Aim. Persistent wound drainage has been recognized as one of the major risk factors of periprosthetic joint infection (PJI). Currently, there is no consensus on the management protocol for patients who develop wound drainage after total joint arthroplasty (TJA). The objective of our study was to describe a multimodal protocol for managing draining wounds after TJA and assess the outcomes. Methods. We conducted a retrospective study of 4,873 primary TJAs performed between 2008 and 2015. Using an institutional database, patients with persistent wound drainage (>48 hours) were identified. A review of the medical records was then performed to confirm persistent drainage. Draining wounds were first managed by instituting local wound care measures. In patients that drainage persisted over 7 days, a superficial irrigation and debridement (I&D) was performed if the fascia was intact, and if the fascia was not intact modular parts were exchanged. TJAs that underwent subsequent I&D, revision surgery, or developed PJI within one year were identified. Results. Draining wounds were identified in 6.2% (302/4,873) of all TJAs. Overall, 65% (196/302) of patients with draining wounds did not require any surgical procedures. Of the patients with persistent drainage, 9.8% underwent I&D, 25.0% underwent revision arthroplasty. Moreover, 15.9% of these patients developed PJI within one year. Compared to those without wound drainage, TJAs complicated by wound drainage demonstrated an odds ratio of 16.9 (95% CI: 9.1–31.6) for developing PJI, and 18.0 (95% CI: 11.3–28.7) for undergoing subsequent surgery. Conclusions. Wound drainage after TJA is a major risk factor for subsequent PJI and its proper management has paramount importance. Our results demonstrated that drainage ceased spontaneously in 65% of the patients with local wound care measures alone. Wounds with persistent drainage were at substantially higher risk for PJI than those that healed uneventfully

We present the first systematic review conducted by the UK Defence Medical Services in conjunction with the Cochrane Collaboration. Irrigation fluids are used to remove contamination during the surgical treatment of traumatic wounds in order to prevent infection. This review aims to determine whether there is evidence that one wound irrigation fluid is superior to another at reducing infection. A pre-published methodology was used and two reviewers independently assessed the search results. The search produced 917 studies, of which three met the inclusion criteria. All were studies in open fractures, incorporating a total of 2,903 patients. Each RCT involved a distinct comparison, precluding meta-analysis: i) sterile saline vs. distilled/boiled water; ii) antibiotic solution vs. soap solution; iii) saline vs. soap solution. The odds ratios of infection following irrigation with various fluids was as follows: i) saline vs. distilled or boiled water 0.25 (95%CI 0.08–0.73); ii) antibiotic solution vs. soap 1.42 (95%CI 0.82–2.46); iii) saline vs. soap solution 1.00 (95%CI 0.80–1.26). These results suggest that neither soap nor antibiotic solution is superior to saline and that saline is inferior to distilled or boiled water.

Despite long-standing dogma, a clear relationship between the timing of surgical irrigation and the development of subsequent deep infection has not been established in the literature. Traditionally, irrigation of an open fracture has been recommended within six-hours of injury based on animal studies from the 1970s, however the clinical basis for this remains unclear. Using data from a multi-centre randomized controlled trial of 2,447 open fracture patients, the primary objective of this secondary analysis is to determine if a relationship exists between timing of wound irrigation (within six hours of injury versus beyond six hours) and subsequent reoperation rate for infection or healing complications within one year for patients with open extremity fractures requiring surgical treatment.

To adjust for the influence of patient and injury characteristics on the timing of irrigation, a propensity score was developed from the data set. Propensity-adjusted regression allowed for a matched cohort analysis within the study population to determine if early irrigation put patients independently at risk for reoperation, while controlling for confounding factors. Results were reported as odds ratios (ORs), 95% Confidence Intervals (CIs), and p-values. All analyses were conducted using STATA 14 (StataCorp LP, College Station, TX, USA).

Two thousand, two hundred eighty-six of 2,447 patients randomized to the trial from 41 orthopaedic trauma centers across five countries had complete data regarding time to irrigation. Prior to matching, the patients managed with early irrigation had a higher proportion requiring reoperation for infection or healing complications (17% versus 12.8%, p=0.02), however this does not account for selection bias of more severe injuries preferentially being treated earlier. After the propensity score-matching algorithm was applied, there were 373 matched pairs of patients available for comparison. In the matched cohort, reoperation rates did not differ between early and late groups (16.1% vs 16.6%, p=0.84). When accounting for propensity matching in a logistic regression analysis, early irrigation was not associated with reoperation (OR 0.93, 95% CI 0.62 to 1.40, p=0.73).

