Despite proven advantages, pulsatile lavage seems to be used infrequently during preparation in cemented total knee arthroplasty. This remains irritating, as the technique has been suggested to improve radiological survival in cemented TKA, where aseptic loosening of the tibial component represents the main reason for revision. Furthermore, there may be a potential improvement of fixation strength for the tibial tray achieved by increased cement penetration. In this study, the influence of pulsed lavage on mechanical stability of the tibial component and bone cement penetration was analyzed in a cadaveric setting. Six pairs of cadaveric, proximal tibia specimen underwent computed tomography (CT) for assessment of bone mineral density (BMD) and exclusion of osseous lesions. Following surgical preparation, in one side of a pair, the tibial surface was irrigated using 1800ml normal saline and pulsatile lavage, while in the other side syringe lavage using the identical amount of fluid was applied. After careful drying, bone cement was hand-pressurized on the bone surface, tibial components were inserted and impacted in an identical way. After curing of cement, specimen underwent a postimplantation CT analysis). Cement distrubution was then assessed using a three-dimenionsional visualization software. Trabecular bone, cement and implant were segmented based on an automatic thresholding algorithm, which had been validated in a previous study. This allowed to determine median cement penetration for the entire cemented area. Furthermore, fixation strength of the tibial trays was determined by a vertical pull-out test using a servohydraulic material testing machine. Testing was performed under displacement control at a rate of 0,5mm/sec until implant failure. Data was described by median and range. Results were compared by a Wilcoxon matched pairs signed rank test with a type 1 error probability of 5 %. Median pull-out forces in the pulsed lavage group were 1275N (range 864–1391) and 568N (range 243–683) in the syringe lavage group (p=0.031). Cement penetration was likewise increased (p=0.031) in the pulsed lavage group (1.32mm; range 0.86–1.94), when compared to the syringe irrigated group (0.79mm; range 0.51–1.66). Failure occurred in the pulsatile lavage group at the implant-cement interface and in the syringe lavage group at the bone-cement interface, which indicates the weakness of the latter. Altogether, improved mechanical stability of the tibial implant and likewise increased bone cement interdigitation could be demonstrated in the current study, when pulsed lavage is implemented. Enhanced fixation strength was suggested being a key to improved survival of the implant. If this is the case, pulsatile lavage should be considered being a mandatory preparation step when cementing tibial components in TKA

Aims. To evaluate the impact of negative pressure wound therapy (NPWT) on the odds of having deep infections and health-related quality of life (HRQoL) following open fractures. Methods. Patients from the Fluid Lavage in Open Fracture Wounds (FLOW) trial with Gustilo-Anderson grade II or III open fractures within the lower limb were included in this secondary analysis. Using mixed effects logistic regression, we assessed the impact of NPWT on deep wound infection requiring surgical intervention within 12 months post-injury. Using multilevel model analyses, we evaluated the impact of NPWT on the Physical Component Summary (PCS) of the 12-Item Short-Form Health Survey (SF-12) at 12 months post-injury. Results. After applying inverse probability treatment weighting to adjust for the influence of injury characteristics on type of dressing used, 1,322 participants were assessed. The odds of developing a deep infection requiring operative management within 12 months of initial surgery was 4.52-times higher in patients who received NPWT compared to those who received a standard wound dressing (95% confidence interval (CI) 1.84 to 11.12; p = 0.001). Overall, 1,040 participants were included in our HRQoL analysis, and those treated with NPWT had statistically significantly lower mean SF-12 PCS post-fracture (p < 0.001). These differences did not reach the minimally important difference for the SF-12 PCS. Conclusion. Our analysis found that patients treated with NPWT had higher odds of developing a deep infection requiring operative management within 12 months post-fracture. Due to possible residual confounding with the worst cases being treated with NPWT, we are unable to determine if NPWT has a negative effect or is simply a marker of worse injuries or poor access to early soft-tissue coverage. Regardless, our results suggest that the use of this treatment requires further evaluation. Cite this article: Bone Jt Open 2022;3(3):189–195

