Aim

The purpose of this study is to report the overall infection control rate and prognostic factors associated with acute, hematogenous and chronic PJIs treated with DAIR.

Aims. Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care. Methods. Questionnaires were sent to orthopaedic waiting list patients at the start of the UK’s first COVID-19 lockdown to capture key quantitative and qualitative aspects of patients’ health. A total of 888 respondents were divided into quintiles, with sampling stratified based on the Index of Multiple Deprivation (IMD); level 1 represented the ‘most deprived’ cohort and level 5 the ‘least deprived’. Results. The least deprived cohort were older (mean 65.95 years (SD 13.33)) than the most deprived (mean 59.48 years (SD 13.85)). Mean symptom duration was lower in the least deprived areas (68.59 months (SD 112.26)) compared to the most deprived (85.85 months (SD 122.50)). Mean pain visual analogue scores (VAS) were poorer in the most compared to the least deprived cohort (7.11 (SD 2.01) vs 5.99 (SD 2.57)), with mean mood scores also poorer (6.06 (SD 2.65) vs 4.71 (SD 2.78)). The most deprived areas exhibited lower mean quality of life (QoL) scores than the least (0.37 (SD 0.30) vs 0.53 (SD 0.31)). QoL findings correlated with health VAS and Generalized Anxiety Disorder 2-item (GAD2) scores, with the most deprived areas experiencing poorer health (health VAS 50.82 (SD 26.42) vs 57.29 (SD 24.19); GAD2: 2.94 (SD 2.35) vs 1.88 (SD 2.07)). Least-deprived patients had the highest self-reported activity levels and lowest sedentary cohort, with the converse true for patients from the most deprived areas. Conclusion. The most deprived patients experience poorer physical and mental health, with this most adversely impacted by lengthy waiting list delays. Interventions to address inequalities should focus on prioritizing the most deprived. Cite this article: Bone Jt Open 2022;3(10):777–785

Interstitial supraspinatus tears can cause persistent subacromial impingement symptoms despite non operative treatment. Autologous tendon cell injection (ATI) is a non-surgical treatment for tendinopathies and tear. We report a randomised controlled study of ATI compared to corticosteroid injection (CS) as treatment for interstitial supraspinatus tears and tendinopathy. Inclusion criteria were patients with symptom duration > 6 months, MRI confirmed intrasubstance supraspinatus tear, and prior treatment with physiotherapy and ≥ one CS or PRP injection. Participants were randomised to receive ATI to the interstitial tear or corticosteroid injection to the subacromial bursa in a 2:1 ratio, under ultrasound guidance. Assessments of pain (VAS) and function (ASES) were performed at baseline, and 1, 3, 6 and 12 months post treatment. 30 participants (19 randomised to ATI) with a mean age of 50.5 years (10 females) and a mean duration of symptoms of 23.5 months. Baseline VAS pain and ASES scores were comparable between groups. While mean VAS pain scores improved in both groups at 3 months after treatment, pain scores were superior with ATI at 6 months (p=0.01). Mean ASES scores in the ATI group were superior to the CS group at 3 months (p=0.026) and 6 months (p=0.012). Seven participants in the CS group withdrew prior to 12 months due to lack of improvement. At 12 months, mean VAS pain in the ATI group was 1.6 ± 1.3. The improvements in mean ASES scores in the ATI group at 6 and 12 months were greater than the MCID (12.0 points). At 12 months, 95% of ATI participants had an ASES score > the PASS (patient acceptable symptom state). This is the first level one study using ATI to treat interstitial supraspinatus tear. ATI results in a significant reduction in pain and improvement in shoulder function

Aim. Debridement, antibiotics and implant retention (DAIR) are considered as an optimal curative treatment option for prosthetic joint infection (PJI) when the biofilm is still immature and radical debridement is achievable. There are two main groups of patients suitable for DAIR. Those with an early acute PJI and patients with acute hematogenous PJI. However, there is also a third group of early PJI resulting from a wound healing problem or leaking hematoma. These may be either high or low grade depending on the microorganisms that infected the artificial joint “per continuitatem”. Methods. We retrospectively analysed 100 successive DAIR procedures on prosthetic hip and knee joints performed between January 2010 and January 2022, from total of 21000 primary arthroplasties implanted within the same time period. We only included PJI in primary total replacements with no previous surgeries on the affected joint. Patients data (demographics, biochemical, microbiological, histopathological results, and outcomes) were collected from hospital bone and joint infection registry. The aim of surgery was radical debridement and the mobile parts exchange. The standardized antibiotic regime based on antibiofilm antibiotics. Results. The mean age of patients was 70 years (60% women, 43 hips, 57 knees) with a mean follow-up of 3 years. 45 cases were early acute or related to wound healing problems, 55 were hematogenous PJI. 25 patients received preoperative antibiotics. 6 of these were culture negative. The mean symptom duration was 7 days. Mean age of the prosthesis was 30 days for early, and 1064 days for the hematogenous group. Conclusions. In our cohort the success rate of DAIR is 94% which indicates that the protocol is highly successful in PJI with short-lasting symptoms and “debridable” joints. Antibiotic protocol violation and duration of symptoms may have a role in failures

