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

Most patients treated at our clinical setting present during chronic osteomyelitis stage, which is anecdotally likely to be poly-microbial. Adults with poly-microbial infection have a predilection for gram-negative bacteria and anaerobes, a scenario that hypothetically leads to a higher morbidity of poly-microbial osteomyelitis following trauma. Our study looks into the epidemiology of poly-microbial osteomyelitis treated at our Tumour and Infection unit. Retrospective study of patients treated for osteomyelitis from 2016 to 2020. Records of eligible patients were retrieved for examination. Demographics such as age, sex and race were recorded. Clinical presentation, organisms cultured, including their anti-microbial sensitivities were documented. There were 63 participants in the study. 31 (49.21%) had mono-microbial osteomyelitis with 32 (50.79%) having poly-microbial osteomyelitis. Majority of the poly-microbial patients presented with a sinus (68.75%) mostly located in the tibia (50%). Multiple mixed pathogens (both gam-positive and gram-negative) were cultured in our patients and this comprised 71.21% of the total bacteria cultured. Staphylococcus Aureus was the commonest bacteria (30%) isolated, followed by Enterococcus faecalis (12%). The commonest gram-negative bacteriae cultured was Enterococcus cloacae (10%) followed by Acinetobacter baumannii (7%). Most enterobacteriacae species were sensitive to Ertapenem and Ceftazidime. A slightly higher incidence of poly-microbial osteomyelitis was found in our study than that reported in literature. Furthermore, our study demonstrated a wide variety of organisms found in poly-microbial osteomyelitis, with a large contribution made by gram-negative anaerobic rod-shaped bacteria

Trauma patients present with different injuries and some of them require emergency surgical procedures. Orthopaedic department at Steve Biko Academic Hospital (SBAH) have seen an increasing number of patients presenting with serious orthopaedic injuries due to Delivery Motorbike Accidents (DMBA). The aim of the study was to establish the epidemiology and pattern of orthopaedic injuries sustained following Delivery Motorbike Accident. Motor Vehicle Accident (MVA) administration office at SBAH in emergency department was approached for patients registers used between 1 January 2020 and 31 December 2022. There patients were registered as Motor Vehicle Accident (MVA), Motorbike Accident (MBA) and Pedestrian Vehicle Accident (PVA) by the administration office. The details of patients classified as MBA were collected and used to obtain clinical data from medical and radiological records in the form of patient's files and PACS respectively. Approximately 240 patients presented to Emergency department with orthopaedic injuries following a motorbike accident. About 78 files could not be retrieved from the patient's records department. About 74patients had their occupation recorded as unknown or unemployed. Approximately 70 patients had their occupation indicated in the file by the Clinicians or Administration Clerks. About 40 patients had their occupation as delivery man or working for a delivery company. 16 patients did not have images on the PACS system. Most of the patients were males, presented after hours and sustained multiple injuries that were managed surgically. Very few patients had their helmet status indicated in the file. The study suggests that accidents due to delivery motorbikes are prevalent at SBAH and result in orthopaedic injuries. Almost 50% of patients who had their occupation indicated in the file were delivery employees. A follow up prospective study is recommended to ensure complete collection of data from patients at presentation to ED

Aim. Currently, gram-negative bacteria (GNB), including multidrug-resistant (MDR-GNB) pathogens, are gaining importance in the aetiology of prosthetic joint infection (PJI). To characterize the antimicrobial resistance patterns of Gram-negative bacteria (GNB) causing hip prosthetic joint infections in elderly patients treated at a Brazilian tertiary academic hospital. Method. This is a retrospective, cross-sectional study of patients over 60 years of age undergoing hip arthroplasty from 2018 to 2023 at a tertiary academic trauma, which were diagnosed with hip prosthetic joint infection. PJI diagnosed was based on EBJIS criteria, in which intraoperative tissue cultures identified the pathogens. Demographics, reason for arthroplasty, type of implant and susceptibility patterns using disk diffusion method were analysed. Results. Overall, among 17 elderly patients diagnosed with hip infected arthroplasty, 45 bacterial isolated were identified. Debridement, irrigation, antibiotic and implant retention (DAIR) procedures due to uncontrolled infection occurred in 47.0% (n=8/17), and five patients underwent more than two DAIR surgeries. Tissue cultures yielded eleven different bacterial species, with GNB accounted for 64.4% (n=29/45) of pathogens. Klebsiella pneumoniae, Acinetobacter baumannii, Escherichia coli, and Pseudomonas aeruginosa were identified in 34.5% (n=10/29), 17.25% (n=5/29), 13.8% (n=4/29), and 13.8% (n=4/29), respectively. In the resistance profile analysis, E. coli was most sensitive to antibiotics, whereas K. pneumoniae showed resistance rates higher than 70% for cephalosporins, carbapenems, and quinolones. All A. baumannii isolates were resistant to meropenem, and 80% of these isolates were resistant to amikacin. Conclusions. This study emphasizes the role of GNB in the microbiological profile of PJI among elderly patients at a tertiary hospital in a Brazilian centre. The present study portrays a worryingly higher rates of MDR-GNB, mainly to quinolones and cephalosporins resistance which have been the cornerstone of PJI antibiotic treatment. In addition, higher rates carbapenems and aminoglycosides resistance shows a threat to antibiotic treatment of PJI. More global studies need to be carried out to show a likely change in the microbial epidemiology of PJI

