The number of operatively treated clavicle fractures has increased over the past decades. Consequently, this has led to an increase in secondary procedures required to treat complications such as fracture-related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and propose a standardized protocol for the surgical management of this complication. All patients with a clavicle fracture who underwent open reduction and internal fixation (ORIF) between 1 January 2015 and 1 March 2022 were retrospectively evaluated. This study included patients with an FRI who were diagnosed and treated according to the recommendations of a multidisciplinary team at the University Hospitals Leuven, Belgium.Aim
Method
To review the primary bone tumours of the spine treated at our unit. Retrospective review of folders and x-rays of all the patients with primary bone tumours of the spine treated at our unit between 2005 and 2012. All haematological tumours were excluded.Purpose of the study
Description of methods
Soft tissue sarcomas (STS) arising in the adductor compartment of the thigh are frequently large before clinical detection, posing particular challenges with surgical resection and associated with a high risk of wound complications. This study compares oncological and functional outcomes and complications following treatment of adductor compartment soft tissue sarcomas from three international centres with different treatment philosophies. 184 patients with new primary, non-metastatic, deep STS in the adductor compartment diagnosed between 1990 and 2001 were identified from the centres' local databases. The Toronto Extremity Salvage Score (TESS) was used to assess function in patients. There were 94 male and 90 female patients, with ages ranging from 13 to 88 years (median age 57 years). The period of follow-up ranged from 1 to 162 months. The overall survival was 65% at 5 years and related to grade and size of the tumour. There was no difference in overall survival or systemic relapse between the three centres. There was however a significant difference in local control (28% LR in centre 1 compared to 10% in centre 2 and 5% in centre 3, which appeared to be principally related to the use of radiotherapy and surgical margins.) 66 patients (36%) from the three centres developed wound complications post-operatively and it was shown to be associated with high grade and large tumours (>10cm). Functional scores averaged 78% but were significantly worse for patients with wound complications or high-grade tumours; however, they were not affected by timing of radiotherapy or use of prophylactic free muscle flaps. This large series of adductor compartment STS has shown that survival factors do not vary across international boundaries but that treatment factors affect complications, local recurrence and function. Centralisation of adjuvant treatment like radiotherapy may have an important role in improving local control.Conclusion
Aim. To describe the risk factors, microbiology and
The optimum indications for debridement, antibiotics and implant retention (DAIR) are unclear. Previous studies have demonstrated higher success rate of DAIR within one year of the primary arthroplasty. This study aimed to compare the success rate of DAIR vs revision in “early” and “late” infections to provide guidance for clinical decision making. The Prosthetic Joint Infection in Australia and New Zealand Observational (PIANO) cohort prospectively recorded PJIs between July 2014 and December 2017 in 27 hospitals. This study included PIANO patients with first time PJIs occurring after primary TKA. Treatment success was defined as the patient being alive, free from further revision and without clinical or microbiological evidence of reinfection at two years follow-up. “Early” and “late” infections were analyzed separately. Univariate analysis compared demographic and disease specific factors between the DAIR and Revision groups. Multivariate binary logistic regression identified whether treatment strategy and other risk factors were associated with treatment success in “early” and “late” infections. In 117 “early” (<1 year) infections, treatment success rate was 56% in the DAIR group and 54% in the revision group (p=0.878). No independent risk factors were associated with
Aim. Acute hematogenous periprosthetic joint infection (AHI) is a diagnosis on the rise. The management is challenging and the optimum treatment is not clearly defined. The purpose of this study was to evaluate the characteristics of AHI, and to study risk factors affecting
There is no consensus regarding the optimum frequency of ultrasound for monitoring the response to Pavlik harness (PH) treatment in developmental dysplasia of hip (DDH). The purpose of our study was to determine if a limited-frequency hip ultrasound (USS) assessment in children undergoing PH treatment for DDH had an adverse effect on
