We undertook a retrospective case-control study to assess the clinical variables associated with infections in open fractures. A total of 1492 open fractures were retrieved; these were Gustilo and Anderson grade I in 663 (44.4%), grade II in 370 (24.8%), grade III in 310 (20.8%) and unclassifiable in 149 (10.0%). The median duration of prophylaxis was three days (interquartile range (IQR) 1 to 3), and the median number of surgical interventions was two (1 to 9). We identified 54 infections (3.6%) occurring at a median of ten days (IQR 5 to 20) after trauma. Pathogens intrinsically resistant to the empirical antibiotic regimen used (enterococci, Enterobacter spp, Pseudomonas spp) were documented in 35 of 49 cases (71%). In multivariable regression analyses, grade III fractures and vascular injury or compartment syndrome were significantly associated with infection. Overall, compared with one day of antibiotic treatment, two to three days (odds ratio (OR) 0.6 (95% confidence interval (CI) 0.2 to 2.0)), four to five days (OR 1.2 (95% CI 0.3 to 4.9)), or > five days (OR 1.4 (95% CI 0.4 to 4.4)) did not show any significant differences in the infection risk. These results were similar when multivariable analysis was performed for grade III fractures only (OR 0.3 (95% CI 0.1 to 3.4); OR 0.6 (95% CI 0.2 to 2.1); and OR 1.7 (95% CI 0.5 to 6.2), respectively).

Infection in open fractures is related to the extent of tissue damage but not to the duration of prophylactic antibiotic therapy. Even for grade III fractures, a one-day course of prophylactic antibiotics might be as effective as prolonged prophylaxis.

Cite this article: Bone Joint J 2013;95-B:831–7.

We report the incidence of and risk factors for complications after scoliosis surgery in patients with Duchenne muscular dystrophy (DMD) and compare them with those of other neuromuscular conditions.

We identified 110 (64 males, 46 females) consecutive patients with a neuromuscular disorder who underwent correction of the scoliosis at a mean age of 14 years (7 to 19) and had a minimum two-year follow-up. We recorded demographic and peri-operative data, including complications and re-operations.

There were 60 patients with cerebral palsy (54.5%) and 26 with DMD (23.6%). The overall complication rate was 22% (24 patients), the most common of which were deep wound infection (9, 8.1%), gastrointestinal complications (5, 4.5%) and hepatotoxicity (4, 3.6%). The complication rate was higher in patients with DMD (10/26, 38.5%) than in those with other neuromuscular conditions (14/84, 16.7% (p = 0.019). All hepatotoxicity occurred in patients with DMD (p = 0.003), who also had an increased rate of deep wound infection (19% vs 5%) (p = 0.033). In the DMD group, no peri-operative factors were significantly associated with the rate of overall complications or deep wound infection. Increased intra-operative blood loss was associated with hepatotoxicity (p = 0.036).

In our series, correction of a neuromuscular scoliosis had an acceptable rate of complications: patients with DMD had an increased overall rate compared with those with other neuromuscular conditions. These included deep wound infection and hepatotoxicity. Hepatotoxicity was unique to DMD patients, and we recommend peri-operative vigilance after correction of a scoliosis in this group.

Cite this article: Bone Joint J 2014; 96-B:943–9.

In England and Wales more than 175 000 hip and knee arthroplasties were performed in 2012. There continues to be a steady increase in the demand for joint arthroplasty because of population demographics and improving survivorship. Inevitably though the absolute number of periprosthetic infections will probably increase with severe consequences on healthcare provision. The Department of Health and the Health Protection Agency in United Kingdom established a Surgical Site Infection surveillance service (SSISS) in 1997 to undertake surveillance of surgical site infections. In 2004 mandatory reporting was introduced for one quarter of each year. There has been a wide variation in reporting rates with variable engagement with the process. The aim of this article is to improve surgeon awareness of the process and emphasise the importance of engaging with SSISS to improve the quality and type of data submitted. In Exeter we have been improving our practice by engaging with SSISS. Orthopaedic surgeons need to take ownership of the data that are submitted to ensure these are accurate and comprehensive.

Cite this article: Bone Joint J 2015;97-B:1170–4.

This study evaluates the long-term survival of spinal implants after surgical site infection (SSI) and the risk factors associated with treatment failure.