Aim. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is commonly associated with serious cases of community-onset skin and musculoskeletal infections (Co-SMSI). Molecular epidemiology analysis of CA-MRSA recovered from skin and soft tissues specimens is lacking in Latin America. This study aimed to identify phenotypic and genotypic features of MRSA isolates recovered from patients presenting Co-SMSI. Methods. Consecutive MRSA isolates recovered from Co-SMSI of patients admitted from March 2022 to January 2023 in a Brazilian teaching hospital were tested for antimicrobial resistance and characterized by their genotypic features. Identification was carried out by automated method and through MALDI-TOF MS. Antimicrobial susceptibility was tested by disk diffusion, broth microdilution and E-test strips for determination of the minimal inhibitory concentration (MIC) according to recommendations from the Brazilian Committee on Antimicrobial Susceptibility Testing (BrCAST) and European Committee on Antimicrobial Susceptibility Testing (EUCAST). Gene mecA characterization and Sccmec typing were performed by multiplex polymerase chain reaction (PCR) assay, and gene lukF detection by single PCR. Patients were prospectively followed up for two months, in order to determine their clinical characteristics and outcomes. Results. Overall, 48 Staphylococcus aureus isolates were obtained from 68 samples recovered from patients with Co-SMSI. Twenty two (42%) were phenotypically characterized as MRSA, although mecA gene was only identified in 20 of those samples. Sccmec was untypable in 12 isolates, Sccmec was type II in 4 isolates and 2 were classified as type IVa. LukF gene was identified in 5 isolates. Antimicrobial resistance profile showed that all isolates were susceptible to linezolid and vancomycin with MIC = 1 and MIC = 2 in 66,7% and 33.3%, respectively. Susceptibility to quinolones was worryingly low and none of the isolates were sensitive to usual doses of ciprofloxacin and levofloxacin, and showed increased rates of resistance to increased exposure to these drugs, as well. Isolates were both susceptible to gentamicin and tetracycline in 85% and resistance to also Sulfamethoxazole/Trimethoprim occurred in only 2 isolates. Mortality rate evaluated within 1 month of the initial evaluation was 10% among MRSA isolates. Conclusions. Our results showed that CA-MRSA isolates causing Co-SMSI demonstrated an alarming pattern of multidrug resistance, including to β-lactam and quinolones, which have been commonly prescribed as empirical therapy for patients with skin, soft tissue and musculoskeletal infections

