Aims. Tissue adhesives (TAs) are a commonly used adjunct to traditional surgical wound closures. However, TAs must be allowed to dry before application of a surgical dressing, increasing operating time and reducing intraoperative efficiency. The goal of this study is to identify a practical method for decreasing the curing time for TAs. Methods. Six techniques were tested to determine which one resulted in the quickest drying time for 2-octyle cyanoacrylate (Dermabond) skin adhesive. These were nothing (control), fanning with a hand (Fanning), covering with a hand (Covering), bringing operating room lights close (OR Lights), ultraviolet lights (UV Light), or prewarming the TA applicator in a hot water bath (Hot Water Bath). Equal amounts of TA were applied to a reproducible plexiglass surface and allowed to dry while undergoing one of the six techniques. The time to complete dryness was recorded for ten specimens for each of the six techniques. Results. Use of the Covering, OR Lights, and Hot Water Bath techniques were associated with a 25- (p = 0.042), 27- (p = 0.023), and 30-second (p = 0.009) reduction in drying time, respectively, when compared to controls. The UV Light (p = 0.404) and Fanning (p = 1.000) methods had no effect on drying time. Conclusion. Use of the Covering, OR Lights, and Hot Water Bath techniques present a means for reducing overall operating time for surgeons using TA for closure augmentation, which can increase intraoperative efficiency. Further studies are needed to validate this in vivo. Cite this article: Bone Jt Open 2022;3(8):607–610

Introduction. Wound surveillance has been reported to result in a significant fall in the incidence of wound sepsis in total knee arthroplasty (TKA). However, there is currently little guidance on the definition of surgical wound infection that is best to be used for surveillance. The purpose of this study was to assess the agreement between three common definitions of surgical wound infection as a performance indicator in TKA; (a) the CDC 1992 definition, (b) the NINSS modification of the CDC definition and (c) the ASEPSIS scoring method applied to the same series of surgical wounds. Methods. A prospective study of 500 surgical wounds in patients who underwent knee arthroplasties between May 2002 and December 2004 from a single tertiary centre were assessed according to the different definitions of surgical wound infection. Results. A total of 500 wounds were assessed in 482 patients. Mean age of patients was 70+/−11 years, 61.6% were females, duration of surgery was 101+/−49 minutes and mean follow-up was 35.2+/−25.7 months. The most commonly isolated species were Coagulase negative staphylococci (33.3%), Staphylococcus aureus (25%) and Pseudomonas aeruginosa (16.6%). The mean percentage of wounds classified as infected differed substantially with different definitions: 5.8% with the CDC definition, 3.6% with the NINSS version and 2.2% with an ASEPSIS score > 20. When superficial infections (according to CDC category) were included, 5.2% (26) of all observed wounds received conflicting diagnoses, and 1.4% (7) were classified as infected by both ASEPSIS and CDC definitions. When superficial infections were excluded, the two definitions estimated about the same overall percentage infection (2.2% and 2.6% respectively), but there were almost three times as many conflicting infection diagnoses (n=14) as concordant ones (n=5). Conclusion. Distinctions in surgical wound infection definitions contribute to notable differences in how infections are classified after TKA. Even small changes made to the CDC definition, as with the NINSS version, caused major variation in estimated percentage of wound infection. A single definition used consistently can show changes in wound infection rates over time at a single centre. However, differences in interpretation prevent comparison between different centres

Introduction and Objectives: We studied the incidence rate of surgical wound infections (SWI) after total hip replacement (THR). Materials and Methods: This is a prospective study of a cohort in a hospital of the Autonomous Community of Madrid in which we included all the patients that underwent THR as elective surgery over a 6 month period with a maximum follow-up of 2 years. We carried out an estimation based on a sample with a potency of 95%, and a confidence of 90%, with losses of 5% of a prevalence below 5%. We estimated we would need 57 patients to perform the study. Results: We studied 61 patients. The percentage of men was 45.9% and of women 54.1% (p> 0.05). Mean age was 63.1 years (SD=14.4) and 72.1 years (SD=8.3) respectively (p< 0.05). The rate of infection in this series was 4.9% with a standardized ratio of 1.57% in relation to national rates of infection. Staphylococcus aureus was the most frequent pathogen. No risk factor was identified. Discussion and Conclusions: Measures to prevent infection do not always guarantee the suppression of surgical wound infections. It is the responsibility of health care personnel to follow preventive and surveillance systems as closely as possible, since they not only act as a guarantee for patients but also for the system. Therefore, they must remain vigilant and study all cases in an attempt to continue decreasing the incidence of infection

