Aims. This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures. Methods. Using the National Surgical Quality Improvement Programme (NSQIP) database, patients who underwent common orthopaedic surgery procedures from 1 January to 31 December 2021 were extracted. Patient preoperative COVID-19 status, demographics, comorbidities, type of surgery, and postoperative complications were analyzed. Propensity score matching was conducted between COVID-19-positive and -negative patients. Multivariable regression was then performed to identify both patient and provider risk factors independently associated with the occurrence of 30-day postoperative adverse events. Results. Of 194,121 included patients, 740 (0.38%) were identified to be COVID-19-positive. Comparison of comorbidities demonstrated that COVID-19-positive patients had higher rates of diabetes, heart failure, and pulmonary disease. After propensity matching and controlling for all preoperative variables, multivariable analysis found that COVID-19-positive patients were at increased risk of several postoperative complications, including: any adverse event, major adverse event, minor adverse event, death, venous thromboembolism, and pneumonia. COVID-19-positive patients undergoing hip/knee arthroplasty and trauma surgery were at increased risk of 30-day adverse events. Conclusion. COVID-19-positive patients undergoing orthopaedic surgery had increased odds of many 30-day postoperative complications, with hip/knee arthroplasty and trauma surgery being the most high-risk procedures. These data reinforce prior literature demonstrating increased risk of venous thromboembolic events in the acute postoperative period. Clinicians caring for patients undergoing orthopaedic procedures should be mindful of these increased risks, and attempt to improve patient care during the ongoing global pandemic. Cite this article: Bone Jt Open 2023;4(9):704–712

SARS-CoV-2 emerged in Wuhan, China in December 2019 causing pneumonia and resulting in a pandemic, commonly known as COVID-19. This pandemic led to significant changes to our daily lives due to restrictions, such as social distancing, quarantining, stay at home orders and closure of restaurants and shops among other things. The psychological effects of this uncertainty as well as of these changes to our lives have been shown to be significant. This study is a prospective study investigating the mental effects of the pandemic on hand and wrist patients seen in our clinic during this pandemic. A prospective database on wrist pain was used to identify patients seen in our hand clinic from January 1, 2018 to December 10, 2021. All participants had been diagnosed with either radial sided wrist pain or ulnar side wrist pain. The Center for Epidemiological Studies Depression (CES-D) Scale was used to assess the mental health of our participants before and during this pandemic. An independent samples t-test was used to compare the scores of the 2 groups. A total of 437 CES-D questionnaires were collected during this period. 118 of them belonging to the pandemic group and 319 to the pre-pandemic group. A difference (p < 0 .05) in the CES-D score was observed between the pre-pandemic and during pandemic groups. The mean score for the pre-pandemic group was found to be 9.23 (8.94) and 12.81 (11.45) for the pandemic group. However, despite the increase in score, it didn't exceed the cut off score of 16 or greater used to assess depression. Our results indicate that there was a slight increase in score for depression in hand and wrist patients, but not above the cut off level of 16 to be of a significant risk for depression. Other global studies have shown an increase in depression in the general public. Our mild results might be attributed to the fact that British Columbia did not implement severe restrictions compared to other countries or regions, i.e no stay at home orders. Additionally, our study population was skewed and included more middle age and older patients compared to younger ones and age might be a factor in keeping the score down

Unstable chest wall injuries have high rates of mortality and morbidity. These injuries can lead to respiratory dysfunction, and are associated with high rates of pneumonia, sepsis, prolonged ICU stays, and increased health care costs. Numerous studies have demonstrated improved outcomes with surgical fixation compared to non-operative treatment. However, an adequately powered multi-centre randomized controlled study using modern fixation techniques has been lacking. We present a multi-centred, prospective, randomized controlled trial comparing surgical fixation of acute, unstable chest wall injuries with the current standard of non-operative management. Patients aged 16–85 with a flail chest (3 or more consecutive, segmental, displaced rib fractures), or severe deformity of the chest wall, were recruited from multiple trauma centers across North America. Exclusion criteria included: severe pulmonary contusion, severe head trauma, randomization>72 hours from injury, inability to perform surgical fixation within 96 hours from injury (in those randomized to surgery), fractures of the floating ribs, or fractures adjacent to the spine not amendable to surgical fixation. Patients were seen in follow-up for one year. The primary outcome was days free from mechanical ventilation in the first 28 days following injury. Secondary outcomes were days in ICU, rates of pneumonia, sepsis, need for tracheostomy, mortality, general health outcomes, pulmonary function testing, and other complications of treatment. A sample size of 206 was required to detect a difference of 2 ventilator-free days between the two groups, using a 2-tailed alpha error of 0.05 and a power of 0.80. A total of 207 patients were recruited from 15 sites across Canada and USA, from 2011–2018. Ninety-nine patients were randomized to non-operative treatment, and 108 were randomized to surgical fixation. Overall, the mean age was 53 years, and 75% of patients were male, with 25% females. The commonest mechanisms of injury were: motor vehicle collisions (34%), falls (20%), motorcycle collisions (14%), and pedestrian injuries (11%). The mean injury severity score (ISS) at admission was 26, and patients had a mean of 10 rib fractures. Eighty-nine percent of patients had pneumothorax, 76% had haemothorax, and 54% had pulmonary contusion. There were no differences between the two groups in terms of demographics. The final results will be available and presented at the COA meeting in Halifax. This is the largest randomized controlled trial to date, comparing surgical fixation to non-operative treatment of unstable chest wall and flail chest injuries. The results of this study will shed light on the best treatment options for patients with such injuries, help understand outcomes, and guide treatment. The final results will be available and presented at the COA meeting in Halifax

