJI). Our aim is to compare the preoperative performance of three PJI definitions comparing it to definitive postoperative classification. Method. This is a multicenter retrospective study of patients who have undergone total hip or knee revision surgery in four different European institutions. For this specific study, cases with no preoperative synovial fluid differential leukocyte count and less than four intraoperative microbiology samples were excluded. Cases were classified using the 2021 EBJIS, the 2018 International Consensus Meeting (ICM) and the 2013 Musculoskeletal Infection Society (MSIS) PJI definitions. Preoperative classification was based on clinical features, inflammatory markers and synovial fluid leukocyte count and microbiology results. Results. Preoperative and definitive PJI classification status of the 384 patients included are presented in figure 1. EBJIS definition showed the highest agreement between preoperative and definitive classification (k=0.86, CI95% 0.81–0.90, p<0.001) compared to ICM 2018 (k=0.80, CI95% 0.75–0.84, p<0.001) or MSIS 2013 (k=0.70, CI95% 0.62–0.77, p<0.001). Compared to its respective definitive classification: EBJIS preoperative unlikely result shows 86.8% (95%CI 81.3%–91.2%) sensitivity and 87.7% (95%CI 83.3%–91.1%) negative predictive value (NPV); ICM 2018 preoperative not infected result shows 83.5% (95%CI 77.4%–88.5%) sensitivity and 86.2% (95%CI 81.9%–88.6%) NPV and; MSIS 2013 preoperative not infected result shows 63.9% (95%CI 55.0%–72.1%) sensitivity and 84.3% (95%CI 81.1%–87.1%) NPV. Around half of the preoperative EBJIS likely (45.8%) and ICM 2018 inconclusive (54.5%) turn out to be infected postoperatively. If we consider the more sensitive definition (EBJIS) as the gold standard: ICM 2018 preoperative not infected result shows 75.1% (95%CI 68.5%–81.0%) sensitivity and 78.3% (95%CI 73.9%–82.2%) NPV and; MSIS 2013 preoperative not infected result shows 42.1% (95% CI 35.2%–49.4%) sensitivity and 62.0% (59.2%–64.8) NPV. Conclusions. The EBJIS 2021 definition is not only the most sensitive definition as it was shown to be the most effective in preoperatively ruling out PJI when there is a negative result. For any tables or figures, please contact the authors directly

Aim. Our goal is to assess diagnostic accuracy of synovial fluid testing in diagnosing prosthetic joint infection (PJI) as defined by the European Bone and Joint Infection Society (EBJIS). In addition to differential leukocyte count, simples and inexpensive biomarkers such as synovial fluid C-reactive protein (CRP), adenosine deaminase (ADA) and alpha-2-macrogloblulin(A2M) were also investigated and its possible role in increasing accuracy assessed. Method. Between January/2013 and December/2019 total hip or knee arthroplasty revision cases (regardless of preoperative diagnosis) were prospectively included provided enough synovial fluid for biomarker analysis was collected and at least four tissue samples, as well as the implant for sonication, were gathered for microbiological study. Definitive diagnosis was classified according to the new EBJIS PJI definition. Using receiver operating characteristic curves, we determined cutoff values as well as diagnostic accuracy for each marker. Results. Out of 364 revision arthroplasties performed, 102 fully respected inclusion criteria. There were 58 unlikely, 8 likely and 36 confirmed infections. Synovial fluid total leukocyte count, proportion of polymorphonuclear neutrophils (PMN), CRP, ADA and A2M were significantly different between groups. Area under the curve was 0.94 for total leucocyte count, 0.91 for proportion of PMN, 0.90 for CRP, 0.82 for ADA and 0.76 for A2M. Sensitivity, specificity, and predictive values for statistically optimal but also selected rule-in and rule-out cutoffs values are shown in Table 1. Interpreting a raised level of CRP(>2.7mg/L) or ADA(>60U/L) together with high leukocyte count (>1470 cells/μL) or proportion of PMN (>62.5%) significantly increases specificity and positive predictive value for affirming PJI. Conclusions. Differential leukocyte count cutoffs proposed by the EBJIS PJI definition are shown to perform well in ruling out (<1,500 cells/μL) and ruling in (>3,000 cells/μL) PJI. Adding simple and inexpensive biomarkers such synovial CRP or ADA is helpful in interpreting inconclusive results. For any tables or figures, please contact the authors directly

