Our aim was to explore factors associated with early post operative infection for surgically managed base of 4th/5th metacarpal fractures. We hypothesised that K-wires crossing the 4th and 5th carpometacarpal joint (CMCJ) would be associated with an increased risk of post-operative infection.

Data from consecutive patients requiring surgical fixation for a base of 4th/5th metacarpal fracture from October 2016 to May 2021 were collected. Patient demographics, time to surgery, length of surgery, operator experience, use of tourniquet, intra-operative antibiotics, number and thickness of K-wire used, as well as whether or not the K-wires crossed CMCJ joints were recorded. Factors associated with post operative infection were assessed using Chi Squared test and univariable logistic regression using R studio.

Of 107 patients, 10 (9.3%) suffered post operative infection. Time to surgery (p 0.006) and length of operation (p=0.005) were higher in those experiencing infection. There was a trend towards higher risk of infection seen in those who had K-wires crossed (p=0.06). On univariable analysis, patients who had wires crossed were >7 times more likely to experience infection than those who didn't (OR 7.79 (95% CI, 1.39 - 146.0, p=0.056). Age, smoking, K-wire size, number of K-wires used, intraoperative antibiotics, tourniquet use and operator experience were not associated with infection.

In patients with a base of 4th/5th metacarpal fractures requiring surgical fixation, we find an increased risk of post-operative infection associated with K-wires crossing the CMCJ, which has implications for surgical technique. Larger prospective studies would be useful in further delineating these findings.

Aims. The purpose of this study was to: review the efficacy of the induced membrane technique (IMT), also known as the Masquelet technique; and investigate the relationship between patient factors and technique variations on the outcomes of the IMT. Methods. A systematic search was performed in CINAHL, The Cochrane Library, Embase, Ovid MEDLINE, and PubMed. We included articles from 1 January 1980 to 30 September 2019. Studies with a minimum sample size of five cases, where the IMT was performed primarily in adult patients (≥ 18 years old), in a long bone were included. Multivariate regression models were performed on patient-level data to determine variables associated with nonunion, postoperative infection, and the need for additional procedures. Results. A total of 48 studies were included, with 1,386 cases treated with the IMT. Patients had a mean age of 40.7 years (4 to 88), and the mean defect size was 5.9 cm (0.5 to 26). In total, 82.3% of cases achieved union after the index second stage procedure. The mean time to union was 6.6 months (1.4 to 58.7) after the second stage. Our multivariate analysis of 450 individual patients showed that the odds of developing a nonunion were significantly increased in those with preoperative infection. Patients with tibial defects, and those with larger defects, were at significantly higher odds of developing a postoperative infection. Our analysis also demonstrated a trend towards the inclusion of antibiotics in the cement spacer having a protective effect against the need for additional procedures. Conclusion. The IMT is an effective management strategy for complex segmental bone defects. Standardized reporting of individual patient data or larger prospective trials is required to determine the optimal implementation of this technique. This is the most comprehensive review of the IMT, and the first to compile individual patient data and use regression models to determine predictors of outcomes. Cite this article: Bone Joint J 2020;102-B(12):1723–1734

Aims. The primary aim of this study was to determine if delayed clavicular fixation results in a greater risk of operative complications and revision surgery. Patients and Methods. A retrospective case series was undertaken of all displaced clavicular fractures that underwent plate fixation over a ten-year period (2007 to 2017). Patient demographics, time to surgery, complications, and mode of failure were collected. Logistic regression was used to identify independent risk factors contributing towards operative complications. Receiver operating characteristic (ROC) curve analysis was used to determine if a potential ‘safe window’ exists from injury to delayed surgery. Propensity score matching was used to construct a case control study for comparison of risk. Results. A total of 259 patients were included in the analysis. Postoperative infection occurred in 3.9% of all patients (n = 10); the only variable associated was a greater time interval from injury to fixation (p = 0.001). Failed primary surgery requiring revision fixation was required in 7.7% of the cohort (n = 20), with smoking (p < 0.001), presence of a postoperative infection (p < 0.001), increasing age (p = 0.018), and greater time delay from injury to surgery (p = 0.015) identified as significant independent predictors on regression analysis. ROC analysis revealed that surgery beyond 96 days from injury increased the rate of major complications and revision surgery. Using a matched case cohort of cases before (n = 67) and after (n = 77) the ‘safe window’, the risk of postoperative infection increased (odds ratio (OR) 7.7, 95% confidence interval (CI) 1.9 to 62.9; p = 0.028), fixation failure (OR 3.8, 95% CI 1.2 to 12.1; p = 0.017) and revision surgery (OR 4.8, 95% CI 1.5 to 15.0; p = 0.004). Conclusion. A delay to primary fixation of up to three months following injury may be acceptable, beyond which there is an increased risk of major operative complications and revision surgery. Cite this article: Bone Joint J 2019;101-B:1385–1391