Introduction. The epidemiology of re-revision total hip arthroplasty (THA) is not well understood. The purpose of this study is to investigate the epidemiology of re-revision THA, and identify risk factors that are associated with failure of re-revision THA. Methods. A retrospective analysis was performed on 288 patients who underwent revision THA at a single institution between 1/2012 and 12/2013. Patients who underwent revision hip arthroplasty two or more times were included. Patients were excluded if their indication for their first revision was due to periprosthetic joint infection (PJI). Patient demographics, surgical indications, revision details, and available follow-up information were collected through the electronic medical record. Re-revision failure was defined as the need for any additional return to the operating room, regardless of indication. A logistic regression analysis was performed to assess for significant predictors of re-revision failure. Results. A total of 51 re-revision patients were included in this study. Mean age at re-revision was 59.6 (±14.2 years). There were 32 (67%) females. Mean BMI was 28.8 (±5.4). Median ASA level was 2 (23; 55%). The median number of revisions was 3 (range 2–11). The most common indication for re-revision was acetabular component loosening (15; 29%), followed by PJI (13; 25%) and instability (9; 18%). Among re-revision patients, the most common indication of the first revision was acetabular component loosening (11; 27%), followed by polyethylene wear (8; 19%) and instability (8; 19%) (Figure 1). There was a significantly increased risk of re-revision failure if the re-revision procedure involved exchanging only the head and polyethylene liner (RR=1.792; p=0.017), if instability was the indication for the first revision (RR=3.000; p<0.001), as well as if instability was the indication for the re-revision (RR=1.867; p=0.038). If only the femoral component was exchanged during the re-revision, there was a decreased risk of failure (RR=0.268, p=0.046). 1-year re-revision survival was 54% (23/43). Discussion. Acetabular component loosening and PJI were the most common indications for re-revision. There was an increased risk of re-revision failure if instability was a cause for reoperation at any point during the revision history, or if only an isolated head and polyethylene liner exchange was indicated during the re-revision procedure. There was a decreased risk of re-revision failure if only an isolated femoral stem revision was performed. A better understanding of the indications and patient factors that are associated with re-revision failures can help align surgeon and patient expectations in this challenging population. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Femur shaft fractures (FSF) are markers of high energy transfer after injury. The comprehensive, population based epidemiology of FSF is unknown. The purpose of this prospective study was to describe the epidemiology of FSF with special focus on patient physiology and timing of surgery. A 12-month prospective population-based study was performed on consecutive FSF in a 600,000 population area including all ages and pre-hospital deaths. Patient demographics, mechanism, injury severity score (ISS), shock parameters (SBP, BD and Lactate), transfusion requirement, fracture type (AO), co-morbidities, performed procedure and outcomes were recorded. Patients were categorized: Stable, borderline, unstable and in extremis. A total of 125 patients (20.8/100,000/year) with 134 femur fractures. (62% male, age 37±28 years, ISS 20±19, 51% multiple injuries) were identified in two hospitals. 69 patients (55%) sustained a high energy injury (MVA, MBA, train related, high fall) with 16 (23%) of these being polytrauma patients (ISS 28±12, SBP 98±39, BD 6.5±5.8, Lactate 4±2), 15 (94%) required massive transfusion (12±12 URBC, 8±5 FFP, 1±0.4 PLT, 13±8 Cryo). Of the 125 patients 69% were stable (14.5/100,000/year), 9% borderline (1.8/100,000/year), 4% unstable (0.8/100,000/year) patients and 2% (0.3/100,000/year) were in extremis. 2 borderline, 1 unstable and 2 extremis patients died of severe CHI. One patient in extremis died due to uncontrollable hemorrhage from a pelvic fracture. 20 patients (16%) (3.3/100,000/year) with FSF were prehospital deaths and died due to the severity of their multiorgan injuries or CHI. The overall LOS was 18±15 days and the ICU LOS was 5±6 days. All high energy patients went to theatre within 6±13 hours. 56 patients (45%) sustained a low energy injury. Of these patients 85% had multiple co-morbidities. 8 patients needed 3±1 transfusions and none of the patients died. Time to surgery was 25±37 hrs and LOS was 15±11 days. There were 29 paediatric FSF, 20 of these were low and 9 high energy injuries. Only 3 patients required surgery. LE-FSF are as frequent as HE-FSF. 73% of the femur fractures are complicated (open, compromised physiology, multiple injured, bilateral, elderly with co-morbidities etc.) requiring major resources and highly specialized care

The Royal Marines regularly deploy to Norway to conduct Cold Weather, Arctic and Mountain Warfare training. A total of 1200 personnel deployed to Norway in 2010 over a 14-week period. Patients, whose injuries prevented them from continuing training, were returned to the UK via AEROMED. The aim of this investigation was to describe the epidemiology of musculoskeletal injuries during cold weather training. All data on personnel returned to the UK was prospectively collected and basic epidemiology recorded. 53 patients (incidence 44/1,000 personnel) were returned to the UK via AEROMED. 20/53 (38%) of cases were musculoskeletal injuries (incidence 17/1000 personnel). 15/20 musculoskeletal injuries were sustained while conducting ski training (incidence 13/1,000): 4/20 were non-alcohol related injuries, 1/20 was related to alcohol consumption off duty. Injuries sustained whilst skiing: 5/15 sustained anterior shoulders dislocation, 5/15 Grade 1-3 MCL/LCL tears, 2/15 sustained ACJ injuries, 1/15 crush fracture T11/T12, 1/15 tibial plateau fracture and 1/15 significant ankle sprain. Non-Training injuries: 1 anterior shoulder dislocation, 1 distal radial fracture, 1 olecranon fracture, 1 Scaphoid Fracture and one 5th metatarsal fracture. 60% of injuries were upper limb injuries. The most common injury was anterior shoulder dislocation 6/20 (Incidence 5/1000). Our results suggest that cold weather warfare training has a high injury rate requiring evacuation: 4% of all people deployed will require AEROMED evacuation, and 2% have musculoskeletal injuries. Ski training causes the majority of injuries, possibly due to the rapid transition from non-skier to skiing with a bergen and weapon. Military Orthopaedic and rehabilitation units supporting the Royal Marines, should expect sudden increases in referrals when large scale cold weather warfare training is being conducted. Further research is required to see if musculoskeletal injury rates can be decreased in cold weather warfare training

