Introduction. Superficial pin site infection is a common problem associated with external fixation, which has been extensively reported. However, the incidence and risk factors with regards to deep infection is rarely reported in the literature. In this study, we investigate and explore the incidence and risk factors of deep infection following circular frame surgery. For the purpose of this study, deep infection was defined as: persistent discharge or collection for which surgical intervention was recommended. Materials and Methods. Retrospective review of all patients whom underwent frame surgery between 1. st. of April 2015 to 1. st. April 2019 in our unit with a minimum of 1 year follow up following frame removal. We recorded patient demographics, patient risk factors, trauma or elective procedure, number of days the frame was in situ, location of infection and fracture pattern. Results. 304 patients were identified. 27 patients were excluded as they were lost to follow up or had their primary frame surgery as a treatment for infection. This provided us with 277 patients for analysis. Mean age was 47 years (range 9–89 years), the male to female ratio was 1.5:1 and 80% were trauma frames. 13 patients (4.69%) developed deep infection and all occurred in trauma patients. Of the 13 patients who developed deep infection, 4 had infection before frame removal and 9 occurred after frame removal. 8 deep infections occurred within a year of frame removal, 1 occurred between 1 and 2 years. Within the 13 frame procedures for trauma, 12 were periarticular multifragmentary fractures, 3 of which were open, and the remaining was an open diaphyseal fracture. The periarticular fractures were more likely to develop deep infection than diaphyseal fractures (p–0.033). 12 patients (out of 13) also had concurrent minimally invasive internal fixation with screws in very close proximity of the wires. Conclusions. The rate of deep infection following circular frame surgery appears to be low. Pooled, multicentre data would be required to analyse risk factors however multifragmentary, periarticular fracture and the requirement for additional internal fixation appears to be an associated factor

Aim. In recent years, many studies on revision for infection after arthroplasty have been published. In national arthroplasty registers, revision for infection is defined as surgical debridement, with or without removal or exchange of the entire or parts of the prosthesis due to deep infection, and should be reported to the register immediately after surgery. The diagnosis of infection is made at the surgeon's discretion, based on pre- and perioperative assessment and evaluation, and is not to be corrected to the register based on peroperative bacterial cultures. Due to this lack of validation, the rate of revision for infection will only be an approximation of the true rate of periprosthetic joint infection (PJI). Our aim was to validate the reporting of infection after total hip arthroplasty, and to assess if revisions for infection actually represented true PJI. Methods. We investigated the reported revisions for infection and aseptic loosening after total hip arthroplasty from 12 hospitals, representing one region of the country, reported during the period 2010–2020. The electronic patient charts were investigated for information on surgical treatment, use of antibiotics, biochemistry and microbiology findings. PJI was defined as growth of at least two phenotypically identical microbes in perioperative tissue samples. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated. Results. 145 revisions for infection and 137 revisions for aseptic loosening were reported. Of the reported infections, there were 141/145 true positives and 4/145 false positives. Of the reported aseptic loosenings, there were 126/137 true negatives and 11/137 false negatives. This gives a positive predictive value of 0.97, negative predictive value of 0.92, sensitivity of 0.93, specificity of 0.97 and accuracy of 0.95. Interpretation. We found the reporting revision for infection after total hip arthroplasty to the national register accurate. There was high correlation between reported revision for infection and PJI. Studies on revision for infection from arthroplasty registers may therefore be considered as reliable as studies of true PJI