Aims. Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP. Methods. This is a retrospective and observational study containing data from nine patients with a mean age of 14.1 years (9 to 25; three female, six male) with OP who were treated in our hospital between April 2008 and October 2018 with 20 surgical procedures due to 17 different fractures. Patient data included age, sex, operating time, length of stay, genetic type of the disease, previous surgery, fractures, complications, and comorbidity. Results. The mean follow-up period was 92.5 months (25 to 140). Bony union was observed in all of our patients. Osteomyelitis developed in two patients with femoral shaft fractures, and two patients had peri-implant stress fractures. Conclusion. Treatment of fractures in OP patients is difficult, healing is protracted, and the risk of postoperative infection is high. In children and young adults with OP who have open medullary canal and the epiphyses are not closed, fractures can be treated with surgical techniques such as intramedullary titanium elastic nail (TENS) technique or fixation with Kirschner (K)-wire. Cite this article: Bone Joint J 2020;102-B(8):1082–1087

Cheilectomy is a recommended procedure for early stage osteoarthritis of the 1st metatarsophalangeal joint. Although improvement in symptoms has been reported in many studies, long term performance is not well understood. It is thought that significant numbers of patients require subsequent arthrodesis or arthroplasty. We report on a large cohort of patients receiving this procedure and on complications, and mid-term outcome. This is a retrospective study looking at all patients undergoing cheilectomy for hallux rigidus between November 2007 and August 2018. Departmental database was used to record outcome measures including: postoperative wound infection, patient reported improvement in pain and incidence of further surgical interventions like revision cheilectomy, conversion to arthrodesis and arthroplasty. Osteoarthritis was staged radiographically using PACS (Hattrup and Johnson classification). A total of 240 feet in 220 patients (20 bilateral surgeries) were included with 164 females (75%) and 56 males (25%), the median age being 55 years (range 22–90 years). Radiological assessment showed 89 stage 1 arthritis (42%), 105 stage 2 (50%), 17 stage 3 (8%) and 9 patients were excluded due to unavailable radiographs. 5 patients (2%) had superficial wound infections. There were 16 further surgeries (7%); 12 arthrodesis (5%), 3 revision cheilectomy and 1 conversion to arthroplasty. 157 patients were found to be pain-free at the latest post-operative visit (77%), 48 reported minimal pain (23%), 15 patients were excluded due to incomplete data. Cheilectomy appears to effectively reduce pain with low complication rates. Rates of conversion to arthrodesis/arthroplasty are lower than in many reported studies

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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.

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The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes.

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The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs.

Objective. The development of surgical site infection in the early weeks following open reduction and internal fixation (ORIF) is a challenging problem. There are no evidence-based guidelines to direct the number of surgical debridements prior to definitive wound closure. The purpose of this study was to assess the success of infection resolution, and to identify risk factors for failure, in post-operative infections treated with a single debridement and primary wound closure. Methods. We retrospectively reviewed 61 postoperative infections (60 patients) that developed following fracture ORIF that were treated with a single debridement and primary closure. Data was collected from a review of the patients’ medical record. Variables were compared between the two groups using univariate and multivariate logistic regression analysis. Results. Twenty nine cases (48%) in 28 patients achieved successful outcome following a single debridement and primary closure without hardware removal. Risk factors for treatment failure, identified by multivariate analysis, were AO/OTA classification B and C type fractures (odds ratio = 2.539; 95% confidence interval = 1.110, 5.807; p = 0.027) and elevated C-reactive protein at admission (odds ratio = 1.017; 95% confidence interval = 1.002, 1.032; p = 0.026). Conclusions. Acute postoperative infection following ORIF treated by a single debridement and primary closure with hardware retention is successful in only half of the cases

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Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery.

