Aim. Decubitus ulcers are found in approximately 4.7% of hospitalized patients, with a higher prevalence (up to 30%) among those with spinal cord injuries. These ulcers are often associated with hip septic arthritis and/or osteomyelitis involving the femur. Girdlestone resection arthroplasty is a surgical technique used to remove affected proximal femur and acetabular tissues, resulting in a substantial defect. The vastus lateralis flap has been employed as an effective option for managing this dead space. The aim of this study was to evaluate the long-term outcomes of this procedure in a consecutive series of patients. Method. A retrospective single-center study was conducted from October 2012 to December 2022, involving 7 patients with spinal cord injuries affected by chronic severe septic hip arthritis and/or femoral head septic necrosis as a consequence of decubitus ulcers over trochanter area. All patients underwent treatment using a multidisciplinary approach by the same surgical team (orthopedic and plastic surgeons) along with infectious disease specialists. The treatment consisted of a one-stage procedure combining Girdlestone resection arthroplasty with unilateral vastus lateralis flap reconstruction, alongside targeted antibiotic therapy. Complications and postoperative outcomes were assessed and recorded. The mean follow-up period was 8 years (range 2-12). Results. Of the 7 patients, 5 were male and 2 were female, with a mean age of 50.3 years at the time of surgery. Minor wound dehiscence occurred in 28.6% of the flap sites, and 2 patients required additional revisional procedures—one for hematoma and the other for bleeding. There were no instances of flap failure, and complete wound healing was achieved in an average of 32 days (range 20-41), with the ability to load over the hip area. No cases of infection recurrence or relapse were observed. Conclusions. An aggressive surgical approach is strongly recommended for managing chronic hip septic arthritis or proximal femur osteomyelitis in patients with spinal cord injuries. A single-stage procedure combining Girdlestone resection arthroplasty with immediate vastus lateralis muscle flap reconstruction proves to be an effective strategy for dead space management and localized antibiotic delivery through the vastus muscle, giving reliable soft tissue coverage around the proximal femur to avoid the recurrence of pressure ulcers. The implementation of a standardized multidisciplinary protocol contributes significantly to the success of reconstruction efforts

Introduction. Plantar fasciopathy is a common cause of heel pain, and is usually treated in primary practice with conservative measures. Intractable cases can prove very difficult to treat. Currently plantar fasciopathy is not routinely imaged and treatment is empirical. At the Royal Surrey County Hospital patients with intractable plantar fasciopathy are managed in a unique ‘one-stop’ Heel Pain clinic. Here they undergo clinical assessment, ultrasound scanning and targeted therapy. Methods. Patients referred to the clinic since 2009, with symptoms lasting longer than 6 months and failed conservative management, were prospectively followed. Plantar fasciopathy was confirmed on ultrasound scanning. The ultrasound scans were used to classify the disease characteristics of the plantar fascia. Results. 125 feet (120 patients) were found to have plantar fascia disease. Ultrasound scans demonstrated 64% with typical insertional pathology only. The remaining 36% had atypical distal fascia involvement, with either pure distal disease or a combination of insertional and distal disease. Patients with atypical distal disease were found to have either distal thickening or discrete fibromata. Conclusion. The high proportion of atypical (non-insertional) disease in this cohort shows that ultrasound scanning is valuable in determining location and characterising the pathology in the plantar fascia. Atypical pathology would otherwise not be detected. We propose a new classification for plantar fasciopathy; insertional fasciopathy or non-insertional fasciopathy. This is in keeping with current classification of achilles tendinopathy. The main benefit of this Guildford Classification is in determining optimum treatments for recalcitrant plantar fasciopathies. Empirical treatment is not adequate for recalcitrant cases

