COVID-19 confers a three-fold increased mortality risk among hip fracture patients. The aims were to investigate whether vaccination was associated with: i) lower mortality risk, and ii) lower likelihood of contracting COVID-19 within 30 days of fracture. This nationwide cohort study included all patients aged >50 years with a hip fracture between 01/03/20-31/12/21. Data from the Scottish Hip Fracture Audit were collected and included: demographics, injury and management variables, discharge destination, and 30-day mortality status. These variables were linked to population-level records of COVID-19 vaccination and testing. There were 13,345 patients with a median age of 82.0 years (IQR 74.0–88.0), and 9329/13345 (69.9%) were female. Of 3022/13345 (22.6%) patients diagnosed with COVID-19, 606/13345 (4.5%) were COVID-positive within 30 days of fracture. Multivariable logistic regression demonstrated that vaccinated patients were less likely to be COVID-positive (odds ratio (OR) 0.41, 95% confidence interval (CI) 0.34–0.48, p<0.001) than unvaccinated patients. 30-day mortality rate was higher for COVID-positive than COVID-negative patients (15.8% vs 7.9%, p < 0.001). Controlling for confounders (age, sex, comorbidity, deprivation, pre-fracture residence), unvaccinated patients with COVID-19 had a greater mortality risk than COVID-negative patients (OR 2.77, CI 2.12–3.62, p < 0.001), but vaccinated COVID19-positive patients were not at increased risk (OR 0.93, CI 0.53–1.60, p = 0.783). Vaccination was associated with lower COVID-19 infection risk. Vaccinated COVID-positive patients had a similar mortality risk to COVID-negative patients, suggesting a reduced severity of infection. This study demonstrates the efficacy of vaccination in this vulnerable patient group, and presents essential data for future outbreaks

Sclerostin (SOST) is an endogenous inhibitor of Wnt/β-catenin signalling pathway to impair osteogenic differentiation and bone anabolism. SOST immunotherapy like monoclonal antibody has been observed to control bone remodeling and regeneration. This study is aimed to develop a SOST vaccine and test its protective effects on estrogen deficiency-induced bone loss in mice. Gene sequences coded SOST peptide putative targeting Wnt co-receptor LRP5 were cloned and constructed into vectors expressing Fc fragment to produced SOST-Fc fusion protein. Mice were subcutaneously injected SOST-Fc to boost anti-SOST antibody. Bone mineral density, microstructure, and mechanical property were quantified using μCT scanning and material testing system. Serum bone formation and resorption markers and anti-SOST levels were measured using ELISA. SOST-Fc injections significantly increased serum anti-SOST antibody levels but reduced serum SOST concentrations. SOST-Fc vaccination significantly reduced estrogen deficiency-induced serum bone resorption markers CTX-1 increased serum bone formation marker osteocalcin. Of note, it significantly alleviated the severity of estrogen-induced loss of bone mineral density, trabecular morphometric properties, and biomechanical forces of bone tissue. Mechanistically, SOSF-Fc vaccination attenuated trabecular loss histopathology and restored immunostaining of Wnt pathway like Wnt3a, β-catenin, and TCF4 in bone tissue along with increased serum osteoclast inhibitor OPG levels but decreased serum osteoclast enhancer RANKL concentrations. Taken together, SOST-Fc vaccination boosts anti-SOST antibody to neutralize SOST and mitigates the estrogen deficiency-induced bone mass and microstructure deterioration through preserving Wnt signalling. This study highlights an innovative remedial potential of SOST vaccine for preventing osteoporosis