Prolonged length of stay (LOS) is a significant contributor to the variation in surgical health care costs and resource utilization after elective spine surgery. The primary goal of this study was to identify patient, surgical and institutional variables that influence LOS. The secondary objective is to examine variability in institutional practices among participating centers. This is a retrospective study of a prospectively multicentric followed cohort of patients enrolled in the CSORN between January 2015 and October 2020. A logistic regression model and bootstrapping method was used. A survey was sent to participating centers to assessed institutional level interventions in place to decrease LOS. Centers with LOS shorter than the median were compared to centers with LOS longer than the median. A total of 3734 patients were included (979 discectomies, 1102 laminectomies, 1653 fusions). The median LOS for discectomy, laminectomy and fusion were respectively 0.0 day (IQR 1.0), 1.0 day (IQR 2.0) and 4.0 days (IQR 2.0). Laminectomy group had the largest variability (SD=4.4, Range 0-133 days). For discectomy, predictors of LOS longer than 0 days were having less leg pain, higher ODI, symptoms duration over 2 years, open procedure, and AE (p< 0.05). Predictors of longer LOS than median of 1 day for laminectomy were increasing age, living alone, higher ODI, open procedures, longer operative time, and AEs (p< 0.05). For posterior instrumented fusion, predictors of longer LOS than median of 4 days were older age, living alone, more comorbidities, less back pain, higher ODI, using narcotics, longer operative time, open procedures, and AEs (p< 0.05). Ten centers (53%) had either ERAS or a standardized protocol aimed at reducing LOS. In this study stratifying individual patient and institutional level factors across Canada, several independent predictors were identified to enhance the understanding of LOS variability in common elective lumbar spine surgery. The current study provides an updated detailed analysis of the ongoing Canadian efforts in the implementation of multimodal ERAS care pathways. Future studies should explore multivariate analysis in institutional factors and the influence of preoperative patient education on LOS

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

Objective. Sarcomas are a rare group of tumours, which pose numerous problems regarding correct diagnosis and appropriate management. This study aimed to examine whether symptom duration and tumour size at diagnosis have changed over time, using size and symptom duration as methods of comparison. Methods. All patients diagnosed with sarcoma were identified retrospectively from a prospective database from 1963 to 2005. Demographic data concerning age at diagnosis, sex and diagnosis were recorded. Data were also collected on duration of symptoms and size of tumour at diagnosis. Symptom duration is defined as the length of time the patient was experiencing symptoms for until the date of diagnosis. Changes in size and symptom duration over time were compared by grouping date of diagnosis into time periods and comparing them against each other using non-parametric statistical analysis. Results. 4560 met our inclusion and exclusion criteria, with 2492 Bone Sarcomas (BS) and 2068 Soft Tissue Sarcomas (STS). Overall analysis of both BS and STS showed that size at diagnosis has decreased and symptom duration has increased. Analysis of STS showed that size has decreased over time, particularly following the introduction of referral guidelines in 1999 (median size pre 99 = 10cm, post = 8cm, Mann-Whitney-U test p=0.000 to 3 sig. fig.), but symptom duration has remained unaltered over time. Duration of symptoms reported for BS has significantly increased over time; however, size at diagnosis has remained unchanged over time. Conclusions. It appears from this study that STS are being diagnosed more quickly and that this is most likely due to the introduction of specific STS guidelines in 1999. This result is particularly heartening, and should encourage further promotion of such guidelines. Awareness of BS still appears to be low as size at diagnosis remains unchanged over time