Beadmill processing combined with automated blood culture bottle methods (BACTEC™) has a greater sensitivity and specificity, and a shorter time to positivity compared with primary plates (PP) for prosthetic joint infection (PJI) diagnosis but the clinical impact of Bactec on antimicrobial therapy has not yet been evaluated. We compared time-to-positivity of Columbia agar with horse blood plates (BA) and chocolatized horse blood plates (CHOC) versus anaerobic (ANA) and aerobic blood culture bottles (02) in patients with PJI. We compared the contributions of the two methods to the commencement of effective and targeted antimicrobial therapy. Retrospective observational study from June 2013 to March 2014. Inclusion criteria were confirmed PJI (IDSA criteria) with at least 2 perioperative samples. After beadmill processing BA and CHOC plates were incubated for 2 days and discarded if negative, BactecTM bottles were incubated for 14 days and sub-cultured if positive. MALDI-TOF (Microflex, Brucker) was used for identification and all isolates had sensitivities performed (Phoenix, BD). Standard empirical antibiotic treatment was teicoplanin, piperacillin/tazobactam and amikacin. We defined time to switch as difference between date of sample collection and date of commencing targeted or effective therapy; prior antibiotic therapy was defined as the use of antibiotics within 14 days before samples collection. Fifty cases were identified during the study period. 330 microbiological isolates were included: 24 (7.3%) were considered contaminants; 153 isolates (50.0%) were detected both from BactecTM and PP; 152 (49.7%) from BactecTM only; 1 isolate (0.3%) from PP only. 17 (34%) diagnoses of PJI was made exclusively by BactecTM. The majority of isolates on BA and CHOC plates grew in the first 24 hours (81.2% and 77.5% respectively). 293/305 isolates from BactecTM (96.1%) grew in the first 2 days. Antibiograms were available after 2.5 days from PP versus 4 days from BACTEC (p<0.0001). When we compared time to switch from empiric to targeted therapy, no difference was seen between patients with positive BACTEC cultures only (median 4 days, range 2–15) versus patients with positive PP cultures, (median 5 days, range 2–9) (p=0.984). Where organisms were resistant to empirical therapy, PP results did not contribute to switching to effective therapy. Prior antibiotic therapy had no impact on time-to-positivity for both methods (R=−0.005, p=0.936). Compared to BACTEC cultures for the diagnosis of PJIs, primary plate cultures did not provide additional diagnostic information and did not significantly reduce the time to effective or targeted antimicrobial therapy

Chondrosarcoma responds poorly to adjuvant therapy and therefore, new targeted therapy is required. Animal models have been utilised to test therapeutic candidates, however clinically relevant, orthotopic models are lacking. The aim of this study was to develop such a model. In vitro: two human chondrosarcoma cell lines, JJ012 and FS090, were compared with respect to proliferation, colony formation, invasion, MMP-2 and MMP-9 secretion, osteoclastogenesis, endothelial tube stimulation, and expression of the angiogenic factor VEGF, and the anti-angiogenic factor RECK on western blotting. In vivo: 20,000 cells (JJ012 or FS090) were injected either into the intramedullary canal of the mouse tibia (n=5 for each cell line), or into the tibial periosteum (n=5 for each cell line). Animals were measured, and x-rayed weekly. Once euthanised, tibias and lungs were preserved, embedded and sectioned to determine the presence of tumour and lung metastases. In vitro: compared with FS090, JJ012 demonstrated significantly higher proliferative capacity at both day two and day four (p=0.017, and p=0.01). JJ012 had a significantly greater ability to invade Matrigel with an average number of 812.5 invading cells, versus 140.8 FS090 cells (p=0.0005). JJ012 readily formed colonies in collagen I, while FS090 formed none. JJ012 conditioned medium stimulated endothelial tube formation and osteoclastogenesis with a greater potency than FS090 conditioned medium. In vivo: tumours formed in the intratibial and periosteal groups injected with JJ012, whilst no mice injected with FS090 cells developed discernable tumours on physical inspection, caliper measurement or histological section. Periosteal tumours grew to three times the non-injected limb size by seven weeks, whereas intratibial injected limbs required 10 weeks to achieve the same extent of tumour growth. All JJ012 periosteal tumours resulted in lung micrometastases, while only 2/4 JJ012 intratibial tumours demonstrated metastases. Lung metastases stained positive with Von Kossa and alizarin red stains, indicating a tendency for calcification, which is similar to metastases in the human disease. Sectioned tumour tissue demonstrated features of grade II-III chondrosarcoma. Similarities with the human disease were also noted on the X-ray, including endosteal scalloping, and cortical thickening. Both intratibial and periosteal JJ012 models replicate the site, morphology, and many behavioural characteristics of human chondrosarcoma. Local tumour invasion of bone and spontaneous lung metastasis offer valuable assessment tools to test the potential of novel agents for future chondrosarcoma therapy

