The accessory navicular (AN) is a separate ossification center for the tuberosity of the navicular that is present in approximately 5–14% of the general population. It produces a firm prominence on the plantar-medial aspect of the midfoot. There may be a co-existent flexible flatfoot, but there is no conclusive evidence of a cause-and-effect relationship between the two conditions. It is usually not symptomatic, and few cases necessitate operative intervention. When symptoms require surgical treatment, excision of the AN, with or without advancement of the posterior tibial tendon, usually is considered. To describe new technique of AN excision and tibialis posterior tendon advancement (TPTA) using a bio-absorbable tenodesis screw and to investigate the outcome of this cohort in comparison to conventional simple excision. Retrospective 2 Cohort study. Single surgeon series from single institution. All patients younger than 18 years from Jan 2000 to Aug 2012 undergoing simple excision (SE) or excision with TPTA were identified from the prospectively collected database. Case notes were reviewed and data regarding demographics, indications for surgery, presence of Pes Planus, time from presentation to surgery, length of follow-up, patient satisfaction and complications were recorded. Pain and functional outcome were measured using Visual Analogue Score (VAS) and patient reported outcome measure- Oxford Ankle Foot Questionnaire- Child and Teenager Version. There were 6 patients in SE group. There were 3 males and 3 females. Mean age at surgery was 13.9 years. Surgical indication was painful swelling in all patients and in addition 1 had pes planus. There were 7 in SE & TPTA group. There were 3 males and 4 females. The mean age at surgery was 13.1 years. Surgical indication was painful swelling in all patients and in addition 1 had hind foot rigidity and 3 had pes planus. Postoperative protocol involved weight bearing with or without cast in SE group and non-weight bearing in cast for 6 weeks in TPA group. All patients reported excellent to good outcome. There were no complications and no reoperations after tendon advancement. In conclusion, based on our study findings, we think AN excision and TP advancement is a safe and effective technique for symptomatic pain relief. It is a novel technique which achieved excellent to good outcome in our series

Introduction. The popliteus tendon is a component of the posterolateral corner of the knee, which controls the external rotation of the tibia. In our clinical practice, the femoral footprint of the popliteus tendon is occasionally excised as the bone is resected during total knee arthroplasty (TKA). Although the excision of the popliteus tendon femoral footprint could result in excessive external rotation of the tibia and may have adverse effects on the long-term outcomes of TKA, little attention has been paid to the popliteus tendon femoral footprint during TKA. The purpose of the present study is to assess the frequency of the excision and its associated risk factors. Methods. One hundred eleven knees of 90 patients with varus knee osteoarthritis who underwent primary TKA were included in the present study. There were 13 males and 77 females, and their average age was 74 years. The NexGen knee replacement system (Zimmer, Warsaw, IN, USA) was used in all cases. The excision of the popliteus tendon femoral footprint was intraoperatively evaluated, and the patients were divided into three groups depending on the status of the femoral footprint, i.e., the preserved, partially excised, and completely excised groups. The thickness of the distal femoral osteotomy, femoral component size, and background data including height, body weight, gender, and age were compared among these groups. Analysis of variance followed by Student–Newman–Keuls test were used to compare the continuous values and ordinal scales. Gender was compared using Fisher's exact test and residual analysis. Statistical significance was set at p < 0.05. Results. The popliteus tendon femoral footprint was preserved in 48 knees (43.2%), partially excised in 45 knees (40.5%), and completely excised in 18 knees (16.2%). The mean patient height was 154.6, 150.1, and 148.7 cm in the preserved, partially excised, and completely excised groups, respectively, and these differences were statistically significant (p < 0.01). Femoral component size was significantly smaller in the partially and completely excised groups compared with that in the preserved group (p < 0.05). The preserved group included more male patients (p < 0.01). There were no significant differences in body weight, age, and thickness of the distal femoral osteotomy among the groups. Conclusion. The partial or complete excision of the popliteus tendon femoral footprint was observed in more than half of the evaluated knees. Shorter height, smaller femoral component size, and female sex were considered to be the possible risk factors for the excision of the popliteus tendon femoral footprint