Abstract. Background. Elderly patients with degenerative lumbar disease are increasingly undergoing posterior lumbar decompression without instrumented stabilisation. There is a paucity of studies examining clinical outcomes, morbidity & mortality associated with this procedure in this population. Methods. A retrospective analysis of aged 80–100 years who underwent posterior lumbar decompression without instrumented stabilisation at University Hospitals of Derby &Burton between 2016–2020. Results. Total 167 eligible patients, 163 octogenarians & 4 nonagenarians. Mean age was 82.78 ± 3.07 years. Mean length of hospital stay 4.79 ± 10.92 days. 76% were pain free at 3months following decompression. The average Charleston co-morbidity index (CCI) was 4.87. No association found with CCI in predicting mortality (ODD ratio 0.916, CI95%). 17patients suffered complications; dural tear (0.017%), post-op paralysis (0.017%), SSI(0.01%), and 0.001% of hospital acquired pneumonia, delirium, TIA, urinary retention, ileus, anaemia. High BMI (35+) was associated with increased incidence of complication (CI 95%, p<0.002). There was significant social drift following discharge as 147 patients went home and 4 patients to rehabilitation facility (p<0.001FE test). The mean operative time was 91.408±41.17 mins and mean anaesthetic time was 36.8±16.06 mins. Prolonged operative time was not associated with increased mortality.2year revision decompression rate was 0.011%. Conclusion. Posterior lumbar decompression without instrumented stablisation in elderly is safe & associated with low mortality with 99.5%survival at 1 year. It significantly improves PROMs & has extremely low revision rate. Incidence of post-op complication is <0.05% and 54% of patients get discharged within 72hours of surgery. Careful selection & optimising patients with high BMI would reduced perioperative morbidity and mortality

Introduction. Since the expanded war in Ukraine in 2022, explosives, mines, debris, blast waves, and other factors have predominantly caused injuries during artillery or rocket attacks. These injuries, such as those from shelling shrapnel, involve high-energy penetrating agents, resulting in extensive necrosis and notable characteristics like soft tissue defects and multiple fragmentary fractures with bone tissue defects and a high rate of infection complications caused by multi resistant gram-negative (MRGN) pathogens. Material and Methods. We conducted a prospective study at our center between March 2022 and December 2023. Out of the 56 patients from Ukraine, 21 met the inclusion criteria who had severe war injuries were included in the study. Each of these patients presented with multiple injuries to both bones and soft tissues, having initially undergone treatment in Ukraine involving multiple surgeries. The diagnosis of infection was established based on the EBJIS criteria. Prior to our treatment patients had undergone multiple revision surgeries, including debridement, biopsies, implant and fixator replacement. Additionally, soft tissue management required previously VAC therapy and flap reconstruction for successful treatment. Results. All 21 infections manifested as bone infections (11; 52%), followed by implant-associated infections (5; 24%), soft tissue infections (4; 19%), and septic arthritis (1; 5%). In all patients, the infection was polymicrobial, caused by 3- and 4-MRGN pathogens, as Klebsiella pneumonia 4MRGN, Proteus mirabilis 4MRGN, Enterobacter cloacae 4MRGN etc. Upon admission, all patients carried a diagnosis and exhibited signs indicative of chronic infection. 19 (90.5%) patients required complex antibiotic regimens combined with multiple wound revisions and debridements, changes of fixators and combination of systemic and local antibiotic therapy. In 6 patients (28%) high dosages of local antibiotics such as gentamycin, vancomycin and meropenem were incorporated into a carrier of bio-absorbable calcium sulfate, calcium sulfate/hydroxyapatite which were introduced into the hip joint, femoral canal or bone defect for dead space management during the surgery. When local antibiotics were administered at intervals, the microbiology results at implantation showed negative results. 2 (9%) patients had new infections (different site, different pathogens), 1 (4.8%) is still under the treatment. In 17 (81%) patients infection complications were treated successfully with no recurrence of infection. Conclusion. War injuries result in complex bone and soft-tissue infections caused by 3-, 4-MRGN pathogens. Addressing this challenge necessitates multidisciplinary approach with multiple, thorough surgical debridements, effective local, and systemic antimicrobial therapy. As for the outlook we can see potential in local antibiotic carriers