Aims. Prior to the availability of vaccines, mortality for hip fracture patients with concomitant COVID-19 infection was three times higher than pre-pandemic rates. The primary aim of this study was to determine the 30-day mortality rate of hip fracture patients in the post-vaccine era. Methods. A multicentre observational study was carried out at 19 NHS Trusts in England. The study period for the data collection was 1 February 2021 until 28 February 2022, with mortality tracing until 28 March 2022. Data collection included demographic details, data points to calculate the Nottingham Hip Fracture Score, COVID-19 status, 30-day mortality, and vaccination status. Results. A total of 337 patients tested positive for COVID-19. The overall 30-day mortality in these patients was 7.7%: 5.5% in vaccinated patients and 21.7% in unvaccinated patients. There was no significant difference between post-vaccine mortality compared with pre-pandemic 2019 controls (7.7% vs 5.0%; p = 0.068). Independent risk factors for mortality included unvaccinated status, Abbreviated Mental Test Score ≤ 6, male sex, age > 80 years, and time to theatre > 36 hours, in decreasing order of effect size. Conclusion. The vaccination programme has reduced 30-day mortality rates in hip fracture patients with concomitant COVID-19 infection to a level similar to pre-pandemic. Mortality for unvaccinated patients remained high. Cite this article: Bone Joint J 2022;104-B(12):1362–1368

In many countries Haemophilus influenzae type b (Hib) is the second most common cause of septic arthritis in children. In Finland large-scale immunisation against Hib using conjugate vaccines began in 1986, four years after a multicentre prospective study of orthopaedic infections in children had started. Since 1982, including six years before and ten after starting routine Hib vaccination, there has been a major change in the pattern of septic arthritis. From 1982 to 1988, 32 of 61 cases (53%) were caused by staphylococci, 22 (36%) by Hib and 7 (11%) by other bacteria. Since 1988, Hib infection has disappeared, and one-third of cases of childhood septic arthritis has been eliminated. This change has allowed us to reduce initial antimicrobial therapy for such children to cover only Gram-positive cocci. The more limited treatment is safer, reduces cost, and simplifies treatment

Research into COVID-19 has been rapid in response to the dynamic global situation, which has resulted in heterogeneity of methodology and the communication of information. Adherence to reporting standards would improve the quality of evidence presented in future studies, and may ensure that findings could be interpreted in the context of the wider literature. The COVID-19 pandemic remains a dynamic situation, requiring continued assessment of the disease incidence and monitoring for the emergence of viral variants and their transmissibility, virulence, and susceptibility to vaccine-induced immunity. More work is needed to assess the long-term impact of COVID-19 infection on patients who sustain a hip fracture. The International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics (IMPACT) formed the largest multicentre collaborative audit conducted in orthopaedics in order to provide an emergency response to a global pandemic, but this was in the context of many vital established audit services being disrupted at an early stage, and it is crucial that these resources are protected during future health crises. Rapid data-sharing between regions should be developed, with wider adoption of the revised 2022 Fragility Fracture Network Minimum Common Data Set for Hip Fracture Audit, and a pragmatic approach to information governance processes in order to facilitate cooperation and meta-audit. This editorial aims to: 1) identify issues related to COVID-19 that require further research; 2) suggest reporting standards for studies of COVID-19 and other communicable diseases; 3) consider the requirement of new risk scores for hip fracture patients; and 4) present the lessons learned from IMPACT in order to inform future collaborative studies.

Cite this article: Bone Joint Res 2022;11(6):342–345.

Shoulder injury related to vaccine administration (SIRVA) is a prolonged episode of shoulder dysfunction that commences within 24 to 48 hours of a vaccination. Symptoms include a combination of shoulder pain, stiffness, and weakness. There has been a recent rapid increase in reported cases of SIRVA within the literature, particularly in adults, and is likely related to the mass vaccination programmes associated with COVID-19 and influenza. The pathophysiology is not certain, but placement of the vaccination in the subdeltoid bursa or other pericapsular tissue has been suggested to result in an inflammatory capsular process. It has been hypothesized that this is associated with a vaccine injection site that is “too high” and predisposes to the development of SIRVA. Nerve conduction studies are routinely normal, but further imaging can reveal deep-deltoid collections, rotator cuff tendinopathy and tears, or subacromial subdeltoid bursitis. However, all of these are common findings within a general asymptomatic population. Medicolegal claims in the UK, based on an incorrect injection site, are unlikely to meet the legal threshold to determine liability. Cite this article: Bone Joint J 2023;105-B(8):839–842