Longstanding un-united scaphoid fractures or scapholunate insufficiency can progress to degenerative wrist osteoarthritis (termed scaphoid non-union advanced collapse (SNAC) or scapho-lunate advanced collapse (SLAC) respectively). Scaphoid excision and partial wrist fusion is a well-established procedure for the surgical treatment of this condition. In this study we present a novel technique and mid-term results, where fusion is reserved for the luno-capitate and triquetro-hamate joints, commonly referred to as bicolumnar fusion. The purpose of this study was to report functional and radiological outcomes in a series of patients who underwent this surgical technique. This was a prospective study of 23 consecutive patients (25 wrists) who underwent a bicolumnar carpal fusion from January 2014 to January 2017 due to a stage 2 or 3 SNAC/SLAC wrist, with a minimum follow-up of one year. In all cases two retrograde cannulated headless compression screws were used for inter-carpal fixation. The clinical assessment consisted of range of motion, grip and pinch strength that were compared with the unaffected contralateral side where possible. Patient-reported outcome measures, including the DASH and PRWE scores were analysed. The radiographic assessment parameters consisted of fusion state and the appearance of the radio-lunate joint space. We also examined the relationship between the capito-lunate fusion angle and wrist range of motion, comparing wrists fused with a capito-lunate angle greater than 20° of extension with wrists fused in a neutral position. The average follow-up was 2.9 years. The mean wrist extension was 41°, flexion 36° and radial-ulnar deviation arc was 43° (70%, 52% and 63% of contralateral side respectively). Grip strength was 40 kg and pinch strength was 8.9 kg, both 93% of contralateral side. Residual pain for activities of daily living was 1.4 (VAS). The mean DASH and PRWE scores were 19±16 and 29±18 respectively. There were three cases of non-union (fusion rate of 88%). Two wrists were converted to total wrist arthroplasty and one partial fusion was revised and healed successfully. Patients with an extended capito-lunate fusion angle trended toward more wrist extension but this did not reach statistical significance (P= 0.07). Wrist flexion did not differ between groups. Radio-lunate joint space narrowing progressed in 2 patients but did not affect their functional outcome. After bicolumnar carpal fusion using retrograde headless screws, patients in this series maintained a functional flexion-extension arc of motion, with grip-pinch strength that was close to normal. These functional outcomes and fusion rates were comparable with standard 4-corner fusion technique. A capito-lunate fusion angle greater than 20° may provide more wrist extension but further investigation is required to establish this effect. This technique has the advantage that compression screws are placed in a retrograde fashion, which does not violate the proximal articular surface of the lunate, preserving the residual load-bearing articulation. Moreover, the hardware is completely contained, with no revision surgery for hardware removal required in this series

Osteochondromas occur are most commonly in the distal femur, proximal tibia and fibula and the proximal humerus. There are no large studies focusing on the clinical presentation, management and outcome of treatment for patients with an osteochondroma involving the proximal fibula. The purpose of this study is to specifically understand the manifestation of the proximal fibular osteochondroma on the preoperative peroneal nerve function, and how surgical management of the osteochondroma affects function immediately postoperatively and at long-term followup. This is an IRB-approved retrospective review of a consecutive series of patients with a proximal fibular osteochondroma (PFO) treated operatively at a single institution from 1990 to 2013. The medical record was carefully reviewed to identify demographic data, clinical data and especially the status of the peroneal function at various time points. There were 25 patients with 31 affected extremities who underwent surgical excision of the PFO at an average age of 12.4 years (range 3.0–17.9 years). There were 16 males and 9 females. The underlying diagnosis was isolated PFO in 2(8%) patients and multiple hereditary exostosis (MHE) in 23(92%) patients. Preoperatively, 9 (29%) had a foot drop and 22 (71%) did not. Those with preoperative foot drop underwent surgery at a younger age (9.1 vs 13.8 years) (p<0.004). Five of the nine (55.5%) had complete resolution, three (33.3%) had improvement, and one (11.1%) persisted postoperatively and required AFO. Of the 22 who were normal preoperatively, 5 (22.7%) developed a postoperative foot drop-three (60%) completely resolved, 1 (20%) improved, and 1 (20%) persisted and was found to have a transected nerve at exploration. In total, 23 of the 25 (92%) patients who had a PFO excision, had a normal or near-normal peroneal nerve function including those who had poor function preoperatively. A proximal fibular osteochondroma can result in a high incidence of peroneal nerve dysfunction prior to any treatment, but responds the majority of the time to surgical intervention with removal of the osteochondroma. For those who have normal preoperative function, 1 in 4 will develop a postoperative foot drop but nearly all improve spontaneously unless iatrogenic injured