Surgical site infections (SSIs) after spinal fusion surgery increase healthcare costs, morbidity and mortality. Routine measures of obesity fail to consider site specific fat distribution. We aimed to assess the association between the spine adipose index and deep surgical site infection and determine a threshold value for spine adipose index that can assist in preoperative risk stratification in patients undergoing posterior instrumented lumbar fusion (PILF). A multicentre retrospective case-control study was completed. We reviewed patients who underwent PILF from January 1, 2010 to December 31, 2018. All patients developing a deep primary incisional or organ-space SSI within 90 days of surgery as per US Centre for Disease Control and Prevention criteria were identified. We gathered potential pre-operative and intra-operative deep infection risk factors for each patient. Spine adipose index was measured on pre-operative mid-sagittal cuts of T2 weighted MRI scans. Each measurement was repeated twice by three authors in a blinded fashion, with each series of measurement separated by a period of at least six weeks. Forty-two patients were included in final analysis, with twenty-one cases and twenty-one matched controls. The spine adipose index was significantly greater in patients developing deep SSI (p =0.029), and this relationship was maintained after adjusting for confounders (p=0.046). Risk of developing deep SSI following PILF surgery was increased 2.0-fold when the spine adipose index was ≥0.51. The spine adipose index had excellent (ICC >0.9; p <0.001) inter- and intra-observer reliabilities. The spine adipose index is a novel radiographic measure and an independent risk factor for developing deep SSI, with 0.51 being the ideal threshold value for pre-operative risk stratification in patients undergoing PILF surgery

Aim. This study aimed to identify risk factors for development of deep periprosthetic joint infection (PJI) in patients following surgical treatment of neck of femur fracture. Method. This study identified a consecutive series of 2,822 (2,052 female, 73%) patients who underwent either hemiarthroplasty (n=1,825, 65%) or fixation (DHS) (n=997, 35%) for fractured neck of femur performed between January 2009 and June 2015 at our institution. Full patient demographics, co-morbidity and peri-operative complication data were determined. The majority of patients were either ASA 2 (n=663, 23%) or ASA 3 (n=1,521, 54%), mean age = 81.3 years (SD 10.3). All patients were followed up post-operatively by a dedicated surgical site infection (SSI) monitoring team in order to identify patients who developed a PJI within 1 year. A stepwise multivariable logistic regression model was used to identify patient and surgical factors associated with increased risk of infection. Predictors with a p-value of <0.20 in the univariate analysis were included in the multivariate analysis. Results. Thirty-nine (39) cases of deep periprosthetic infection were identified (hemiarthroplasty n=35, DHS n=4) representing an overall deep infection rate of 1.4% (hemiarthroplasty 1.9%, DHS 0.4%). The most common infecting pathogen was a pure growth of coagulase negative Staphylococcus (n=9, 23%) followed by a pure growth of Staphylococcus aureus (n=7, 18%). An increased risk of PJI was observed in patients who underwent hemiarthroplasty compared to those treated by fixation (odds ratio (OR) 6.50, 95%CI 2.26 – 18.7, p=0.001). Of patient factors, only blood transfusion within 30 days (OR 3.51, 95%CI 1.72 – 7.13, p=0.001) and the presence or development of pressure sores on or during admission (OR 2.99, 95%CI 1.24 – 7.19, p=0.015) were significantly associated with an increased risk of development of PJI. Use of high-dose dual antibiotic cement (gentamicin and clindamycin) was associated with a two-fold reduction in the risk of PJI (OR 0.39, 95%CI 0.20 – 0.76, p=0.005) vs standard dose gentamicin antibiotic cement. Conclusions. This study found: 1) a deep infection rate similar to that reported earlier from large number studies from the UK, 2) a six-fold higher deep infection rate in hemiarthroplasties, compared to internal fixations, and 3) a three-fold higher infection rate in patients who suffer concomitant pressure sores or receive a blood transfusion up to 30 days post-operatively