Aims. The aims of this study were to quantify health state utility values (HSUVs) after a tibial fracture, investigate the effect of complications, to determine the trajectory in HSUVs that result in these differences and to quantify the quality-adjusted life years (QALYs) experienced by patients. Patients and Methods. This is an analysis of 2138 tibial fractures enrolled in the Fluid Lavage of Open Wounds (FLOW) and Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trials. Patients returned for follow-up at two and six weeks and three, six, nine and 12 months. Short-Form Six-Dimension (SF-6D) values were calculated and used to calculate QALYs. Results. Compared with those who did not have a complication, those with a complication treated either nonoperatively or operatively had lower HSUVs at all times after two weeks. The HSUVs improved in all patients with the passage of time. However, they did not return to the remembered baseline preinjury values nor to US age-adjusted normal values by 12 months after the injury. Conclusion. While the acute fracture and complications may have resolved clinically, the detrimental effect on a patient’s quality of life persists up to 12 months after the injury. Cite this article: Bone Joint J 2018;100-B:1227–33

Aims. The Fluid Lavage in Open Fracture Wounds (FLOW) trial was a multicentre, blinded, randomized controlled trial that used a 2 × 3 factorial design to evaluate the effect of irrigation solution (soap versus normal saline) and irrigation pressure (very low versus low versus high) on health-related quality of life (HRQL) in patients with open fractures. In this study, we used this dataset to ascertain whether these factors affect whether HRQL returns to pre-injury levels at 12-months post-injury. Patients and Methods. Participants completed the Short Form-12 (SF-12) and the EuroQol-5 Dimensions (EQ-5D) at baseline (pre-injury recall), at two and six weeks, and at three, six, nine and 12-months post-fracture. We calculated the Physical Component Score (PCS) and the Mental Component Score (MCS) of the SF-12 and the EQ-5D utility score, conducted an analysis using a multi-level generalized linear model, and compared differences between the baseline and 12-month scores. Results. We found no clinically important differences between irrigating solutions or pressures for the SF-12 PCS, SF-12 MCS and EQ-5D. Irrespective of treatment, participants had not returned to their pre-injury function at 12-months for any of the three outcomes (p < 0.001). Conclusion. Neither the composition of the irrigation solution nor irrigation pressure applied had an effect on HRQL. Irrespective of treatment, patients had not returned to their pre-injury HRQL at 12 months post-fracture. Cite this article: Bone Joint J 2018;100-B:88–94

Septic Arthritis is an important life threatening condition affecting all age groups with a mortality of up to 11%. Our aim was to perform a study of the demographics, length of stay, complications and investigate if time delay of surgical treatment from the time of diagnosis has an impact on mortality and morbidity of the patients. Methods. We performed a retrospective study of all the patients presented to our Hospital between 2005 and 2009 with septic arthritis who underwent arthroscopic lavage as definitive intervention. We excluded the patients involving minor joints. Data collection was performed from case notes, microbiology and haematology laboratory results. We divided the patients into three groups based on the time from diagnosis to arthroscopic lavage as T1 (less than 12 hours), T2 (12–24 hours) and T3 (more than 24 hours). Our primary outcome measures were mortality and complications such as Intensive Care Admission. Secondary outcome measures included average length of stay in each group. Results. A total of 57 patients were evaluated. The average age of the patients was 49.7 (10 months–94 years). 2 patients of T1 group died (5.4%) 3 patients of T1 group needed Intensive Care Unit (ICU) management (8.1%). There were no deaths or ICU admissions in the other groups. 40.3% of patients needed arthroscopic lavage more than once. The average length of stay of T1 was 19.8 days, T2–11.5 days and T3–27.5 days. Majority of the joints involved were knees (63.1%).23 patients (40.3%) had a preceding intervention performed in the same joint. Staphyloccus aureus was the most common organism isolated in 14 patients (26.3%). Conclusion. There was insufficient evidence to show a significant correlation between the time lag and mortality associated with septic arthritis. However, further large scale retrospective multicenter based studies would be beneficial in identifying the factors associated with complications of septic arthritis. Our study demonstrates high morbidity and mortality rates in T1 group which may be biased due to highly unstable patients in this group in comparision to the other two groups

Aims

Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.