When accounting for other variables, late irrigation does not independently increase risk of reoperation.

Many studies report the incidence and prevalence of surgical site infections (SSIs) following open fractures; however, there is limited information on the treatment and subsequent outcomes of superficial SSIs in open fracture patients. There is also a lack of clinical studies describing the prognostic factors that are associated with failure of antibiotic treatment (non-operative) for superficial SSI. To address this gap, we used data from the FLOW (Fluid Lavage in Open Fracture Wounds) trial to determine how successful antibiotic treatment was for superficial SSIs and to identify prognostic factors that could be predictive of antibiotic treatment failure.

This is a secondary analysis of the FLOW trial dataset. The FLOW trial included 2,445 operatively managed open fracture patients. FLOW participants who had a non-operatively managed superficial SSI diagnosed in the 12 months post-fracture were included in this analysis. Participants were grouped into two categories: 1) participants whose superficial SSI resolved with antibiotics alone and 2) participants whose SSI did not resolve with antibiotics alone (defined as requiring surgical management or SSI being unresolved at final follow-up (12-months post-fracture for the FLOW trial)). Antibiotic treatment success and the date when this occurred was defined by the treating surgeon. A logistic binary regression analysis was conducted to identify factors associated with superficial SSI antibiotic success. Based on biologic rationale and previous literature, a priori we identified 13 (corresponding to 14 levels) potential factors to be included in the regression model.

Superficial SSIs were diagnosed in168 participants within 12 months of their fracture. Of these, 139 (82.7%) had their superficial SSI treated with antibiotics alone. The antibiotic treatment was successful in resolving the superficial SSI in 97 participants (69.8%) and unsuccessful in resolving the SSI in 42 participants (30.2%). We found that superficial SSIs that were diagnosed later in follow-up were associated with failure of treatment with antibiotic alone (Odds ratio 1.05 for every week in diagnosis delay, 95% Confidence Interval 1.004–1.099; p=0.03). Age, sex, fracture severity, fracture pattern, wound size, time from injury to initial surgical irrigation and debridement were not associated with antibiotic treatment failure.

Our secondary analysis of prospectively collected FLOW data found antibiotics alone resolved superficial SSIs in 69.8% of patients diagnosed with superficial SSIs. We also found that superficial SSIs that were diagnosed earlier in follow-up were associated with successful treatment with antibiotics alone. This suggests that if superficial SSIs are diagnosed and treated promptly, there is a higher probability that they will resolve with antibiotic treatment.

Introduction

Infection is disastrous in arthroplasty surgery and requires multidisciplinary treatment and debilitating revision surgery. Between 80-90% of bacterial wound contaminants originate from colony forming units (CFUs) present in operating room air, originating from bacteria shed by personnel present in the operating environment. Steps to reduce bacterial shedding should reduce wound contamination. These steps include the use of unidirectional laminar airflow systems and the introduction of theatre attire modelled on this principle (e.g. total body exhaust suits). Our unit introduced the use of the Stryker Sterishield Personal Protection System helmet used with laminar flow theatre systems. This study compares an enclosed helmet system used with standard gowns, with standard hood and mask attire.

Statement of purpose

To demonstrate how contemplating reconstructive options among members of Orthoplastic team can prevent accidental damage during initial wound debridement in foot and ankle injuries

Complex defects of the foot and ankle often require input from plastic and orthopaedic surgeons. There are different reconstructive options but one excellent regional option for small defects is the Extensor Digitorum Brevis muscle (EDB) flap. The anatomy of the flap and surgical technique and utility are described and demonstrated through a case series.

We present a series of 4 consecutive cases of the use of the pedicled EDB flap for soft tissue coverage of difficult defects around the foot and ankle. This regional pedicled flap can be proximally based to cover defects around the ankle or distally based for distal foot coverage. When possible, it facilitates a reconstruction with minimal donor site morbidity, shorter operating times, and fewer complications than alternative options

The flap would usually be performed by the plastic surgical member of the orthoplastic team, but an understanding of it by foot and ankle and reconstructive orthopaedic surgeons is relevant as it's vascular supply via the lateral tarsal artery can be easily damaged, preventing its use in the management of wound complications or trauma.

The optimal choice of irrigating solution or irrigating pressure in the initial management of open fracture wounds remains controversial. FLOW compared the effect of castile soap versus normal saline, and low versus high pressure pulsatile lavage on one year re-operation rates in patients with open fracture wounds.