This case series highlights the use of the Ganz approach (trochanteric slide approach) and surgical dislocation for excision of fibrous dysplasia of the femoral neck, pigmented villonodular synovitis and synovial chondromatosis of the hip. The first patient was a 16-year-old girl, who presented with pain in her hip, having fallen whilst playing football. Investigations revealed a fibrous dysplasia, which was successfully excised returning her to an active lifestyle. The second patient was a 27-year-old lady, who presented having suffered left hip pain for four years. She was diagnosed with a pigmented villonodular synovitis, which was excised and the patient was able to return to the gym. The third patient was a 41-year-old lady, who presented after experiencing right hip pain both at night and at rest for a year, without any trauma. She was diagnosed with synovial chondromatosis and returned to all activities of daily living. The Ganz approach allows safe dislocation of the hip joint without the risk of osteonecrosis of the femoral head. We demonstrate that it is possible to obtain excellent exposure of the femoral neck, head and acetabulum to surgically treat these three tumours of the hip. The surgeon can thus be reassured that complete excision of the tumour has occurred. This series can recommend the Ganz approach with trochanteric slide and full surgical dislocation of the hip to excise pigmented villonodular synovitis, synovial chondromatosis and fibrous dysplasia of the hip

Aims. Delays to diagnosis and management of soft tissue sarcomas are preventable but still occur. The introduction of a referral proforma to the Thames Valley Cancer Network in 2005 and National guidelines in 2006 aimed to decrease the incidence of partially and inadequately managed soft tissue sarcomas. This study aims to assess referrals for partially or inadequately managed soft tissue sarcomas and their subsequent management. Methods. A prospective analysis of all patients referred to the Oxford Sarcoma Service following inadvertent excision of a soft tissue sarcoma between January 2010 and August 2011 was carried out. Pre-operative investigation and subsequent secondary managements were recorded. Patients with a diagnosis of dermatofibrosarcoma protuberans were excluded. Results. 24 patients (17 male) with a mean age of 54.3 (6–96), representing 14.5% of all soft tissue sarcomas during this time period were followed up following incomplete or inadvertent excision. 66% were referred from secondary care, 54% had no pre-operative imaging, with the remainder having incomplete imaging. 79% of lesions were found in the extremities, with 12.5 % presenting with metastatic disease. 79% required further surgery, with 8% requiring amputation. The most common pathologies were leiomyosarcoma (29.1%), fibromyxoid sarcoma (12.5%), spindle cell sarcoma (12.5 %) and liposarcoma (8.3%). Conclusion. The consequences of incomplete initial management of soft tissue sarcomas are a cause of significant morbidity and demand on health care services. The introduction of referral guidelines has not prevented the partial management of these lesions