Introduction. Elective surgery elicits a systemic immune response and may result in immunosuppression in certain patients. It is currently unknown whether patients are at an increased risk for viral infection and associated illness in the immediate postoperative period following total joint arthroplasty. This question has become more important given the ongoing coronavirus disease 2019 (COVID-19) pandemic. Methods. We analyzed 3 large administrative datasets (Medicare 5% and 100% standard analytic files, Humana claims database) to identify patients who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA) from 2005 to 2013. The influenza vaccination status of each patient was defined using the presence or absence of a code for vaccination. The incidence of a flu diagnosis was recorded in both vaccinated and unvaccinated patients at 1 month, 3 months, and 6 months following the date of surgery and was compared to a cohort of vaccinated patients who did not undergo surgery. Results. The incidence of postoperative influenza diagnoses codes in TKA and THA patients were similar to that of vaccinated patients who did not undergo TJA at all time points. The results were largely consistent across all three datasets. Conclusion. Large administrative databases fail to show an increased incidence of influenza codes in patients who have recently undergone total joint arthroplasty. While the lack of signal is reassuring and provides evidence, these findings are limited by the nature of large administrative datasets and the accuracy of coding for influenza. Further studies will be necessary to fully understand an individual patient's postoperative risk for contracting a viral illness

This international multicentre retrospective cohort study aimed to assess: 1) prevalence of COVID-19 in hip fracture patients, 2) effect on mortality, and 3) clinical factors associated mortality among COVID-19-positive patients. A collaboration among 112 centres in 14 nations collected data on all patients with a hip fracture between 1st March-31st May 2020. Patient, injury and surgical factors were recorded, and outcome measures included admission duration, COVID-19 and 30-day mortality status. There were 7090 patients and 651 (9.2%) were COVID-19-positive. COVID-19 was independently associated with male sex (p=0.001), residential care (p<0.001), inpatient fall (p=0.003), cancer (p=0.009), ASA grade 4–5 (p=0.008; p<0.001), and longer admission (p<0.001). Patients with COVID-19 had a significantly lower chance of 30-day survival versus those without (72.7% versus 92.6%, p<0.001), and COVID-19 was independently associated with increased 30-day mortality risk (p<0.001). Increasing age (p=0.028), male sex (p<0.001), renal (p=0.017) and pulmonary disease (p=0·039) were independently associated with higher 30-day mortality risk in patients with COVID-19 when adjusting for confounders. The prevalence of COVID-19 in hip fracture patients was 9% and was independently associated with a three-fold increased 30-day mortality risk. Clinical factors associated with mortality among COVID-19-positive hip fracture patients were identified for the first time. This is the largest study, and the only global cohort, reporting on the effect of COVID-19 in hip fracture patients. The findings provide a benchmark against which to determine vaccine efficacy in this vulnerable population and are especially important in the context of incomplete vaccination programmes and the emergence of vaccine-resistant strains

Introduction: Haemophilus influenzae type B has been the pathogen responsible for a significant proportion of cases of septic arthritis in children in the past. Vaccination was introduced in the United Kingdom in October, 1992 in order to combat meningitis and epiglottitis. This study looks at the effects of vaccination on childhood septic arthritis in Wales. Methods: Data was collected prospectively from 1988 by the Public Health Laboratory Service in Wales. Data was analysed with a two-sample t-test. Results: There were 17 cases in children in which 16 were attributed to type B. 14 cases occurred in the 5 years before mass immunisation. Only 2 cases occurred in the 8 years following immunisation. The incidence of Haemophilus influenzae septic arthritis in children has fallen significantly since the introduction of immunization (P=0.009). Discussion: Vaccination has resulted in a significant fall in the incidence of Haemophilus influenzae type B septic arthritis in children in Wales. This may have consequences on guidelines for the empirical treatment of septic arthritis. If a child if found to have Haemophilus influenzae septic arthritis, this is suspicious of immunocompromise, or an alternate type infection. The novel way in which infection has been controlled may be one which can be used in future to control multi-resistant bacterial infection in orthopaedic surgery

