The aim of this investigation is to firstly quantify the burden of disease, and secondly qualify the organisms being cultured during debridement to establish their sensitivities to available antibiotics. This study will also look at the concomitant burden of Human Immunodeficiency Virus (HIV) and Diabetes Mellitus (DM) in cases of hand sepsis, to establish whether these two disease processes require special consideration and treatment tailoring. The method employed to collect the data will be retrospective collection of patient information, using random sampling. Included patients will be adult patients who undergo debridement and have a sample registered on the National Health Laboratory System (NHLS). The daily intake sheet will be used to collect patients details and these details will then be used to collect results of intra-operative specimens using the NHLS. These patient details will also be used to check patients’ HIV results and HBA1c (Glycated Haemoglobin A1c) results. Majority of the specimens revealed Methicillin Sensitive Staphylococcus Aureus (MSSA), with a reassuringly low rate of Methicillin Resistant Staphylococcus Aureus (MRSA) when compared to international data. The yield of patients tested for HIV or DM was lower than expected, despite this being the standard of care. The projected impact of this study will be assessment of the current burden of disease and then clarification of our current management strategy, in order to assess if it would be possible to change to a more cost-effective antibiotic with a narrower spectrum of bacteria coverage. The potential exists to not only implement cost saving measures, but also promote antibiotic stewardship by decreasing the practice of empiric broad-spectrum antibiotic use

Dysglycemia in the post-operative period has been associated with increased rates of infection following total joint arthroplasty. Additionally, patients without clinical diagnosis of diabetes with hemoglobin A1c% values between 5.7% and 6.4% have been shown to be dysglycemic in the peri-operative period. This study examines the influence of post-operative blood glucose management on rates of re-operation for infection in patients undergoing total joint arthroplasty in diabetic, and clinically non-diabetic patients. We performed a retrospective review of prospectively collected data, for all primary, elective total hip and total knee arthroplasties performed at The Ottawa Hospital between April 2010 and October 2017. Kaplan-Meier survivorship, and mutivarient regression analysis were used to determine predictors of infection based on pre-operative diabetes status, HbA1c%, and post-operative insulin management. 4159 joints met inclusion criteria. Patients with HbA1c 5.7–6.4% had lower rate of revision for infection if they received post-operative blood glucose management (0.80%), vs without glucose management (1.20%). Kaplan-Meier survivorship analysis showed this difference to be insignificant (p=0.23). Patients with DM1 had statistically worse survivorship when compared to other groups (p=0.010). Patients with undiagnosed perioperative dysglycemia may be at a greater predisposition for developing infection, requiring re-operation, following total joint arthroplasty. This study may be underpowered due to overall low rates of revision. More rigorous peri-operative glucose management strategies may be required for patients, who otherwise receive no glycemic management outside of hospital. This is more pertinent with trends towards decreasing post-operative lengths-of-stay

Introduction. Wound condition after primary total knee arthroplasty (TKA) is important for prevention of periprosthetic infection. Any delay in wound healing will cause deep infection, which leads to the arthroplasty failure. Prevention of soft tissue problems is thus essential to achieve excellent clinical results. However, it is unknown as to the important surgical factors affecting the wound healing using detailed wound score after primary TKA so far. It was hypothesized that operative technique would affect wound healing in primary TKA. The purpose of the present study was to investigate and to clarify the important surgical factors affecting wound score after primary TKA. Methods. A total of 139 knees in 128 patients (mean 73 years) were enrolled. All primary TKAs were done by single surgeon. All patients underwent unilateral or bilateral TKA using Balanced Knee System®, posterior stabilized (PS) design (Ortho Development, Draper, UT) or Legion®, PS design (Smith and Nephew, Memphis, TN) under general and/or epidural anesthesia. Patients with immunosuppressive therapy, hypokalemia, poor nutrition (albumin < 3.4 g/dL), diverticulosis, infection elsewhere, uncontrolled diabetes mellitus (HbA1C>7.0%), obesity (Body Mass Index > 35 kg/m2), smoking, renal failure, hypothyroidism, alcohol abuse, rheumatoid arthritis, posttraumatic arthritis, and previous knee surgery were excluded. Hollander Wound Evaluation Score (HWES) was assessed on postoperative day 14. We evaluated age, sex, body mass index, HbA1C (%), preoperative femorotibial angle (FTA) on plain radiograph. In addition, intraoperative patella eversion, intraoperative anterior translation of the tibia, patella resurfacing, surgical time, tourniquet time, unidirectional barbed suture and length of skin incision were also evaluated as surgical factors. Multiple regression analysis was done using stepwise method to identify the surgical factors affecting HWES. Results. Detailed demographic data was presented in Table 1. The average HWES was 5.0 ± 0.8 point. As to the distribution of the HWES, data was shown in Figure 1. Namely, HWES was 3 point in 5 cases, 4 in 29 cases, 5 in 63 cases, and 6 in 42 cases. As any adverse events were not found in each TKA, there were no cases requiring debridement and re-closure of the wound after primary TKA. According to stepwise forward regression test, intraoperative patella eversion and anterior translation of the tibia were entered in this model, while age, Sex, BMI, HbA1C, FTA, surgical time, tourniquet time, patella resurfacing, unidirectional barbed suture and length of skin incision were not entered in the model. The multiple regression analysis in the current study would show the appropriate results, as Durbin-Watson ratio was 1.762. Standardized partial regression coefficient was as follows; 0.57 in anterior translation of the tibia, 0.38 in patella eversion (Table 2). Discussion. The results of the present study would support out hypothesis that operative technique would affect wound healing in primary TKA. Specifically, intraoperative patella eversion and anterior translation of the tibia should be avoided for quality cosmesis of the wound healing in primary TKA. To view tables/figures, please contact authors directly