Patients presenting with a fractured neck of femur are a fragile group with multiple co-morbidities who are at risk of post-operative complications. As many as 52% of patients are reported to suffer a urinary tract infection post hip fracture surgery. There are little data surrounding the effects of post-operative urinary tract infections on mortality and deep prosthetic infection. We prospectively investigated the impact of post-operative urinary tract infection (UTI) in 9168 patients admitted to our institution with a diagnosis of proximal femoral fracture over an eleven year period in a prospective population study. We examined the effects of post operative UTI on the incidence of deep infection, survivorship and length of stay. Post-operative UTI occurred in 6.1% (n=561) and deep infection in 0.89% (n=82). Deep infection was significantly more common in patients complicated with a UTI (3.2% vs 0.74% p< 0.001) with a relative risk of 3.7:1. In 58% of patients the same organisms was cultured in the urine and hip samples. A postoperative UTI did not adversely effect 90 day survival, however was associated with an increased length of stay (ROC analysis AUC=0.79). Delays to surgery and age were not predictive of a post operative UTI. Recognition of the risks posed by post operative UTI, the risk factors for development of infection and early treatment is essential to reduce the risks of increased subsequent periprosthetic infection

Grade III Open fractures of the tibia represent a serious injury. It is recognised that combined management of these cases by experienced orthopaedic and plastic surgeons improves outcomes. Previous studies have not considered the timing of definitive soft tissue cover in relation to the definitive orthopaedic management. We reviewed medical notes of 73 patients with 74 Grade III Open tibia fractures (minimum 1 year follow up), to compare deep infection rates in patients who had a) a single-stage definitive fixation and soft tissue coverage vs. those who had separate operations, and b) those who had definitive treatment completed in < 72 hours vs. > 72 hours. Of subjects that underwent definitive fixation and coverage in a single procedure, 4.2% developed deep infections, compared with 34.6 % deep infection(p<0.001) in those who underwent definitive treatment at separate operations. Of patients who had definitive treatment completed in < 72-hours, 20.0% developed deep infections a compared with 12.2%(p=0.4919) in the >72-hour group. Patients with Gustilo III open tibial fractures have lower rates of deep infection if definitive fixation and coverage are performed in a single-stage procedure. Emphasis should be placed on timely transfer to a specialist centre, aiming for a single-stage combined orthoplastic surgery

Introduction. Despite the advances in adjuvant chemotherapy and surgical techniques, the diagnosis of a bone tumour still carries with it a significant risk of mortality. This study investigates factors affecting survival, in patients treated for malignant tumours of bone using Endoprosthetic replacement (EPR). Methods. Our tertiary referral musculoskeletal tumour unit has taken referrals over 40 years. Electronic patient records have been prospectively kept on all patients seen since 1986 and data has been entered retrospectively for patients seen between 1966 and 1986. A consecutive series of 1264 patients underwent endoprosthetic reconstruction; after 158 patients were excluded, 1106 patients were left in the study group. Factors including diagnosis, size of tumour, surgical margins, percentage tumour necrosis following chemotherapy, tumour site, local recurrence, decade of reconstruction, fracture and post-operative deep infection were analysed. Results. Overall population survival was 58.4% at 5 years, 50.5% at 10 years and 44.6% at 20 years. Significant prognostic factors on cox-regression analysis included locally recurrent disease (p<0.001), metastatic disease (p<0.001), chemotherapy (p<0.001), percentage tumour necrosis after chemotherapy (p=0.001), tumour size (p<0.001), post-operative surgical margin (p<0.001), fracture (p<0.001) and post-operative deep infection (p=0.05). Univariate analysis showed proximal femoral site (p=0.01) and EPRs after 1991 (p=0.05) were significant factors. Patients diagnosed with a deep infection within 2.5 years from implantation had 63.2% 10 year survival, compared to 49.4% in the non infected group. When stratified by diagnosis this was significant in patients with myeloma (p=0.01) and a showed strong trend in those with osteosarcoma (p=0.1). Trends towards better survival with Staphylococcal infections (p=0.2) were not demonstrated with other organisms. Discussion and conclusion. Several known prognostic factors were demonstrated for malignant bone tumours but there was evidence for increased survival after deep post-operative infection. The authors feel the results of this study and other recent evidence warrant further investigation