Background. Medical grade Calcium Sulphate can be used as a delivery vehicle for antibiotics. We use these for treating patients with established osteomyelitis, but also use it prophylactic for contaminated war injuries, to fill voids in bone with osteo conductve filler that delivers local antibiotics, and can integrate with bone. Although antibiotic loaded calcium sulphate is increasingly used, there is little data to demonstrate that systemic levels generated by local release of antibiotics are safe. For this reason, we routinely assay systemic levels of antibiotics. Objectives. To determine if systemic toxicity occurs after the use of antibiotic loaded calcium sulphate in the treatment of bone and soft tissue infection. Material and Method. Bone cavities and soft tissue dead spaces were aggressively debrided, lavaged and packed with Calcium Sulphate (10–40 cc) loaded with Vancomycin (1–4 g) and Gentamicin (240–960 mg). Post-operatively serial assays of Vancomycin and Gentamicin levels 1 hour after surgery then daily for three days. Renal function was also measured. Results. In patients with normal renal function. : The systemic levels were either un-measurable at the first assay, or below the acceptable trough level (Mean 2.4 and 1.8 for Vancomycin and Gentamycin respectively). They had measurable systemic levels at the third assay . In patients with renal dysfunction. : Systemic levels were in the therapeutic range determined for systemically administered antibiotics, but these levels remained high and did not decrease until patients had undergone their routine dialysis. Conclusions. In patients treated with antibiotic loaded Calcium Sulphate: Antibiotic assays are not necessary in patients who have normal renal function. Patients with impaired renal function should have:. Use lower doses of antibiotics. Should undergo assays routinely. Ensure dialysis after surgery. If they remain high, the antibiotic loaded calcium sulphate could be removed

Introduction. Radiolucencies beneath the tibial component are well recognized in knee arthroplasty; the aetiology and significance are poorly understood. Non-progressive narrow radiolucencies with a sclerotic margin are thought not to be indicative of loosening. Factors which decrease the incidence of radiolucencies include cementless fixation and the use of pulse lavage. Leg/component alignment or BMI do not influence radiolucency. We are not aware of any studies that have looked at the effect of load type on radiolucency. The Oxford domed lateral tibial component was introduced to decrease the bearing dislocation rate that was unacceptably high with the flat tibial tray. However, the introduction of the domed tibial component alters the forces transmitted through the implant-cement-bone interface. As the Oxford UKR uses a fully congruent mobile bearing, the forces transmitted through the interface with a flat tray are compressive, except for the effect of friction. However, with the domed tibial component shear forces are introduced. The aim of this study was to assess the prevalence of radiolucency beneath the previous flat design and the new domed tibial tray. Patients and methods. A consecutive series of 248 cemented lateral UKRs (1999–2009) at a single institution were assessed. The first 55 were with a flat tibia and the subsequent 193 with a domed component. One year post-op radiographs were assessed, by two observers, for the presence (full or partial) and distribution of radiolucency. The distribution and thickness of each radiolucency. Cases were excluded for missing or poorly aligned radiographs. Results. In the flat group there were 42 patients (17 male, 25 female) with 42 joints. In the domed group there were 139 patients (44 male, 95 female) with 146 joints. There was a statistical significant difference between groups for the presence and extent of radiolucency (p<0.001). In the flat group, 6 (14%) had a full radiolucency and 18 (43%) had a partial radiolucency. 14 of the 18 partial radiolucencies involved the far lateral zones (1&2) and 3 partial radiolucencies involved the keel. In the domed group 6, (4.1%) had a full radiolucency and 13 (8.9%) had a partial radiolucency. All radiolucencies observed were less than 1 mm thick. Intra-class correlation for inter-observer agreement for assessment of radiolucency was 0.679. Discussion. The introduction the domed lateral tibial component results in a reduction in prevalence of radiolucency compared to a flat component. This suggests, as the mode of fixation is identical, that the forces across the tibial-cement-bone interface have a significant effect on the development of the tissue at that interface. In particular it suggests that compressive forces alone tend to cause soft tissue to be formed at the interface, whereas shear force causes bone