A Kaplan-Meier survival analysis was carried out on 43 patients who had undergone a posterior spinal fusion with instrumentation between January 2006 and December 2008, and who consecutively developed an acute deep surgical site infection. All were appropriately treated by surgical debridement with a tailored antibiotic program based on culture results for a minimum of eight weeks.

A ‘terminal event’ or failure of treatment was defined as implant removal or death related to the SSI. The mean follow-up was 26 months (1.03 to 50.9). A total of ten patients (23.3%) had a terminal event. The rate of survival after the first debridement was 90.7% (95% confidence interval (CI) 82.95 to 98.24) at six months, 85.4% (95% CI 74.64 to 96.18) at one year, and 73.2% (95% CI 58.70 to 87.78) at two, three and four years. Four of nine patients required re-instrumentation after implant removal, and two of the four had a recurrent infection at the surgical site. There was one recurrence after implant removal without re-instrumentation.

Multivariate analysis revealed a significant risk of treatment failure in patients who developed sepsis (hazard ratio (HR) 12.5 (95% confidence interval (CI) 2.6 to 59.9); p < 0.001) or who had > three fused segments (HR 4.5 (95% CI 1.25 to 24.05); p = 0.03). Implant survival is seriously compromised even after properly treated surgical site infection, but progressively decreases over the first 24 months.

Cite this article: Bone Joint J 2013;95-B:1121–6.

The June 2015 Oncology Roundup³⁶⁰ looks at: Infection in megaprosthesis; Impressive results for mid femoral reconstruction; Revered teaching or old myth? Femoral neck protection in metastatic disease; Megaprosthesis about the knee; Malignant transformation in multiple hereditary exostoses; Fracture of intercalary bone allograft; Comorbidity and outcomes in sarcoma; A worrying turn? Use of denosumab for giant cell tumour of bone

Knee arthrodesis is a potential salvage procedure for limb preservation after failure of total knee arthroplasty (TKA) due to infection. In this study, we evaluated the outcome of single-stage knee arthrodesis using an intramedullary cemented coupled nail without bone-on-bone fusion after failed and infected TKA with extensor mechanism deficiency. Between 2002 and 2012, 27 patients (ten female, 17 male; mean age 68.8 years; 52 to 87) were treated with septic single-stage exchange. Mean follow-up duration was 67.1months (24 to 143, n = 27) (minimum follow-up 24 months) and for patients with a minimum follow-up of five years 104.9 (65 to 143,; n = 13). A subjective patient evaluation (Short Form (SF)-36) was obtained, in addition to the Visual Analogue Scale (VAS). The mean VAS score was 1.44 (SD 1.48). At final follow-up, four patients had recurrent infections after arthrodesis (14.8%). Of these, three patients were treated with a one-stage arthrodesis nail exchange; one of the three patients had an aseptic loosening with a third single-stage exchange, and one patient underwent knee amputation for uncontrolled sepsis at 108 months. All patients, including the amputee, indicated that they would choose arthrodesis again. Data indicate that a single-stage knee arthrodesis offers an acceptable salvage procedure after failed and infected TKA.

Cite this article: Bone Joint J 2015;97-B:649–53.

We report on two cases of infective spondylodiscitis caused by Gemella haemolysans in otherwise healthy patients. This organism has only rarely been identified as a cause of bone and joint infection, with only two previous reports of infective spondylodiscitis.

We describe the clinical features, investigations and treatment options.

Patients with osteoarthritis undergoing knee replacement have been reported to have an overall reduced mortality compared with that of the general population. This has been attributed to the selection of healthier patients for surgery. However, previous studies have had a maximum follow-up time of ten years. We have used information from the Swedish Knee Arthroplasty Register to study the mortality of a large national series of patients with total knee replacement for up to 28 years after surgery and compared their mortality with that of the normal population. In addition, for a subgroup of patients operated on between 1980 and 2002 we analysed their registered causes of death to determine if they differed from those expected.

We found a reduced overall mortality during the first 12 post-operative years after which it increased and became significantly higher than that of the general population. Age-specific analysis indicated an inverse correlation between age and mortality, where the younger the patients were, the higher their mortality. The shift at 12 years was caused by a relative over-representation of younger patients with a longer follow-up. Analysis of specific causes of death showed a higher mortality for cardiovascular, gastrointestinal and urogenital diseases. The observation that early onset of osteoarthritis of the knee which has been treated by total knee replacement is linked to an increased mortality should be a reason for increased general awareness of health problems in these patients.