Eighteen cases of bone and joint tuberculosis in children were diagnosed in the Stockholm region (about 1,500,000 population) over the period 1961-1974. BCG infection was verified by culture and identification of bacterial type in seven, all after 1968. The same origin can be presumed in most of the remaining eleven cases, in spite of the absence of bacterial verification. The increased frequency of complications after BCG vaccination may necessitate a revision of the vaccination programme. We recommend operative treatment, which has not led to any growth disturbances or impairment of joint function, although the lesions were invariably localised close to growth zones and joints

Background: Prosthetic joint infection (PJI) is most commonly caused by skin-derived, biofilm-forming staphylococci, with Staphylococcus aureus being most virulent and MRSA becoming a substantial problem. Cephaloporins are almost universally used as prophylaxis against PJI, yet Methicillin - resistant S aureus (MRSA) is becoming increasingly common in hospitals, nursing homes and now in the community. Such strains are not susceptible to cephalorsporins or to a range of other antimicrobials. In view of this increasing antibiotic resistance, an alternative approach to preventing S. aureus PJI is needed, and we propose that vaccination is a promising approach. Having regard to the distinct pathogenesis of PJI, this must target key events in infection establishment, such as adhesion to the implant, via the plasma conditioning film, mediated by bacterial binding proteins. It must also have the potential to protect against all S. aureus regardless of antibiotic resistance profile. Fibronectin-binding protein-A (FnBP-A) is one example, but the potential of FnBP-A as a PJI vaccine candidate has not been thoroughly investigated and data in previous literature are contradictory. Methods: Here, polyclonal rabbit antibody against recombinant(r) FnBP-A binding domain was produced and investigated for the first time for activity against S. aureus adhesion to rabbit plasma-conditioned steel coupons in-vitro. Results: The adhesion of homologous S. aureus 8325-4 (fnbA+, fnbB+), and a heterologous MRSA arthroplasty isolate was significantly (p < 0.05) reduced when pre-exposed to anti-FnBP-A antiserum (un-purified and IgG-purified), compared to pre-exposure with pre-immune serum. This was not observed with mutant strain S. aureus DU5883 (fnbA?, fnbB?), indicating the involvement of FnBP-A – specific inhibitory antibody (IgG). Results clearly demonstrate the potential of rFnBP-A binding domain as a vaccine antigen for prevention of PJI and merit further investigation. The implications of this are that vaccination using this peptide might be expected to protect patients about to undergo elective arthroplasty from infection with S aureus whatever its antibiotic susceptibility, so offering a realistic solution to the problem of increasing resistance

Most infections in arthroplasty are caused by staphylococci, about half being due to S. aureus. One of the most worrying aspects of this organism, and particularly of MRSA, is increasing multiple drug resistance, so that antimicrobial prophylaxis is probably already compromised. Vaccination offers a novel approach to overcome this. Detailed consideration of the pathogenesis of prosthesis–related infection indicates that a) prosthetic material rapidly becomes coated after implantation with plasma–derived conditioning film, and b) attachment of the bacteria to the conditioning film, by means of specific bacterial surface binding proteins, is an essential primary event. We hypothesise that antibodies to these binding proteins will block bacterial adhesion to the prosthesis, so reducing the incidence of infection. The aim of this research was to determine the effect of specific antibodies to two binding proteins (fibronectin - and fibrinogen–binding proteins, Fnbp and Fgbp respectively) on bacterial adherence to orthopaedic biomaterials coated with plasma conditioning film. Antibodies to recombinant sequences of Fnbp and Fgbp were raised in rabbits. A strain of S. aureus bearing a genetically inserted fluorescent reporter (GFP) was used. Orthopaedic biomaterials (steel, titanium and PMMA) were coated with FFP–derived conditioning film, placed in a specially–designed flow cell and exposed to a flow of S. aureus for 3h. Images were captured every 15min and analysed for adherent bacteria using image analysis software. The experiment was repeated in the presence of the antibodies and the results compared. Each antibody reduced the number of bacteria binding to all three materials by greater than 50%. Combining the two antibodies gave similar results to those when they were used individually. These preliminary results suggest that while further research is required, vaccination aimed at blocking bacterial attachment to conditioning film on implanted prostheses might reduce the incidence of S. aureus infection in arthroplasty. If so, this would apply even to MRSA. Questions remaining to be addressed include the clinical relevance of a 50% reduction in attachment, and future research will attempt to link this to a reduction in infection