Objectives. To assess the affects of a delay in diagnosis on the survival rates of Bone Sarcoma (BS) using size and symptom duration as measures of delay. Methods. All patients diagnosed with a Primary BS from 1970 to 2005 were included. Demographic data concerning age, sex, diagnosis and tumour site were recorded. The data were collected retrospectively from a prospective database, with 2573 patients included. Symptom duration is defined as the length of time the patient was experiencing symptoms for until the date of diagnosis. Survival analysis was performed using Kaplan-Meier curves and Cox Regression was carried out to identify variables affecting outcome. Results. 2489 patients with Primary BS that matched out inclusion and exclusion criteria were identified. Osteosarcoma (40.4%), Chondrosarcoma (20.6%) and Ewing's Sarcoma (17.6%) were the most common diagnoses, with a median size of 10cm at presentation. Overall 5 year survival was 61.2%, extremity sited tumours carried a statistically significant better prognosis compared to axial tumours (5yr survival 63.2% vs. 53.3%) and patients with axial tumours had significantly longer symptom duration (Mann-Whitney U test p = 0.000 31 and 12 weeks). Overall analysis of all BS diagnoses showed lengthier duration of symptoms was associated with a better outcome (Hazard Ratio = 0.998, p = 0.000), which suggests that 1 extra week of symptoms confers an increased survival of 0.2%. Larger tumour size was associated with a poorer survival rate (p=0.000 to 3 sig. fig, Hazard Ratio 1.059 respectively) which suggests that for every 1cm increase in size there is a decreased survival of 5.9%. Conclusions. Although many factors have been associated with survival, the limited literature concerning symptom interval and outcome is varied. This large study has shown that regardless of diagnosis, overall, shorter symptom duration and a large tumour size are associated with a poorer prognosis

Aim. The aim of the study was to assess the accuracy of the alpha defensin lateral flow test for diagnosis of periprosthetic joint infection (PJI) using an optimized diagnostic algorithm and three classification systems. In addition, we compared the performance with synovial fluid leukocyte count, the most sensitive preoperative test. Method. In this prospective multicenter study we included all consecutive patients with painful prosthetic hip and knee joints undergoing diagnostic joint aspiration. Alpha defensin lateral flow test was used according to manufacturer instructions. The following diagnostic criteria were used to confirm infection: Musculoskeletal Infection Society (MSIS), Infectious Diseases Society of America (IDSA) and Swiss orthopedics and Swiss Society of Infectious Diseases (SOSSID). In the latter, PJI was confirmed when at least one of following criteria applied: macroscopic purulence, sinus tract, positive cytology of joint aspirate (>2000 leukocytes/μl or >70% granulocytes), histological proof of acute inflammation in periprosthetic tissue, positive culture (from aspirate, tissue or sonication fluid). Infection was classified as chronic, if symptom duration was more than 3 weeks or if infection manifested after more than 1 month after surgery. The sensitivity and specificity of the alpha defensin lateral flow test and leukocyte count in synovial fluid were calculated and compared using McNemar Chi-square test. Results. Of 151 included patients evaluated for painful prosthetic joints (103 involved knees, 48 hips), the median patient age was 69 years (range, 41–94 years) and 75 patients were female. Systematically evaluating the included patients according to the different diagnostic criteria, MSIS and IDSA revealed both 33 patients with PJI (22%), whereas SOSSID disclosed 47 septic failures (31%), among them 36 chronic infections (77%). Sensitivity of the test was 79% when applying MSIS criteria, 70% with IDSA criteria and 57% with SOSSID criteria. Specificity ranged from 96% (IDSA) to 98% (MSIS) and 99% (SOSSID). Applying the most stringent definition criteria (SOSSID), leukocyte count showed significantly higher sensitivity than the alpha defensin lateral flow test (91% vs. 57%, p<0.001), especially in chronic infections (88% vs. 48%, p<0.001.) In acute infections, both tests detected all infection cases. Processing turnaround time was shorter in Alpha defensin lateral flow test than automated leukocyte count (10 min vs. 2–4 hours). Conclusions. Semi-quantitative alpha defensin test was rapid and highly specific for diagnosing PJI (> 95%). However, sensitivity was limited, especially when applying definition criteria including also low grade infections (SOSSID criteria). Therefore, the alpha defensin lateral flow test does not allow a reliable exclusion of PJI, especially not in chronic infections but may be used as confirmatory test