Diabetes is a poor prognostic indicator after an acute ankle fracture. Many surgeons avoid essential surgery due to their concerns regarding complications. We performed a retrospective analysis of complication rates for acute ankle fractures in diabetics with a control non-diabetic patient treated by all surgeons in our unit and assessed factors for success including long-segment fixation methodologies. Patient records were cross-referenced with departmental databases and a retrospective review of all ankle fractures managed in our department was conducted from 2014. All patients subjected to a retrospective review of their notes and assessment of their follow up for at least 6 months. Radiographs were assessed of the ankle before and at completion of treatment were reviewed independently (RA and FR). We identified all patients with a diabetic ankle fracture their HB1Ac (for diabetic control) and systematic co-morbidities. Fractures were classified into unimalleolar, bi malleolar and trimalleolar and surgery grouped into standard or long-segment-rigid fixation. Statistical analysis was conducted using absolute/relative risk (RR); numbers needed to treat (NNT) were calculated. We compared a control-group, a diabetic group managed conservatively, and undergoing surgery; comparing the concept of rigid fixation. Further sub-analysis conducted to assess differences between diabetic neuropathy, retinopathy and nephropathy. Ethics approval was granted as per our institutional policy by our governance lead. We identified 64 patients with a diabetic ankle fractures, their fracture pattern and a control group. Thirty-one had conservative treatment; 33 had operative fixation of which 13 had rigid fixation. Compared to the control (n=32) both diabetic groups had a higher risk of possible complication. The relative risk was between 3.1–3.4 (P<0.002) and linked to systematic complications of diabetes e.g. neuropathy 5.9 (P<0.003); HBA1c 4.6 P<0.004); and neuropathy and retinopathy 6.2 P<0.0003). We observed RR is reduced for a complication occurring following surgery with prolonged immobilization (0.86) and rigid fixation (0.65) and NNT required to see a benefit from rigid fixation was 7. The overall RR for a complication was similar between conservative and surgical management (4.6 vs.5.1). We agree diabetics have a higher risk for complications than non-diabetics, however the risk is not as great as previously reported. There is little difference in surgical or conservative treatment but strong evidence indicating rigid long-segment-fixation with prolonged-immobilization could improve the risk benefit ratio when compared to non- operative management alone but further evaluation is required

The mid foot joints are usually the first to be affected in Charcot neuroarthropathy(CN). Reconstruction is technically demanding and fraught with complications. Fixation methods have evolved over time from cancellous screws, plates, bolts and a combination of these. We present our experience of mid foot fusion in CN from a tertiary diabetic foot centre. In this series we undertook mid foot corrective fusion in 27 feet (25patients) and are presenting the results of those with a minimumof six months follow up. Twelve of these had concurrent hindfoot fusion. Eleven patients had type 1 diabetes, 12 had type 2 and 2 were non-diabetics. 23 patients were ASA grade3 and 2 were ASA 2. 21 feet had ulcers preoperatively and mean HbA1c was 8.2. 13 patients had diabetic retinopathy and 6 had nephropathy. Average patient age was 59 (43 to 80) and our mean follow up was 35 months (7 to 67). One patient was lost to follow up and 2 patients died. 18 patients had plates, 3 had bolts and 6 had a combination. Complete follow up data was available for 26 feet in 24 patients. Satisfactory correction of deformity was achieved in all patients. The mean correction of calcaneal pitch was from 0.6 preoperatively to 10.6 degrees postoperatively, mean Meary angle from 22 to 9 degrees, talo- metatarsal angle on AP view from 33 to 13 degree. Bony union was achieved in 21 out of 26 feet and atleast one joint failed to fuse in 5. 19 out of 24 patients were able to mobilize fully or partially weight bearing. We had 6 patients with persisting and 3 withrecurrent ulceration. Seven repeat procedures were carried out which included 2 revision fixations. 4 out of 5 non-unions were seen where bolts were used alone or supplemented with plates. With our technique and a strict protocol 100% limb salvage and 81% union was achieved. 80% patients were mobile and ulcer healing was achieved in 72%. Corrective mid foot fusion is an effective procedure in these complex casesbut require the input of a multidisciplinary team for perioperative care

Aims

To evaluate safety outcomes and patient satisfaction of the re-introduction of elective orthopaedic surgery on ‘green’ (non-COVID-19) sites during the COVID-19 pandemic.

Aims

Diabetes mellitus is the most common co-morbidity associated with necrotising fasciitis. This study aims to compare the clinical presentation, investigations, Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score, microbiology and outcome of management of this condition in diabetic and non-diabetic patients.