Aims. To compare the cost-utility of standard dressing with incisional negative-pressure wound therapy (iNPWT) in adults with closed surgical wounds associated with major trauma to the lower limbs. Methods. A within-trial economic evaluation was conducted from the UK NHS and personal social services (PSS) perspective based on data collected from the Wound Healing in Surgery for Trauma (WHiST) multicentre randomized clinical trial. Health resource utilization was collected over a six-month post-randomization period using trial case report forms and participant-completed questionnaires. Cost-utility was reported in terms of incremental cost per quality-adjusted life year (QALY) gained. Sensitivity analysis was conducted to test the robustness of cost-effectiveness estimates while uncertainty was handled using confidence ellipses and cost-effectiveness acceptability curves. Results. The incremental cost of standard dressing versus iNPWT over six months was £2,037 (95% confidence interval (CI) £349 to £3,724). There was an insignificant increment in QALYs gained in the iNPWT group (0.005, 95% CI -0.018 to 0.028). The probability of iNPWT being cost-effective at £20,000 per QALY was 1.9%. The results remained robust in the sensitivity analysis. Conclusion. The within-trial economic evaluation suggests that iNPWT is unlikely to be a cost-effective alternative to standard dressing in adults with closed surgical wounds to their lower limbs. Cite this article: Bone Joint J 2020;102-B(8):1072–1081

Introduction and Aims: The rate of wound infection for HIV positive patients, range from 0–33% for closed fractures to 72–80% for compound fractures. For the outcome at our institute, I undertook to study the rate of surgical wound infection in HIV positive patients undergoing unreamed intramedullary fixation for acute fractures. Method: A prospective single blind study involving 45 patients, who sustained acute fractures of the femur and/or tibia were treated with unreamed intramedullary nails at Durban’s Metropolitan hospitals during April 2002 to June 2003. Eighteen patients were HIV positive with a mean age of 29 years (20–47) compared to 28.5 years (15–56) amongst the HIV negative. There were six and three females in HIV positive and negative groups respectively. Motor vehicle accidents involving pedestrians and gunshot injuries accounted for the majority of the fractures. Although all of the patients were asymptomatic prior to injury, fourteen had associated injuries. Results: The mean follow-up was 7.3 months (1–14). Following discharge from hospital, patients were seen at two and six weeks, three, six, nine, and 12 months post-operatively. Amongst patients with closed fractures, nine were HIV positive, seven with femur and two with tibia fractures and amongst the HIV negative group 12 patients had femur and seven tibia fractures. Three of the HIV positive patients had compound fracture tibia, each with a Gustilo type II, type IIIA and type IIIB fracture, while four HIV negative patients with, two each of grade II and grade IIIB fracture tibia. Amongst the six HIV positive patients who had compound fractures of the femur one had a grade I, two grade II, two grade IIIA and two grade IIIB fractures. Four HIV negative patients had compound femoral fractures, three with grade II and one grade IIIA. Two patients had wound infection, at one week a HIV positive male with a grade IIIA fracture of the femur and a HIV negative female at two weeks with a grade IIIB fracture of the tibia, resulting in an infection rate 5.5% and 3.7% for the HIV positive and HIV negative patients respectively. This difference was not statically significant (p=0.641). Conclusion: The results show that when asymptomatic HIV positive patients are treated operatively for acute long bone fractures, be they closed or compound, the rate of surgical wound infection is comparable to those of HIV negative patients