Purpose. Traditional recommendations suggest that open fractures require urgent surgical debridement to reduce infection. Although many papers comparing early vs late debridement have found no difference in infection rates, these papers have not taken into account important confounding factors. We attempt to answer whether delay between injury and surgical debridement in open fractures is associated with a higher infection rate after accounting for these important confounders. Method. Five hundred and twenty three open extremity fractures in 417 patients were identified using the Sunnybrook trauma and orthopaedic department registries. Thirty patients (36 fractures) did not have complete follow-up. Seven patients were excluded due to incomplete data (complete follow-up rate=91%). A further 14 patients died during their hospitalization. A total of 459 fractures in 364 patients were reviewed. Data was collected on demographics, ISS score, ASA, time to initial operative debridement, timing of antibiotic administration, mechanism of injury, presence of significant contamination, and Gustillo-Anderson fracture grade. Deep infection was defined as an unplanned return to the operating room for treatment of infection. The influence of time to initial debridement was examined in an unadjusted analysis as a continuous variable and at thresholds of 6 and 12 hours of delay. A multivariable logistic regression was used to analyze the effect of delay while controlling for important confounding variables. Results. 46 deep infections occurred in 459 fractures (10%). In an unadjusted analysis, infection was associated with male sex(p=0.038), higher fracture grade(p=0.007), tibial fractures(p=0.027) and gross contamination (p=0.0001). In an unadjusted analysis, delay to debridement was not associated with deep infection (p=0.08) however, higher grade fractures, tibial fractures and grossly contaminated fractures were debrided earlier than less severe open fractures. Multivariable analysis showed infection was associated with each additional hour of delay (OR=1.033 95%CI 1.01 to 1.057), tibial fractures (OR=2.44 95%CI 1.26 to 4.73), higher Anderson & Gustillo grade (OR=1.99 95%CI 1.004 to 3.954), and gross contamination (OR=3.12 95%CI 1.36 to 7.36). Conclusion. Among more severe open fractures the impact of delay to debridement translates into a larger absolute increase in probability of infection. For example, a grade 2 injury of the forearm without contamination will have a predicted infection rate increase from 2.38% to 2.86% with an additional 6 hours of delay. However, a grade 3b tibial fracture with contamination will have a predicted infection rate increase from 35.6% to 43.3% with 6 hours of further delay. We recommend severe open fractures be debrided emergently while less severe open fractures be debrided urgently

Periprosthetic joint infection (PJI) complicates between 0.5% and 1.2% primary total hip arthroplasties (THAs) and may have devastating consequences. The traditional assessment of patients suffering from PJI has involved the serological study of inflammatory markers and microbiological analysis of samples obtained from the joint space. Treatment has involved debridement and revision arthroplasty performed in either one or two stages.

We present an update on the burden of PJI, strategies for its diagnosis and treatment, the challenge of resistant organisms and the need for definitive evidence to guide the treatment of PJI after THA.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):27–30.

Background. Traditional recommendations suggest that open fractures require urgent surgical debridement to reduce infection. However, this has recently been challenged by a number of investigations. However, in many cases, these studies were not able to control for important confounding factors. The purpose of our study was to evaluate the relationship between delay to definitive surgical debridement while controlling for important confounders. Method. 364 patients with 459 open fractures treated at a level one trauma centre over four years were reviewed. Time to definitive surgical debridement was modelled as a predictor of infection while controlling for fracture grade, anatomic site of fracture, and presence of significant contamination. Time to debridement was modelled as both a continuous variable and a categorical variable with cut off points at 6 and 12 hours of delay. Results. 46 deep infections occurred in 459 fractures(10%). There were no infections among grade one open fractures(0/55). Delay to debridement using cut-points of 6 hours and 12 hours was not associated with an increased infection rate. However, with delay to debridement analyzed as a continuous variable each additional hour of delay was associated with an increase in the odds of infection(OR=1.033 95%CI 1.01–1.057). Multivariable analysis also showed that infection was associated with tibial fractures(OR=2.44 95%CI 1.26–4.73), higher Anderson & Gustillo grade (OR=1.99 95%CI 1.004–3.954), and gross contamination (OR=3.12 95%CI 1.36–7.36). Among more severe open fractures the impact of delay to debridement translates into a larger absolute increase in probability of infection. Conclusion. We recommend that higher grade open fractures be treated with definitive debridement as soon as possible given that the risk of infection increases in a linear fashion with time delay. For severe open fractures, especially tibial, we recommend emergent debridement as soon as the patient has been resuscitated and is stable enough to undergo surgery

