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

Introduction and Objective. Found in bone-associated prosthesis, Cutibacterium acnes (C. acnes) is isolated in more than 50% of osteoarticular prosthesis infections, particularly those involving shoulder prostheses. Ongoing controversies exist concerning the origin of C. acnes infection. Few reports construct a reasonable hypothesis about probable contaminant displaced from the superficial skin into the surgical wound. Indeed, despite strict aseptic procedures, transecting the sebaceous glands after incision might result in C. acnes leakage into the surgical wound. More recently, the presence of commensal C. acnes in deep intra-articular tissues was reported. C. acnes was thus detected in the intracellular compartment of macrophages and stromal cells in 62.5% of the tested patients who did not undergo skin penetration. Among bone stromal cells, mesenchymal stem cells (MSCs) are predominantly found in bone marrow and periosteum. MSCs are the source of osteogenic lines of cells capable of forming bone matter. In this study, the pathogenicity of C. acnes in bone repair context was investigated. Materials and Methods. Human bone marrow derived MSCs were challenged with C. acnes clinical strains harvested from non-infected bone site (Cb). The behaviour of Cb strain was compared to C. acnes took from orthopaedic implant-associated infection (Ci). The infective capabilities of both strains was determined following gentamicin-based antibiotic protection assay. The morphology and ultrastructural analysis of infected MSCs was performed respectively through CLSM pictures of Phalloidin. ®. stained MSCs cytoskeleton and DAPI labelled Cb, and transmission and scanning electron microscopies. The virulence of intracellular Ci and Cb (Ci-MSCs and Cb-MSCs) was investigated by biofilm formation on non-living bone materials; and the immunomodulatory response of infected MSCs was investigated (PGE-2 and IDO secretion detected by ELISA). Bone cells (osteoblasts and PMA differentiated macrophages) were then challenged with Cb-MSCs and Ci-MSCs. Intracellular accumulation of ROS within infected macrophages was assessed by flow cytometry after 2 h of infection and the catalase production by Cb-MSC and Ci-MSC was evaluated. Statistical analyses were performed using Mann & Whitney test. Results. Following MSCs infection by C. acnes, the rate of viable bacteria inside MSCs was about 4% and 6% for Cb and Ci, respectively. Cb showed however a lower invasiveness in comparison to Ci (0.6-fold, p=0.01), confirming the higher pathogenicity of Ci. The ultrastructural and morphology analysis of infected MSCs confirmed the presence of bacteria free in MSCs cytoplasm, localized between F-actin fibers of MSCs, which preserved their elongated morphology. Considering the high level of secreted immunomodulatory mediators (PGE-2 and IDO), our results suggest that Cb-infected MSCs could promote a transition of macrophages from a primarily pro-inflammatory M1 to a more anti-inflammatory M2 phenotype. In comparison with Cb, Cb-MSCs increased significantly the formation of biofilm on TA6V and PEEK but reduced the biofilm formation on 316L SS. Ci-MSCs showed a significant increase in biofilm formation on PEEK vs Ci, while no difference in biofilm formation was noticed on TA6V and 316L SS. Regarding the ability of MSCs bacteria to infect osteoblasts, our results showed a higher infective capabilities of Cb-MSCs versus Cb (>2-fold, p=0.02), while no difference was noticed between Ci and Ci-MSCs. Along with an increase in catalase production by Cb-MSCs, we noticed its higher persistence to macrophage degradation. Conclusions. Taken together, our results demonstrate a shift in commensal Cb to pathogenic following infection. Indeed, Cb- MSCs acquires features that (i) increase biofilm formation on orthopedic based materials, (ii) increase the osteoblast infection and (iii) develop resistance to the macrophage degradation, through the increase of catalase production. Overall, these results showed a direct impact of C. acnes on bone marrow derived MSCs, providing new insights into the development of C. acnes during implant-associated infections