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

INTRODUCTION. Shoulder arthroplasty (SA) is an effective procedure for managing patients with shoulder pain secondary to degenerative joint disease or end stage arthritis that has failed conservative treatment. Insurance status has been shown to be an indicator of patient morbidity and mortality. The objective of the current study is to evaluate the effect of patient insurance status on outcomes following shoulder replacement surgery. METHODS. Data was obtained from the Nationwide Inpatient Sample between 2004 and 2011. Analysis included patients undergoing shoulder arthroplasty procedures determined by ICD-9 procedure codes. Patient demographics and comorbidities were analyzed and stratified by insurance type. The primary outcome was medical and surgical complications occurring during the same hospitalization with secondary analysis of mortality. Pearson's chi¬squared test and multivariate regression were performed. RESULTS. A data inquiry identified 103,290 patients (68,578 Medicare, 27,159 private insurance, 3,544 Medicaid/uninsured, 4,009 Other) undergoing partial, total and reverse total shoulder replacements. The total number of complications was 17,810 (17.24%), and the top three complications included acute cardiac events (8,165), urinary tract infections (3,154), and pneumonia (1,635). The highest complication rate was observed in the Medicare population (20.3%), followed by the Medicaid/uninsured (16.9%), other (11.1%), and the privately-insured cohort (10.5%). Multivariate regression analysis indicated that having Medicare insurance, white race, increasing age, higher comorbidity, and urgent or emergent admissions was associated with medical complications. Black patients, increasing age and comorbities was associated with surgical complications. Overall mortality was 0.20% and was more common in total shoulder arthroplasty and surgeries done on emergent or urgent admissions. DISCUSSION. This data reveals that patients with Medicare, Medicaid or no insurance were more likely to have medical complications, most commonly cardiac complications, UTIs and pneumonia. Primary insurance payer status can be considered as an independent risk factor during preoperative risk stratification and planning

Flail chest and multiple rib fractures are common injuries in trauma patients. Several small randomized studies have suggested significant improvements in patient outcomes with surgical fixation, compared to nonoperative management, yet emerging population-level data report some conflicting results. The objectives of this study were to compare the results of surgical fixation and nonoperative management of multiple rib fractures and flail chest injuries and to assess whether effects varied by study design limitations, including risk of confounding by indication. A comprehensive search of electronic databases (Medline, Embase, Web of Science) was performed to identify randomized controlled trials and observational studies. Random effects models were used to evaluate weighted risk ratios (RR) and mean differences (MD). Risk of confounding by indication was assessed for each study (low, medium, and high risk), and this categorization was used to stratify results for clinical outcomes. Publication bias was assessed. Thirty-nine studies, with a total of 19,357 patients met inclusion criteria. Compared to nonoperative treatment, surgical fixation of flail chest and multiple rib fractures was associated with decreased risk of death (overall RR 0.40, 95% confidence interval (CI) 0.28–0.56), pneumonia (overall RR 0.70, 95% CI 0.52–0.93), tracheostomy (overall RR 0.62, 95% CI 0.41–0.93), and chest wall deformity (overall RR 0.16, 95% CI 0.06–0.42). However, many of the observational studies were at risk of confounding by indication, and results varied according to risk of confounding by indication. Differences in ventilator time, intensive care unit length of stay (LOS), hospital LOS, and return to work will be assessed (results pending). Compared to nonoperative treatment, surgical fixation of flail chest and multiple rib fractures is associated with improved clinical outcomes. Discrepancies between some study results may be due to confounding by indication. Additional prospective randomized trials and high-quality observational studies are required to overcome potential threats to validity and to expand on existing evidence around optimal treatment of these injuries