Aim. Synovial fluid investigation is the best alternative to diagnose prosthetic joint infection (PJI) before adequate microbiological/histology sampling during revision surgery. Although accurate preoperative diagnosis is certainly recommended, puncturing every patient before revision arthroplasty raises concerns about safety and feasibility issues especially in difficult to access joint (e.g., hip), that often require OR time and fluoroscopy/ultrasound guidance. Currently there is no clear guidelines regarding optimal indications to perform preoperative joint aspiration to diagnose PJI before revision surgery. The main goal of this study is to determine the accuracy of our institutional criteria using the new European Bone and Joint Infection Society (EBJIS) PJI definition. Method. We retrospectively evaluated every single- or first-stage for presumed aseptic or known infected revision total hip/knee arthroplasty procedures between 2013–2020. Preoperative clinical and laboratory features were systematically scrutinized. Cases with insufficient information for accurate final PJI diagnosis (i.e., no perioperative synovial fluid examination or no multiple cultures including sonication of removed implant) were excluded. Preoperative joint aspiration is recommended in our institution if any of the following criteria are met: 1) elevated CRP and/or ESR; 2) early failure (<2 years) or repeat failure; 3) high clinical suspicion/risk factors are present. Performance of such criteria were compared against final postoperative EBJIS definition PJI diagnosis. Results. A total of 364 revision THAs or TKAs were performed during the study period. After excluding 258 cases with insufficient information, a total of 106 patients were ultimately included. 38 (35,8 %) were classified as confirmed infections, 10 (9.4 %) as likely infected and 58 (54.7%) as infection unlikely. Of those, 37 confirmed infection cases, 9 likely infected cases and 32 infection unlikely cases did have indication for preoperative synovial fluid collection before revision surgery. Institutional criteria showed 95.8 % Sensitivity, 44.83 % Specificity, 92.9 % Negative Predictive Value (NPV) and 59 % Positive Predictive Value (PPV). Conclusions. Sensitivity and NPV of the aforementioned institutional criteria are very high even with the use of the more sensitive EBJIS PJI definition. As such they seem to be a valid alternative in selecting patients that should be punctured before revision arthroplasty. They identify the vast majority of infected patients while saving a significant number of patients from unnecessary procedures

Aim. Cutibacterium acnes, a skin commensal, is responsible for 5–10% of prosthetic joint infections (PJI). All current microbiological definitions of PJI require two or more identical commensal isolates to be recovered from the same procedure to diagnose PJI and rule out contamination. Unlike coagulase negative staphylococci, C.acnes shows a highly stereotypical susceptibility profile making impossible to phenotypically assess the clonal relationship of isolates. In order to determine the clonal relationship of multiple C.acnes isolates recovered from arthroplasty revisions, we analyzed by multi-locus sequence typing (MLST) C.acnes isolates grown from orthopedic device-related infections (ODRI) in a reference center for bone and joint infection. Methods. Laboratory records from January 2009 to January 2014 were searched for monomicrobial C.acnes ODRI with growth of C. acnes in at least 2 intraoperative and/or preoperative samples. Clinical, biological and demographic information was collected from hospital charts. All corresponding isolates biobanked in cryovials (−80°C) were subcultured on anaerobic blood agar, and identification confirmed by MALDI-TOF-MS. C.acnes isolates were typed using the MLST scheme described by Lomholt et al. Plasmatic pre-operative C-reactive protein (CRP) levels were determined using DimensionEXL (Siemens). A threshold of 10 mg/L was used to determine serologically positive ODRIs from negatives. Results. Over a 5-year period, 37 cases of monomicrobial C.acnes ODRI were diagnosed in our center. Among these 37 cases, 113/153 C.acnes isolates were cryopreserved. 110/113, corresponding to 36/37 cases, were typed by MLST: 14/36 (39%) ODRI cases were found to feature isolates belonging to two or more different STs and were qualified to be heteroclonal whereas 22/36 (61%) of ODRI cases were found to feature isolates belonging to the same ST and were qualified to be homoclonal. Homoclonal infections were significantly more likely to have elevated CRP levels compared to heteroclonal cases (p=0.0011, Fisher test). Patients with only two positive intraoperative samples had significantly lower CRP values than patients with three or more positive intraoperative samples (12,7mg/L vs 67mg/L; p=0,01, homoscedastic two-tailed Student's t test). Conclusions. This study suggests that what is classified microbiologically as C.acnes ODRIs comprises: i) true homoclonal infections eliciting an inflammatory response, ii) heteroclonal infections lacking inflammatory response where C.acnes could be an innocent bystander and iii) false positives where no strain achieves true microbiological significance. Our study shows that a stricter threshold of 3 intraoperative positive samples could be more adequate than 2. These results reinforces the need for a more specific definition of C.acnes ODRI