Background. Surgical wound closure is not the surgeon”s favorite part of the total knee arthroplasty (TKA) surgery however it has vital rule in the success of surgery. Knee arthoplasty wounds are known to be more prone to infection, breakdown or delayed healing compared to hip arthroplasty wounds, and this might be explained by the increased tensile force applied on the wound with knee movement. This effect is magnified by the enhanced recovery protocols which aim to obtain high early range of movement. Most of the literature concluded that there is no difference between different closure methods. Objectives. We conducted an independent study comparing the complication rate associated with using barbed suture (Quill-Ethicon), Vicryl Rapide (polyglactins910-Ethicon) and skin staples for wound closure following TKA. Study Design & Methods. Retrospective study where the study group included all the patients admitted to our unit for elective primary knee arthroplasty in 2015, we excluded patients admitted for partial knee arthroplasty, revision knee arthroplasty or arthroplasty for treatment of acute trauma due to the relatively higher complication rates. All the patients notes were reviewed to identify wound related problems such as wound dehiscence, wound infection and delayed healing (defined as delayed wound healing more than 6 weeks). Results. 327 patients were included in this study; 151 in Quill group, 99 in staples group and 77 in the last group where the wound closed with Rapide. We identified 9 (5.9%) cases of wound dehiscence in the Quill group, 3 cases of wound dehiscence in each of other two groups (3.8%) with Rapide and (3%) with staples. On the other hand superficial wound infection was higher with staples with 6 (6%) cases of wound infection compared to the other groups, wound infection occurred in 2 patients (2.5%) with Rapide and 5 patients (3.3%) in the Quill”s group. Most of the delayed wound healing happened after using Quill where it is reported in 5 patients (3.3%) and the lowest was in staples group with 1 patient (1%) and slightly higher percentage in Rapide group 2 patients (2.5%). The total figure of wound related problems was the highest in Quill”s group with 19 reported cases (12.5%), lower in staples” group with 10 cases (1.1%) and the lowest in Rapide”s group with 7 cases (9%). Conclusions. Our study showed different results to the reported literature suggesting that each closure method has its own advantages and disadvantages. Quill is quick, knotless and absorbable but on the other side it is significantly more expensive than other alternatives and it is associated with the highest complication rates. On the other hand Rapide is cheap absorbable alternative with the lowest percentage of wound problems but on the negative side it is time consuming. Finally staples method is the quickest, relatively cheap and rarely associated with wound dehiscence but it is not absorbable which might cause inconvenience to patients

We describe a case series using calcium sulphate bio composite with antibiotics (Cerament/Stimulan) in treating infected metalwork in the lower limb. Eight patients aged 22–74 (7 males, 1 female) presented with clinical evidence of infected limb metal work from previous orthopaedic surgery. Metal work removal with application of either cerement in 5 cases (10–20ml including 175mg–350mg gentamycin) or stimulan in 3 cases (10–20ml including either 1g vancomycin or clindamycin 1.2g or 100mg tigecycline) into the site was performed. Supplemental systemic antibiotic therapy (oral/intravenous) was instituted based on intraoperative tissue culture and sensitivity. Four patients had infected ankle metalwork, 2 patients infected distal tibial metalwork and 2 had infected external fixators. Metal work was removed in all cases. The mean pre operative CRP was 15.8mg/l (range 1–56mg/l). The mean postoperative CRP at 1 month was 20.5mg/l (range 2–98mg/l). The mean pre op WCC was 7.9×10. 9. (range 4.7–10.5 ×10. 9. ). Mean post op WCC at 1 month was 7.1×10. 9. (range 5.0–9.2×10. 9. ). The organisms cultured included enterobacter, staphylococcus aureus, staphylococcus epidermidis, staphylococcus cohnii, stenotrophomonas, acinetobacter, group B streptococcus, enterococcus and escherichia coli. No additional procedures were required in any case. All surgical wounds went on to heal uneventfully. Infection control and union was achieved both clinically and radiologically in all cases. Our results support the use of a calcium sulphate bio composite with antibiotic as an adjuvant for effective local infection control in cases with implant related bone sepsis. The technique is well tolerated with no systemic or local side effects. We believe that implant removal, debridement and local antibiotic delivery can minimise the need for prolonged systemic antibiotic therapy in such cases

In this study we aimed to identify which anatomical site was the most effective for methicillin resistant staphylococcus aureus (MRSA) detection within an elective orthopaedic setting. A retrospective review was performed of 13,373 elective orthopaedic patients from pre-assessment and admission screening swabs taken over a five year period (2005-2010). Swabs were taken from the nose, the axilla and either the groin or perineum. MRSA was identified in 136(1.02%) of patients. The nose was found to be positive for MRSA in 89.6% of cases identified. Therefore only 10.4% of the MRSA carriers (0.1% of all admissions) would not have been identified had a single nasal swab been taken. There was no additional benefit in swabbing the axilla. We believe that for the majority of orthopaedic elective admissions a single nasal swab should be sufficient. In hip arthroplasty patients it may be beneficial to additionally swab the groin given the close proximity of the surgical wound