Surgical fixation of tibial plateau fractures in elderly patients with open reduction and internal fixation (ORIF) provides inferior outcomes compared to younger patients. Primary total knee arthroplasty (TKA) may be of benefit in patients with pre-existing arthritis, marked osteopenia, or severe fracture comminution. Rationale for primary TKA includes allowing early mobility in hopes of reducing associated complications such as deconditioning, postoperative pneumonia, or venous thromboembolism, and reducing post-traumatic arthritis which occurs in 25% to 45% of patients and requires revision TKA in up to 15%. Subsequent revision TKA has been shown to have significantly worse outcomes than TKA for primary osteoarthritis. This systematic review sought to elicit the clinical outcomes and peri-operative complication rates following primary TKA for tibial plateau fractures. A comprehensive search of MEDLINE, Embase, and PubMed databases from inception through March 2018 was performed in accordance with PRISMA guidelines. Two reviewers independently screened papers for inclusion and identified studies featuring perioperative complications and clinical outcomes following primary TKA for tibial plateau fractures. Studies were included for final data analysis if they met the following criteria: (1) studies investigating TKA as the initial treatment for tibial plateau fractures, (2) patients must be ≥ 18 years old, (3) have a minimum ≥ 24-month follow-up, and (4) must be published in the English language. Case series, cohort, case-control, and randomized-control trials were included. Weighted means and standard deviations are presented for each outcome. Seven articles (105 patients) were eligible for inclusion. The mean age was 73 years and average follow-up was 39 months. All-cause mortality was 4.75% ± 4.85. The total complication rate was 15.2% ± 17.3% and a total of eight patients required revision surgery. Regarding functional outcomes, the Knee Society score was most commonly reported. The average score on the knee subsection was 85.6 ± 5.5 while the average function subscore was 64.6 ± 13.7. Average range of motion at final follow-up was 107.5° ± 10°. Total knee arthroplasty for the treatment of acute tibial plateau fractures is enticing to allow early mobility and weightbearing. However, complication rates remain high. Functional outcomes are similar to patients treated with ORIF or delayed arthroplasty. Given these findings, surgeons should be highly selective in performing TKA for the immediate treatment of tibial plateau fractures

Aim. Bone and joint infections are frequent in African countries and their prevention and treatment remain a great challenge. This study aimed to determine the bacterial ecology and sensitivity of isolates to locally available antibiotics in orthopedic unit of a tertiary care hospital in Cameroun. Method. During a 12 months period, all the patients presenting with osteomyelitis or septic arthritis irrespective of the mechanism and the location were enrolled in this study. Intraoperative samples (biopsies) were taken and sent for microbiological analysis, and all strains isolated were tested for antibiotic sensitivity according to conventional methods. Results. on the 52 bacteriological analysis performed, 48 were positive. The most isolated germs were staphylococcus aureus (41.9 % of isolates), pseudomonas aeruginosa (14.5 %), Escherichia coli (14.5 %) and Klebsiella pneumonia (12.9 %). The antibiotic sensitivity pattern revealed worrying resistance rates for common and affordable antibiotics: ampicillin (94 %), amoxicillin + clavulanic acid (63.9 %), ceftazidim (65.5%), ticarcillin + clavulanate (57.4%), gentamycin (49 %), ciprofloxacin (40 %), cefuroxim (40 %), tobramycin (38.5 %). The strains of Staphylococcus aureus showed resistance to penicillin G (83%), oxacillin (25%), lincomycin (27%) and vancomycin (7%). The overall highest sensitivity rates were observed with amikacin (92 %) and imipenem (90.1%), which for many patients were the only effective locally available antibiotics. The daily cost of treatment with those two antibiotics is close to the guaranteed minimum wage in our country. Conclusions. The alarming rate of multidrug-resistant bacteria makes the long antibiotic treatment of bone infections unaffordable (in a context of lack of social insurance) for most of our patients. We advocate strong national policies for bacteriological surveillance and antibiotic misuse de-escalation to prevent antibiotic resistance