Aims. Infections of bone usually require multiple surgery and prolonged periods of treatment. One reason for problems is found in the presence of stationary phase bacteria embedded in biofilms that show increased resistance against conventional antibiotic therapy (up to 1000x MIC). Biofilms adhere to surfaces of avital material making radical debridement a prerequisite for cure. Osseous defects are common in such conditions and need to be addressed. To avoid re-infection high local antbiotic concentrations are necessary. Allograft bone may be impregnated with high loads of antibiotics using a special incubation technique. The resulting antibiotic bone compound (ABC) provides high and long lasting concentrations at the site of infection and is likely to restore bone stock simultaneously. Based on this technology we have developed a new surgical technique. Methods. 42 patients (10–67yrs) with chronic osteitis were included into a prospective study using a standardized protocol. Infection was at the humerus (1x), femur (10x), tibia (29x) or femur+tibia (2x), respectively. Treatment consisted of removal of foreign material, radical sequestrectomy and soft-tissue debridement followed by pressurized lavage. Surfaces of sclerotic bone were trimmed down to vital areas. The remaining osseous defects were filled with ABC, using an impaction technique resulting in complete dead space management. The allograft was impregnated with vancomycin, in cases with mixed pathogens combinations with tobramycin were used. Internal fixation was performed the same time whenever applicable. Sites were drained and closed immediately; rehabilitation did not differ from uninfected procedures. Results. 1 patient died shortly after surgery from cardiac failure. 41 could be followed for a minimum of 2 and a maximum of 6years (mean 3,1years). In 2 patients wound healing was unsatisfactory requiring additional coverage with a muscle flap. 2 patients showed material failure after intramedullary nailing, requiring exchange of the implant. In those cases no sign of infection was present at the time of revision. There were 3 cases with recurrence of infection, all originating from foci not detected during the index operation and becoming apparent between 3 and 12 months after surgery. Two could successfully be revised using the same technique; one refused revision and shows continuing fistulation. Radiological incorporation of allografts appeared as after conventional bone grafting, union of pseudarthroses was achieved between 2 and 6 months after (re-) stabilization. 40 patients (95,2%) were fully weight bearing, painfree and without any sign of infection at the latest follow up. Conclusion. Using antibiotic impregnated allograft bone eradication of pathogens, grafting of defects, dead space management and insertion of osteosynthetic material may be accomplished in a one stage procedure. Since the graft gradually is replaced by healthy own bone improved long term results may be expected as well as improved conditions in the case of another revision. The new technique provides for quick rehabilitation, improved results and markedly reduced costs of treatment in cases of bone infection

Aims

Despite long-standing dogma, a clear relationship between the timing of surgical irrigation and debridement (I&D) and the development of subsequent deep infection has not been established in the literature. Traditionally, I&D 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 multicentre 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 I&D (within six hours of injury vs beyond six hours) and subsequent reoperation rate for infection or healing complications within one year for patients with open limb fractures requiring surgical treatment.

Aims

Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures.

This study compared the quality of reduction and complication rate when using a standard ilioinguinal approach and the new pararectus approach when treating acetabular fractures surgically. All acetabular fractures that underwent fixation using either approach between February 2005 and September 2014 were retrospectively reviewed and the demographics of the patients, the surgical details and complications were recorded.

A total of 100 patients (69 men, 31 women; mean age 57 years, 18 to 93) who were consecutively treated were included for analysis. The quality of reduction was assessed using standardised measurement of the gaps and steps in the articular surface on pre- and post-operative CT-scans.

There were no significant differences in the demographics of the patients, the surgical details or the complications between the two approaches. A significantly better reduction of the gap, however, was achieved with the pararectus approach (axial: p = 0.025, coronal: p = 0.013, sagittal: p = 0.001).

These data suggest that the pararectus approach is at least equal to, or in the case of reduction of the articular gap, superior to the ilioinguinal approach.

This approach allows direct buttressing of the dome of the acetabulum and the quadrilateral plate, which is particularly favourable in geriatric fracture patterns.

Cite this article: Bone Joint J 2015;97-B:1271-8.

Although the use of constrained cemented arthroplasty to treat distal femoral fractures in elderly patients has some practical advantages over the use of techniques of fixation, concerns as to a high rate of loosening after implantation of these prostheses has raised doubts about their use. We evaluated the results of hinged total knee replacement in the treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were socially dependent and poorly mobile.

Within the first year after implantation 22 of the 54 patients had died, six had undergone a further operation and two required a revision of the prosthesis. The subsequent rate of further surgery and revision was low.

A constrained knee prosthesis offers a useful alternative treatment to internal fixation in selected elderly patients with these fractures, and has a high probability of surviving as long as the patient into whom it has been implanted.

