Aim. Swedish guidelines on antibiotic prophylaxis in arthroplasty surgery recommend cloxacillin in fixed doses that pay little attention to the patient's renal function and weight. Nevertheless, there are no studies on whether the resulting free prophylactic cloxacillin in vivo concentrations are optimal. We aimed to evaluate whether the current recommended prophylactic dosage of cloxacillin is adequate. Method. We performed a prospective two-centre study, measuring the free (active) cloxacillin concentrations in plasma throughout surgery, in patients subject to primary hip and knee prosthetic joint replacements, aiming at 100 patients per centre. To account for plasma-bone exposure differences, concentrations were considered adequate if twice the epidemiological cut-off value for cloxacillin concerning wild type Staphylococcus aureus whereas two-three times were labelled threshold values. The two enrolling hospitals are acute care hospitals in central Sweden, also performing 600 - 1200 primary hip and knee joint arthroplasties annually. All patients scheduled for elective primary hip or knee replacements from January 2022 to April 2024 were eligible for participation. Exclusion criteria were allergy towards penicillins, cognitive disorders leading to inability to sign informed consent, and an absence of interpreter in case of a patient not speaking Swedish or English. Results. We present results from the first 49 patients included. Four patients had free cloxacillin concentrations below cut-off (8.2%). These four cases had prolonged surgeries of 77-100 minutes. An additional 5/49 (10.2%) had threshold values. Conversely 5/49 (10.2%) cases had concentrations exceeding 15 times the needed. No cases with threshold or low cloxacillin concentrations were attributable to a lack of concerning timing and dosing of cloxacillin. All concentrations were above or equal to our cut-off at the start of surgery. Eighteen percent of patients were of normal of weight (BMI 18.5- 25). Of the rest 4% were morbidly obese (BMI >40), 41% obese (BMI 30-40) and 37% overweight (BMI 25-30). Twenty seven percent (43/159) had diabetes and 45% suffered cardiac disease. Conclusions. Some patients in our cohort had insufficient active cloxacillin levels at the end of prosthetic joint surgery. Previous studies indicate that insufficient prophylactic antibiotic concentrations might lead to an enhanced risk of prosthetic joint infections. Other patients were massively overdosed, leading to unnecessary ecological effects and potentially adverse reactions. As inadequate cloxacillin concentrations were not associated with a lack of compliance to current guidelines a change in practise might be needed. Our final results may help to determine how dosing should be adjusted

Aims. Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements. Methods. We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma. Results. Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon. Conclusion. Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies. Cite this article: Bone Jt Open 2021;2(10):850–857

The Journal of Bone and Joint Surgery published in the A and B volumes remains the premier Orthopaedic Journal of the world. Like other specialist scientific journals it is coming under increasing pressure from the move to more electronic publication on the Internet and the wider availability of freely downloadable information. The need to move to the new technology must be balanced against the needs of the majority of our subscribers, who still require the paper journal, and with the financial requirements of a charitable based not-for-profit publication. The paper will discuss how these pressures might be met and the plans for the redesign of our website to deliver a wider range of material, including the possibility of electronic pre-prints. The future of the Combined subscription CD-ROM will also be addressed together with the exciting future possibilities offered by the developments in digital information technology

The statistical quality of 103 original articles published in The Journal of Bone and Joint Surgery (British Volume) in 1984 was assessed. Some papers were found to be deficient: thus, it was not always clear how series were selected and sometimes neither the data nor the results were clearly presented. Sample sizes were frequently inadequate for the conclusions reached and statistical techniques should have been used more frequently. A majority of papers were descriptions of case series for which no comparative data were made available. It is suggested that collaborative research would best advance knowledge about the relative benefits of various managements, and that statistical advice could make a substantial contribution

Duplicate publication in orthopaedic journals may further an author’s academic career but this is at the cost of both scientific integrity and knowledge. Multiple publications of the same work increase the workload of editorial boards, misguide the reader and affect the process of meta-analysis. We found that of 343 ‘original’ articles published in the Journal of Bone and Joint Surgery in 1999, 26 (7.6%) had some degree of redundancy. The prevalence of duplicate publications in the orthopaedic literature appears to be less than that in other surgical specialties but it is still a matter of concern. It is the author’s responsibility to notify the editor of any duality when submitting a paper for publication

Osteomyelitis is one of the oldest diseases known. It took many years before the acute infection could be brought under control with antibiotics and chronic osteomyelitis remains difficult to manage. The modern history of the disease is reflected in the pages of the

Introduction

Foot and ankle is a well-established and growing sub specialty in orthopaedics. It accounts for 20 to 25 per cent of an average department's workload. There are two well established foot and ankle specialist journals but for many surgeons the Journal of Bone and Surgery (JBJS) remains the preeminent journal in orthopaedics and a highly sought after target journal for publication of research. It is our belief that foot and ankle surgery is underrepresented in the JBJS. We undertook a study to test this hypothesis.

Over a 13-year period we studied all patients who underwent major hip and knee surgery and were diagnosed with objectively confirmed symptomatic venous thromboembolism, either deep venous thrombosis or non-fatal pulmonary embolism, within six months after surgery. Low-molecular-weight heparin had been given while the patients were in hospital.

There were 5607 patients. The cumulative incidence of symptomatic venous thromboembolism was 2.7% (150 of 5607), of which 1.1% had developed pulmonary embolism, 1.5% had deep venous thrombosis and 0.6% had both. Patients presented with deep venous thrombosis at a median of 24 days and pulmonary embolism at 17 days after surgery for hip fracture. After total hip replacement, deep venous thrombosis and pulmonary embolism occurred at a median of 21 and 34 days respectively. After total knee replacement, the median time to the presentation of deep venous thrombosis and pulmonary embolism was 20 and 12 days respectively. The cumulative risk of venous thromboembolism lasted for up to three months after hip surgery and for one month after total knee replacement. Venous thromboembolism was diagnosed after discharge from hospital in 70% of patients who developed this complication.