Introduction: Proximal femoral fracture (PFF) is the leading cause of Trauma admission. Deep surgical wound infection occurs in approximately 3% of these patients. The purpose of this study was to assess the cost of deep infection to the patient, in terms of mortality and social consequences, and to the National Health Service, in terms of financial burden. Methods: 61 consecutive patients (51 females, 10 males) treated for PFF, complicated with deep surgical wound infection over a seven-year period are presented. A control group consisting of 122 patients, without infection, were individually case matched (2:1) for factors that affect outcome after PFF (age, sex, ASA grade, fracture type, operation, and pre-fracture residence, social dependence, and mobility). Outcomes included length of admission (Trauma unit, rehabilitation bed, community hospital), number of operations, antibiotic administration and outpatient treatment, final destination, and mortality at one, three, and six months. A total cost of treatment was obtained from this data and supplied finance department figures. Results: MRSA was responsible for 31 cases. Infected cases required an average of two wound debridements. 16 patients had a Girdlestones procedure of whom two were subsequently revised to total hip replacement. For all patients, the average Trauma unit admission was 58 days in the infected cases, with a further 40 days spent in rehabilitation or community beds, versus 16 days and 27 days respectively in the controls (p < 0.001). 34% of infected cases died before discharge versus 15% of controls (p = 0.004). For the patients surviving to discharge, the mean total hospital stay was 124 days for the infected cases versus 45 days in the controls (p < 0.001). A higher proportion of the survivors in the control group returned to their original residence compared to the infected survivors (p = 0.002). The mortality rates in the infected group were 15% at 1 month, 31% at 3 months, and 38% at six months, versus 9%, 20%, and 25% respectively in the control group (p = 0.36, 0.12, 0.12). The median cost of treatment per infected case was 23960 versus 7390 per control case. Conclusions: Deep surgical wound infection after proximal femoral fracture is a devastating complication for both the patient and the NHS. It is associated with a higher in-patient mortality, and fewer survivors return to their pre-fracture residence. Hospital stay is greatly increased and survivors spend 4 months on average in hospital. Additional costs are huge and are incurred at all levels. The extra financial cost of treating a single infected case would fund the treatment of two non-infected cases. These costs should be considered when allocating funds and beds to Trauma services, in addition to ensuring measures known to minimise infection rates are in place

Orthopaedic surgical site infections (SSI's) prolong total hospital stays by a median of 2 weeks per patient, approximately double re-hospitalization rates, and increase healthcare costs by more than 300%. Patients with orthopaedic SSI's have significant reductions in their health-related quality of life. We performed a systematic review and meta-analysis to compare differences in outcomes between use of sutures and non-absorbable staples for closure of orthopaedic surgical wounds in adults. The primary outcomes were rates of superficial and deep SSI. Secondary outcomes included wound dehiscence, length of hospital stay, patient satisfaction and pain during removal of closure material. Data sources including PubMed, EMBASE, Scopus, Web of Science, Cochrane Library, . clinicaltrials.gov. , National Institute for Health and Research, UK clinical trials gateway were searched for randomised controlled trials (RCT's) meeting inclusion criteria. Sixteen RCT's published between 1987 and 2017 were included. Overall, wound infection outcomes (superficial and deep infections combined) showed no statistically significant difference between closure with staples compared with sutures with arelative risk of 1.17 (95% CI 0.59–2.30, p=0.66). A subgroup was performed specific to hip wound infection outcomes. Interestingly, a sensitivity analysis demonstrated sutures to be statistically favourable (p=0.04) in terms of hip wound infection outcomes. There was no statistically significant difference among secondary outcomes between sutures and staple groups. Overall it appears the choice of sutures or staples in closure of orthopaedic wounds has no effect on wound complications. However, caution is needed in applying the findings to different population groups due to heterogeneity across studies

A suitable wound closure is an indispensable requirement for an uncomplicated and expedient recovery after an abdominal surgery. The closure technique will have a great impact on the healing process of the wound. Surgical complications, such as wound dehiscence (sometimes associated with evisceration), infection, hernia, nerve injury and incisional pain are very common in the postoperative period of an abdominal surgery. Besides, although their development can be promoted by other risk factors like age, sex, lifestyle, diet, health condition, the closure method can also influence the emergence of these undesirable complications. For this reason, and having the wellbeing and quality of life of the patients in mind, particularly high-risk patients, a closure system consisting of anchors applied on either side of the wound that aims to reduce the tension caused on the surrounding tissues of a wound and, consequently, decrease the risk of herniation was evaluated in a pilot animal study and compared with the traditional suture approach