Purpose. The objective of this meta-analysis was to compare the effects of early and delayed surgery on the risk of mortality, common post-operative complications, and length of hospital stay among elderly hip fracture patients. Methods. We searched MEDLINE and EMBASE for relevant prospective studies evaluating surgical delay in patients undergoing surgery for hip fractures published in all languages between 1966 and 2008. Two reviewers independently assessed methodological quality and extracted relevant data. Results. Of 1939 citations identified, 16 observational studies that included a total of 13,478 patients with complete mortality data (1764 total deaths) met our inclusion criteria. Irrespective of the cut-off for delay (24, 48, or 72 hours), earlier surgery (< 24, < 48, or < 72 hours) was significantly associated with a reduction in the risk of unadjusted one-year mortality (relative risk 0.55; 95% confidence interval, 0.40 to 0.75, p=0.0002) and adjusted mortality rates (relative risk 0.81; 95% confidence interval, 0.68 to 0.96, p=0.01). Based on unadjusted data, earlier surgery also reduced in-hospital pneumonia (relative risk 0.59; 95% confidence interval, 0.37 to 0.93, p=0.02), pressure sores (relative risk 0.48; 95% confidence interval, 0.34 to 0.69, p< 0.0001) and hospital stay (weighted mean difference 9.95 days; 95% confidence interval, 1.52 to 18.39, p=0.02). Conclusion. Earlier surgery was associated with a reduced risk of mortality, post-operative pneumonia, pressure sores, and length of hospital stay among elderly hip fracture patients. This suggests that it may be warranted to reduce surgical delays whenever possible. However, unadjusted analyses are certainly confounded, and residual confounding may be responsible for apparent effects in adjusted analyses. A definitive answer to this issue will require the conduct of a large randomised controlled trial to evaluate the effect of earlier surgery among patients admitted with a hip fracture

Down syndrome (DS), is a genetic disorder caused by a third copy of the 21st chromosome (Trisomy 21), featuring typical facial characteristics, growth delays and varying degrees of intellectual disability. Some degree of immune deficiency is variably present. Multiple orthopaedic conditions are associated, including stunted growth (90%), ligamentous laxity (90%), low muscle tone (80%), hand and foot deformities (60%), hip instability (30%), and spinal abnormalities including atlanto-axial instability (20%) and scoliosis. Hip disease severity varies and follows a variable time course. Rarely a child presents with DDH, but during the first 2 years the hips are characteristically stable but hypermobile with well-formed acetabulae. Spontaneous subluxation or dislocation after 2 presents with painless clicking, limping or giving way. Acute dislocation is associated with moderate pain, increased limp and reduced activity following minor trauma. Hips are reducible under anesthesia, but recurrence is common. Eventually concentric reduction becomes rarer and radiographic dysplasia develops. Pathology includes: a thin, weak fibrous capsule, moderate to severe femoral neck anteversion and a posterior superior acetabular rim deficiency. A number of femoral and acetabular osteotomies have been reported to treat the dysplasia, with acetabular redirection appearing to be most successful. However, surgery can be associated with a relatively high infection rate (20%). Additionally, symptomatic femoral head avascular necrosis can occur as a result of slipped capital femoral epiphysis. Untreated dysplasia patients can walk with a limp and little pain into the early twenties even with fixed dislocation. Pain and decreasing hip function is commonly seen as the patient enters adult life. Occasionally the hip instability begins after skeletal maturity. Total hip arthroplasty (THA) is the standard treatment when sufficient symptoms have developed. The clinical outcomes of 42 THAs in patients with Down syndrome were all successfully treated with standard components. The use of constrained liners to treat intra-operative instability occurred in eight hips and survival rates were noted between 81% and 100% at a mean follow-up of 105 months (6 – 292 months). A more recent study of 241 patients with Down syndrome and a matched 723-patient cohort from the Nationwide Inpatient Sample compared the incidence of peri-operative medical and surgical complications in those who underwent THA. Compared to matched controls, Down syndrome patients had an increased risk of complications: peri-operative (OR, 4.33; P<.001), medical (UTI & Pneumonia OR, 4.59; P<.001) and surgical (bleeding OR, 3.51; P<.001), Mean LOS was 26% longer (P<.001). While these patients can be challenging to treat, excellent surgical technique and selective use of acetabular constraint can reliably provide patients with excellent pain-relief and improved function. Pre-operative education of all clinical decision makers should also reinforce the increased risk of medical and surgical complications (wound hemorrhage), and lengths of stay compared to the general population

Among the most critical factors to reducing the risk of infection include the use of pre-incisional antibiotics, appropriate skin preparation with clippers (as opposed to a razor for hair removal) and the use of an alcohol-based skin preparation. Host factors are also likewise critically important including obesity, diabetes, inflammatory arthritis, renal insufficiency, skin disorders and patients who are otherwise immune-compromised. If modifiable risk factors are identified, it would seem reasonable to delay elective surgery until these can be optimised. One other factor to consider is the nutritional status of the patient. In a study of 501 consecutive revisions, we found that serological markers suggestive of malnutrition (albumin, transferrin or total lymphocyte count) were extremely common. Specifically, 53% of patients who presented for treatment of a chronic infection had at least one marker for malnutrition, compared to 33% in the group of patients undergoing revision for an aseptic reason. Malnutrition was found to be an independent risk factor for septic failure (p < 0.001 and OR 2.1). Interestingly, malnutrition was most common among patients of normal weight but was also common among obese patients (so-called “paradoxical” malnutrition). What was more disturbing, however, was that of those patients undergoing an aseptic revision, serum markers of malnutrition were associated with a 6× risk of acute post-operative infection complicating the patient's aseptic revision. We have confirmed this association using the NSQIP database where hypoalbuminemia was associated with a higher risk of infection, pneumonia and readmission. At our center, we also have studied the use of dilute betadine at the end of the case, prior to wound closure, in an attempt to decrease the load of bacteria in the wound. In a retrospective review the prevalence of acute post-operative infection was reduced from just under 1% (18/1862) to 0.15% (1 of 688; p = 0.04). It is critical that the betadine utilised be STERILE and the dilution we use is 0.35% made by diluting 17.5cc of 10% povidone-iodine paint in 500cc of normal saline