Non-tuberculous mycobacteria (NTM)—previously considered as saprophytic organisms—are now increasingly recognized as human pathogens [1, 2]. Although humans are routinely exposed to NTM, clinical infection rates are low; further, these infections typically occur in immunocompromised patients. However, an increasing incidence of NTM infections in immunocompetent hosts—caused by direct inoculation, such as contamination from surgical procedures or penetrating trauma—has been noted [1]. Clinically and histopathologically, musculoskeletal infections caused by NTM resemble those caused by Mycobacteria tuberculosis; however, they are largely resistant to routine anti-tuberculosis agents [3,4]. Therefore, NTM infections can either be missed or even regarded as drug resistant tuberculosis, causing a significant delay in diagnosis. Here, we present the features and outcomes of 6 immunocompetent patients with musculoskeletal infections caused by NTM. We retrospectively analyzed the outcomes of musculoskeletal infections caused by NTM in 6 healthy, immunocompetent hosts admitted between 2004 and 2015. The etiology was traced, and available culture reports were reviewed. NTM inoculation was traced to open fractures in 2 patients (1, patella; 1, humerus), intra-articular injection in 2 patients (1, hip; 1, shoulder), local steroid injection to the calcaneum in 1 patient, and an arthroscopic procedure in the knee joint in 1 patient. Histopathological analyses revealed chronic granulomatous inflammation, with positive NTM cultures. Following radical debridement and targeted antibiotic therapy for NTM, all 6 patients showed complete resolution over a follow-up period of 8 months to 10 years, with no recurrence. NTM are an uncommon pathogen in immunocompetent patients. In patients with chronic granulomatous infection not responding to standard anti-tuberculous treatment and with a history suggestive of inoculation—namely open fractures, surgical intervention, or injection—the possibility of NTM infection should be considered. Appropriate antibiotic therapy based on drug susceptibility reports gives good outcomes. While the hallmark of M. tuberculosis infections is chronic granulomatous inflammation, not every case of mycobacterial granulomatous inflammation is due to M. tuberculosis

The relationship between pain catastrophising and emotional disorders including anxiety and depression in patients with osteoarthritis (OA) undergoing total joint replacement (TJR) is an emerging area of study. The purpose of this study was to examine the association between pain catastrophising, anxiety, depression and preoperative patient characteristics. A prospective cohort study of preoperative TJR patients at one centre over 12-months was conducted. We examined association between catastrophising, anxiety, depression and preoperative patient characteristics including demographics, pain and function. Pain catastrophising was assessed using the Pain Catastrophising Scale (PCS), and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS-A, HADS-D). Patient perceived level of hip/knee pain was measured using a visual analogue (VAS) pain scale. Patient perception of function was measured using the Oxford Score. Preoperative radiographic grading of OA was determined using the Kellgren and Lawrence (K-L) scale. Logistic regression was used to assess pattern of relationship between preoperative characteristics and PCS or HADS. Adjusted odds ratio (OR) and 95% confidence interval (CI) were reported. A secondary quantile regression analysis examined whether a model not restricted to pre-defined PCS and HADS categories would yield comparable results to the logistic regression model described in the primary analysis. P-values less than 0.05 were considered statistically significant. The sample included 463 TJR patients (178 hips, 285 knees). VAS pain (OR 1.23,95%CI 1.04–1.45) and Oxford score (OR 1.13,95%CI 1.07–1.20) were identified as significant predictors for PCS. The same two variables were the strong predictors for all sub-domains of PCS excluding rumination. Oxford Score was the only significant predictor for abnormal HADS-A (OR 1.10,95%CI 1.04–1.17) while VAS pain (OR 1.27,95%CI 1.02–1.52) and Oxford (OR 1.09,95%CI 1.01–1.17) were significant predictors for abnormal HADS-D. Similar pattern of association for PCS and HADS was observed in the quantile regression model, where larger VAS pain and Oxford scores significantly increased median PCS across all domains. Female gender, younger age or having a higher ASA grade were associated with higher median HADS-A, but unlike in the logistic regression, this association was statistically significant. Pain catastrophising and emotional disorders generally result in poor functional outcomes in TJR patients. The most important predictor of catastrophising, anxiety/depression is pain and subjective function. At risk patients include those with high preoperative pain with generally good preoperative function, as well as younger females with significant comorbidities. Such patients should be identified, and targeted psychological therapy implemented preoperatively to optimise coping strategies and adaptive behaviour to mitigate inferior TJR outcomes including pain and patient dissatisfaction