Aims. This study aims to estimate economic outcomes associated with 30-day deep surgical site infection (SSI) from closed surgical wounds in patients with lower limb fractures following major trauma. Methods. Data from the Wound Healing in Surgery for Trauma (WHiST) trial, which collected outcomes from 1,547 adult participants using self-completed questionnaires over a six-month period following major trauma, was used as the basis of this empirical investigation. Associations between deep SSI and NHS and personal social services (PSS) costs (£, 2017 to 2018 prices), and between deep SSI and quality-adjusted life years (QALYs), were estimated using descriptive and multivariable analyses. Sensitivity analyses assessed the impact of uncertainty surrounding components of the economic analyses. Results. Compared to participants without deep SSI, those with deep SSI had higher mean adjusted total NHS and PSS costs (adjusted mean difference £1,577 (95% confidence interval (CI) -951 to 4,105); p = 0.222), and lower mean adjusted QALYs (adjusted mean difference -0.015 (95% CI -0.032 to 0.002); p = 0.092) over six months post-injury, but this difference was not statistically significant. The results were robust to the sensitivity analyses performed. Conclusion. This study found worse economic outcomes during the first six months post-injury in participants who experience deep SSI following orthopaedic surgery for major trauma to the lower limb. However, the increase in cost associated with deep SSI was less than previously reported in the orthopaedic trauma literature. Cite this article: Bone Jt Open 2022;3(5):398–403

Introduction

Nowadays, autologous platelet-rich plasma is used commonly in wound treatment. However, platelet gel, which was derived from allogeneic platelet-rich plasma (PRP) [1,2], has never been studied about efficacy in vivo or animal models. We aimed to determine efficacy of allogeneic platelet-gel on wound healing in rats by comparing with untreated, antibiotic-gel (Mupirocin 2%) treated and gel (sodium carboxymethylcellulose(NaCMC))-treated control.

Post-discharge surveillance of surgical site infection is necessary if accurate rates of infection following surgery are to be available. We undertook a prospective study of 376 knee and hip replacements in 366 patients in order to estimate the rate of orthopaedic surgical site infection in the community. The inpatient infection was 3.1% and the post-discharge infection rate was 2.1%. We concluded that the use of telephone interviews of patients to identify the group at highest risk of having a surgical site infection (those who think they have an infection) with rapid follow-up by a professional trained to diagnose infection according to agreed criteria is an effective method of identifying infection after discharge from hospital.

Persistent wound drainage after total joint arthroplasty (TJA) has been associated with a higher incidence of superficial and deep periprosthetic infection but the predictors for prolonged drainage and its outcome have not been thoroughly studied.

A consecutive series of 7,153 TJA cases performed between 2000 and 2006 at our institute, were recruited into this study. There were 301 cases (4.2%) of persistent wound drainage, defined as discharge from the wound for > 48 hours. The cases were matched in a 2:1 ratio for type of surgery, joint replaced, and date of surgery.

This study identified higher BMI (p< 0.005), malnutrition as defined by serum albumin< 3.4g/dl (p< 0.04), longer operative time (p< 0.01), and higher medical comorbidities, in particular diabetes (p< 0.001) as important risk factors for persistent wound drainage. In addition, patients in the drainage group were more likely to have a peak INR of > 1.5 (p< 0.001) during their hospital stay. Patients with wound drainage had a significantly lower hemoglobin postoperatively (p< 0.01) that necessitated greater number of postoperative allogenic transfusions (p=0.004). The hospital length of stay for the drainage group was also significantly higher (p< 0.005). One of the major risk factors for development of deep infection was prolonged drainage (> 7 days). In the deep hematoma and periprosthetic subgroups, the mean of delay in treatment was 6 days in those with retention of the prosthesis and successful outcome, and 9.5 days for those with failure of incision and drainage leading to resection arthroplasty (p= 0.03).

72% of the patient were successfully treated by oral or intravenous antibiotics. 27% required at least one re-operation for deep hematoma and 13% developed deep periprosthetic infection, resulting in 6% rate of resection arthroplasty. 1.5% of those with drainage remained in girdlestone status.