Aim

Apart from other biomarkers isolated in the synovial fluid, alpha-defensin appears to be a promising diagnostic tool to confirm a periprosthetic joint infection (PJI) in the hip or knee. The purpose of this study was to evaluate the sensitivity and specificity of an alpha defensin lateral flow (ADLF) test compared to usual standard classifications in the diagnostic management of PJI.

Aim. Propionibacterium acnes is a skin commensal colonizing the deeper structures of the pilous bulb. It is responsible for 5–10% of lower limb prosthetic joint infections (PJI) but accounts for as many as 50% of shoulder arthroplasty infections. P. acnes PJIs characteristically feature limited systemic inflammation, limited polymorphonuclear infiltration and clinical signs compatible with aseptic loosening. All current microbiological definitions of PJI require two or more identical commensal isolates to be recovered from the same procedure to diagnose PJI to increase specificity and rule out contamination. Whereas the antimicrobial susceptibility patterns of coagulase negative staphylococci are highly polymorphic and commonly allow the ready distinction of unrelated strains, P. acnes shows a highly stereotypical susceptibility profile and it is impossible to phenotypically assess the clonal relationship of isolates. In order to determine the clonal relationship of multiple P. acnes isolates recovered from arthroplasty revisions, we analyzed by multi-locus sequence typing (MLST) P. acnes isolates grown from PJI in a reference center for bone and joint infection. Method. We retrospectively selected all cases of microbiologically documented monomicrobial PJI caused by P. acnes diagnosed in our center from January 2009 to January 2014. Microorganisms were identified by MALDI-TOF mass spectrometry (Bruker Daltonics). All corresponding P.acnes isolates biobanked in cryovials frozen at −80°C were subcultured on anaerobic blood agar, DNA extracted by freeze-thawing and bead-milling, and typed according to the 9 gene MLST scheme proposed by Lomholt HB. and al. Results. Over the 5-year period, 39 cases of PJI positive with P. acnes were diagnosed in our center. Three to ten intraoperative samples were sent for microbiological analysis per surgery. Overall, 113 P. acnes isolates were grown from 210 samples. On average, four samples were positive out of six. In 34/39 cases, all isolates belonged to the same ST. In 5 cases, multiples STs were found among the P.acnes isolates. In 3/39 cases (7.7%), a single ST was found to be microbiologically significant, with a single isolate of the alternate ST. In 2/39 cases (5.1%), we found that each isolate belonged to a different ST. Conclusions. P. acnes PJI were found to be polyclonal by MLST in 12.8% of cases in our experience, with more than 5% of cases not fulfilling the requirements for microbiological significance. The criteria for microbiological significance do not necessarily apply to commensal agents with no antimicrobial susceptibility pattern variation such as P. acnes