This study aims to determine the incidence of surgical site infection leading to reoperation for sepsis following minor hand procedures performed outside the main operating room using field sterility in the South African setting.

The investigators retrospectively reviewed the records of 485 patients who had WALANT-assisted minor hand surgery outside a main operating theatre, a field sterility setting between March 2019 and April 2023. The primary outcome was the presence or absence of deep surgical site infection that required reoperation within four weeks. Cases included where elective WALANT minor hand procedures, a minimum age of 18 with complete clinical records.

The patients were mostly female (54.8%), with a mean age of 56.35 years. The majority of cases were trigger finger and carpal tunnel release. An overall 485 cases were reviewed, the deep surgical site infection rate resulting in reoperation within 4 weeks post-operatively was 1.24% ((95% Confidence Interval (CI) 0.0034 to 0.0237); p = 0.009).

Minor hand procedures performed under field sterility using WALANT have a low surgical site infection rate. The current study's infection rates are comparable to international surgical site infection rates for similar surgeries performed in main operating rooms using standard sterilisation procedures. Field sterility is a safe and acceptable clinical practice that may improve work efficiency in public sector.

The practice at most centers in North America for the investigation and management of non-acute infection after hip replacement has been relatively standard for some time. Diagnosis has depended on a thorough history, physical examination, plain radiographs, straightforward laboratory inflammatory markers, joint aspiration for bacteriologic study, intraoperative frozen section in selected cases, and intraoperative synovial biopsies for confirmatory bacteriologic evaluation. The cornerstone of treatment on this continent has revolved around two-stage revision hip replacement, with increasing popularity for the use of interval articulating antibiotic loaded spacers, and increasing use of cementless fixation at the second stage. But this standard approach has been under increasing scrutiny in recent years, for good reason.

The use of more precise “best evidence” paradigms on which to base the diagnosis have been developed. There is encouraging work on the application of more specific synovial and serum markers. The need to remove all implant material in all cases has been challenged. And there is evidence that the two stage approach is associated with greater morbidity, mortality and cost. The latter has led to a re-examination of the role and results of single-stage exchange revision, at least in selected cases, where the patient is immune competent, the soft tissue and bone anatomy is not badly deficient, the organism is known, and the antibiotic sensitivity is favorable.

The most encouraging of the recent developments is the increasing consensus that multicenter collaborative study is required if we are to make genuine progress in the one-stage/two-stage debate. At least one multicenter prospective randomised study is scheduled to commence in 2015.

Background

Periprostetic joint infections (PJI) are often difficult to diagnose, to treat and often leave the patient with severe impaired function. The presence of low virulent bacteria is frequently discovered in apparent aseptic revisions of shoulder arthroplasties and pose a challenge to diagnose preoperatively.

Dual Isotope In111 Leucocyte/ Tc99 Bone Marrow SPECT CT scan (L/BMS) is considered the radionuclide gold standard in preoperative diagnosing PJI with reported high specificity and sensitivity in hip and knee arthroplasties.

Unfortunately, it is labour-intensive and expensive to perform and documentation using L/BMS on shoulder arthroplasties lack.

