The April 2014 Research Roundup³⁶⁰ looks at: scientific writing needed in orthopaedic papers; antiseptics and osteoblasts; thromboembolic management in orthopaedic patients; nicotine and obesity in post-operative complications; defining the “Patient Acceptable Symptom State”; and cheap and nasty implants of poor quality.

Aims

Advocates of debridement, antibiotics and implant retention (DAIR) in hip periprosthetic joint infection (PJI) argue that a procedure not disturbing a sound prosthesis-bone interface is likely to lead to better survival and functional outcome compared with revision. This case-control study aims were to compare outcome of DAIRs for infected primary total hip arthroplasty (THA) with outcomes following primary THA and two-stage revision of infected primary THAs.

The rate of surgical site infection after elective foot and ankle surgery is higher than that after other elective orthopaedic procedures.

Since December 2005, we have prospectively collected data on the rate of post-operative infection for 1737 patients who have undergone elective foot and ankle surgery. In March 2008, additional infection control policies, focused on surgical and environmental risk factors, were introduced in our department.

We saw a 50% reduction in the rate of surgical site infection after the introduction of these measures. We are, however, aware that the observed decrease may not be entirely attributable to these measures alone given the number of factors that predispose to post-operative wound infection.

Cite this article: Bone Joint J 2015;97-B:516–19.

Objectives

Effective analgesia after total knee arthroplasty (TKA) improves patient satisfaction, mobility and expedites discharge. This study assessed whether continuous femoral nerve infusion (CFNI) was superior to a single-shot femoral nerve block in primary TKA surgery completed under subarachnoid blockade including morphine.

Objectives

Rotator cuff tears are among the most frequent upper extremity injuries. Current treatment strategies do not address the poor quality of the muscle and tendon following chronic rotator cuff tears. Hypoxia-inducible factor-1 alpha (HIF-1α) is a transcription factor that activates many genes that are important in skeletal muscle regeneration. HIF-1α is inhibited under normal physiological conditions by the HIF prolyl 4-hydroxylases (PHDs). In this study, we used a pharmacological PHD inhibitor, GSK1120360A, to enhance the activity of HIF-1α following the repair of a chronic cuff tear, and measured muscle fibre contractility, fibrosis, gene expression, and enthesis mechanics.

The purpose of this article is to provide the reader with a seven-step checklist that could help in minimising the risk of PJI. The check list includes strategies that can be implemented pre-operatively such as medical optimisation, and reduction of the bioburden by effective skin preparation or actions taking during surgery such as administration of timely and appropriate antibiotics or blood conservation, and finally implementation of post-operative protocols such as efforts to minimise wound drainage and haematoma formation.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):18–22.

The August 2015 Shoulder & Elbow Roundup³⁶⁰ looks at: Clavicular fractures are being fixed – but how?; Propionibacterium acnes: a pain in the shoulder?; Bacteria, armpits and arthroplasty; Living longer, but unhappy: the woes of shoulder arthroplasty in the under 50s; Recurrent dislocations in the adolescent population; Splinting for elbow stiffness; Revision Bankart repair

The October 2015 Hip & Pelvis Roundup³⁶⁰ looks at: Smoking and complications in arthroplasty; Smoking cessation beneficial in arthroplasty; Intermediate care and arthroplasty; Do we still need cell salvage?; Femoroacetabular impingement in the Japanese population; Trunnionosis or taperosis and geometry; Decontamination for staphylococcus aureus works!; Policeman or opportunity? Quality improvement with registries; Death rates higher in readmission to other hospitals

Tibial nonunion represents a spectrum of conditions which are challenging to treat, and optimal management remains unclear despite its high rate of incidence. We present 44 consecutive patients with 46 stiff tibial nonunions, treated with hexapod external fixators and distraction to achieve union and gradual deformity correction. There were 31 men and 13 women with a mean age of 35 years (18 to 68) and a mean follow-up of 12 months (6 to 40). No tibial osteotomies or bone graft procedures were performed. Bony union was achieved after the initial surgery in 41 (89.1%) tibias. Four persistent nonunions united after repeat treatment with closed hexapod distraction, resulting in bony union in 45 (97.8%) patients. The mean time to union was 23 weeks (11 to 49). Leg-length was restored to within 1 cm of the contralateral side in all tibias. Mechanical alignment was restored to within 5° of normal in 42 (91.3%) tibias. Closed distraction of stiff tibial nonunions can predictably lead to union without further surgery or bone graft. In addition to generating the required distraction to achieve union, hexapod circular external fixators can accurately correct concurrent deformities and limb-length discrepancies.