Introduction. Acetabular bone deficiency, especially proximal and lateral deficiency, is a difficult technical problem during primary total hip arthroplasty (THA) in developmental hip dysplasia (DDH). We report a configuration-based acetabular classification, a modification of the Crowe's classification, of DDH, including a definition of shallow acetabuli. We also report a new reconstruction method using a medial reduced cemented socket andadditional bulk bone in conjunction with impaction morselized bone grafting (Ad-BBG method). We aimed to evaluate usefulness of the classification and the method's clinical/radiographic outcomes. Methods. One hundred thirty one hips of 330 THAs for DDH (40%) were defined shallow. The Ad-BBG methodwas performed on 102 hips (78% shallow hips). For the 24 remaining hips, THA was performed using the conventional interposition bulk bone grafting (Ip-BBG) (8 hips)or without bone grafting by using rigid lateral osteophyte (16 hips). Japanese Orthopaedic Association (JOA) scores and the Merle d'Aubigne and Postel (M&P) scores were used in follow-up; radiographs were analyzed retrospectively. The criteria used for determining loosening were migration or a total radiolucent zone between the prosthesis/bone cement and host bone. The follow-up period was 9.2 ± 2.6 (range, 5.0–14.0) years. Operative Technique. Theresected femoral head was sectioned at 1–2-cm thickness, and a suitable size of the bulk bone graft was placed on the lateral iliac cortex and fixed by polylactate absorbable screws. Autogenous impaction morselized bone grafting, with or without hydroxyapatite granules, was performed along with the implantation of medial reduced cemented prosthetic hip socket. The same surgical team performed all surgical procedures. Results. Acetabular component was revised in only one case with a shallow and Crowe Type IV acetabulum. The mean JOA and M&P scores improved from preoperative 39.3 and 6.8 points to postoperative 93.9 and 17.2 points, respectively. Within 2 years postoperatively, most Ad-BBGs cases showed successful bone remodeling and bone graft reorientation on radiographs. Conclusions. We had good results of acetabular reconstruction in primary THA using the medial reduced cemented socket and bone grafting methods including the Ad-BBG technique in conjunction with impaction morselized bone grafting for shallow dysplastic hip. Osteointegration and good clinical outcomes were achieved in most cases. However, long-term outcomes should be subject of further investigation. Summary. Reconstruction methods for shallow dysplastic hip using medial reduced cemented socket and additional bulk bone grafting in conjunction with impaction morselized bone grafting are presented

Introduction

The successful performance of ceramic on ceramic bearings in today's THA can mainly be addressed to the excellent tribological behaviour and the minimal wear of ceramic bearings. The clearance between head and shell plays a major role in this functionality of artificial hip joints. Knowledge about the deformation behaviour of the shell during implantation but also under daily loads is essential to be able to define a minimum clearance of the system. The aim of this work is to establish a tool for determining maximum ceramic shell deformation in order to predict minimum necessary clearance between heads and monolithic ceramic shells.

Introduction

Accurate diagnosis of peri-prosthetic joint infection is critical to allow adequate treatment. Currently, the criteria of the Musculo-Skeletal Infection Society (MSIS) serve as a validated reference tool. More recently, these criteria have been modified for better accuracy. The goal of this study was to compare retrospectively the diagnostic accuracy of these two different tools in cases of known peri-prosthetic hip or knee infection or in aseptic cases and to analyze one additional criterion: presence of an early loosening (prior to 2 years after implantation).

Aim

The diagnosis of peri-prosthetic infection is sometimes difficult to assess, and there is no universal diagnostic test. The recommendations currently accepted include several diagnostic criteria, and are based mainly on the results of deep bacteriological samples, which only provide the diagnosis after surgery. A predictive score of the infection might improve the peri-operative management before repeat surgery after total hip arthroplasty (THA). The goal of this study was to attempt defining a composite score using conventional clinical, radiological and biological data that can be used to predict the positive and negative diagnosis of peri-prosthetic infection before repeat surgery after THA. The tested hypothesis was that the score thus defined allowed an accurate differentiation between infected and non-infected cases in more than 75% of the cases.