Although it is widely accepted that grade IIIB open tibial fractures require combined specialised orthopaedic and plastic surgery, the majority of patients in the UK initially present to local hospitals without access to specialised trauma facilities. The aim of this study was to compare the outcome of patients presenting directly to a specialist centre (primary group) with that of patients initially managed at local centres (tertiary group).

We reviewed 73 consecutive grade IIIB open tibial shaft fractures with a mean follow-up of 14 months (8 to 48). There were 26 fractures in the primary and 47 in the tertiary group. The initial skeletal fixation required revision in 22 (47%) of the tertiary patients. Although there was no statistically-significant relationship between flap timing and flap failure, all the failures (6 of 63; 9.5%) occurred in the tertiary group. The overall mean time to union of 28 weeks was not influenced by the type of skeletal fixation. Deep infection occurred in 8.5% of patients, but there were no persistently infected fractures. The infection rate was not increased in those patients debrided more than six hours after injury.

The limb salvage rate was 93%. The mean limb functional score was 74% of that of the normal limb. At review, 67% of patients had returned to employment, with a further 10% considering a return after rehabilitation. The times to union, infection rates and Enneking limb reconstruction scores were not statistically different between the primary and tertiary groups.

The increased complications and revision surgery encountered in the tertiary group suggest that severe open tibial fractures should be referred directly to specialist centres for simultaneous combined management by orthopaedic and plastic surgeons.

We studied 60 patients with an acute displaced fracture of the femoral neck and with a mean age of 84 years. They were randomly allocated to treatment by either internal fixation with cannulated screws or hemiarthroplasty using an uncemented Austin Moore prosthesis. All patients had severe cognitive impairment, but all were able to walk independently before the fracture. They were reviewed at four, 12 and 24 months after surgery. Outcome assessments included complications, revision surgery, the status of activities of daily living (ADL), hip function according to the Charnley score and the health-related quality of life (HRQOL) according to the Euroqol (EQ-5D) (proxy report).

General complications and the rate of mortality at two years (42%) did not differ between the groups. The rate of hip complications was 30% in the internal fixation group and 23% in the hemiarthroplasty group; this was not significant. There was a trend towards an increased number of re-operated patients in the internal fixation group compared with the hemiarthroplasty group, 33% and 13%, respectively (p = 0.067), but the total number of surgical procedures which were required did not differ between the groups. Of the survivors at two years, 54% were totally dependent in ADL functions and 60% were bedridden or wheelchair-bound regardless of the surgical procedure. There was a trend towards decreased mobility in the hemiarthroplasty group (p = 0.066). All patients had a very low HRQOL even before the fracture. The EQ-5D_index score was significantly worse in the hemiarthroplasty group compared with the internal fixation group at the final follow-up (p < 0.001).

In our opinion, there is little to recommend hemiarthroplasty with an uncemented Austin Moore prosthesis compared with internal fixation, in patients with severe cognitive dysfunction.

The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing.

The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy.

Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required.

In a randomised prospective study, 20 patients with intra-articular fractures of the distal radius underwent arthroscopically- and fluoroscopically-assisted reduction and external fixation plus percutaneous pinning. Another group of 20 patients with the same fracture characteristics underwent fluoroscopically-assisted reduction alone and external fixation plus percutaneous pinning. The patients were evaluated clinically and radiologically at follow-up of 24 months. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and modified Mayo wrist score were used at 3, 9, 12 and 24 months postoperatively. In the arthroscopically- and fluoroscopically-assisted group, triangular fibrocartilage complex tears were found in 12 patients (60%), complete or incomplete scapholunate ligament tears in nine (45%), and lunotriquetral ligament tears in four (20%). They were treated either arthroscopically or by open operation. Patients who underwent arthroscopically- and fluoroscopically-assisted treatment had significantly better supination, extension and flexion at all time points than those who had fluoroscopically-assisted surgery. The mean DASH scores were similar for both groups at 24 months, whereas the difference in the mean modified Mayo wrist scores remained statistically significant.

Although the groups are small, it is clear that the addition of arthroscopy to the fluoroscopically-assisted treatment of intra-articular distal radius fractures improves the outcome. Better treatment of associated intra-articular injuries might also have been a reason for the improved outcome.