Adhesive capsulitis of the shoulder is a common debilitating condition with prevalence in the order of 2 to 5%. Whilst it is usually a self-limiting condition, patients are typically not willing, nor are they able, to wait to the end of the recovery phase. A number of treatment strategies have been described. Manipulation under anaesthesia can significantly increase motion in all planes, but carries a significant risk of fracture. Capsular release also significantly improves motion with fewer potential side effects. We hypothesise that performing an arthroscopic excision of the abnormal capsulitis tissue will give better results with least risk of recurrence. Data was collected both retrospectively and prospectively for patients undergoing this procedure. Range of motion and Oxford shoulder scores was documented pre-operatively and post-operatively, at 6 weeks, 3 months and 6 months. 41 patients were included. At 3 months mean flexion had increased from 101 to 152 degrees, abduction from 91 to 151 degrees, and external rotation from 18 to 44 degrees. Mean Oxford shoulder score had increased from 20.6 to 35.8 at 3 months. The results support the use of this technique for treating adhesive capsulitis. Larger patient numbers and longer term follow up will help compare it against the other well established techniques

Background

Resection of sacral chordoma remains challenging because complex anatomy and important nerves in the sacrum make it difficult to achieve wide surgical margins. Computer-assisted navigation has shown promise in aiding in optimal preoperative planning and in providing accurate and precise tumour resection during surgery.

Background

A randomised prospective study has already demonstrated that at 1-year follow-up, palmaris longus interposition or flexor carpi radialis (FCR) ligament reconstruction and tendon interposition do not improve the outcome of trapeziectomy for the treatment of painful osteoarthritis of the trapeziometacarpal joint. This study consisted of 183 thumbs in 162 women.

Aim. To compare pre-referral microbiology and previous bone excision in long bone osteomyelitis with intra-operative microbiology from a specialist centre. Method. A prospective observational cohort study of patients referred to a single tertiary centre who met the following criteria: (i) aged ≥18 years, (ii) received surgery for long bone osteomyelitis and (iii) met diagnostic criteria for long bone osteomyelitis. Patient demographics, referral microbiology and previous surgical history were collected at the time of initial clinic appointment. During surgery, a minimum of 5 intra-operative deep tissue samples were sent for microbiology. Antimicrobial options were classified from the results of susceptibility testing using the BACH classification of long bone osteomyelitis as either Ax (unknown or culture negative), A1 (good options available) or A2 (limited options available). The cultures and susceptibility of pre-referral microbiology were compared to the new intra-operative sampling results. In addition, an association between previous osteomyelitis excision and antimicrobial options were investigated. Results. 79 patients met inclusion criteria during the study period. From these, 39 (49.4%) patients had information available at referral regarding microbiology obtained from either sinus swab (n=16), bone biopsy (n=11), previous osteomyelitis excision sampling (n=7), aspiration (n=4) or blood culture (n=1). From these 39 patients, microbiology information at referral fully matched microbiology samples taken at operation in 8 cases (20.5%). Fifteen of the 39 patients (38.5%) had a different species isolated at surgery compared to referral microbiology. The remaining 16 patients (41.0%) had a culture-negative osteomyelitis on surgical sampling. Based on the microbiology obtained in our centre, 35 patients were classified as A1 (44.3%), 15 as A2 (18.9%) and 29 as culture negative, Ax (36.7%). Patients who had received previous excision of osteomyelitis before referral (n=32, 40.5%) had an increased odds ratio (OR) of having microbiology with limited antimicrobial options compared to those undergoing primary osteomyelitis excision (OR: 3.8, 95% CI 1.2 – 11.2, P=0.023, Fisher's exact test). Conclusions. Patients are frequently referred with limited microbiological information. Pre-referral microbiology in long bone osteomyelitis correlated with intra-operative samples taken at our centre in less than one quarter of cases. Pre-referral microbiology data should be used with caution for planning treatment in osteomyelitis. Previous surgery for osteomyelitis was associated with microbiology culture with limited antimicrobial treatment options