Aims

The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Hip fractures are among the most common orthopaedic injuries and represent a growing burden on healthcare as our population ages. Despite improvements in preoperative optimisation, surgical technique and postoperative care, complication rates remain high. Time to surgery is one of the few variables that may be influenced by the medical team. The aim of the present study was to evaluate the impact of time to surgery on mortality and major complications following surgical fixation of hip fractures. Utilising the American College of Surgeons' National Quality Improvement Program (NSQIP) database, we analysed all hip fractures (femoral neck, inter-trochanteric, and sub-trochanteric) treated from 2011 to 2013 inclusively. We divided patients into three groups based on time to surgery: less than one day (<24h), one to two days (24–48h), and two to five days (48–120h). Baseline characteristics were compared between groups and a multivariate analysis performed to compare 30-day mortality and major complications (return to surgery, deep wound infection, pneumonia, pulmonary embolus, acute renal failure, cerebrovascular accident, cardiac arrest, myocardial infarction, or coma) between groups. A total of 14,730 patients underwent surgical fixation of a hip fracture and were included in our analysis. There were 3,475 (24%) treated <24h, 9,960 (67%) treated 24–48h, and 1,295 (9%) treated 48–120h. Thirty-day mortality and major complication rates were 5.0% and 6.2% for the <24h group, 5.3% and 7.0% for the 24–48h group, 7.9% and 9.7% for the 48–120h group respectively. After controlling for baseline demographic differences between groups (age, sex, race) as well as pertinent comorbidities (diabetes, dyspnea, chronic obstructive pulmonary disease, chronic steroid use, hypertension, cancer, bleeding disorders, and renal failure), time to surgery beyond 48h resulted in greater odds of both mortality (1.45, 95%CI 1.10–1.91) and major complications (1.45, 95%CI 1.12–1.84). Time to surgery is one of the few variables that can be influenced by timely medical assessment and access to the operation room. Expediting surgery within 48h of hip fracture is of paramount importance as it may significantly reduce the risk of mortality as well as major complications

Almost any kind of bacteria can be involved in prosthetic joint infections (PJI). In 2014 we collected data on 3 patients presenting with hip or knee pain and radiological signs of prosthetic joint mobilization without any other clinical or biochemical suspect of infection. Interestingly, in all cases we isolated bacteria very rarely involved in human infections: Cupriavidus pauculus, Ralstonia paucula and Neisseria flavescens. Both Cupriavidus pauculus and Ralstonia paucula are Gram negative environmental bacteria which can contaminate water (tap, pool and mineral) and have been isolated from a variety of human clinical sources including blood, wounds, sputum, urine, eye, throat and peritoneal fluid, as non pathogenic flora. In such two patients we were able to cure the infection with quinolones (both strains were sensible). Neisseria species are Gram-negative bacteria included among the proteobacteria. Neisseria flavescens is often found in the upper respiratory tract and oropharynx of humans, rarely associated with infectious process (necrotizing pneumonia and empyema). In this last patient we successfully used piperacillin-tazobactam i.v. during hospitalization and shifted to amoxicillin-clavulanate per os at discharge. In conclusion, any bacteria can induce PJI: in some cases pre-operative blood tests are normal and therefore useless. We need new tests to overcome this diagnostic problem (such as alpha-defensin) and we must check on rare bacteria prolonging incubation to a more extended period of time (as in Propionebacterium acnes or Mycobacterium spp) and/or sending samples to specialized laboratories. We thank all the medical and nurse staff of Prosthetic Joint Replacement Unit of Orthopaedic Center, Humanitas Research Hospital