There is increasing interest in the use of image free computer assisted surgery (CAS) in total hip arthroplasty (THA). Many of these systems require the registration of the Anterior Pelvic Plane (APP) via the bony landmarks of the anterior superior iliac spines (ASIS) and pubic tubercles (PT) in order to accurately orient the acetabular cup in terms of anteversion and inclination. Given system accuracies are within 1mm and 1° and clinical validation studies have given accuracy by cup position. However, clinical outcomes contain not only system inaccuracies but also variations due to clinical practice. To understand the effects of variation in landmark acquisition on the identification of the acetabular cup orientation, independent bench testing is required. This requires a phantom model that can represent the range of pelvises, male and female, encountered during THA and introduce deliberate known errors to the acquisition to see the effect on anteversion and inclination angles. However, there is a paucity of information in the literature with regards to these specific pelvic dimensions (pelvic width and height). Therefore the aims of this work were to generate the normal expected range of sizes of the APP for both males and females and to use these to manufacture a phantom model that could be used to assess CT free navigation systems.

In the first part of the study 35 human cadavers and 100 pelvic computed tomography (CT) scans were examined.

All cadavers had no gross pelvic abnormalities or previous surgeries. Measurements were carried out with cadavers placed in a supine position. The first author made three sets of measurements using a millimeter ruler. Solid steel pins were used to identify the palpated ASISs and PTs. String was tied between the two ASIS pins and the pelvic width measured. The midpoint of the pubic tubercles was taken to be the midpoint of the pubic symphysis. Pelvic height was measured from the midpoint of the ASIS distance (marked on the string) to the midpoint of the PTs. One hundred pelvic CT scans with no bony abnormalities, previous surgery or metal prosthesis (due to artefacts) were obtained retrospectively from the hospital radiological online system (PACS, Kodak). Mimics software (Mimics12 Materialise, Leuven, Belgium) was used to automatically reconstruct three-dimensional (3D) models using the ‘Bone’ thresholding function. This eliminated any soft tissue from the 3D models. The most anterior ASIS and PT points were then identified on the 3D model surface and measurements of distances made. As the software did not allow identification of points not on the model surface it was not possible to directly obtain the midpoint of the ASIS distance. Therefore to obtain the pelvic height measurements the distance between each ASIS and the ipsilateral and contralateral PTs was also measured. The pelvic height was then calculated using trigonometric functions. The ratio of width to height was calculated (ratio > 1 indicating pelvis width greater than pelvis height). Student's t test was used analyse any differences between male and female pelvic measurements with a p<0.05 being statistically significant.

Using the results from above an aluminium pelvic phantom model was designed and manufactured. It was machined from a billet of marine grade aluminium alloy using a vertical computer numerical controlled (CNC) milling machine. The top surface represented the APP and sides (which represented the acetabuli) were angled to give anteversion and inclination angles of 20° and 45° respectively. Co-ordinates for ASIS and PT points were given based on the 99% prediction intervals from the pelvic data and additional points were milled to give up to a 20 mm error mediolaterally and also in height. Each co-ordinate point was drilled with a 2.0mm diameter ball-nose cutter to a depth of 1.0mm, these holes designed to accommodate the ball-nosed pointer tip to ensure it remained at the same position in space at all orientations of the pointer. Further to this, known errors in height were introduced using accurately manufactured blocks with similar points milled on the surface to fit a ball-nosed pointer. These blocks could be secured to the top surface of the model using screws. A Perspex base unit with tracker attachments was made to hold the phantom and provide the reference frame. A further support that enables the phantom to also be used in the “lateral” position was manufactured.