Aim. The frequency of arthroplasty among older people is increasing. Taking care of Prosthetic Joint infection (PJI) in this specific population is a challenge. The purpose of this multicentric retrospective study was to evaluate the bacterial epidemiology of hip and knee PJI in octogenarians and nonagenarians over ten years. Method. Data were collected using two softwares* in each of the 4 Centers participating. Inclusion criteria:. -. age ≥ 80 years PJI (knee or hip). -. between January 2007 and December 2016. -. microbiological data available (strains isolated from osteo-articular samples). Bacterial identification: biochemical methods, followed by Malditof since 2009. For Staphylococcus aureus, Pseudomonas aeruginosa and Enterobacteriaceae, resistance profiles to antibiotics frequently used in PJI were collected. Antimicrobial susceptibility testing: disk diffusion (recommendations: French Society of Microbiology yearly updated). Results. 413 patients were included: median age was 85 years and sex ratio was 0.6. 137 were knee PJI and 276 hip. 34% of the infections occurred < 1 month after implantation, and 49% > 6 months after implantation. Among all bacterial isolates (N=817), there was 55% of Gram positive cocci and 36% of Gram negative rods. 112 (27%) were polymicrobial infections. There was a majority of gram negative rods (41%) among isolates from polymicrobial infections. Concerning drug resistance, there was a stable proportion of ESBL among Enterobacteria (16%), whereas Methicillin resistance among S. aureus decreased from 43% in 2007 to 12% in 2016. Conclusions. An important proportion of PJI in older patients are polymicrobials, and a lot of them involve gram negative rods, almost as frequently as S. aureus. These infections are difficult to treat, and resistance of gram negative strains is one of the obstacles to overcome among these patients where surgery is not always possible. * Sirweb (I2A) and Glims (MIPS)

Introduction. Revision Total Knee Arthroplasty (TKA) is becoming increasingly prevalent as the number of TKA procedures grow in a younger, higher-demand population. Factors associated with patients requiring multiple revision TKAs are not yet well understood. The purpose of this study is to investigate the epidemiology of re-revision TKA, and identify risk factors that are associated with failure of re-revision TKA. Methods. A retrospective analysis was performed on 358 patients who underwent revision TKA at a single institution between 1/2012 and 12/2013. Patients who underwent revision knee arthroplasty two or more times were included. Patients were excluded if their indication for the first revision was periprosthetic joint infection (PJI). Patient demographics, surgical indications, revision details, and available follow-up information were collected. Re-revision failure was defined as the need for any additional operative intervention. A logistic regression analysis was performed to assess for significant predictors of re-revision failure. Results. A total of 66 re-revision TKA patients were included in this study. Mean age at re-revision was 60 (±11 years). There were 48 (73%) females. Mean BMI was 31.8 (±6.9). Median ASA level was 2 (40/59; 68%). Average follow up was 2.1 (±1.0) years, with 68% (45/66) of patients having greater than 2 year follow up (Table 1). The median number of revisions was 2 (range 2–11). The most common indication for re-revision was arthrofibrosis (15; 23%), followed by PJI (14; 21%) and aseptic component loosening (13; 20%). Among re-revision patients, the most common indication of the first revision was aseptic component loosening (17; 30%), followed by arthrofibrosis (16; 28%) and instability (9; 16%) (Table 2). Among the top four indications for re-revision, both the re-revision and initial revision indication were the same. Additionally, 42% of patients possessed the same indication for re-revision as the initial revision. The proportion of patients that had a lateral release performed in either the index procedure or initial revision was higher in re-revisions performed for patellar maltracking (p=0.013). There was a significantly increased risk of re-revision failure if the patient had a higher BMI (OR=1.22; p=0.006). Re-revision survival at 30 days was 92% (60/65), at 1 year was 81% (52/64), and at 2 years 73% (33/45). The indication history of re-revision failure is shown on Table 3. Discussion. Arthrofibrosis and PJI were the most common indications for re-revision. There was an increased risk of re-revision failure in patients with a higher BMI. It was common to have a re-revision TKA for the same indication as the initial revision. A better understanding of the indications and patient factors that are associated with re-revision failures can help align surgeon and patient expectations in this challenging population. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