Aim. Smoking is known to impair wound healing and to increase the risk of peri-operative adverse events and is associated with orthopaedic infection and fracture non-union. Understanding the magnitude of the causal effect on orthopaedic infection recurrence may improve pre-operative patient counselling. Methods. Four prospectively-collected datasets including 1173 participants treated in European centres between 2003 and 2021, followed up to 12 months after surgery for clinically diagnosed orthopaedic infections, were included in logistic regression modelling with Inverse Probability of Treatment Weighting for current smoking status [1–3]. Host factors including age, gender and ASA score were included as potential confounding variables, interacting through surgical treatment as a collider variable in a pre-specified structural causal model informed by clinical experience. The definition of infection recurrence was identical and ascertained separately from baseline factors in three contributing cohorts. A subset of 669 participants with positive histology, microbiology or a sinus at the time of surgery, were analysed separately. Results. Participants were 64% male, with a median age of 60 years (range 18–95); 16% of participants experienced treatment failure by 12 months. 1171 of 1173 participants had current smoking status recorded. As expected for the European population, current smoking was less frequent in older participants (Table 1). There was no baseline association between Charlson score or ASA score and smoking status (p=0.9, p=1, Chi squared test). The estimated adjusted odds ratio for treatment failure at 12 months, resulting from current smoking at the time of surgery, was 1.37 for all participants (95% CI 0.75 to 2.50) and 1.53 for participants with recorded confirmatory criteria (95% CI 1.14 to 6.37). Conclusions. Smoking contributes to infection recurrence, particularly in people with unequivocal evidence of osteomyelitis or PJI. People awaiting surgery for orthopaedic infection should be supported to cease smoking, not only to reduce anaesthetic risk, but to improve
Aim. This study investigated if co-administration of rifampicin with moxifloxacin led to a decrease in moxifloxacin concentrations in relevant tissues in a porcine model of implant-associated osteomyelitis caused S. aureus. Pharmacokinetics were measured using microdialysis and treatment effect was measured by quantifying bacterial load from implant and periprosthetic bone following a 1-stage revision and antibiotics. Method. 15 female pigs received a stainless-steel implant in the right proximal tibia and were randomized into two groups. Infection was introduced by inoculating the implant with Staphylococcus aureus as previously described. 1. On day 7 post surgery, all pigs were revised with implant removal, debridement of implant cavity and insertion of a sterile implant. 7 days of treatment was then initiated with either moxifloxacin 400 mg iv q.d. (M) or moxifloxacin and rifampicin 450 mg iv b.i.d. (RM). At day 14, animals were sedated and microdialysis was applied for continuous sampling of moxifloxacin concentrations during 8 h in five compartments: the implant cavity, cancellous bone in both the infected and non-infected proximal tibia, and adjacent subcutaneous tissue on both the infected and non-infected side using a previously described setup. 2. Venous blood samples were collected. Implant and adjacent bone were removed for analysis. Results. Comparable cure rates (sterilization of both implant and bone) were observed with 5/8 pigs in the RM group compared to 3/7 in the M group, p= 0.62 (Fisher's exact test). Due to the small number of samples with growth, median log CFU/ml was 0 for implant and bones in both groups. AUC. 0-last. was significantly smaller in plasma for the RM group, 407; 315 – 499 min µg/mL vs 625; 536 – 724 min µg/mL (mean;95% CI), p= 0.002 (Student's t-test). For the implant cavity, there was a trend toward a lower AUC. 0-last. 425; 327 – 524 min µg/ml vs 297; 205 – 389 min µg/ml in the RM group compared to M, yet this difference was not statistically different, p = 0.06. For the other compartments for other parameters (C. max. and T. max. ) across all compartments, there was no difference. Conclusions. While the AUC. 0-last. was lower in plasma for animals treated with RM, both the concentrations at the site of infection and
Introduction. Numerous fixation modalities can be used for various indications, including deformity correction, trauma, infection, and non-union. The Modular Rail System (MRS) is a well-tolerated apparatus that is a viable option for patients who do not want a circular frame or for whom internal fixation is not appropriate due to poor soft tissues/co-morbidities. This case series evaluates the outcomes of the use of the MRS in our centre. Materials and Methods. Cases were identified from a prospectively gathered database. Data were collected including indication for treatment, frame duration, complications and
Aim. Fungal orthopaedic infections most commonly affect people with complex surgical histories and existing comorbidities. Recurrence and re-infection rates are high, even with optimal surgical and systemic antifungal treatment. AmBisome liposomal amphotericin B has been suggested for local antifungal therapy, as an adjunctive treatment for fungal osteoarticular infections. Few case series have examined its clinical use when combined with polymethylmethacrylate cement PMMA), or with absorbable local antibiotic carriers. We aimed to evaluate the clinical use of local antifungal therapy with AmBisome liposomal amphotericin B (ABlaB), including tolerated doses, serious adverse events, and
Introduction. Orthopaedic rehabilitation of adolescences and young adults with high dislocation of the femur is rather challenging. The role of palliative salvage procedures is controversial enough in the cohort of patients. Materials and Methods.