For the assessment of pelvic size there were 66 females and 69 males, mean age 62.3 years (range from 20 to 99 years). The mean width was 238 mm (SD 20 mm) and mean height was 93 mm (SD 11 mm) with a mean ratio of 2.6 (SD 0.3). There were no statistically significant differences in mean between males and females (p>0.4 in all cases). From this data set the range of APP sizes required to cover 99% of population (width 186 to 290 mm and height 66 to 120 mm) and therefore the measurements for the model were generated. The manufactured model can be used to give the range of pelvis sizes from 170mm to 290mm in width and 60mm to 120mm in height and also to add up to 20 mm of error in palpation of each of the ASISs and PT.

This study generated APP sizes to cover 99% of the general population over a wide age range. It illustrated that a single pelvic model would fit both sexes. The model allows the determination of the effects of changes of the pelvic dimensions may have on the acetabular orientation measured on an image free CAS system including the assessment of point acquisition and deliberate errors. The model has been successfully used in preliminary testing and can be used to assess any CT free system.

Aim. Diagnosing periprosthetic joint infections (PJI) can be very challenging, especially infections caused by low virulence microorganisms. No single test with a 100% accuracy is available yet. Hence, different infection definitions were introduced to improve the diagnostic confidence and quality of research articles. Due to constant developments in this field, infection definitions are adopted continuously. The aim of our study was to find the most sensitive currently available infection definition among three currently used criteria (International Consensus Meeting – criteria 2018 (ICM), Infectious Diseases Society of America - criteria 2013 (IDSA), and European Bone and Joint Infection Society – criteria 2021 (EBJIS)) for the diagnosis of PJI. Method. Between 2015 and 2020, patients with an indicated revision surgery due to septic or aseptic failure after a total hip or knee replacement were included in this retrospective analysis of prospectively collected data. A standardized diagnostic workup was done in all patients. The components of the IDSA-, ICM-, and EBJIS- criteria for the diagnosis of PJI were identified in each patient. Results. Overall, 206 patients (hip: n=104 (50%); knee: n=102 (50%)) with a median age of 74 years (IQR 65 – 80y) were included. 101 patients (49%) were diagnosed with PJI when using the EBJIS- criteria. Based on the IDSA- and ICM- criteria, 99 patients (48%, IDSA) and 86 patients (42%, ICM) were classified as septic. Based on all three criteria, 84 cases (41%) had an infection. 15 septic cases (n=15/206; 7%) were only identified by the IDSA- and EBJIS- criteria. In 2 patients (n=2/206, 1%), an infection was present based on only the ICM and EBJIS criteria. No case was classified as infected by one infection definition alone. A statistically significant higher number of inconclusive cases was observed when the ICM criteria (n=30/206; 15%) were used in comparison to the EBJIS criteria (likely infections: n=16/206; 8%) (Fisher's exact test, p=0.041). The EBJIS definition showed a better preoperative performance in comparison to the other two definitions (p<0.0001). Conclusions. The most sensitive infection definition seems to be the novel EBJIS– criteria covering all infections diagnosed by the IDSA- and ICM-criteria without detecting any further infection. In addition, less inconclusive (infection likely) cases were detected by the EBJIS-criteria in comparison with the ICM-criteria reducing the so called ‘grey zone’ significantly which is of utmost importance in clinical routine

Trauma and elective orthopaedic demands in New Zealand are increasing. In this study, prospective and retrospective data has been collected at Nelson Hospital and across New Zealand to identify the percentage of elective theatre time lost due to cancellation for acute patient care. Data has been collected from theatre management systems, hospital data systems and logged against secretarial case bookings, to calculate a percentage of elective theatre time lost to acute operating or insufficient bed capacity. Data was collected over a five-month period at Nelson Hospital, with a total of 215 elective and 226 acute orthopaedic procedures completed. A total of 95 primary hip or knee arthroplasties were completed during this trial while 53 were cancelled. The total number of elective operative sessions (one session is the equivalent of a half day operating theatre time) lost to acute workload was 47.9. Thirty-three percent of allocated elective theatre time was cancelled - an equivalent of approximately one-full day elective operating per week. Over a five-week period data was collected across all provincial hospitals in New Zealand, with an average of 18% of elective operating time per week lost due to acute workload. Elective cancellations were due to acute operating 40% of the time and bed shortages 60% of the time. The worst effected centre was Palmerston North which had an average of 33% of elective operating cancelled per week to accommodate acute surgery or due to bed shortages. New Zealand's provincial orthopaedic surgeons are under immense pressure from acute operating that impedes provision of elective surgery. The New Zealand government definition of an ‘acute case’ does not reflect the nature of today's orthopaedic burden. Increasing and aging populations along with staff and infrastructure shortages have financial and societal impacts beyond medicine and require better definitions, further research, and funding from governance