This study suggests early surgery for persistent drainage and avoidance of aggressive anticoagulation.

The posterior midline approach used in spinal surgery has been associated with a significant rate of wound dehiscence. This study investigates anatomical study of the arterial supply of the cervical and thoracic spinal muscles and overlying skin at each vertebral level. It aimed to provide possible anatomical basis for such wound complications.

A dissection and angiographic study was undertaken on 8 cadaveric neck and posterior torso from 6 embalmed and 2 fresh human cadavers. Harvested cadavers were warmed and hydrogen peroxide was injected into the major arteries. Lead oxide contrast mixture was injected in stepwise manner into the subclavian and posterior intercostal arteries of each specimen. Specimens were subsequently cross-sectioned at each vertebral level and bones elevated from the soft tissue. Radiographs were taken at each stage of this process and analysed.

The cervical paraspinal muscles were supplied by the deep cervical arteries, transverse cervical arteries and vertebral arteries. The thoracic paraspinal muscles were supplied by the superior intercostal arteries, transverse cervical arteries and posterior intercostal arteries. In the thoracic region, two small vessels provide the longitudinal connection between the segmental arteries and in the cervical region, deep cervical arteries provide such connection from C3 to C6. The arterial vessels supplying the paraspinal muscles on the left and right side anastomose with each other, posterior to the spinous processes in all vertebral levels. At cervical vertebral levels, source arteries travel near the surgical field and are not routinely cauterised; Haematoma is postulated to be the cause of wound complications. At thoracic levels, source arteries travel in the surgical field and tissue ischemia is a contributing factor to wound complications, especially in operations over extensive levels.

Post-operative wound complications is a multi-factorial clinical problem, the anatomical findings in this study provide possible explanations for wound dehiscence in the posterior midline approach. It is postulated that drain tubes may reduce the incidence of haematoma in the cervical level.

Background: Several studies have shown that uncomplicated hip or knee arthroplasties induce an abrupt rise in serum C-reactive protein (CRP) concentration for a few days, falling thereafter to preoperative level within a couple of weeks, if no infection is present.

Aim: To evaluate the computer-aided CRP levels analysis in a primary hospital care setting.

Material and Methods: 300 patients undergoing total knee and hip replacements were screened before and for 5 days after arthroplasty. The data were recorded in a database and mathematical algorithm to obtain integral and progressive field surface of the CRP curve.

Results: An elevated C-reactive protein level on the fifth postoperative day correlated positively with the development of acute periprosthetic infection in the first three months postoperatively.

Conclusions: The patient’s individual pattern not following one of the four normal patterns can be argued to necessitate introduction of any infection treatment (whether debridement with retention or antimicrobial therapy alone) within the first three months after the operation.

Background. Acute soft tissue defects (wound dehiscence or necrosis) after a total knee arthroplasty (TKA) may be the cause of the devasting complication of deep infection. When a medium (4–6cm) defect is present, in patellar or infra-patellar localization, a medial hemi-gastrocnemius flap is widely used to cover it, because of its low morbidity and high functional results. Normally, this coverage is not associated to a debridement, antibiotics and implant retention surgery (DAIR). When facing this situation, we should consider associating to the coverage treatment, like muscle flap, a DAIR procedure, in order to treat the possible acute infection, even when the diagnosis of infection is not clear. We could not find any studies comparing the benefice of this association in the same surgical act to isolated treatment of soft tissue defects. Our hypothesis was that when a TKA surgical wound defect is present, the risk of an acute infection is elevated and the patient would benefit from a muscle flap with DAIR procedure and polyethylene exchange. Methods. We performed a retrospective study to compare TKA infection clearance in patients with DAIR and flap in the same surgical act against those who received an isolated flap procedure for soft tissue coverage after an acute surgical wound defect. Patients were identified from a prospectively collated TKA database. Between 2005 and 2021, 19 patients met our inclusion criteria. A medial hemi-gastrocnemius flap was performed in 15 patients (78%). Healing or TKA infection clearance was defined as the presence of the original prosthesis after soft tissue coverage intervention, no need of DAIR after soft tissue coverage or no suppressive antibiotic treatment. Results. We obtained two groups. The first one, included those patients who had received the association of DAIR with polyethylene exchange and Flap (n=12). The other group included those who had received an isolated flap (n=7). We did not find differences in comorbidities and risk factors between both groups. In the combination treatment group 66,6% patients healed after treatment. In the other group, these favourable results decrease to 42,9%. Even though results were better in the combination treatment group, no significant differences were found. Conclusion. Although no significant statistical differences were found, probably due to small sample, the association of DAIR with polyethylene exchange and muscle flap is recommended in the coverage over an acute dehiscence or necrosis after TKA. More studies, with bigger sample are needed to extrapolate results in general population