We conducted a multicentre, blinded, two-by-two factorial, pilot randomised trial of 111 patients with open fracture wounds receiving either castile soap solution or normal saline and either high or low pressure pulsatile lavage. The primary outcome, re-operation within one year, included infections, wound healing problems, and nonunions. Secondary outcomes included all operative and non-operative infections, wound healing problems, nonunion and functional outcomes. We followed the intention to treat principle.

Eighty-nine patients (80.2%) completed the 12-month follow-up. As anticipated in this small-sample-size pilot study, results were compatible with substantial benefit and substantial harm. The hazard ratio (HR) for re-operation with castile soap was 0.77 (95% Confidence Interval (CI) 0.35 to 1.69, p=0.52). With low pressure lavage, the hazard ratio for the risk of re-operation was 0.56, 95% CI 0.25 to 1.27, p=0.17. Secondary outcomes showed a significant relative risk reduction for nonunion of 63% in favour of castile soap (p=0.036), and a trend for a relative risk reduction for nonunion of 44% in favour of low pressure lavage (p=0.22). Functional outcome scores showed no significant differences at any time point between groups.

The FLOW pilot randomised controlled trial demonstrated the possibility that the use of low pressure may decrease the re-operation rate for infection, wound healing problems, or nonunion. Our findings provide compelling rationale for continued investigation in a pivotal FLOW trial of 2280 patients.

Aim. Identifying the optimal agent for irrigation for periprosthetic joint infection remains challenging as there is limited data. The ideal solution should have minimal cytotoxicity while maintaining bactericidal activity. We developed a novel activated-zinc solution containing zinc-chloride (ZnCl. 2. ) and sodium-chlorite (NaClO. 2. ). The purpose of this study was 1.) to investigate the antimicrobial efficacy of 2 concentrations (“CZ1”, “CZ2”) against Staphylococcus aureus and Pseudomonas aeruginosa and 2.) to evaluate untoward effects of the solution on local wound tissue 24 hours after solution exposure in pig wound models. Method. The study was conducted and reported in accordance to ARRIVE guidelines. We created twenty-four 1.5cm wounds on the back of a Yorkshire-cross pig. Wounds were inoculated with standardized Pseudomonas and S. aureus. 8 wounds were designated as controls (inoculum without treatment), 8 treated with CZ1, and 8 with CZ2. Punch biopsies were taken 1 hour after treatment and bacteria quantified. Wound necrosis/neutrophil infiltrate was measured 24-hours post-exposure. Results. After 1-hour, the control, CZ1 and CZ2 wounds had total bacteria of 5.7, 2.8 and 3.5 logCFU/g, respectively (p=0.017). The control, CZ1 and CZ2 wounds had S. aureus of 5.3, 2.3 and 1.6 logCFU/g, respectively (p=0.009). The control, CZ1 and CZ2 wounds had Pseudomonas of 5.5, 0.3 and 0.0 logCFU/g, respectively (p=0.000). After 24 hours of exposure to CZ1 and CZ2, there was no statistically significant increased necrosis (p=0.12, p=0.31, respectively). CZ1 had increased, moderate neutrophil infiltrate (p=0.04) when compared to controls, however CZ2 was not significant (p=0.12). Conclusions. Our novel solution demonstrated 99.5–99.9% reduction in total bacteria, 99.9–99.98 % reduction in S. aureus, and 100% eradication of Pseudomonas 1-hour after exposure, without significantly increased necrosis and no-to-minimally-increased neutrophil infiltrate. This novel solution may provide another significant tool in the arsenal to treat and/or prevent PJI and other wound infections

Persistent post-surgical pain and associated disability are common after a traumatic fracture repair. Preliminary evidence suggests that patients' beliefs and perceptions may influence their prognosis. We sought to explore this association. We used data from the Fluid Lavage of Open Wounds trial to determine, in 1560 open fracture patients undergoing surgical repair, the association between Somatic PreOccupation and Coping (captured by the SPOC questionnaire) and recovery at 1 year. Of the 1218 open fracture patients with complete data available for analysis, 813 (66.7%) reported moderate to extreme pain at 1 yr. The addition of SPOC scores to an adjusted regression model to predict persistent pain improved the concordance statistic from 0.66 to 0.74, and found the greatest risk was associated with high SPOC scores [odds ratio: 5.63, 99% confidence interval (CI): 3.59–8.84, absolute risk increase 40.6%, 99% CI: 30.8%, 48.6%]. Thirty-eight per cent (484 of 1277) reported moderate to extreme pain interference at 1 yr. The addition of SPOC scores to an adjusted regression model to predict pain interference improved the concordance statistic from 0.66 to 0.75, and the greatest risk was associated with high SPOC scores (odds ratio: 6.06, 99% CI: 3.97–9.25, absolute risk increase: 18.3%, 95% CI: 11.7%, 26.7%). In our adjusted multivariable regression models, SPOC scores at 6 weeks post-surgery accounted for 10% of the variation in short form-12 physical component summary scores and 14% of short form-12 mental component summary scores at 1 yr. Amongst patients undergoing surgical repair of open extremity fractures, high SPOC questionnaire scores at 6 weeks post-surgery were predictive of persistent pain, reduced quality of life, and pain interference at 1 yr