Aims. Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier. Methods. A prospective series of 100 patients with Cierny-Mader Types III and IV chronic ostemyelitis, affecting 105 bones, were treated with a single-stage procedure including debridement, deep tissue sampling, local and systemic antibiotics, stabilization, and immediate skin closure. Chronic osteomyelitis was confirmed using strict diagnostic criteria. The mean follow-up was 6.05 years (4.2 to 8.4). Results. At final follow-up, six patients (six bones) had recurrent infection; thus 94% were infection-free. Three infections recurred in the first year, two in the second year, and one 4.5 years postoperatively. Recurrence was not significantly related to the physiological class of the patient (1/20 Class A (5%) vs 5/80 Class B (6.25%); p = 0.833), nor was it significantly related to the aetiology of the infection, the organisms which were cultured or the presence of nonunion before surgery (1/10 with nonunion (10%) vs 5/90 without nonunion (5.6%); p = 0.570). Organisms with intermediate or high-grade resistance to gentamicin were significantly more likely in polymicrobial infections (9/21; 42.8%) compared with monobacterial osteomyelitis (7/79 (8.9%); p < 0.001). However, recurrence was not significantly more frequent when a resistant organism was present (1/16 for resistant cases (6.25%) vs 5/84 in those with a microbiologically sensitive infection (5.95%); p = 0.958). Conclusion. We found that a single-stage protocol, including the use of a high-delivery local antibiotic ceramic carrier, was effective over a period of several years. The method can be used in a wide range of patients, including those with significant comorbidities and an infected nonunion. Cite this article: Bone Joint J 2022;104-B(9):1095–1100

Introduction. Patients with long-bone osteomyelitis are frequently referred with limited microbiological information. This study compared pre-referral microbiology in long bone osteomyelitis with intra-operative microbiology from a specialist centre. Materials and Methods. All patients referred to a single tertiary centre between February 2019 and February 2020, aged ≥18 years and received surgery for confirmed long-bone osteomyelitis were included. Patient demographics, referral microbiology and previous surgical history were collected at the time of initial clinic appointment. During surgery, a minimum of 5 intra-operative deep tissue samples were sent for microbiology. Antimicrobial options were classified from the results of susceptibility testing using the BACH classification of long bone osteomyelitis as either Ax (unknown or culture negative), A1 (good options available) or A2 (limited options available). The cultures and susceptibility of pre-referral microbiology were compared to the new intra-operative sampling results. In addition, an association between previous osteomyelitis excision and antimicrobial options were investigated. Results. 79 patients met inclusion criteria during the study period. From these, 39 (49.4%) patients had information available at referral regarding microbiology obtained from either sinus swab (n–16), bone biopsy (n–11), previous osteomyelitis excision sampling (n–7), aspiration (n–4) or blood culture (n–1). From these 39 patients, microbiology information at referral fully matched microbiology samples taken at operation in 8 cases (20.5%). Fifteen of the 39 patients (38.5%) had a different species isolated at surgery compared to referral microbiology. The remaining 16 patients (41.0%) had a culture-negative osteomyelitis on surgical sampling. Based on the microbiology obtained in our centre, 35 patients were classified as A1 (44.3%), 15 as A2 (18.9%) and 29 as culture negative, Ax (36.7%). Patients who had received previous excision of osteomyelitis before referral (n–32, 40.5%) had an increased odds ratio (OR) of having microbiology with limited antimicrobial options compared to those undergoing primary osteomyelitis excision (OR: 3.8, 95% CI 1.2–11.2, P–0.023, Fisher's exact test). Conclusions. Pre-referral microbiology correlated with intra-operative samples taken at our centre in less than one quarter of cases of long-bone osteomyelitis. Previous failed surgery for osteomyelitis was associated with increased antimicrobial resistance, reducing options for effective treatment

PVNS or TGCT (Pigmented Villonodular Synovitis, or Tenosynovial Giant Cell tumour) is a benign tumour affecting the synovial lining of joints and tendon sheaths, historically treated with surgical excision or debridement. We have shown previously this management is fraught with high recurrence rates, especially in its diffuse form. We present the encouraging early results of medical management for this condition with use of a CSF1 inhibitor, in comparison to a cohort of 137 cases previously treated at our institution