Gunshot-induced fractures of the proximal femur typically present with severe comminution and bone loss. These fractures may also be associated with local damage to soft tissue, neurovascular structures and injuries to abdominal organs. The aim was to evaluate the outcomes of civilian gunshot injuries to the proximal femur at a major trauma center in South Africa. A retrospective review of all patients who sustained gunshot-induced proximal femur fractures between January 2014 and December 2017 was performed. Patients with gunshot injuries involving the hip joint, neck of femur or pertrochanteric fractures were included. Patient demographics, clinical-
Aim. Rifampicin as a biofilm-active antibiotic drug has a significant role in the treatment of periprosthetic joint infection (PJI). However, rifampicin resistance is an increasing threat to PJI treatment. This study aimed to evaluate the prevalence of rifampicin resistant staphylococci over time and its association with infection-free survival after PJI in a single centre in Sweden. Methods. We included 238 PJIs in 238 patients who had undergone PJI revision surgery from 2001 to 2020 on whom the causative bacteria were staphylococci, and the agent was tested for rifampicin resistance. Data regarding agents, rifampicin resistance,
Aim. To compare outcomes of PJI in relation to treatment method versus classification using the JS-BACH system. Method. Patients having surgery for EBJIS Criteria Confirmed PJI between 2010–2015 were included. Index surgical procedures were 1-stage or 2-stage revision or debridement and implant retention (DAIR). Patients completed the EuroQol EQ-5D-3L questionnaire and were followed clinically to a median of 4.7 years (IQR 2.7–6.7 years). Patients were stratified using the JS-BACH classification1 into either ‘Uncomplicated’, ‘Complex’ or having ‘Limited treatment options’, by two separate classifiers, blinded to clinical outcome. Results. 216 patients met the inclusion criteria. There were 51 patients classified as Uncomplicated (23.6%), 127 (58.8%) as Complex and 38 (17.6%) having Limited treatment options. Patients underwent either DAIR (n=97), 1-stage (n=35) or 2-stage (n=84) revision. Patients classified as Uncomplicated PJI had the lowest risk of recurrence or treatment failure, regardless of index procedure performed. Complex patients were significantly more likely than Uncomplicated patients to have recurrence following 2-stage revision (Odds Ratio 1.85; p=0.040) or DAIR (OR 1.83; p=0.037), but not 1-stage revision (OR 0.518; p=0.675). Limited treatment option patients had the highest recurrence risk regardless of index procedure (1-stage: OR 2.5 p=0.036; 2-stage: OR 3.3 p=0.004; DAIR: OR 3.40 p=0.006). At one year after surgery, Uncomplicated patients had the highest EQ-index scores (a marker of Quality of Life), with all treatments (EQ-5D-3L mean index scores; Uncomp 0.773, Complex 0.512, Limited Options 0.310: p<0.01). Differences in patient-reported outcomes were greater between the JS-BACH classification groups than between any methods of treatment. Conclusions. The JS-BACH classification effectively predicted outcome after three common PJI
Aim. Adequate debridement of necrotic bone is of paramount importance for eradication of infection in chronic osteomyelitis. Currently, no tools are available to detect the exact amount of necrotic bone in order to optimize surgical resection. The aim of the present study was to evaluate the feasibility of an intraoperative illumination method (VELscope. ®. ) and the correlation between intraoperative and pathohistological findings in surgically treated chronic fracture related infection patients. Method. Ten consecutive patients with chronic fracture related infections of the lower extremity were included into this prospectively performed case series. All patients had to be treated surgically for fracture related infections requiring bony debridement. An intraoperative illumination method (VELscope®) was used to intraoperatively differentiate between viable and necrotic bone. Tissue samples from the identified viable and necrotic bone areas were histopathologically examined and compared to intraoperative findings. Results. In all