Cite this article: Bone Joint J 2015;97-B:1417–22.

The February 2013 Trauma Roundup³⁶⁰ looks at: the risk of ankle fractures; absorbable implants; minimally invasive heel fracture fixation; pertrochanteric fractures; arthroplasty and intracapsular hip fractures; and extensor mechanism disruption.

The number of arthroplasties being undertaken is expected to grow year on year, and periprosthetic joint infections will be an increasing socioeconomic burden. The challenge to prevent and eradicate these infections has resulted in the emergence of several new strategies, which are discussed in this review.

Cite this article: Bone Joint J 2015;97-B:1162–9.

Two protocols for the operative technique and care of the pin-site with external fixation were compared prospectively. There was a total of 120 patients with 46 in group A and 74 in group B. Infection was defined as an episode of pain or inflammation at a pin site, accompanied by a discharge which was either positive on bacterial culture or responded to a course of antibiotics.

Patients in group B had a lower proportion of infected pin sites (p = 0.003) and the time to the first episode of infection was longer (p < 0.001). The risk of pin-site infection is lower if attention is paid to avoiding thermal injury and local formation of haematoma during surgery and if after-care includes the use of an alcoholic antiseptic and occlusive pressure dressings.

Objective

Dunkin Hartley guinea pigs, a commonly used animal model of osteoarthritis, were used to determine if high frequency ultrasound can ensure intra-articular injections are accurately positioned in the knee joint.

The June 2014 Research Roundup³⁶⁰ looks at:Intraoperative irrigation a balance of toxicities; Ibandronate effective in bone marrow oedema; Risk stratification in damage control surgery; Osteoblast like cells potentially safe; Better wear and antibacterial?; Assessing outcomes in hip fracture.

Things have not been quiet in the Cochrane Collaboration in the four months since the last 'Cochrane Corner', with the publication of six new or updated reviews summarised here, all conducted with the bulletproof Collaboration's methodology representing the pinnacle of evidence relevant to orthopaedic surgeons.

We report our experience of staged revision surgery for the treatment of infected total elbow arthroplasty (TEA). Between 1998 and 2010 a consecutive series of 33 patients (34 TEAs) underwent a first-stage procedure with the intention to proceed to second-stage procedure when the infection had been controlled. A single first-stage procedure with removal of the components and cement was undertaken for 29 TEAs (85%), followed by the insertion of antibiotic-impregnated cement beads, and five (15%) required two or more first-stage procedures. The most common organism isolated was coagulase-negative Staphylococcus in 21 TEAs (62%).

A second-stage procedure was performed for 26 TEAs (76%); seven patients (seven TEAs, 21%) had a functional resection arthroplasty with antibiotic beads in situ and had no further surgery, one had a persistent discharge preventing further surgery.

There were three recurrent infections (11.5%) in those patients who underwent a second-stage procedure. The infection presented at a mean of eight months (5 to 10) post-operatively. The mean Mayo Elbow Performance Score (MEPS) in those who underwent a second stage revision without recurrent infection was 81.1 (65 to 95).

Staged revision surgery is successful in the treatment of patients with an infected TEA and is associated with a low rate of recurrent infection. However, when infection does occur, this study would suggest that it becomes apparent within ten months of the second stage procedure.

Cite this article: Bone Joint J 2013;95-B:1681–6.

We studied the safety of external fixation during post-operative chemotherapy in 28 patients who had undergone distraction osteogenesis (17, group A) or vascularised fibular grafting (11, group B) after resection of a tumour. Four cycles of multi-agent post-operative chemotherapy were administered over a mean period of 14 weeks (6 to 27). The mean duration of external fixation for all patients was 350 days (91 to 828). In total 204 wires and 240 half pins were used.

During the period of post-operative chemotherapy, 14 patients (11 in group A, 3 in group B) developed wire- and pin-track infection. A total of ten wires (4.9%) and 11 half pins (4.6%) became infected. Seven of the ten infected wires were in periarticular locations.

External fixation during post-operative chemotherapy was used safely and successfully for fixation of a vascularised fibular graft and distraction osteogenesis in 27 of 28 patients. Post-operative chemotherapy for malignant bone tumours did not adversely affect the ability to achieve union or cause hypertrophy of the vascularised fibular graft and had a minimal effect on distraction osteogenesis. Only one patient developed osteomyelitis which required further surgery.