In the knee, involvement is mainly synovial, with local extension eroding the bone. Pure tuberculous osteitis is rare, with a few occasional reports. Patella tuberculosis is extremely rare. We report the case of patella tuberculosis with 7-years decline. A 10-years old boy suffered from knee siftness and pain. The patient had correct BCG vaccination. Clinical examination was relatively unrevealing, with tenderness on palpation of the medial joint surface of the patella, patellar crepitation, and slight effusion. On standard X-ray, the lateral view showed a circumferential rosette form with a light peripheral halo. The patient underwent open surgery with a medial parapatellar approach and arthrotomy. Joint fluid was sampled. Direct exploration of the medial side of the patella found soft but continuous cartilage on palpation. The histoligical examination confirmed the diagnosis of tuberculosis. The patient had 12 month anti-tuberculosis chemotherapy. After 7 years of the treatement, the patient had no recurrence and good clinical result. Bone tuberculosis remains difficult to diagnose. Certain locations should always be borne in mind, however rare, in case of pandemic or immunodeficiency. In case of osteolysis, associated with abscess or not, infectious etiology is to be considered and appropriate samples should be taken. Diagnosis is confirmed by histology and bacteriology. The slow evolution of bone tuberculosis requires local treatment of lesions and abscesses. Antibiotherapy regularly ensures recovery

Introduction: Despite worldwide vaccination programmes Polio is still endemic in some developing countries. Numerous new cases of polio are seen every year in India resulting in significant childhood deformity. The Rotary Club funds voluntary camps aimed at correcting deformities in children. I was part of the surgical team in Jan 2007 led by Mr. J. Clegg. Clinical experience: Some 141 procedures were carried out in 3 days, 99 by SPR’s under senior supervision. The most frequent procedure was a supra-condylar femoral osteotomy, followed by hip and knee soft tissue releases. For more complex operations we assisted or observed. Some deformity corrections were for non-polio cases. Interesting cases in the OPD included skeletal dysplasias, rickets and congenital deformities. Conclusion: At the time where MMC restricts overseas training opportunities, I believe this type of mini-fellowship provides valuable experience. Training programmes should have such opportunities available to all trainees

Aims

Knowledge on total knee arthroplasties (TKAs) in patients with a history of poliomyelitis is limited. This study compared implant survivorship and clinical outcomes among affected and unaffected limbs in patients with sequelae of poliomyelitis undergoing TKAs.

Aim: The literature suggests that the incidence of osteomyelitis in the paediatric population has changed. We undertook to examine changes in incidence, causative organisms and treatment regimes over a 13 year period. Methods: Patients admitted with a diagnosis of osteomyelitis between January 1991 and January 2004 were identified from hospital records and data collected from their medical and laboratory records. Results: A total of 362 patients were admitted over the study period with a mean age of 5.9 years. A significant decrease in the number of patients presenting over the study period with osteomyelitis was noted, from a peak of 77 cases in 1991 to 12 cases in 2003 (p< 0.05). There was no significant difference in patient age or length of hospital stay over the study period. The majority of cases involved the lower appendicular skeleton with Staphylcoccus Aureus being the commonest organism cultured (accounting for 60% of positive cultures). All cases were initially treated empirically with intravenous Flucloxicillin and oral Fusidic acid. Surgical debridement/decompression was required in 11% of cases. Conclusion: Osteomyelitis now appears to be a rare condition in children with a marked decrease in the incidence being noted over the study period. This correlates with the introduction of the Haemophilus Influenzae B vaccination in Ireland and may partly explain the decrease in incidence. The majority of cases settled on a course of non-operative management