included patients, the intraoperative illumination was deemed helpful to differentiate between necrotic and viable bone tissues during bony debridement. The histopathological examination of the samples showed good correlation of the intraoperative illumination findings with histopathological signs of necrosis for areas deemed dead and histopathological signs of intact bone for areas deemed vital during illumination. Conclusions. The fluorescence-assisted, intraoperative detection of necrotic and viable bone using the VELscope. ®. is an easy-to-use procedure that can help surgeons to optimize intraoperative bone resection in chronic fracture related infections by unmasking viable from necrotic bone tissue. This may help to improve resection techniques and eventually
Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this. Included RCTs were ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation), a two-arm study of surgery versus non-surgical treatment for proximal humerus fractures, and UK FROST (United Kingdom Frozen Shoulder Trial), a three-arm study of two surgical and one non-surgical treatment for frozen shoulder. To determine whether early treatment effects were present, the primary outcome of Oxford Shoulder Score (OSS) was compared on forest plots for: the chief investigator’s (CI) site to the remaining sites, the first five sites opened to the other sites, and patients grouped in quintiles by randomization date. Potential for bias was assessed by comparing mean age and proportion of patients with indicators of poor outcome between included and excluded/non-consenting participants.Aims
Methods
The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit. We analyzed the retrospective record review from 2014 to 2020 of patients with long bone COM. All were managed by multidisciplinary infection team (MDT) protocol. Adequate debridement was employed for all cases, and no case of wide resection was included.Aims
Methods
Dermatofibrosarcoma protuberans (DFSP) is a rare, monoclonal dermal neoplasm. DFSP is known to be locally aggressive and infiltrative, but with a very low systemic recurrence risk. It is reported to be associated with high local recurrence rates following surgical excision. Positive or marginal resection margins can lead to a high risk of local recurrence. The objective was to determine the oncologic outcome for DFSP treated at our institution. We reviewed our prospectively collected database for all DFSP treated at our unit between 1990 and 2016. Patients were included whether or not they had excision prior to referral (“whoops” procedure). Those with fibrosarcomatous degeneration at presentation to our unit or less than 1 year of follow-up were excluded. The goal of surgery was a negative margin with a minimum margin of 2 cm where possible. Patients were followed up after surgery to monitor complications, recurrence, transformation and/or metastasis. 139 patients with a mean age of 42.7 (SD=14.1) were included. Mean follow-up was 56 months.101 patients had prior “whoops” surgery before referral. 14 patients were also treated with radiotherapy (13 preoperatively, 1 postoperatively). Following surgery, 6 patients had positive margins, 4 underwent radiation treatment while the other 2 had no further treatment. One patient who presented to our unit with a local recurrence developed a further local recurrence, which demonstrated fibrosarcomatous degeneration at the time of resection (1/139, 0.7%). 1 other patient developed a lesion at another site. The recurrence rate in our DFSP cohort is significantly lower than previous reports. Wide margin resection following oncologic principles can result in a very low recurrence rate. After the initial recovery phase, these patients do not require ongoing, frequent follow-up. Future studies should look at if closer margins can also produce similar
Numerous surgical techniques have been proposed and described in the treatment of Kienbock's disease. The objective of this systematic review was to assess the current evidence and trends in the management of Lichtman Stages IIIA and IIIB. We performed a literature search using the Medline, Embase, and Cochrane databases to identify studies evaluating