The prevalence of Staphylococcus infections do not decrease despite the preventive measures. The methicillin-resistant staphylococcus aureus (MRSA) has become a major nosocomial pathogen in community hospitals and responsible 60% of staph infections. Through this study we try to study the epidemiology of methicillin-resistant Staphylococcus in the bone and joint infections. We report a 2-year study retrospectipevelly about 25 cases of bone and joint infection staphilococcus methicillin-resistant. All patients underwent clinical examination, an inflammatory balance and surgical treatment with sampling and bacteriological study of the removal liquid and regular monitoring in all patients. The mean age was 5 years and a half. The sexe ratio was 1.2. mean follow-up of 3 months. One patient had dificit G6PD. The mostaffected area was the capital in 64% of cases. The most common location was at the knee in 32%. The most frequent diagnosis was arthritis followed by osteomyelitis. The antibiotics of the first intention was based on amoxicillin and clavulanic acid associated with an aminoglycoside. It was effective in 75%, and modified according to the results of susceptibility testing in 10 cases. The average duration of antibiotic therapy in IV was ten days. The duration of treatment by oral route relay varies from 10 to 21 days. The apyrexia on day 1 postoperatively was obtained in 73%. The screening of patients at risk of carrying MRSA and isolation should help keep to a minimum cross transmission of infections and the number of non-colonized patients. Place of antibiotic therapy is preponderant and meets pharmacodynamic and pharmacokinetic criteria that must be followed in order to optimize medical treatment

Knee arthroscopy with debridement is commonly performed to treat osteoarthritis and degenerative meniscal tears in older adults; however robust evidence does not support sustained benefit from this procedure. Current Canadian guidelines advise against its use as first line treatment. Characterizing the use of this low value procedure will facilitate efforts to maximize quality of care, minimize harm and decrease healthcare costs. We sought to understand:

Data were derived from National Ambulatory Care Reporting System (NACRS), the Discharge Abstract Database (DAD) and the National Physician Database for years 2011-12 to 2019-20. The study included all elective knee arthroscopies (CCI codes 1.VG.80.DA,1.VG.80.FY and 1.VG.87.DA) performed in day surgery and acute care settings in 9 provinces and 3 territories of Canada. Quebec was not included in the analysis due to different reporting methods. We set a threshold of 60 years of age at which it would be highly unlikely that a patient would undergo arthroscopy to treat anything other than osteoarthritis or degenerative meniscal tear. Trends at national and provincial levels were analyzed using regression. Costs were estimated separately using the 2020 case mix groups (CMG) and comprehensive ambulatory care classification system (CACS) methodologies. Surgeons were classified by decade of graduation from medical school (1989 and prior, 1990-99, 2000-09 and 2010+) and categorized based on the proportion of their patient population who were above (“high proportion inappropriate”) or below (“low proportion inappropriate”) the overall national proportion of ≥ 60 years of age.

The number of knee arthroscopies decreased by 37% (42,785 in 2011-12 to 27,034 in 2019-20) overall and 39% (11,103 in 2011-12 to 6,772 in 2019-20) in those 60 years and older (p 25% of patients 60 years and older. Fifty four percent of surgeons who graduated prior to 1989 were considered high proportion inappropriate, whereas only 30.1% of surgeons who graduated in 2010 or later were considered high proportion inappropriate (p < 0 .0001).

Knee arthroscopy continues to be a common procedure in patients over 60 despite strong evidence for lack of benefit. Lower rates in this population in some provinces are encouraging for potential opportunity for improvement. Efforts at practice change should be targeted at surgeons in practice the longest. Canada spends over $12,000,000 per year on this procedure, decreasing its use could allow these resources to be directed to other areas of orthopaedics that provide higher value care.