Pelvic tilt (PT) is always described as the pelvic orientation along the transverse axis, yet four PT definitions were established based on different radiographic landmarks: anterior pelvic plane (PT. a. ), the centres of femoral heads and sacral plate (PT. m. ), pelvic outlet (PT. h. ), and sacral slope (SS). These landmarks quantify a similar concept, yet understanding of their relationships is lacking. Some studies referred to the words “pelvic tilt” for horizontal comparisons, but their PT definitions might differ. There is a demand for understanding their correlations and differences for education and research purposes. This study recruited 105 sagittal pelvic radiographs (68 males and 37 females) from a single clinic awaiting their hip surgeries. Hip hardware and spine pathologies were examined for sub-group analysis. Two observers annotated four PTs in a gender-dependent manner and repeated it after six months. The linear regression model and intraclass correlation coefficient (ICC) were applied with a 95% significance interval. The SS showed significant gender differences and the lowest correlations to the other parameters in the male group (-0.3< r <0.2). The correlations of SS in scoliosis (n = 7) and hip implant (female, n = 18) groups were statistically different, yet the sample sizes were too small. PT. m. demonstrated very strong correlation to PT. h. (r > 0.9) under the linear model PT. m. = 0.951 × PT. h. - 68.284. The PT. m. and PT. h. are interchangeable under a simple linear regression model, which enables study comparisons between them. In the male group, SS is more of a personalised spinal landmark independent of the pelvic anatomy. Female patients with hip implant may have more static spinopelvic relationships following a certain pattern, yet a deeper study using a larger dataset is required. The understanding of different PTs improves anatomical education

Aims. Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set. Methods. A total of 11 databases were searched. A subset of studies published between 1 October 2020 and 1 January 2011 from a larger review mapping research on limb reconstruction and limb amputation for the management of lower limb COM were eligible. All outcomes were extracted and recorded verbatim. Outcomes were grouped and categorized as per the revised Williamson and Clarke taxonomy. Results. A total of 3,303 records were screened, of which 99 studies were included. Most studies were case series (77/99; 78%) and assessed one method of reconstruction (68/99; 69%). A total of 511 outcomes were reported, which were grouped into 58 distinct outcomes. Overall, 143/511 of all outcomes (28%) were provided with a clear, in-text definition, and 231 outcomes (45%) had details reported of how and when they were measured. The most commonly reported outcome was ‘recurrence of osteomyelitis’ (62; 12%). The single-most patient-reported outcome measure was ‘pain’. Conclusion. This study has highlighted significant inconsistencies in the defining, reporting, and measuring of outcomes across studies investigating surgical management for chronic osteomyelitis of the lower limb in adults. Future studies should clearly report complete details of how outcomes are defined and measured, including timing. The development of a standardized core outcome set would be of significant benefit in order to allow evidence synthesis and comparison across studies. Cite this article: Bone Jt Open 2023;4(3):146–157