Aims. We studied the outcomes following arthroscopic primary repair of bucket handle meniscus tears to determine the incidence of re-tears and the functional outcomes of these patients. Methodology. Prospective cohort study. Over a 4-year period (2016 to 2020), 35 adult patients presented with a bucket handle tear of the meniscus. Arthroscopic meniscal repair was performed using either the all inside technique or a combination of all-inside and inside-out techniques. 15 patients also underwent simultaneous arthroscopic anterior cruciate ligament reconstruction. Functional knee scores were assessed using IKDC and Lysholm scores. Results. Mean patient age at surgery was 27 years (range, 17 to 53years). Medial meniscus was torn in 20 and lateral in 15 cases. Zone of tear was white on white in 19, red on white in 9 and red on red in 7 cases. Average delay from injury to surgery was 4 months. At a mean follow-up of 4.5 years, the meniscus repair failed in 3 patients (8.5 %). Outcome following re-tear was meniscus excision. Average IKDC scores in patients with intact repair were 74.04 against 56.67 in patients with a failed repair (p< 0.0001). Similarly, Lyshlom scores were 88.96 and 67.333, respectively (p<0.0001). Conclusion. The survivorship of primary repair of bucket handle meniscus tears in our series was 91.5% at medium term follow-up. Functional outcomes were significantly poor in patients with a failed repair compared to those with an intact repair

Sternoclavicular joint infections are uncommon but severe and complex condition usually in medically complex and compromised hosts. These infections are challenging to treat with risks of infection extending into the mediastinal structures and surgical drainage is often faced with problems of multiple unplanned returns to theatre, chronic non-healing wounds that turn into sinus and the risk of significant clinical escalation and death. Percutaneous aspirations or small incision drainage often provide inadequate drainage and failed control of infection, while open drainage and washout require multidisciplinary support, due to the close proximity of the mediastinal structures and the great vessels as well as failure to heal the wounds and creation of chronic wound or sinus. We present our series of 8 cases over 6 years where we used the plan of open debridement of the Sternoclavicular joint with medial end of clavicle excision to allow adequate drainage. The surgical incision was not closed primarily, and a suction vacuum dressing was applied until the infection was contained on clinical and laboratory parameters. After the infection was deemed contained, the surgical incision was closed by local muscle flap by transferring the medial upper sternal head of the Pectoralis Major muscle to fill in the sternoclavicular joint defect. This technique provided a consistent and reliable way to overcome the infection and have the wound definitively closed that required no secondary procedures after the flap surgery and no recurrence of infections so far. We suggest that open and adequate drainage of Sternoclavicular joint staged with vacuum dressing followed by pectoralis major local flap is a reliable technique for achieving control of infection and wound closure for these challenging infections

Abstract. Introduction. Displaced olecranon fractures in the elderly are challenging due to associated comorbidities, poor tissue quality, high risk of complications, and the possible need for implant removal. Treatment options with such fractures range from non-operative management to internal fixation with various types of implants. Currently, there is no consensus on the treatment of olecranon fractures in the elderly with relatively low functional demand. Aim. The aim of this systematic review was to analyse the clinical outcomes of various treatment modalities for olecranon fracture in the elderly. Methods. We systematically reviewed the literature covering the treatment of olecranon fractures in the elderly according to PRISMA guidelines. We used search tools of Medline, Embase, Wiley online library, Cochrane and Scopus. Keywords used in the search were Olecranon fracture and Elderly OR Geriatric in all fields. Studies involving patients older than 60 years of age and all modalities of treatment were included. Results. 14 papers studying 270 patients were identified of which, 112 were treated non-operatively, 25 with limited fixation, 98 with tension band wire fixation, 34 with plate fixation, and 1 patient was treated with excision. Conclusions. Nonoperative as well as limited fixation were shown to provide satisfactory results in the elderly. Treatment decisions in this age group should be individualised to factors such as fracture stability, quality of bone & soft tissues, and patient's functional demand. We recommend a treatment protocol for treating olecranon fracture in the elderly based on the above factors