High-energy firearms do not necessarily produce ‘high-energy’ Gun Shot Wounds (GSWs). The aim of this study was to characterise the gun shot injuries sustained by UK forces, and secondly test the hypothesis that the likely severity of GSWs can be predicted by features of the wound. The UK Military trauma registry was searched for cases injured by GSW in the five years between 01 Jan 2009 and 31 Dec 2013: only UK personnel were included. There were 450 cases who met the inclusion criteria. 96 (21%) were fatally injured, with 354 (79%) surviving their injuries. Of the 325 survivors with full records, 236 had GSWs to the limbs and pelvis. ‘Through and through’ wounds were strongly associated with less requirement for debridement (p<0.0001). Fractures were associated with a requirement for a greater number of wound debridements (p=0.00022) GSW with intact, retained bullets and those involving bullet fragmentation, required similar numbers of wound debridements (p=0.53744). This study characterises the GSWs sustained by UK Military personnel over 5-years of warfare. More complex wounds as indicated by the requirement for repeated debridements are associated with injuries where the bullet does not pass straight through the body, or where a bone is fractured

1. Reconstruction of Failed Hip Abductors following THA-A New Surgical Technique using Graft Jacket Matrix. 2. A Comparison of Modular Tapered versus Cylindrical Stems for Complex Femoral Revisions. 3. Clinical Presentation and Imaging Results of Patients With Symptomatic Gluteus Medius Tears. 4. Should Patients Undergoing Elective Arthroplasty Be Screened for Malnutrition. 5. Revision UKA to TKA: Not a Slam Dunk. 6. HgBA1C – A Marker for Surgical Risk in Diabetic Patients Undergoing Total Joint Arthroplasty. 7. Dexamethasone Reduces Post Operative Hospitalisation and Improves Pain and Nausea After Total Joint Arthroplasty. 8. Infection Following Simultaneous Bilateral TKA. 9. Staph Decolonisation in Total Joint Arthroplasty Is Effective. 10. Comparison of One Versus Two Stage Revision Results for Infected THA. 11. Should Draining Wounds and Sinuses Associated With Hip and Knee Arthroplasties Be Cultured. 12. Differences In Short Term Complications Between Spinal and General Anesthesia for Primary TKA

Introduction. The results of a prospective study of primary bone grafting in a selective group of patients with High energy open fractures (Grade III) of limbs with communition or bone loss are presented. Materials and methods. Out of 310 Gustilo Grade III Open injuries managed over a 4 year period, 42 patients with Grade III injuries underwent bonegrafting after satisfying the inclusion criteria (Age <60, Debridement within 12hrs, Stable fracture fixation, wound cover within 72hrs) at or before the time of wound closure or soft tissue cover. Patients with Grade IIIc fractures, farmyard injuries, needing freeflaps, ASA grade of 3 or more, injury severity score > 25 or monomelic polytrauma were excluded. The bone involved was femur in 26 patients, tibia in 4, forearm in 9 and humerus in 3 patients. The injury was Grade IIIA in 11 and Grade IIIB in 31 patients. Wounds were primarily closed immediately after debridement in 28 (66.7%) patients, by split thickness skingrafting in 7 (16.7%) and by suitable regional flaps in 7 (16.7%) patients. Rigid fixation was achieved in all patients with variety of implants depending on the fracture personality. Autologous Cortico-cancellous bonegrafting was done immediately after debridement in 33 (78.6%) and within 72hrs at the time of soft tissue cover in 9 (21.4%) patients. Results. At a mean follow-up of 2.4 (1-4) yrs all fractures had united except one which ended in infected nonunion (2.4%). Deep Infection was present in 4 (9.5%) patients. The mean time for Union was 15 (10-32) wks for Grade IIIA and 16.6 (12-32) wks for Grade IIIB fractures. No complications specific to bonegrafting were noted. Secondary procedures were needed in 4 (9.5%) patients to achieve union. Conclusion. Primary bonegrafting was possible in 13.5% of the total patients with Grade III open fractures managed and it is a safe procedure that can hasten bone healing and reduce the union time without increased risk of complications. A team approach (Ortho+Plastic) from day one of management with careful patient selection is the key