Aims. Medial unicompartmental knee arthroplasty (mUKA) is an advised treatment for anteromedial knee osteoarthritis. While long-term survival after mUKA is well described, reported incidences of short-term surgical complications vary and the effect of surgical usage on complications is less established. We aimed to describe the overall occurrence and treatment of surgical complications within 90 days of mUKA, as well as occurrence in high-usage centres compared to low-usage centres. Methods. mUKAs performed in eight fast-track centres from February 2010 to June 2018 were included from the Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Database. All readmissions within 90 days of surgery underwent chart review and readmissions related to the surgical wound or the prosthesis were recorded. Centres were categorized as high-usage centres when using mUKA in ≥ 20% of annual knee arthroplasties. The occurrence of complications between high- and low-usage centres were compared using Fisher’s exact test. Results. We included 3,757 mUKAs: 2,377 mUKAs from high-usage centres and 1,380 mUKAs from low-usage centres. Surgical complications within 90 days occurred in 69 cases (1.8%), 45 (1.9%) in high-usage centres and 24 (1.7%) in low-usage centres (odds ratio (OR) 1.1 (95% confidence interval (CI) 0.65 to 1.8)). The most frequent complications were periprosthetic joint infections (PJIs) (n = 18; 0.48%), wound-related issues (n = 14; 0.37%), and periprosthetic fractures (n = 13; 0.35%). Bearing dislocations (n = 7; 0.19%) occurred primarily in procedures from high-usage centres. In high-usage centres, seven periprosthetic fractures (0.29%) occurred compared to six (0.43%) in low-usage centres (OR 0.68 (95% CI 0.20 to 2.0)). In high-usage centres, nine PJIs (0.38%) occurred compared to nine (0.65%) in low-usage centres (OR 0.58 (95% CI 0.22 to 1.6)). Conclusion. Surgical complications are rare after fast-track mUKA surgery and with no difference in overall occurrence of surgical complications between high- and low-usage centres, although the risk of some specific surgical complications may favour high-usage centres. Cite this article: Bone Jt Open 2023;4(6):457–462

Aims. Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture. Methods. This single tertiary-institutional, retrospectively matched case-control study included 72 patients who underwent prophylactic or therapeutic fixation for pathological fracture of the humerus, femur, or tibia with either a titanium (control group, n = 36) or carbon fibre (case group, n = 36) intramedullary nail between 2016 to 2020. Patients were excluded if intramedullary fixation was combined with any other surgical procedure/fixation method. Outcomes included operating time, blood loss, fluoroscopic time, and complications. Fisher’s exact test and Mann-Whitney U test were used for categorical and continuous outcomes, respectively. Results. Patients receiving carbon nails as compared to those receiving titanium nails had higher blood loss (median 150 ml (interquartile range (IQR) 100 to 250) vs 100 ml (IQR 50 to 150); p = 0.042) and longer fluoroscopic time (median 150 seconds (IQR 114 to 182) vs 94 seconds (IQR 58 to 124); p = 0.001). Implant complications occurred in seven patients (19%) in the titanium group versus one patient (3%) in the carbon fibre group (p = 0.055). There were no notable differences between groups with regard to operating time, surgical wound infection, or survival. Conclusion. This pilot study demonstrates a non-inferior surgical and short-term clinical profile supporting further consideration of carbon fibre nails for pathological fracture fixation in orthopaedic oncology patients. Given enhanced accommodation of imaging methods important for oncological surveillance and radiation therapy planning, as well as high tolerances to fatigue stress, carbon fibre implants possess important oncological advantages over titanium implants that merit further prospective investigation. Level of evidence: III, Retrospective study. Cite this article: Bone Jt Open 2022;3(8):648–655