The benefit of using a long intramedullary device for the treatment of geriatric intertrochanteric hip fractures is unknown. The InterTAN device (Smith and Nephew, Memphis TN) is offered in either Short (180–200 mm) or Long (260–460 mm) constructs and was designed to provide stable compression across primary intertrochanteric fracture fragments. The objective of our study was to determine whether Short InterTANs are equivalent to Long InterTANs in terms of functional and adverse outcomes for the treatment of geriatric intertrochanteric hip fractures. 108 patients with OTA classification 31A–1 and 31A–2 intertrochanteric hip fractures were included in our study and prospectively followed at one of four Canadian Level-1 Trauma Centres. Our primary outcomes included two validated primary outcome measures: the Functional Independence Measure (FIM), to measure function, and the Timed Up and Go (TUG), to measure motor performance. Secondary outcome measures included blood loss, length of procedure, length of stay and adverse events. A pre-injury FIM was measured by retrospective recall and all postoperative outcomes were assessed on postoperative day 3, at discharge, at 6 weeks, 3 months, 6 months and 12 months postoperatively. Unpaired t-tests and Chi-square tests were used for the comparison of continuous and categorical variables respectively between the Short and Long InterTAN groups. A statistically significant difference was defined as p<0.05. Our study included 71 Short InterTAN and 37 Long InterTAN patients with 31A–1 and 31A–2 intertrochanteric hip fractures. Age, sex, BMI, side, living status and comorbidities were similar between the two groups. The mean operative time was significantly lower in the Short InterTAN group (61 mins) as compared to the Long InterTAN group (71 mins)(p0.05). There were 5 periprosthetic femur fractures in the short InterTAN group versus 1 in the long InterTAN group. Non-mechanical adverse outcomes such as myocardial infarction, pulmonary embolism, urinary tract infections, pneumonia and death all had similar incidence rates between the two InterTAN groups. Both the Short and Long InterTAN patient cohorts displayed similar improvements in performance and overall function over the course of a year following intertrochanteric hip fracture fixation. The recorded operative times for Short InterTAN fixation were significantly shorter than those recorded for the Long InterTAN patients. Alternatively, a significantly higher proportion of Short InterTAN patients sustained periprosthetic femur fractures within a year of implantation as compared to the Long InterTAN group

Utilising the (ACS-NSQIP) database, we aimed to evaluate the impact of resident level of training on surgical outcome following (TKA) and to compare the US and Canadian health care training system in regards to 30 days postoperative complications and readmission rates. Using the (CPT) codes we selected from the 2011 and 2012 NSQIP database elective primary TKA with the resident surgeon involved. Of these, all cases with a primary diagnosis code of infection, fracture, mechanical complication, or malignancy and all cases with incomplete or incongruous demographic information were excluded. We also eliminated all the cases with the Attending not present. A total of 2513 cases were included in the study. The cases were stratified into three groups according to the postgraduate level of training {PGY 1 to 3 (junior resident), PGY 4 to 5 (senior resident), and fellow}. Univariate analysis of all patient demographics, comorbidities, intra and postoperative variables, length of surgery, hospital stay and 30 days readmission rates were conducted in order to identify differences between the groups. A standard student's t test was used for continuous variables while the ChiSquared was used for categorical variables. Multivariable logistic regression models were created to assess the independent effect of the resident level of training on the 30 days major complication and re-admission rates while controlling for all other variables. We identified, 854 (34%) TKAs with junior residents, 1013 (40%) TKAs with senior residents and 646 (26%) TKAs with fellows' participation. Junior residents had a significant (p<0.0001) longer operative time (107±36 minutes) compared with senior residents and fellows. Length of hospital stay was longer in the fellow group probably because of their involvement in more complicated cases. Additionally, an increased number of blood transfusion was observed for the cases performed with involvement of senior residents when compared with the other two groups. However, no significant difference in complications was observed across training levels. When comparing US (2074 TKAs) versus Canada (423 TKAs) cases, we found that fellow contribution to TKA surgeries is higher in Canada. The occurrence of pulmonary embolism and pneumonia was three times higher in Canada cases, while blood transfusion was more frequent in US. Increased operative time, ASA class, age, diabetes, percutaneous cardiac intervention, and steroid use were all independent risk factors for complications following primary TKA. However, no significant difference was observed between the two groups with regards to major complications suggesting no difference between Canadian and American training system in regards to post operative complication. Our results support previous study study indicating that involvement of residents did not affect the surgical outcome within 30 days when compared to cases with no resident involvement. Our study suggests that resident level does not independently increase the risk of short term complications and support continuing involvement of junior trainees in TKA