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It is imperative to understand the risks of operating on urgent cases during the COVID-19 (SARS-Cov-2 virus) pandemic for clinical decision-making and medical resource planning. The primary aim was to determine the mortality risk and associated variables when operating on urgent cases during the COVID-19 pandemic. The secondary objective was to assess differences in the outcome of patients treated between sites treating COVID-19 and a separate surgical site.

The reconstruction of lower limb defects after oncological reconstructions is still a problem in limb salvage surgery. Large bony defects need to be treated with sound and durable reconstructions. During recent decades, the life expectancy of patients affected with cancer has improved considerably because of advances in chemotherapy, immunotherapy, hormonal treatment and radiotherapy. This improvement requires greater reliability in the reconstructive procedure in order to avoid mechanical failure during prolonged survival of the patient. The author experience with modular megaprosthesis by Link (megasystem C) allowed us to present a rapid, effective and functional solution. From June 2001 to December 2007 225 patients have been operated with a megaprosthesis C for tumoral resection. The new megaprosthesis C by Link represents a wide-ranging system that can afford a large variety of reconstructions in the inferior limb, from very short replacement of 5 cm in proximal femur, to a total femur and proximal tibia replacement. Modularity is represented by 1 cm increase in length. The different options of cemented and not cemented stem may be used with intraoperative decision. In cemented stem a rough collar seals the osteotomy and prevents polyethylene debris from entering the femoral canal by inducing a scar tissue around the stem entrance (so-called purse-string effect). Moreover in patients with solitary lesions and very good prognosis an allograft-prosthesis composite can be performed with improved clinical results on walking and function. Of the 225 patients that underwent tumoral resection and reconstruction with a modular megaprosthesis approximately 43% (97 cases) were operated for metastatic disease. Among these cases 55 cases were proximal femoral recontructions, 39 cases were distal femoral reconstructions and 3 cases were proximal tibial reconstructions. All cases were performed with cemented stems. We experienced a 7% of postoperative infections, 2% of dislocations of proximal femoral prosthesis and 3% of mechanical failures. While infections and dislocation rates were in the average for this surgery, mechanical failures were relatively high. We should consider that in patients with relatively long resections and muscle deficiency the mechanical stress exerted on the prosthesis can explain this kind of mechanical failure. However the new design of morse tapers have annulled these problems

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The aim of this study was to explore whether time to surgery affects functional outcome in displaced proximal humeral fractures

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The aims of this study were to evaluate the incidence of postoperatively restricted weight-bearing and its association with outcome in patients who undergo surgery for a fracture of the hip.

Introduction. Hip fracture is a worldwide problem, not only as far as epidemiology is concerned but also regarding economical issues. Surgery is the current standard treatment. However owing to age, and patients co-morbidities complications are common. Surgical site infection is directly related to operative procedure, and surgeons' experience may be very important when making plans for outcome improvement. In this paper we study the role of hip surgeons versus general orthopaedic surgeons in relation to postoperative site infection. Operative hypothesis determines that hip surgeons have less infection rates than general orthopaedic surgeons. Null hypothesis that infection rates are rather the same. Material and Methods. In a prospective controlled cohort study 820 patients presenting with a hip fracture were randomizelly operated on by a group of orthopaedic surgeons of the same Hospital Department. Patients were then classified according to surgeons adscription either to a Hip Unit (Group A=215 cases) or not (Group B=605). Variables studied included age, gender, treatment (osteosynthesis or joint replacement), co-morbidities (according to Charlson, s index), and infection rate. Fisher, and Ranksum statistical tests, and simple and multiple logistic regression, for univariate and multivariate, analysis was performed. Results. 237 (28,93 %) patients were male, and 583 (71,06 %) females. Mean age for both groups was 77,58 years (r=16−105; group A=78, group B=81). 215 patients were included in group A, and 605 in group B. 534 (65.12%) underwent an osteosynthesis, and 272 (33,17%) a joint replacement. 14 patients were not operated. Both groups were homogeneous regarding gender, surgical technique, Charlson's index, and functional outcome (Fisher test p=0,777). 17 patients (2,073%) sustained a surgical site infection (group A=7 cases out of 215 [3,27%], and group B=10 cases out of 605 [1,65%]). Multivariate logistic regression showed that there was no relation between gender, surgical site infection, Charlson index, surgical technique, or groups (A or B). Only age was a determinant factor (Raksum test p=0,003; OR 95% CI=1,08, p=0,005). Conclusion. Since there are no differences in the outcomes between surgeons dedicated to a Hip Unit and general orthopaedic surgeons as far as postoperative surgical site infection is concerned, delaying operative treatment for hip fracture or creating a special Unit for that is unworthy. Only age appears as a significant variable