Summary Statement. Innovative nanocomposite carbon coating doped with Si can significantly improve the osseintegration of orthopaedics implants. Additionally, this kind of coating increases the mechanical resistance of the implants, what is especially important on case of joints (frictional pairs). Introduction. Use of layers of carbon-doped silicon, which leads to the synthesis of layers improving mechanical and biological characteristics, let obtain good strength by volume features. Suitable introduction to the structure of amorphous silicon dioxide layer allow for the production of higher adhesion to metallic substrates and consequently the increased thickness and hardness. The increased thickness of the layer leads to a stronger diffusion barrier to harmful metal ions from the implant material and thus consequently improving the biocompatibility of the implant. Moreover, a silicon beneficial effect on stress relaxation layer formed during the synthesis. This allows for improved biocompatibility, also affects other property obtained in the case of silicon carbide layers, the bacteriastability. This further protects the surface of the implant against the risk of bacterial colonization in both the implantation and subsequent use in the body, and preferably suppressing inflammation and faster healing of surgical wounds. The thus obtained product is much better than the biological and mechanical parameters of currently offered. Patients & Methods. In order to evaluate the fabricated coatings conditions examination of the basic physicochemical and mechanical properties were conducted (AFM, Raman, XPS, nanoindentation technique). The in vitro and in vivo tests were also conducted. As a biological material osteoblast Saos-2 cells and endothelial cells line EA. 926 were used. For the evaluation of proliferation and cytotoxicity a “live/dead” test was used. For testing bactericidal activity of the C/Si coatings, an exponential growth phase of E. coli strain DH5 α was used. Test of bacterial immediate toxicity and bacterial colonization were performed. A model of rabbits and guinea pigs were used to obtained results with reference to irritation, intradermal reactivity, sensitization, local effects after implantation with the histopathological examination, cytotoxicity test. Results. XPS results have shown that the silicon content for each group of samples, both steel and titanium alloy is about 3, 4 and 5 percent. Increasing the concentration of silicon above 5% results in the weakening of the mechanical properties of the layer and lead to delamination of the sterilization process. Addition of silicon in the range of 3–5% does not negatively affect the mechanical and structural properties of the modified surface and from this point of view, all the criterion of strength. Performed studies confirmed very good mechanical properties of C/Si coatings. In vitro studies have indicated the optimal concentration of silicon in the coating, where the material is biocompatible and also has good antibacterial properties. Biocompatibility of silicon coatings was also confirmed by irritation and sensitization testing in the in vivo model. Discussion/Conclusion. Final result of the surface modification C/Si coating depends on modification of two effects, i.e. the formation of the transition layer of the substrate material and the synthesis of the outer carbon coating. Results of in vitro and in vivo tests confirmed very good biological properties of coatings which proved the fact that it is possible to improve the parameters of the implant work at the same time adding to the intrinsic the antibactericidal properties

Objectives

In this study, we compared the pain behaviour and osteoarthritis (OA) progression between anterior cruciate ligament transection (ACLT) and osteochondral injury in surgically-induced OA rat models.

The treatment of chronic osteomyelitis often includes surgical debridement and filling the resultant void with antibiotic-loaded polymethylmethacrylate cement, bone grafts or bone substitutes. Recently, the use of bioactive glass to treat bone defects in infections has been reported in a limited series of patients. However, no direct comparison between this biomaterial and antibiotic-loaded bone substitute has been performed.

In this retrospective study, we compared the safety and efficacy of surgical debridement and local application of the bioactive glass S53P4 in a series of 27 patients affected by chronic osteomyelitis of the long bones (Group A) with two other series, treated respectively with an antibiotic-loaded hydroxyapatite and calcium sulphate compound (Group B; n = 27) or a mixture of tricalcium phosphate and an antibiotic-loaded demineralised bone matrix (Group C; n = 22). Systemic antibiotics were also used in all groups.

After comparable periods of follow-up, the control of infection was similar in the three groups. In particular, 25 out of 27 (92.6%) patients of Group A, 24 out of 27 (88.9%) in Group B and 19 out of 22 (86.3%) in Group C showed no infection recurrence at means of 21.8 (12 to 36), 22.1 (12 to 36) and 21.5 (12 to 36) months follow-up, respectively, while Group A showed a reduced wound complication rate.

Our results show that patients treated with a bioactive glass without local antibiotics achieved similar eradication of infection and less drainage than those treated with two different antibiotic-loaded calcium-based bone substitutes.

Cite this article: Bone Joint J 2014; 96-B:845–50.