A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures. We aim to provide a contemporary analysis and compare current clavicle fracture patterns of our adult population with historical reports. A retrospective analysis of a prospectively collected fracture database from an institution serving 598,000 was conducted. Demographic data were recorded prospectively for each patient with an acute clavicle fractures including age, gender, mode of injury, fracture classification, and the presence of associated skeletal injuries. Fractures were classified according to the Robinson system. A total of 312 clavicle fractures were identified, occurring with an incidence of 55.9/100,000/yr (CI 49.8–62.5) and following a bimodal male and unimodal older female distribution. Sporting activity and a simple fall from standing caused the majority of injuries. More than half of simple fall fractures affected the lateral clavicle. The incidence of clavicle fractures has risen over a twenty year period, and a greater proportion of older adults are now affected. Overall, type II midshaft fractures remain the most common, but comparison of this series with historical data reveals that the epidemiology of clavicle fractures is changing. We have identified an increase in the average patient age and overall incidence of clavicle fractures in our adult population. The incidence, relative frequency, and average patient age of type III lateral one-fifth fractures have increased. This epidemiological trend has implications for the future management of clavicle fractures in our region

Background. A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures. Aims. We aim to provide a contemporary analysis and compare current clavicle fracture patterns of our adult population with historical reports. Methods. A retrospective analysis of a prospectively collected fracture database from an institution serving 598,000 was conducted over a 12 month period, beginning July 2007. Demographic data were recorded prospectively for each patient presenting with an acute clavicle fracture including age, gender, mode of injury, fracture classification, and the presence of associated skeletal injuries. Fractures were classified according to the Robinson Classification system. Results. A total of 312 clavicle fractures were identified, occurring with an incidence of 55.9/100,000/yr (CI 49.8–62.5) and following a bimodal male and unimodal older female distribution. Sporting activity and a simple fall from standing caused the majority of injuries. An association between age, mode of injury and fracture type was observed, with younger patients sustaining high energy injury associated with majority of the Type II midshaft fractures; whilst more than fifty-nine percent of Type III lateral one third fractures occur in elderly patients as a result of simple fall. Overall, Type II midshaft fractures remain the most common, but comparison of this series with historical data reveals that the epidemiology of clavicle fractures is changing. Conclusions. We have identified an increase in the average patient age and overall incidence of clavicle fractures in our adult population. The incidence, relative frequency, and average patient age of Type III lateral one-fifth fractures have increased. This epidemiological trend has implications for the future management of clavicle fractures in our region

Aim. Bone and joint infections (BJI) are associated with a heavy morbidity and high health costs. Comorbidities, device associated infections and complicated journeys are associated with increased mortality, treatment failures and costs. For this reason, 24 referral centers (RC) have been created in 2009 in order to advise about management of “complex” BJI in weekly multidisciplinary meetings (MM). Since end of 2012, data from these meetings are gathered in a national database. We aimed to describe the data from this French registry of BJI and determine factors associated with the definition of “complex” BJI. Method. Demographic, clinical, microbiologic and therapeutic characteristics of patients are systematically recorded in the database. Data from the first presentation in RC for each adult patients are presented. Complexity of BJI is recorded after each meeting according to 4 criteria (first failure, complex antibiotic therapy, precarious underlying conditions or complex surgical procedure). Part of unavailable data have been completed by pattern extraction from text-encoded commentaries. Factors associated with complexity were determined by multivariate logistic regression. Results. From 2012 to 2016, 17.527 patients were included corresponding to 30.300 presentations in MM. Median age was 64 years (IQR 50–76) with masculine predominance (61.8%). Comorbidity was present in 50.3%, with at least 2 comorbidities in 26%. Prosthetic joint infection represented 41.4% of patients, followed by chronic osteitis with/without foreign material (24%). Definite microbiologic documentation was available in 68.8% of cases, mostly Staphylococcus aureus (43.9%) followed by Coagulase negative Staphylococci (28.6%) and enterobacteriaceae (23.1%), with 27.4% of polybacterial infections. Antibiotic treatment was proposed in 81.6% and surgery in 70% of cases. BJI were defined as complex in 55.4%, mostly because underlying conditions (50%), and in 57.6% with at least 2 complexity criteria. Factors positively associated with definition of complexity in MM were: background: number of comorbidities, immunodeficiency, neoplasia, liver or kidney failure, intra-cardiac device; microbiology: Mycobacteria, Fungus, MRSA, MSSA, MR-CoNS, MDR enterobacteria, non-fermentative BGN, and atypical pathogens (actinomycetes, nocardia, intra-cellular …); infection characteristics: prosthetic joint infection, osteitis, foreign material infection, arthritis and number of infected sites; surgical procedures: surgical flap, 2 stages prosthesis exchange, spacer, arthrodesis, and joint removal. Simple debridement was negatively associated with complex definition. Conclusions. This registry is the first national prospective database about management of BJI in France and provide many information about epidemiology and management of BJI in France, as well as a more precise definition of complexity