We treated 24 patients with high-energy fractures of the tibial plateau by the Ilizarov fixator and transfixion wires. Eleven fractures were open, and 20 patients had complex injuries. Twelve were treated by ligamentotaxis and percutaneous fixation, seven by limited open reduction and five by extensive open reduction. All were followed for at least 24 months. All the fractures united, with an average time to healing of 14.4 weeks. Thirteen patients achieved full extension and 13 more than 110° of flexion. Twenty-two knees were stable. Fifteen patients walked normally and the rest with only a slight limp. All but two knees had an articular step-off of less than 4 mm and all had normal axial alignment except two. There were no cases of postoperative skin infection, osteomyelitis or septic arthritis. Ilizarov circular fixation is an ideal method of treatment for these fractures when extensive dissection and internal fixation are contraindicated due to trauma to the soft tissue, deficiency of bone stock, and bony comminution

The purpose of this study was to compare the clinical and radiological outcome of patients with intact, broken and removed syndesmosis screws after Weber B or C ankle fracture with an associated injury to the syndesmosis. We hypothesised that there would be no difference. Of a possible 142 patients who fulfilled our inclusion criteria, 52 returned for clinical and radiological assessment at least one year after surgery. Of these, 27 had intact syndesmosis screws, ten had broken screws, and 15 had undergone elective removal of the screw. The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot score was 83.07 (sd 13.59) in the intact screw group, 92.40 (sd 12.69) in the broken screw group, and 85.80 (sd 11.33) in the removed screw group (p = 0.0466).

There was no difference in clinical outcome of patients with intact or removed syndesmotic screws. Paradoxically, patients with a broken syndesmosis screw had the best clinical outcome. Our data do not support the removal of intact or broken syndesmosis screws, and we caution against attributing post-operative ankle pain to breakage of the syndesmosis screw.

Our aim in this pilot study was to evaluate the fixation of, the bone remodelling around, and the clinical outcome after surgery of a new, uncemented, fully hydroxyapatite-coated, collared and tapered femoral component, designed specifically for elderly patients with a fracture of the femoral neck.

We enrolled 50 patients, of at least 70 years of age, with an acute displaced fracture of the femoral neck in this prospective single-series study. They received a total hip replacement using the new component and were followed up regularly for two years.

Fixation was evaluated by radiostereometric analysis and bone remodelling by dual-energy x-ray absorptiometry. Hip function and the health-related quality of life were assessed using the Harris hip score and the EuroQol-5D.

Up to six weeks post-operatively there was a mean subsidence of 0.2 mm (−2.1 to +0.5) and a retroversion of a mean of 1.2° (−8.2° to +1.5°). No component migrated after three months. The patients had a continuous loss of peri-prosthetic bone which amounted to a mean of 16% (−49% to +10%) at two years. The mean Harris hip score was 82 (51 to 100) after two years.

The two-year results from this pilot study indicate that this new, uncemented femoral component can be used for elderly patients with osteoporotic fractures of the femoral neck.

Patients infected with HIV presenting with an open fracture of a long bone are difficult to manage. There is an unacceptably high rate of post-operative infection after internal fixation. There are no published data on the use of external fixation in such patients. We compared the rates of pin-track infection in HIV-positive and HIV-negative patients presenting with an open fracture. There were 47 patients with 50 external fixators, 13 of whom were HIV-positive (15 fixators).

There were significantly more pin-track infections requiring pharmaceutical or surgical intervention (Checketts grade 2 or greater) in the HIV-positive group (t-test, p = 0.001). The overall rate of severe pin-track infection in the HIV-positive patients requiring removal of the external-fixator pins was 7%. This contrasts with other published data which have shown higher rates of wound infection if open fractures are treated by internal fixation.

We recommend the use of external fixation for the treatment of open fractures in HIV-positive patients.