Despite hospital-based thromboprophylaxis, most cases of clinical venous thromboembolism occur after discharge and at different times according to the operation performed.

From 1998 to July 2003 admissions for elective arthroplasty surgery in Derriford Hospital were nursed alongside other orthopaedic and general medical patients. Since August 2003 a policy of pre-operative MRSA screening and a unit reserved exclusively for MRSA-free joint replacement patients have been used. No transfers from other wards were allowed. Patients positive on screening underwent eradication and were admitted to a different ward where they received teicoplanin on induction (in addition to standard policy cephradine). All post-operative wound infections following THR & TKR were monitored (NINSS surveillance system). Infections within 3 months were recorded. A control of non-screened hip hemi-arthroplasty patients was used to ensure a departmental wide reduction in MRSA was not occurring.

1.9% MRSA carriage rate was detected over the study. Before screening, 0.59% of 3386 cases were acutely infected with MRSA. After institution of screening and a dedicated MRSA free unit, 0.10% of 1034 were acutely infected. This was a 6-fold decrease (p<0.05). The infection noted was in a patient treated outside the ringfenced unit on High Dependency. In fact the infection rate on the ringfenced unit was zero. MRSA infection in the control was statistically unchanged during this period.

Randomised controlled trials (RCT) published in the British volume of the JBJS from United Kingdom based institutes have been analysed to review the level of involvement of junior doctors over the past 25 years (1988 to 2012) which included three different training eras: Pre-Calman (1988 to 1995), Calman (1996 to 2006), and MMC (2007 to 2012). Authors were divided into: Senior doctors, Registrars, Fellows, Senior House Officers/ Foundation Doctors, and Others. The level of involvement has been identified as being first author, senior author or co-author.

One hundred and fifty nine RCTs have been identified with a total of 705 authors. Eighty eight registrars, 32 fellows and 19 SHO/ Foundation doctors have been involved in RCT published over the last 25 years (19.7%). Registrars constituted 15% of all authors in the pre-Calman, 12% in the Calman and 11% in the MMC periods. They constituted 33% of all first authors in the pre-Calman, 21% in the Calman, and 12% in the MMC periods. With regards to SHO/ Foundation doctors, they were only 2% of all authors in the pre-Calman, 3% in the Calman, and 4% in the MMC periods. They were not the first author in any RCT in the pre-Calman period, rising to 7% in both the Calman and MMC periods.

Our study shows that registrars involvement was at its highest in the pre-Calman era with gradual decline in their involvement in the subsequent training eras. SHO/Foundation doctors involvement remains very low, however showing increasing rate in the MMC era.

Aim

Chemical debridement is a fundamental step during Periprosthetic joint infection (PJI) surgery. Antiseptic solutions are commonly used, but evidence on the optimal antiseptic, concentration, and irrigation time is lacking. The aim of this study is to analyze and compare the anti-biofilm capacity of povidone iodine, H₂0₂, acetic acid and Bactisure™ after different exposure times, as well as their combinations.

Since Aug‘03 pre-operative MRSA screening & a ward reserved exclusively for MRSA free joint replacement patients has been used. All postoperative wound infections within 3 months following THR & TKR were monitored.

Before screening, 0.59% of 3386 were acutely infected with MRSA. After institution of study policy, 0.10% of 1034, were infected with MRSA.. This was a 6 fold decrease (p< 0.05). The rate of MRSA infection in a control of hemiarthroplasties was unchanged during this period.

A policy of MRSA screening & an MRSA free joint replacement ward reduces the incidence of acute MRSA infections.

Aims

We have previously reported cryoablation-assisted joint-sparing surgery for osteosarcoma with epiphyseal involvement. However, it is not clear whether this is a comparable alternative to conventional joint arthroplasty in terms of oncological and functional outcomes.

The role of joint preserving surgery for Rheumatoid Forefoot is being explored. This involves a Scarf osteotomy of the first Metatarsal along with shortening osteotomy of the lesser metatarsals. This prospective study includes 49 patients (17 Bilateral; Total 66 procedures) with Rheumatoid Forefoot deformities who underwent Scarf Osteotomy of the First Metatarsal and Weil osteotomy of the lesser metatarsals. The minimum follow up was 33 months and the maximum follow up was 58 months with a mean of 43.95 months. All patients were evaluated clinically and radiologically. AOFAS score for forefoot was collected prospectively. The majority (90%) were females with mean age of 56.1 years. There was a significant improvement in the HVA, IMA and SP. The AOFAS score improved significantly from a mean of 39.8 to 88.7(p=< 0.001). Subjective improvement was also noted with In our study patients rated their outcome as excellent in 51 feet (77.27%), good in twelve feet (18.18%) and as fair in three feet (4.54%). Before surgery no patient was pain free but 44 feet (66.66%) caused severe,19 feet (28.78%) caused moderate and 3 feet (4.54%) caused mild pain. After surgery 55 feet (83.33%) were pain free, 7 feet ((10.6%) caused moderate, 4 feet (6.06%) caused mild pain. Residual deformity in terms of recurrence of lesser toes varus deformity was reported in 5 feet (7.5%). Stiffness of toes was reported in 5 feet and 11 (16.7%) had some residual pain. Forefoot joint preserving reconstructive procedure for rheumatoid forefoot is a reliable procedure and should be considered as a safe method for treating rheumatoid forefoot deformities. However in severe hallux valgus with radiological destruction of the first MTPJ we recommend a primary fusion. Therefore joint preserving surgery should be regarded as a complement to various surgical treatments of rheumatoid forefoot