The Control of Infection Committee at a specialist orthopaedic hospital prospectively collected data on all episodes of bacteriologically-proven deep infection arising after primary hip and knee replacements over a 15-year period from 1987 to 2001. There were 10 735 patients who underwent primary hip or knee replacement. In 34 of 5947 hip replacements (0.57%) and 41 of 4788 knee replacements (0.86%) a deep infection developed. The most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. Of the infecting organisms, 72% were sensitive to routine prophylactic antimicrobial agents. Of the infections, 29% (22) arose in the first three months following surgery, 35% between three months and one year (26), and 36% (27) after one year. Most cases were detected early and treated aggressively, with eradication of the infection in 96% (72). There was no significant change in the infection rate or type of infecting micro-organism over the course of this study. These results set a benchmark, and importantly emphasise that only 64% of peri-prosthetic infections arise within one year of surgery. These results also illustrate the advantages of conducting joint replacement surgery in the isolation of a specialist hospital

The purpose of the study was to identify factors that affect the incidence of deep wound infection after hip fracture surgery. Data from a hip fracture database of 7057 consecutively treated patients at a single centre was used to determine the relationship between deep wound sepsis and a number of factors. Fisher's exact test and the unpaired T test were used. All patients were initially followed up in a specialist clinic. In addition a phone call assessment was made at one year from injury to check that no later wound healing complications had occurred. There were 50 cases of deep infection (rate of 0.7%). There was no significant difference in the rate of deep sepsis with regards to the age, sex, pre-operative residential status, mobility or mental test score of the patient. Specialist hip surgeons and Consultants have a lower infection rate compared with surgeons below Consultant grade, p=0.01. The mean length of anaesthesia was longer in the sepsis group (76minutes) compared to the no sepsis group (65minutes), this was significant, p=0.01. The patient's ASA grade and fracture type were not significant factors. The rate of infection in intracapsular fractures treated by hemiarthroplasty was significantly greater than those that had internal fixation, p=0.001. The rate of infection in extracapsular fractures fixed with an extra-medullary device was significantly greater than those fixed with an intra-medullary device, p=0.021. The presence of an infected ulcer on the same leg as the fracture was not associated with a higher rate of deep infection. In conclusion we have found that the experience (seniority) of the surgeon, the length of anaesthesia and the type of fixation used are all significant factors in the development of deep sepsis. These are all potentially modifiable risk factors and should be considered in the treatment of hip fracture patients

Introduction. Open tibial fractures typically occur as a consequence of high energy trauma in patients of working age resulting in high rates of deep infection and poor functional outcome. Whilst improved rates of limb salvage, avoidance of infection and better ultimate function have been attributed to improved centralisation of care in orthoplastic units, there remains no universally accepted method of definitive management of these injuries. The aim of this study is to the report the experience of a major trauma centre utilising circular frames as definitive fixation in patients sustaining Gustilo-Anderson (GA) 3B open fractures. Materials & Methods. A prospectively maintained database was interrogated to identify all patients. Case notes and radiographs were reviewed to collate patient demographics and injury factors . The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventions. Results. 247 open tibial fractures with a soft tissue manipulation in order to achieve skin cover, of which 203 had a minimum follow up of 2 years. Mean age was 43.2 years old, with 72% males, 34% smokers and 3% diabetics. Total duration of frame management averaged 6.4 months (SD 7.7). Nine (4.4%) patients developed a deep infection and 41 (20%) exhibited signs of a pin site infection. Seventy-five (37%) of patients had a secondary intervention of which; 8 comprised debridement of deep infection, 1 amputation for deep infection and the remainder adjustments of frames. Conclusions. Orthoplastic care including circular frame fixation for GA 3B fractures of the tibia results in a low rate of deep infection, around a quarter of contemporary literature for internal fixation