Introduction. Joint reconstruction remains a successful and popular surgery with advances in approaches, implants and techniques continually forthcoming. Various methods of skin closure exist to address issues in efficiency, aesthetics, and barrier to infection. While subcuticular skin closure techniques offer an aesthetic advantage to conventional skin stapling, no measurable differences have been reported. Furthermore, newer barbed sutures, such as the V-loc absorbable suture, theoretically distribute tension evenly through the wound and help decrease knot-related complications. To our knowledge, no literature exists on the rate of wound complications in joint arthroplasty with the use of V-loc suture for skin closure. We hypothesize that despite theoretical gains, skin closure with a V-loc (Covidien, Mansfield, MA) absorbable suture should be performed with caution. Methods & Materials. A retrospective chart review was conducted of 278 consecutive primary joint reconstruction cases performed by a single surgeon in 12 months from July 2009 through June 2010. Pre-operative history & physical reports were evaluated for co-morbidities (i.e diabetes mellitus), smoking status and body mass index (BMI). Operative dictations by the attending surgeon provided information on the surgical procedure, use of drain, wound closure technique and type of suture/staple used for skin closure. Skin was closed by the primary surgeon and his chief resident. Wounds were closed via staple gun or subcuticular stitch (3-0 Biosyn vs V-Loc) in a consecutive manner, depending on the surgeon's preference in that period. Post-operative clinic notes were reviewed to determine the occurrence of wound complications, issuance of antibiotic prescriptions, or return to the operating room. The cohort consisted of 106 males and 161 females at an average age of 63 years (range: 18–92). Overall, there were 153 procedures at the knee (including TKA, uni-compartmental arthroplasty, patello-femoral arthroplasty) and 125 procedures at the hip (including THA and hemi-arthroplasty). Results. In review of 278 consecutive primary joint reconstruction cases, there were 17 (6.1%) post-operative wound complications noted, including cellulitis, stitch abscesses, wound dehiscence, and deeper infections requiring OR irrigation and debridement. In 181 cases, staples were used for skin closure; in these cases, seven wound complications were noted (7/181, 3.9%). In 49 cases closed via a subcuticular Biosyn suture there were 4 wound complications noted (4/49, 8.1%). Six wound complications occurred in cases closed with a V-loc suture (6/45, 13.3%). Discussion. Aesthetics and efficiency often are the driving forces of innovation. We present the rate of wound complications in various superficial wound closure methods, including the V-loc, an innovative absorbable barbed suture. Based on our clinical experience, we promote consideration of wound and infectious complications when choosing a method of skin closure in joint reconstruction procedures

As of April 2010 all NHS institutions in the United Kingdom are required to publish data on surgical site infection, but the method for collecting this has not been decided. We examined 7448 trauma and orthopaedic surgical wounds made in patients staying for at least two nights between 2000 and 2008 at our institution and calculated the rate of surgical site infection using three definitions: the US Centers for Disease Control, the United Kingdom Nosocomial Infection National Surveillance Scheme and the ASEPSIS system. On the same series of wounds, the infection rate with outpatient follow-up according to Centre for Disease Control was 15.45%, according to the UK Nosocomial infection surveillance was 11.32%, and according to ASEPSIS was 8.79%. These figures highlight the necessity for all institutions to use the same method for diagnosing surgical site infection.

If different methods are used, direct comparisons will be invalid and published rates of infection will be misleading.

High-quality randomised controlled trials (RCTs) evaluating surgical therapies are fundamental to the delivery of evidence-based orthopaedics. Orthopaedic clinical trials have unique challenges; however, when these challenges are overcome, evidence from trials can be definitive in its impact on surgical practice. In this review, we highlight several issues that pose potential challenges to orthopaedic investigators aiming to perform surgical randomised controlled trials. We begin with a discussion on trial design issues, including the ethics of sham surgery, the importance of sample size, the need for patient-important outcomes, and overcoming expertise bias. We then explore features surrounding the execution of surgical randomised trials, including ethics review boards, the importance of organisational frameworks, and obtaining adequate funding.

Cite this article: Bone Joint Res 2014;3:161–8.