Introduction. Fracture related infection (FRI) is a challenging complication to manage in an orthoplastic setting. Consensus guidelines have been created to standardise the diagnosis of FRI and comprise confirmatory and suggestive criteria. In this study, the aim is to assess the diagnostic criteria and management of FRI with a particular focus on soft tissue reconstruction. Materials & Methods. A retrospective study to identify the outcomes of FRI in the lower limb over a five year period at a Major Trauma Centre. Fracture specific information that was analysed includes: open versus closed, fractured bone(s) and site, initial fracture management, method of diagnosis and soft tissue management. Results. A total of 40 patients were identified, 80% of whom were male (n= 32). The mean age for FRI diagnosis was 54 years (range 18–83 years). In our patient cohort, 10% were immunosuppressed and another 12.5% had a formal diagnosis of Diabetes Mellitus. A diagnosis of acute FRI (i.e. < six weeks from time of injury) was made in 9 patients (22.5%). Chronic FRI was noted in 25 patients (62.5%). There was equal incidence of FRI in patients with closed fractures and open fractures (42.5%). Tibia and fibula fractures were most common (87.5%, n=35). Regardless of fractured bone(s), the more distal the fracture the higher the incidence of FRI (60% distal versus 12.5% proximal). Gram-positive cocci were the most commonly identified pathogens, identified in 25% of patients. Five patients underwent free flap reconstruction, two patients received pedicled muscle flaps and another two patients received split thickness skin grafts. Conclusions. The diagnosis of FRI can be confirmed through the presence of a combination of confirmatory and suggestive criteria. We advocate a staged approach in the management of FRI with radical wound excision and temporary coverage followed by definitive soft tissue reconstruction

Aim. Chronic bone infections and infected fractures are often treated with excision of the dead bone and implantation of biomaterials which elute antibiotics. Gentamicin has been a preferred drug for local delivery, but this could induce renal dysfunction due to systemic toxicity. This is a particular concern in patients with pre-existing chronic renal disease treated with new antibiotic carriers which achieve very high peak levels of gentamicin in the first few days after surgery. Method. 163 patients (109 males; average age 51.6 years) with Cierny-Mader Type 3 or 4 chronic osteomyelitis had a single-stage operation with excision of the dead bone, filling of the osseous defect with a calcium sulphate-hydroxyapatite carrier, containing gentamicin and immediate soft tissue closure. 2. No patient was given systemic gentamicin or other renal toxic antibiotics. Mean carrier volume was 10.9mls (range 1–30mls) and mean gentamicin dosing was 190.75mg (maximum 525mg). Seven patients had pre-existing renal disease (4 diabetic nephropathy, 1 nephrotic syndrome, 1 renal transplant and 1 previous acute kidney injury). Serum creatinine levels were collected pre-operatively and during the first seven days post-operatively. Glomerular filtration rate (GFR) was calculated using the CKD-epi creatinine equation. Renal function was defined using the Chronic Kidney Disease (CKD) Staging system. Results. 155 cases had adequate data to allow calculation of pre- and post-operative GFR. Pre-operative CKD staging demonstrated 118 Class I (normal renal function), 30 Class II, 3 Class IIIa, 3 Class IIIb, and 1 Class V disease. Mean pre-operative GFR (99.7ml/min/1.73m. 2. , SD 21.0) was no different to post-operative GFR (103.2ml/min/1.73m. 2. , SD 21.3), p= 0.0861. Four cases had a >10% decline in GFR below normal, with only one case dropping a CKD stage, from I (normal) to II (mildly decreased). Only 1/7 cases with pre-existing renal disease had a GFR drop of >10% (from 11ml/min/1.73m. 2. to 8ml/min/1.73m. 2. ). 70/155 (45.2%) had a temporary GFR drop post-operatively, with the biggest drop occurring a mean 3.06 days following surgery (SD 2.1). No patient had clinical signs of new acute renal impairment post-operatively. Conclusions. Renal function is not significantly affected by local implantation of gentamicin up to 525mg. The presence of pre-existing renal disease is not a contraindication to local gentamicin therapy