This study aimed to examine the changing trends in the reasons for total hip replacement (THR) revision surgery, in one country over a twenty-one year period, in order to assess whether changes in arthroplasty practices have impacted revision patterns and whether an awareness of these changes can be used to guide clinical practice and reduce future revision rates. The reason for revision THR performed between January 1999 and December 2019 was extracted from the New Zealand Joint Registry (NZJR). The results were then grouped into seven 3-year periods to allow for clearer visualization of trends. The reasons were compared across the seven time periods and trends in prosthesis use, patient age, gender, BMI and ASA grade were also reviewed. We compared the reasons for early revision, within one year, with the overall revision rates. There were 20,740 revision THR registered of which 7665 were revisions of hips with the index procedure registered during the 21 year period. There has been a statistically significant increase in both femoral fracture (4.1 – 14.9%, p<0.001) and pain (8.1 – 14.9%, p<0.001) as a reason for hip revision. While dislocation has significantly decreased from 57.6% to 17.1% (p<0.001). Deep infection decreased over the first 15 years but has subsequently seen further increases over the last 6 years. Conversely both femoral and acetabular loosening increased over the first 12 years but have subsequently decreased over the last 9 years. The rate of early revisions rose from 0.86% to 1.30% of all revision procedures, with a significant rise in revision for deep infection (13-33% of all causes, p<0.001) and femoral fracture (4-18%, p<0.001), whereas revision for dislocation decreased (59-30%, p<0.001). Adjusting for age and gender femoral fracture and deep infection rates remained significant for both (p<0.05). Adjusting for age, gender and ASA was only significant for infection. The most troubling finding was the increased rate of deep infection in revision THR, with no obvious linked pattern, whereas, the reduction in revision for dislocation, aseptic femoral and acetabular loosening can be linked to the changing patterns of the use of larger femoral heads and improved bearing surfaces

Introduction. Bone transport and distraction osteogenesis have been shown to be an effective treatment for significant bone loss in the tibia. However, traditional methods of transport are often associated with high patient morbidity due to the pain and scarring caused by the external frame components transporting the bone segment. Prolonged time in frame is also common as large sections of regenerate need significant time to consolidate before the external fixator can be removed. Cable transport has had a resurgence with the description of the balanced cable transport system. However, this introduced increasingly complex surgery along with the risk of cable weave fracture. This method also requires frame removal and intramedullary nailing, with a modified nail, to be performed in a single sitting, which raised concern regarding potential deep infection. An alternative to this method is our modified cable transport system with early intramedullary nail fixation. Internal cables reduce pain and scarring of the skin during transport and allow for well controlled transport segment alignment. The cable system is facilitated through an endosteal plate that reduces complications and removes the need for a single-stage frame removal and nailing procedure. Instead, the patients can undergo a pin-site holiday before nailing is performed using a standard tibial nail. Early intramedullary nailing once transport is complete reduces overall time in frame and allows full weight bearing as the regenerate consolidates. We present our case series of patients treated with this modified cable transport technique. Methodolgy. Patients were identified through our limb reconstruction database and clinic notes, operative records and radiographs were reviewed. Since 2019, 8 patients (5 male : 3 female) have undergone bone transport via our modified balanced cable transport technique. Average age at time of transport was 39.6 years (range 21–58 years) with all surgeries performed by the senior author. Patients were followed up until radiological union. We recorded the length of bone transport achieved as well as any problems, obstacles or complications encountered during treatment. We evaluated outcomes of full weight bearing and return to function as well as radiological union. Results. 4/8 bone defects were due to severely comminuted open fractures requiring extensive debridement. All other cases had previously undergone fixation of tibial fractures which had failed due to infection, soft tissue defects or mal-reduction. The mean tibial defect treated with bone transport was 41mm (range 37–78mm). From the start of cable transport to removal of external fixator our patients spent an average of 201 days in frame. 7/8 patients underwent a 2-week pin-site holiday and subsequent insertion of intramedullary nail 2 weeks later. One patient had sufficient bony union to not require further internal fixation after frame removal. 10 problems were identified during treatment. These included 4 superficial infections treated with antibiotics alone and 5 issues with hardware, which could be resolved in the outpatient clinic. 1 patient had their rate of transport slowed due to poor skin quality over the site of the regenerate. 4 obstacles resulted in a return to theatre for additional procedures. 1 patient had a re-do corticotomy and 3 had revision of their internal cable transport constructs due to decoupling or screw pull out. 1 patient had residual ankle joint equinus following treatment which required an Achilles tendon lengthening procedure. Another patient underwent treatment for DVT. There were no deep infections identified and no significant limb length discrepancies or deformities. Conclusions. Overall, we have found that our modified balanced cable transport technique has allowed for successful bone transport for significant defects of the tibia. We have learned from the obstacles encountered during this case series to avoid unnecessary return trips to theatre for our future transport patients. The internal cable system allowed all patients to complete their planned transport without excessive pin tract scarring or pain. Early conversion to intramedullary nail allowed for a shorter time in frame with continued full weight bearing as the regenerate consolidated. No metalwork failure or deformity has occurred in relation to docking site union. All patients have made a good return to pre-operative function during their follow-up period with no evidence of late complications such as deep infection