Objectives

To review the current best surgical practice and detail a multi-disciplinary approach that could further reduce joint replacement infection.

Objectives

The period of post-operative treatment before surgical wounds are completely closed remains a key window, during which one can apply new technologies that can minimise complications. One such technology is the use of negative pressure wound therapy to manage and accelerate healing of the closed incisional wound (incisional NPWT).

We used a goat model of a contaminated musculoskeletal defect to determine the effectiveness of rapidly-resorbing calcium-sulphate pellets containing amikacin to reduce the local bacterial count. Our findings showed that this treatment eradicated the bacteria quickly, performed as well as standard polymethylmethacrylate mixed with an antibiotic and had many advantages over the latter. The pellets were prepared before surgery and absorbed completely. They released all of the antibiotic and did not require a subsequent operation for their removal. Our study indicated that locally administered antibiotics reduced bacteria within the wound rapidly. This method of treatment may have an important role in decreasing the rate of infection in contaminated wounds.

Platelet-rich plasma is a new inductive therapy which is being increasingly used for the treatment of the complications of bone healing, such as infection and nonunion. The activator for platelet-rich plasma is a mixture of thrombin and calcium chloride which produces a platelet-rich gel.

We analysed the antibacterial effect of platelet-rich gel in vitro by using the platelet-rich plasma samples of 20 volunteers. In vitro laboratory susceptibility to platelet-rich gel was determined by the Kirby-Bauer disc-diffusion method. Baseline antimicrobial activity was assessed by measuring the zones of inhibition on agar plates coated with selected bacterial strains.

Zones of inhibition produced by platelet-rich gel ranged between 6 mm and 24 mm (mean 9.83 mm) in diameter. Platelet-rich gel inhibited the growth of Staphylococcus aureus and was also active against Escherichia coli. There was no activity against Klebsiella pneumoniae, Enterococcus faecalis, and Pseudomonas aeruginosa. Moreover, platelet-rich gel seemed to induce the in vitro growth of Ps. aeruginosa, suggesting that it may cause an exacerbation of infections with this organism. We believe that a combination of the inductive and antimicrobial properties of platelet-rich gel can improve the treatment of infected delayed healing and nonunion.

We studied 51 patients with osteo-articular tuberculosis who were divided into two groups. Group I comprised 31 newly-diagnosed patients who were given first-line antituberculous treatment consisting of isoniazid, rifampicin, ethambutol and pyrazinamide. Group II (non-responders) consisted of 20 patients with a history of clinical non-responsiveness to supervised uninterrupted antituberculous treatment for a minimum of three months or a recurrence of a previous lesion which on clinical observation had healed. No patient in either group was HIV-positive. Group II were treated with an immunomodulation regime of intradermal BCG, oral levamisole and intramuscular diphtheria and tetanus vaccines as an adjunct for eight weeks in addition to antituberculous treatment. We gave antituberculous treatment for a total of 12 to 18 months in both groups and they were followed up for a mean of 30.2 months (24 to 49). A series of 20 healthy blood donors served as a control group.

Twenty-nine (93.6%) of the 31 patients in group I and 14 of the 20 (70%) in group II had a clinicoradiological healing response to treatment by five months.

The CD4 cell count in both groups was depressed at the time of enrolment, with a greater degree of depression in the group-II patients (686 cells/mm³ (sd 261) and 545 cells/mm³ (sd 137), respectively; p < 0.05). After treatment for three months both groups showed significant elevation of the CD4 cell count, reaching a level comparable with the control group. However, the mean CD4 cell count of group II (945 cells/mm³ (sd 343)) still remained lower than that of group I (1071 cells/mm³ (sd 290)), but the difference was not significant. Our study has shown encouraging results after immunomodulation and antituberculous treatment in non-responsive patients. The pattern of change in the CD4 cell count in response to treatment may be a reliable clinical indicator.

We used a canine intercalary bone defect model to determine the effects of recombinant human osteogenic protein 1 (rhOP-1) on allograft incorporation. The allograft was treated with an implant made up of rhOP-1 and type I collagen or with type I collagen alone.

Radiographic analysis showed an increased volume of periosteal callus in both test groups compared with the control group at weeks 4, 6, 8 and 10. Mechanical testing after 12 weeks revealed increased maximal torque and stiffness in the rhOP-1 treated groups compared with the control group.

These results indicate a benefit from the use of an rhOP-1 implant in the healing of bone allografts. The effect was independent of the position of the implant. There may be a beneficial clinical application for this treatment.