The incidence of PJI in knee replacements is 2.8% and slightly lower with hip replacement surgery. PJI make up 15% (or even more) of knee revisions. To combat PJI, antibiotic laden bone cement has been used for many decades, but antibiotic stewardship dictates more prudent management of antimicrobials. Projected increase in infection rate, due to increased surgery and latent infection to be almost 5-fold up to 2035. Biofilm is a complex structure of bacteria and polysaccharide matrix and, is recognised as a major component in PJI and other orthopaedic infections. Biofilm is responsible for high incidence of resistance to antimicrobials and ineffective host immune response. Method. Stabilized hypochlorous acid has been reported to have a rapid kill rate on all pathogens, including MDR pathogens associated with chronic and acute wound infections. It destroys biofilm on contact, is not cytotoxic, reduces inflammation and stimulates wound healing. 0,038% of Hypochlorous acid was used as prophylaxis against infection and to treat PJI. We report on our experience with hypochlorous acid as a wound irrigation as prophylaxis against infection (more than 600 cases) and for PJI. We also report on a University study where a head to head analysis was done on the anti-biofilm efficacy between hypochlorous acid 0,038% (Trifectiv Surgical Wound Irrigation) and Product X (an industry-standard product for the prevention and treatment of biofilm infection. Hypochlorous acid offers a valuable addition to the armamentarium of wound antiseptics, with added anti-inflammatory value. An in vitro study demonstrated superior efficacy against biofilm when compared to Product X

Aim. The origin of surgical site and biomaterial-associated infection is still elusive. Microorganisms contaminating the wound may come from the air, the surgical team, or from the skin of the patient. Prior to surgery the skin of patients is disinfected, but bacteria deeper in the skin (e.g. in sweat glands or sebaceous glands), may not be reached. This study aims to assess a potential role of this intracutaneous bacterial reservoir in biomaterial-associated infection. Method. To study if cutaneous microbiota colonize the wound when released from the skin upon cutting, we isolated, quantified and identified aerobic and anaerobic bacteria from the skin of 99 patients undergoing trauma surgery, before and after skin disinfection, from the knife blades and from the wound directly after the first cut. Results. Ninety-nine percent of the patients were culture-positive before disinfection with chlorhexidine. Of these, 40% were still culture-positive after disinfection. Of these, 54% had a positive culture of the wound after the skin cut. Twenty percent of the patients with a negative culture after disinfection, nevertheless had a positive wound culture after cutting the skin. Staphylococcus epidermidis and Cutibacterium acnes were the most often cultured bacterial species. In 9%, more than 100 bacterial colonies were cultured from the wound, a dose that may cause biomaterial-associated infections. Conclusions. Bacteria residing in the skin and not eradicated by disinfection may enter the surgical wound upon cutting, resulting in contamination which may cause a biomaterial-associated infection. Use of two knifes likely reduces the risk of wound contamination

Background. Ankle fractures associated with diabetes experience more complications following standard Open-Reduction-Internal-Fixation (ORIF) than those without diabetes. Augmented fixation strategies namely extended ORIF and hind-foot-nail (HFN) may offer better results, and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes including early post-operative weight bearing and surgical complications. Methods. A national-multicentre retrospective cohort study was conducted between January to June 2019 in 56 centres (10 Major- Trauma-Centres and 46 Trauma-Units) in the United Kingdom; 1360 specifically defined complex ankle-fractures were enrolled. Demographics, fixation choice, surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with/without diabetes. Results. There were 316 patients in the diabetes cohort with mean age 63.9yrs (vs. 49.3yrs in non-diabetes cohort), and greater frailty score >4 (24% vs.14% (non-diabetes cohort) (p<0.03); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% a HFN compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p<0.02) but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications to non-diabetes, even though early-weight- bearing rates were greater than standard-ORIF. Conclusion. Ankle fractures in diabetes occur in older, frailer patients; whilst lower than expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weight-bearing without increasing complications in keeping with modern guidelines in ankle fracture management