Introduction: Recent data from the UK suggests that the incidence of osteomyelitis in the paediatric population is declining. However, the incidence in the Scandic countries has risen in the late eighties and nineties. We undertook to examine the epidemiology of osteomyelitis presenting to a paediatric teaching hospital in an Irish urban setting. Patients and Methods: We undertook a retrospective review to identify patients admitted over a twenty-five year period with a diagnosis of osteomyelitis. Patients were identified from hospital records, theatre log-books and a departmental database. Demographic data was collected, as were details of the infected bony structure, treatment required and organism cultured. Results: A total of 291 patients were admitted over a twenty-four year period, from 1977 to 2000. A marked reduction in osteomyelitis was noted over the twenty-four year incidence of the study. In addition, a shift in the causative organism was noted from an incidence of H Influenzae in the 70’s of up to 30%, to less than 5% in the 90’s. The treatment regime changed markedly over the course of the study period, with a significantly reduced duration of hospital stay reflecting the move away from protracted periods of hospitalisation. Conclusion: A marked fall in osteomyelitis has occurred in the paediatric population. This may be due to improved living conditions and the introduction of H Influenzae vaccinations. The duration of hospital stay has declined markedly and the introduction of newer imaging modalities has aided diagnosis, allowing early aggressive intervention. However, as osteomyelitis is becoming increasingly rare, a higher index of suspicion is required, particularly from non-specialists who are more likely to be the first to encounter these patients

Aims

The aim of this study was to explore clinicians’ experience of a paediatric randomized controlled trial (RCT) comparing surgical reduction with non-surgical casting for displaced distal radius fractures.

Aims

Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England.

Besides the femur and the tibia, the humerus is the third most common localisation of osteosarcoma. 78 patients with osteosarcoma of the humerus have been treated at our institution since 1934. Among these, 7 patients have been admitted before implementation of the Vienna Tumour Registry in 1968, additionally 4 patients had undergone primary surgical resection at another institution. This left 67 patients for follow-up after multi-modal therapy of humeral osteosarcoma comprising neo-adjuvant and adjuvant chemotherapy and surgical resection. (38 males and 29 females with an average age of 21.8 years, range 3.6 to 73.2 years) The subtypes of tumours observed were classic osteosarcoma in 56 patients, parostal sarcoma in 4, teleangiectatic sarcoma in 3, secondary sarcoma in 2 (one in Morbus Paget and one after radiation of a hemangioendothelioma), high-grade surface sarcoma in 1 and a humeral lesion within a multifocal osteosarcoma in 1. The localisation was foremost the proximal humerus (61) and rarely affecting the distal (5) or total bone (1). 11 patients suffered from pulmonary metastases upon primary diagnosis. In 9 cases resection alone was indicated. 9 patients underwent a resection-replantation-plasty, and in 2 patients primary amputation was performed. 46 patients were treated by resection and endoprosthetic reconstruction using ceramic prostheses (7), custom-made endoprostheses (13) or humeral HMRS modular prostheses (26). Before 1980 a non-standardised neo-adjuvant and adjuvant chemotherapy was administered in 12 patients, all patients thereafter received a chemotherapeutic regimen according to the COSS or EURAMOS-1 protocol. In 3 patients with parostal sarcoma no adjuvant therapy was indicated. The patient with multifocal osteosarcoma was treated conservatively by chemotherapy, radiation and immunotherapy by dendritic cell vaccination. The overall survival was 58% at 5 years. 23 patients died of their disease at an average of 25 months after operation (range 2 to 135 months). Average follow-up of the remaining patients was 91 months. (range 1 to 389 months). 4 patients treated before 1982 developed local tumour recurrence leading to secondary amputation in all cases, and death of disease within 12 months in 3 cases, respectively. 16 patients had to undergo one or more revisions, including secondary amputation in 2. Pulmonary metastases were observed in 15 patients, 2 patients developed skeletal metastates. After resection of metastatses, 14 patients died of disease, among them 9 patients died within 12 months after operation. Upon latest follow-up, 3 patients were alive disease-free, the patient with multifocal osteosarcoma was alive with disease 22 months after primary diagnosis. The multimodal treatment of osteosarcoma shows satisfactory oncological results. The implementation of standardised chemotherapeutic protocols has improved overall outcome