Abstract. Aim. To identify the difference in infection rates in ankle fracture surgery in Laminar and Non Laminar flow theatres. Background. The infection rates in ankle fracture surgery range between 1–8%. The risk factors include diabetes, alcoholism, smoking, open fractures, osteoporotic fractures in the elderly, and high BMI. Laminar flow has been shown to reduce infections in Arthroplasty surgeries. Therefore, it has become mandatory to use in those procedures. However, it's not the same with ankle fracture surgery. Materials and Methods. It was a retrospective study. The data was collected over a 5 year period between 2015 and 2020. It was collected from Blue spier, Panda, and theatre register. There were 536 cases in each group i.e. Laminar flow (LF) and Non-Laminar flow (NLF). The variables looked at were: 1. Superficial and deep infection rates in LF and NLF theatres, 2. The number of open fractures, 3. Type of ankle fractures (Bimalleolar, Trimalleolar), 4. The number of infected cases who had external fixation prior to ORIF, 5. The number of cases that had Plastics reconstructive procedures, and 6. The grade of the operating surgeon. Conclusions. Superficial infection rate between NLF and LF was not significantly different 11.5% vs 10.3%. The deep infection rate was statistically significant against NLF theatres at 6.34% vs 4.29%. The open fracture was a major contributing factor for deep SSI (14.7% vs 26%). The application of an external fixator in LF and NLF theatres did not alter the infection. rates. Bimalleolar fractures were associated with a higher infection rate

Introduction. Fracture related infections (FRI) following intramedullary nailing for tibial shaft fractures remain challenging to treat with associated high patient morbidity and healthcare costs. Recently, antibiotic-coated nails have been introduced as a strategy to reduce implant related infection rates in high-risk patients. We present the largest single-centre case series on ETN PROtect® outcomes reporting on fracture union, infection rates and treatment complications. Materials and Methods. 56 adult patients underwent surgery with ETN PROtect® between 01/09/17 and 31/12/20. Indications consisted of acute open fractures and complex revision cases (FRI, non-union surgery and re-fracture) with a mean of 3 prior surgical interventions. 51 patients had an open fracture as their index injury. We report on patient characteristics and outcomes including radiological/clinical union and deep infection. The one-year minimum follow-up rate was 87.5%. Results. One (1.8%) patient developed a deep surgical infection and associated non-union requiring further surgery. In addition, we identified three cases (5.4%) of aseptic non-union following facture treatment with ETN PROtect®. Of the 5 patients who underwent staged complex revision surgery for established FRI with ETN PROtect®, all had treatment failure with ongoing symptoms of deep infection requiring further treatment. Conclusions. Use of the ETN PROtect® nail in high-risk patients in the acute trauma setting demonstrates promising outcomes in the prevention of implant-related infection. In our limited series we have failed to observe any benefit over uncoated nails, when used in treating cases of established FRI/osteomyelitis and would therefore advise caution in their use, especially in view of the high cost