Aims. The principles of evidence-based medicine (EBM) are the foundation of modern medical practice. Surgeons are familiar with the commonly used statistical techniques to test hypotheses, summarize findings, and provide answers within a specified range of probability. Based on this knowledge, they are able to critically evaluate research before deciding whether or not to adopt the findings into practice. Recently, there has been an increased use of artificial intelligence (AI) to analyze information and derive findings in orthopaedic research. These techniques use a set of statistical tools that are increasingly complex and may be unfamiliar to the orthopaedic surgeon. It is unclear if this shift towards less familiar techniques is widely accepted in the orthopaedic community. This study aimed to provide an exploration of understanding and acceptance of AI use in research among orthopaedic surgeons. Methods. Semi-structured in-depth interviews were carried out on a sample of 12 orthopaedic surgeons. Inductive thematic analysis was used to identify key themes. Results. The four intersecting themes identified were: 1) validity in traditional research, 2) confusion around the definition of AI, 3) an inability to validate AI research, and 4) cautious optimism about AI research. Underpinning these themes is the notion of a validity heuristic that is strongly rooted in traditional research teaching and embedded in medical and surgical training. Conclusion. Research involving AI sometimes challenges the accepted traditional evidence-based framework. This can give rise to confusion among orthopaedic surgeons, who may be unable to confidently validate findings. In our study, the impact of this was mediated by cautious optimism based on an ingrained validity heuristic that orthopaedic surgeons develop through their medical training. Adding to this, the integration of AI into everyday life works to reduce suspicion and aid acceptance. Cite this article: Bone Jt Open 2023;4(9):696–703

Chronic postoperative pain (CPP) can occur in elective mid/hindfoot and ankle surgery patients. Multimodal pain management has been reported to reduce postoperative pain and opioid use, which may prevent the development of CPP. However, few studies have examined the impact of multimodal pain management strategies on CPP following complex elective mid/hindfoot and ankle surgery. The purpose of this study was to 1) evaluate current pain management strategies and 2) determine current definitions, incidence, and prevalence of CPP after elective mid/hindfoot and ankle surgery. Three databases (MEDLINE, Embase and Cochrane Library) were manually and electronically searched for English language studies published between 1990 and July 2017. For the first aim, we included comparative studies of adults undergoing elective mid/hindfoot and ankle surgery that investigated pre-, peri- or postoperative pain management. For the second aim, we included observational studies examining CPP definition, incidence, and prevalence. Two reviewers independently screened titles and abstracts, followed by full texts. Conflicts were resolved through discussion with a third reviewer. Reviewers also independently assessed the quality of studies meeting inclusion criteria using the Joanna Briggs Institute Critical Appraisal Checklist. For the first aim, 1159 studies were identified by the primary search, and seven high quality randomized controlled trials were included. Ankle arthroplasty or fusion and calcaneal osteotomy were the most common procedures performed. The heterogeneity of study interventions, though all regional anesthesia techniques, precluded meta-analysis. Most investigated continuous popliteal, sciatic and/or femoral nerve blockade. Participants were typically followed up to 48 hours postoperatively to examine postoperative pain levels and morphine consumption in hospital. Interventions effective at reducing postoperative pain and/or morphine consumption included inserting popliteal catheters using ultrasound instead of nerve stimulation guidance, perineural dexamethasone, and adding continuous femoral blockade to continuous popliteal blockade. Using more than one analgesic was generally more effective than using a single agent. Only two studies examined longer term pain management. One found no difference in pain levels and opioid consumption at two weeks with perineural or systemic dexamethasone use. The other found that pain with activity was significantly reduced at six months postoperatively with the addition of a femoral catheter infusion to a popliteal catheter infusion. For the second aim, only two studies of the 747 identified were selected. One prospective observational study defined CPP as moderate-to-severe pain at one year after foot and ankle surgery, and reported 21% and 43% of patients as meeting their definition at rest and with activity, respectively. The other study was a systematic review that reported 23–60% of patients experienced residual pain after total ankle arthroplasty. There is no standardized definition of CPP in this population, and incidence and prevalence are rarely reported and vary largely based on definition. Although regional anesthesia may be effective at reducing in-hospital pain and opioid consumption, evidence is very limited regarding longer-term pain management and associated outcomes following elective mid/hindfoot and ankle surgery