Aim. Pubic osteomyelitis (PO) is one of less frequent Bone and Joint Infections forms (BJI). Its management is still poorly codified as far as nosological framework is still unclear in medical literature. We aim to describe PO epidemiology and to look for factors associated with management failure. Method. We performed a retrospective cohort study, carried out in two Reference Centres, including patients with PO in 2010–2016. Treatment failure was defined by: (i) persistence of clinical signs despite treatment; (ii) clinical relapse with same microorganisms; (iii) infection recurrence with one or more different microorganism(s);. (iv) new signs of infection (abscess, sinus tract) in same area, without recourse to get microbiological documentation. Factors associated with management failure were determined by univariate Cox analysis (hazard ratio [HR] and 95% confidence interval calculation). Kaplan-Meier curve were compared between groups by log-rank test. Results. Twenty-five patients were included over thirteen years (median age 67 years; 19 men, median ASA score 3). Six (24 %) had a PO from haematogenous origin. Those were all monomicrobial infection, due to S.aureus, mostly identified in young patients without comorbidities, especially in athletes. No surgery was required if no abcess or bone sequestrum were found. Nineteen patients (76 %) had a post-operative chronic PO (developed from 1 month to 11 years after a pelvic surgery); 15 of them had history of pelvic cancer (60%); 12 received radiotherapy at the site of infection (48 %). Infection was polymicrobial in 68 % of cases, including 32 % of cases with multidrug-resistant pathogens. A clinical success was recorded in only 14 patients (56%). Treatment failure was always noticed in chronic post-operative forms. Potential risk factors associated with failure management were: pelvic cancer history (HR 3.8; p=0,089); pelvic radiotherapy history (HR 2.9; p=0.122); clinical sinus tract (HR 5.1; p=0,011); infection with multidrug-resistant bacteria (HR 2.8; p=0,116), and polymicrobial infection (HR 70.5; p=0,090). Conclusions. Our study highlights predominant chronic complex post-operative forms of PO. They are mostly plurimicrobial, sometimes associated with multi-drug resistance, occurring in fragile patients with pelvic cancer. It frequently leads to complex antibiotherapy, with important risk of relapse. Aggressive surgical procedure with large bone resection is frequently required in patients who underwent pelvic radiotherapy