Propionibacterium acnes is an emerging pathogen especially in orthopedic implant infection. Aim of this study was to investigate P. acnes phylogeny and to screen for virulence factors among a large collection of clinical isolates involved in spine material infections, arthroplasty infections and acne lesions. 88 P. acnes clinical isolates were collected between January 2003 and December 2014 at Nantes University Hospital (France). Fifty-eight isolates came from spine infections, 14 from prosthetic infections (knee, hip or shoulder), 14 from acne lesions and two reference strains (ATCC11827 and ATCC6919). Implant associated infections were confirmed using Infectious Diseases Society of America criteria for bone and joint infections. Phylotypes and Multi-Locus Sequence Typing (MLST) was carried out on all isolates as described by Lomholt et al. All isolates were tested by established PCR-based assays for 21 putative virulence factor genes characteristic of P. acnes. MLST analysis revealed an association between clonal complexes (CCs) and origin of P. acnes isolates (p = 0,027). Regarding CCs distribution between different origins, CC36 and phylotype II P. acnes isolates are more frequently observed in prosthetic joint infections. On the other hand, CC18 (IA) and CC28 (IB) P. acnes isolates are more frequently involved in spine infections and acne lesions. Among all virulence factors screened, hyaluronate lyase gene was only present in CC36 and phylotype II P acnes isolates. Other virulence factors were present in all isolates, whatever their origin or CC. Regarding molecular typing results, P. acnes involved in spine infections seem to have a skin origin (same CC as isolates from acne lesion). Interestingly, the origin of prosthetic joint infection isolates seems different and they all carry one more virulence factor. Hyaluronate lyase (Hyl) is a major surface protein of P. acnes with potential antigenetically variable properties that might be essential for P. acnes virulence. Increased tissue permeability caused by the action of hyaluronidase on the extracellular matrix appears to play a role in wound infections, pneumonia, and other sepsis such as bacteremia and meningitis. It could be also take a prominent part in P. acnes prosthetic joint infection pathogenesis

Diagnosis, treatment and outcome in systemic infection caused by Coccidioides Immitis in a non endemic region. First case in Spain. 71 year old patient. Symptoms: stomach aches, tiredness and weight loss of 14kg. Imaging Investigations: Abdominal pelvic US and Gastroscopy were performed as cancer was suspected. This study showed a bilateral suprarrenal mass. Fearing a pulmonary mass a Thoracic Scan was requested. Results proved mediastinal and axillary nodes. Also found was interstitial illness which lead to a working diagnosis of Granulomatous Lymphangitis. BIOPSIES: An axillary lymph node, suprarrenal gland and pulmonary tissues. ANATOMOPATHOLOGY: Necrotising Granulomatous Lymphadenitis. DIFFERENTIAL DIAGNOSIS: TBC, Sarcoidosis and Autoinmune illnesses. SAMPLE CULTURES were repeatedly negative for funghi, bacteria and Mycobacterium. DIAGNOSIS The patient was subsequently he was commenced on Substitute Hormonal Therapy with improvement of symptoms. MANAGEMENT: Due to a gonarthrosis he required Total Knee Arthroplastia. During surgery a prominent SINOVITIS was noticed, with anatomopathology results of Chronic Necrotising Granulomatous Sinovitis with lymphoid folicules. FOLLOW UP: 7 years after the patient attends A&E with signs of infection on the replaced knee. A bacterial infection is suspected and the patient is admitted into hospital for the replacement extraction, cement substitution with Gentamicin and iv antibiotherapy with LEVOFLOXACIN. His symptoms improved up to a month when he returned to A&E with similar presentation THE PATIENT IS ADMITTED ONCE MORE FOR SURGERY:. Sample Cultures from the prosthesis showed positive growth for Coccidiodes Immitis. Article Reviews provided us with brand new information. A new approach was taken and anamnesis was geared towards finding out a possible contact with the funghi in the endemic region. It appeared that the patient had worked as a Shepherd for four years (1957–1961) in Bakersfield. A Southern Californian region north to LA and under San Francisco. After all, he was admitted for 25 days in a local hospital for pneumonia. DIAGNOSIS WAS REACHED thanks to these findings. The old spacer wasswapped for a Cement Spacer with Amphotericin B 250 mg. Oral treatment with FLUCONAZOL 400 mg/day was associated and after a few days changed to ITRACONAZOL 200 mg/12 hours orally. The patient improved local and systemically. After a few months he evolved as planned and now has a good general and local condition with normal biochemistry results. A final ARTHRODESIS was performed. It's quite likely that he may require long life therapy with Antifungals to avoid reactivations. We highlight the originality of the case, as the first diagnosis of articular Coccidioides diagnosed in Spain, and its successful outcome with prosthetic replacement rebound and chronic antifungal therapy