Introduction. Hypoplasia of the glenoid is a rare condition caused by incomplete ossification of the postero-inferior aspect of the developing glenoid. It may be isolated or associated with a more generalised condition. The clinical symptomatology is variable depending on the age at time of presentation. Materials and Methods. We performed a retrospective chart review of patients who presented with shoulder complaints, and in whom a radiographic diagnosis of glenoid hypoplasia had been made. From January 2002 to December 2012, 8 patients (9 shoulders) with radiological signs of glenoid hypoplasia were identified. The mean age at presentation was 39 years (range 23 to 77) and the mean symptom duration was 12.5 months (range 1 to 48). Results. The diagnoses encountered included: impingement with rotator cuff tendonitis (2 shoulders), rotator cuff dysfunction with biceps tendonitis (1 shoulder), a SLAP lesion (2 shoulders), calcific tendonitis (1 shoulder), a posterior labral tear (1shoulder), multidirectional instability (1 shoulder), and adhesive capsulitis (1 shoulder). Of these nine, six shoulders were managed non-operatively and three were managed surgically, all with satisfactory results. The mean follow-up period was 30 months (range 5 to 60) and the mean Oxford shoulder score was 46.7 (range 42 to 48). Conclusion. We present a series of patients, who have been managed for a variety of shoulder pathologies, and in whom underlying glenoid hypoplasia has been diagnosed. NO DISCLOSURES

Manipulation under anaesthetic (MUA) for the treatment of frozen shoulder is well established and effective however timing of surgery remains controversial. Intervention before 9 months has previously been shown to be associated with improved outcome. We test this theory by measuring Oxford Shoulder Score (OSS), re-MUA and subsequent surgery rate. A retrospective review of a prospectively collected, single surgeon, consecutive patient series revealed 244 primary frozen shoulders treated by MUA within 4 weeks of presentation. The mean duration of antecedent symptoms was 28 weeks (95% CI 4-44 weeks) and time to follow up was 26 days (95% CI 11-41 days). The mean OSS improved by 16 points (2-tailed t test p< 0.001) with a mean follow up OSS of 43 (95% CI 38-48). 195 shoulders were manipulated before 38 weeks (9 months) and had the same mean change in OSS (16) as the 49 shoulders manipulated after 38 weeks. 48 shoulders, including 15 diabetic shoulders required further MUA. 8 shoulders had subsequent surgery. These events were also independent of antecedent symptom duration. Early MUA does not appear to produce improved outcomes when compared to later intervention but we note does result in an earlier return to function

Purpose. There is minimal information on outcome of glenohumeral debridement for treatment of shoulder osteoarthritis (OA). The purpose of this study was to examine the outcome of this procedure with or without acromioplasty /resection of clavicle in subjective perception of disability and functional range of motion and strength at one year following surgery. Method. Prospectively collected data of patients with advanced OA of the glenohumeral joint who were not good candidates for shoulder arthroplasty due to young age, high activity level, or desire to avoid major surgery at the time of assessment were included. Arthroscopic debridement included removal of loose bodies, chondral flaps, and degenerative tissue. Resection of the lateral end of the clavicle or acromioplasty was performed as clinically indicated for management of osteoarthritis of the Acromioclavicular (AC) joint or subacromial impingement respectively. Disability at 12 months following surgery was measured by the American Shoulder and Elbow Surgeons (ASES) assessment form, Constant-Murley score (CMS), strength, and painfree range of motion in four directions. Results. Sixty-seven patients (mean age= 57, SD: 15 (range: 25–87), range: 35–86, 35 females, 32 males) were included in analysis. The average symptom duration was 5 years. Fifteen (22%) patients had left shoulder involvement with 37 (55%) having right shoulder problem and 15(22%) reporting bilateral complaints. The right shoulder was operated on in 41 (61%) patients. Fifty two (78%) patients had an associated subacromial decompression [49 (73%) had acromioplasty and 27 (40%) had resection of the lateral end of the clavicle with some procedures overlapping]. Paired student t-tests showed a statistically significant improvement in scores of ASES and CMS (p<0.001) and painfree range of motion (p=0.02) at 1 year follow-up. However, no change was observed in strength (p>0.05). Conclusion. Arthroscopic debridement with or without acromioplasty /resection of the lateral end of the clavicle improves disability and painfree range of motion in patients suffering from osteoarthritis of glenohumeral joint at one year following surgery

Aims

COVID-19 has compounded a growing waiting list problem, with over 4.5 million patients now waiting for planned elective care in the UK. Views of patients on waiting lists are rarely considered in prioritization. Our primary aim was to understand how to support patients on waiting lists by hearing their experiences, concerns, and expectations. The secondary aim was to capture objective change in disability and coping mechanisms.