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

Alternative bearing surfaces has been introduced to reduce wear debris-induced osteolysis after total hip arthroplasty (THA) and offered favorable results. Large population-based data for total joint surgery permit timely recognition of adverse results and prediction of events in the future. The purpose of this study was to present the epidemiology and national trends of bearing surface usage in primary total hip arthroplasty (THA) in Korea using nationwide database. A total of 30,881 THAs were analyzed using the Korean Health Insurance Review and Assessment Service database for 2007 through 2011. Bearing surfaces were sub-grouped according to device code for national health insurance claims and consisted of ceramic-on-ceramic (CoC), metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), and metal-on-metal (MoM). The prevalence of each type of bearing surface was calculated and stratified by age, gender, hospital type, primary payer, and procedure volume of each hospital. The number of primary THAs increased by 25.2% from 5,484 in 2007 to 6,866 in 2011. The average age of the entire study population was 58.1 years, and 53.5% were male [Table 1]. CoC was the most commonly used bearing surface (76.7%), followed by MoP (11.9%), CoP (7.3%), and MoM (4.1%). The distribution of bearing surfaces was identical to that in the general population regardless of age, gender, hospital type, and primary payer [Table 2]. The mean age of patients that received hard-on-hard bearing surfaces (CoC and MoM) was significantly younger than that of patients receiving hard-on-soft bearing surfaces (CoP and MoP) (56.9 years vs. 62.6 years). During the study period, 55.1% of THAs that used a hard-on-hard bearing surface were performed in males, while 53.0% of THAs that used a hard-on-soft bearing surface were performed in females. The order of prevalence of bearing surfaces was identical in low- and medium-volume hospitals (CoC was first, MoP was second, CoP was third, and MoM was fourth). The mean hospital charges did not differ according to the bearing surface used, with the exception of CoP, which was associated with a lower mean hospital charge. There were no changes in the distribution of bearing surfaces in each year between 2007 and 2011. Overall, the percentage of THAs that used CoC bearing surfaces increased substantially from 71.6% in 2007 to 81.4% in 2011, while the percentage that used CoP, MoP, and MoM decreased significantly [Fig. 1]. One of the reasons for the dominant usage of hard-on-hard bearing surfaces may be that the principal diagnosis of primary THAs and the patient age group distribution in Korea differ from those in other countries. The most common indication for primary THA is osteonecrosis of the femoral head in Korea. In contrast, the majority of primary THAs are performed for osteoarthritis in Western countries. The choice of bearing surface may be affected by many factors, including the nation's medical delivery system, payment type, disease pattern, and age distribution of patients that undergo THA. In future, the results of a large-scale nationwide study on primary THAs using CoC bearing surfaces in Korea will be reported. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Aim. To describe the epidemiology, clinical features and outcomes of native joint septic arthritis in adults admitted to Middlemore Hospital in Auckland, New Zealand. Method. Single-centre retrospective cohort study from 2009 to 2014. Patients ≥16 years of age were identified using ICD-10AM coding data. Electronic records were reviewed for demographic, clinical, laboratory, treatment and outcome data. Total and hemi-arthroplasty infections were excluded. Results. 543 episodes in 521 patients were included, with 90% fulfilling Modified Newman's criteria. Septic arthritis incidence was 26/100,000 patient years and was unchanged over the study period. Incidence correlated strongly with age (R. 2. =0.79) and socioeconomic deprivation (R. 2. =0.76). Median age was 49 years, and gender 70% male. Ethnicity was Pacific Island in 36% (22.8% of catchment population). The most commonly involved joints were hand interphalangeal (19%), knee (19%), metacarpophalangeal (17%) and glenohumeral (11%). Arthritis was monoarticular in 93%. Underlying conditions included current smoking (42%), osteoarthritis (29%), diabetes (22%) and gout (15%). Rheumatoid and seronegative arthritis were uncommon (each 2%). Skin/soft tissue infection occurred within 3 months prior in 38%. Osteomyelitis occurred in 26%. Sources of infection included haematogenous (42%), traumatic (34%), and iatrogenic (17%). Causative organism(s) were isolated in 80% of episodes, most commonly Staphylococcus aureus (53%, 13% of which were MRSA) then Streptococcus pyogenes (15%). 28% of culture-positive episodes were polymicrobial. Median antibiotic duration was 4 weeks, with 38% having definitive therapy orally. A median of 1 surgical procedure was undertaken during treatment. Mortality at 30 days was 3%, at 90 days 5% and treatment failure (defined as any of: death <90 days; relapse; reinfection; or ongoing joint infection leading to readmission, amputation, arthrodesis or excision arthroplasty) occurred in 17%. Treatment failure was significantly more common in cases involving large joints (23%, (69/302) vs. 11%, (26/241), p=0.0002) and in haematogenous episodes versus traumatic episodes (21% (47/229) vs. 10% (19/168), p=0.0045). Conclusions. This is the largest series of adult native joint septic arthritis currently available. The extremely high observed septic arthritis incidence (26/100,000 person years) may relate to high rates of skin and soft tissue infection in Auckland, particularly among Pacific people. Small joint infection, often excluded from previous studies, is associated with significantly better outcomes than large-joint infection. Mortality is lower in this cohort than previously reported, possibly due to the inclusion of small joint infections and exclusion of prosthetic joint infections. Acknowledgements. No additional funding was received for this work

Background. Vitamin D deficiency may increase predisposition to a number of paediatric orthopaedic conditions and the prevalence of vitamin D deficiency is increasing in children in developed countries. The aim of this study was to determine the epidemiology of vitamin D deficiency and insufficiency in children presenting to a regional paediatric orthopaedic service. We also examined the relationships between vitamin D status, social deprivation and ethnicity. Methods. Individuals, age < 18 years, presenting to the regional paediatric orthopaedic service at Southampton, UK from 2008 to 2010 were investigated. Deprivation index scores were calculated from indices of deprivation. Results. 187 children (97 male, 90 female, mean age 7.1 years) underwent serum 25-(OH) D level measurement. 82% were white British and 11% of Asian ethnicity. The calculation of the total depravation index for the whole cohort showed 34 (18%) of subjects were in quartile 1 (least deprived), 54 (29%) in quartile 2, 49 (26%) in quartile 3 and 50 (27%) in quartile 4 (Most deprived). 60 (32%) had vitamin D insufficiency with 25-(OH) levels < 50nmol/l and 15 (8%) had vitamin D deficiency. No relation ship was identified between vitamin D level and social depravation score. Conclusions. There is a need for awareness of the prevalence of vitamin D deficiency in the paediatric orthopaedic population presenting with bone pain and lower limb deformity before commencing ‘observation or orthopaedic surgical treatment’