This review compares the outcomes and complication rates of three surgical strategies used for the management of symptomatic os acromiale. The purpose of this study was to help guide best practice recommendations. A systematic review of nine prospective studies, seven retrospective studies, and three case studies published across ten countries between 1993 and 2018 was performed. Adult patients (i.e., ≥ 18 years of age) with a symptomatic os acromiale that failed nonoperative management were included in this review. Surgical techniques utilized within the included studies include excision, acromioplasty, and open reduction and internal fixation (ORIF). The primary outcomes of interest included patient satisfaction and return to activity. Range of motion and several standardized outcome measurement tools were also included in the final analysis. Patient satisfaction was highest in the excision and ORIF groups, with 92% and 82% of patients reporting good to excellent postoperative results, respectively, compared to 63% in the acromioplasty group. All three patient groups experienced improved postoperative objective scores (i.e., patient-reported outcome scores and active range of motion). The excision group experienced a complication rate of 1%, while the acromioplasty group experienced a complication rate of 11% and the ORIF group a rate of 67%. This study reports on the largest sample of patients who have undergone surgical treatment for a symptomatic os acromiale. We have demonstrated that excision of the os with repair of the deltoid resulted in the best clinical outcomes with the least complications. In healthy adult patients with a large os fragment and a normal rotator cuff, surgical fixation may provide increased preservation of deltoid function while offering good patient satisfaction. Such patients should be aware that they are at increased risk of requiring a second procedure due to symptomatic hardware following ORIF

Prosthetic joint infections (PJI) are devastating complications. Our knowledge on hip fractureassociated hemiarthroplasty PJI (HHA-PJI) is limited compared to elective arthroplasty. The goal of this study was to describe the epidemiology, risk factors, management, and outcomes for HHA-PJI. A population-based (465,000) multicentre retrospective analysis of HHAs between 2006-2018 was conducted. PJI was defined by international consensus and treatment success as no return to theatre and survival to 90 days after the initial surgical management of the infection. Univariate, survival and competing risk regression analyses were performed. 1852 HHAs were identified (74% female; age:84±7yrs;90-day-mortality:16.7%). Forty-three (2.3%) patients developed PJI [77±10yrs; 56% female; 90-day-mortality: 20.9%, Hazard-Ratio 1.6 95%CI 1.1-2.3,p=0.023]. The incidence of HHA-PJI was 0.77/100,000/year and 193/100,000/year for HHA. The median time to PJI was 26 (IQR 20-97) days with 53% polymicrobial growth and 41% multi-drug resistant organisms (MDRO). Competing risk regression identified younger age [Sub-Hazard-Ratio(SHR) 0.86, 95%CI 0.8-0.92,p<0.001], chronic kidney disease (SHR 3.41 95%CI 1.36-8.56, p=0.01), body mass index>35 (SHR 6.81, 95%CI 2.25-20.65, p<0.001), urinary tract infection (SHR 1.89, 95%CI 1.02-3.5, p=0.04) and dementia (SHR 9.4, 95%CI 2.89-30.58,p<0.001) as significant risk factors for developing HHA-PJI. When infection treatment was successful (n=15, 38%), median survival was 1632 days (IQR 829-2084), as opposed to 215 days (IQR 20-1245) in those who failed, with a 90-day mortality of 30%(n=12). There was no significant difference in success among debridement, excision arthroplasty or revision arthroplasty. HHA PJI is uncommon but highly lethal. All currently identified predictors are non-modifiable. Due to the common polymicrobial and MDRO infections our standard antibiotic prophylaxis may not be adequate HHA-PJI is a different disease compared to elective PJI with distinct epidemiology, pathogens, risk factors and outcomes, which require targeted research specific to this unique population