The management of chronic osteomyelitis is fraught with difficulties; a multi-disciplinary team approach is recommended for optimum outcome. Thorough debridement, dead space management and organism targeted antibiotic therapy the gives best clinical results. Calcium sulphate beads impregnated with antibiotic is an absorbable option for prolonged local antibiotic elution and dead space management. This study aims to analyse the early results of single stage management of osteomyelitis with antibiotic impregnated calcium sulphate beads. Following surgical debridement, calcium sulphate impregnated typically with tobramycin and/or vancomycin is inserted to obliterate the dead space. Intravenous antibiotics – typically teicoplanin and piperacillin-tazobactam – are administered until culture results permit rationalisation to narrow spectrum agents. Patients are followed up in Infectious Diseases and Orthopaedic clinics for a period of 12 months and discharged if quiescence is achieved. We conducted a retrospective analysis of our prospective database to identify patients treated with our single stage protocol for chronic osteomyelitis. We excluded patients that had (1) less than 6 months of follow up, (2) incomplete metal-ware removal, (3) patients lost to follow up. Fourteen patients (9 men, 5 women) with mean age of 41 (16–73) years and mean follow up of 9 (6–12) months were included in study. Eleven patients had previous surgeries involving internal fixation; the rest were primary osteomyelitis. Seven patients had washouts and removal of metal-ware procedures for osteomyelitis prior to referral to the bone infection service. Clinical, radiographic, and laboratory (microbiological, biochemical and haematological) methods were used to monitor response to treatment. Cierney-Mader classification determined that 8 patients were classed as type A (normal hosts); 4 as BS (systemically compromised); 2 as BLS (locally and systemically compromised). Anatomic analysis suggested 7 were Type 1 (medullary osteomyelitis); the remaining 7 were type 3 (localised disease). Five patients were staged IA; three each staged IIIA and IIIBS; and one each staged IBs, IBLS, IIIBLS. Staphylococcus Aureus was the commonest causative organism. Follow up radiograph monitoring indicated absorption of the beads by 3 months. There has been no evidence of recurrence based on clinical, radiographic and blood based parameters in all patients. Short-term results of single stage osteomyelitis treatment with calcium sulphate beads impregnated with antibiotics are promising

Background and Purpose. Serum lactate has been shown to be an indicator of adverse clinical outcomes in patients admitted secondary to general trauma or sepsis. We retrospectively investigated whether admission serum venous lactate can predict in-hospital mortality in patients with hip fractures. Method and Results. Over a 38-month period the admission venous lactate of 807 patients with hip fractures was collated. Mean age was 82 years. The overall in-hospital mortality for this cohort was 9.4%. Mortality was not influenced by the fracture pattern or the type of surgery - be it internal fixation or arthroplasty (p = 0.7). A critical threshold of 3 mmol/L with respect to the influence of venous lactate level on mortality was identified. Mortality rate in those with a lactate level of less than 3 mmol/L was 8.6% and 14.2% for those whose level was 3 mmol/L or greater. A 1 mmol/L increase in venous lactate was associated with a 1.2 (1.02–1.41) increased risk of in-hospital mortality. Patients with a venous lactate of 3 mmol/L or higher had twice the odds of death in hospital compared to matched individuals. There was no statistically significant difference in ASA distribution between those with a lactate of less than or greater than 3 mmol/L. Conclusions. Patients with an elevated venous lactate following hip trauma should be identified as being at increased risk of death and may benefit from targeted medical therapy

Introduction. Infection following traumatic injury of the tibia is challenging, with surgical debridement and prolonged systemic antibiotic therapy well established. Local delivery via cement beads has shown improved outcome, but these often require further surgery to remove. Osteoset-T is a bone-graft substitute composed of calcium sulphate and 4%-Tobramycin, available in pellets that are packed easily into bone defects. Concerns remain regarding the sterile effluent produced as it resorbs, along with the risk of acute kidney injury following systemic absorption. Purpose. We present outcomes of 22 patients treated with Osteoset-T. Methods. Medical notes were reviewed of every case of osteomyelitis of the tibia over a 30-month period, in which Osteoset-T had been used. Excision of infected soft tissue and tibial debridement was performed. Metalwork whenever present removed, before Osteoset-T pellets were packed into any cortical defects or the intra-medullary canal. Further stabilisation (n=9) and soft tissue reconstruction (n=7) was undertaken as required. Intravenous vancomycin and meropenem was administered after sampling. Meropenem discontinued after 3 days if no gram negatives cultured, and vancomycin continued for 1 week. Thereafter targeted antibiotic therapy given for 6 weeks, or ciprofloxacin and rifampicin orally if no growth. Results. Average follow-up was 16 months, with wound complications encountered in 50%. A wound discharge in the early post-operative period was noted in 8 patients (36%) independent of site of Osteoset-T placement, with 6 demonstrating wound healing complications. Whereas only 5 of 14 patients without wound leak developed wound complications, but the difference did not reach significance (p=0.18, Fisher exact test). Union rate and infection eradication was 100%, with only one patient developing a transient acute kidney injury. Conclusion. Despite a high incidence of wound discharge that may promote healing complications, Osteoset-T is an effective adjunct in treatment of chronic tibial osteomyelitis following trauma, with nephrotoxicity concerns not warranted

Aims

To describe the incidence of adverse clinical outcomes related to COVID-19 infection following corticosteroid injections (CSI) during the COVID-19 pandemic. To describe the incidence of positive SARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) testing, positive SARS-COV2 IgG antibody testing or positive imaging findings following CSI at our institution during the COVID-19 pandemic.