Revision total hip replacement (THR) for young patients is challenging because of technical complexity and the potential need for subsequent further revisions. We have assessed the survivorship, functional outcome and complications of this procedure in patients aged <  50 years through a large longitudinal series with consistent treatment algorithms. Of 132 consecutive patients (181 hips) who underwent revision THR, 102 patients (151 hips) with a mean age of 43 years (22 to 50) were reviewed at a mean follow-up of 11 years (2 to 26) post-operatively. We attempted to restore bone stock with allograft where indicated. Using further revision for any reason as an end point, the survival of the acetabular component was 71% (sd 4) and 54% (sd 7) at ten- and 20 years. The survival of the femoral component was 80% (sd 4) and 62% (sd 6) at ten- and 20 years. Complications included 11 dislocations (6.1%), ten periprosthetic fractures (5.5%), two deep infections (1.1%), four sciatic nerve palsies (2.2%; three resolved without intervention, one improved after exploration and freeing from adhesions) and one vascular injury (0.6%). The mean modified Harris Hip Score was 41 (10 to 82) pre-operatively, 77 (39 to 93) one year post-operatively and 77 (38 to 93) at the latest review.

This overall perspective on the mid- to long-term results is valuable when advising young patients on the prospects of revision surgery at the time of primary replacement.

Cite this article: Bone Joint J 2014;96-B:1047–51.

In March 2012, an algorithm for the treatment of intertrochanteric fractures of the hip was introduced in our academic department of Orthopaedic Surgery. It included the use of specified implants for particular patterns of fracture. In this cohort study, 102 consecutive patients presenting with an intertrochanteric fracture were followed prospectively (post-algorithm group). Another 117 consecutive patients who had been treated immediately prior to the implementation of the algorithm were identified retrospectively as a control group (pre-algorithm group). The total cost of the implants prior to implementation of the algorithm was $357 457 (mean: $3055 (1947 to 4133)); compared with $255 120 (mean: $2501 (1052 to 4133)) after its implementation. There was a trend toward fewer complications in patients who were treated using the algorithm (33% pre- versus 22.5% post-algorithm; p = 0.088). Application of the algorithm to the pre-algorithm group revealed a potential overall cost saving of $70 295.

The implementation of an evidence-based algorithm for the treatment of intertrochanteric fractures reduced costs while maintaining quality of care with a lower rate of complications and re-admissions.

Cite this article: Bone Joint J 2014;96-B:1192–7.

Intramedullary infection in long bones represents a complex clinical challenge, with an increasing incidence due to the increasing use of intramedullary fixation. We report a prospective case series using an intramedullary reaming device, the Reamer–Irrigator–Aspirator (RIA) system, in association with antibiotic cement rods for the treatment of lower limb long bone infections. A total of 24 such patients, 16 men and eight women, with a mean age of 44.5 years (17 to 75), 14 with femoral and 10 with tibial infection, were treated in a staged manner over a period of 2.5 years in a single referral centre. Of these, 21 patients had had previous surgery, usually for fixation of a fracture (seven had sustained an open fracture originally and one had undergone fasciotomies). According to the Cierny–Mader classification system, 18 patients were classified as type 1A, four as 3A (discharging sinus tract), one as type 4A and one as type 1B. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients.

Cite this article: Bone Joint J 2014; 96-B:783–8.

We examined the incidence of infection with methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to the Leicester Royal Infirmary Trauma Unit between January 2004 and June 2006. The influence of MRSA status at the time of their admission was examined, together with age, gender and diagnosis, using multi-variant analysis. Of 2473 patients, 79 (3.2%) were MRSA carriers at the time of admission and 2394 (96.8%) were MRSA-negative. Those carrying MRSA at the time of admission were more likely to develop surgical site infection with MRSA (7 of 79 patients, 8.8%) than non-MRSA carriers (54 of 2394 patients, 2.2%, p < 0.001). Further analysis showed that hip fracture and increasing age were also risk factors with a linear increase in relative risk of 1.8% per year.

MRSA carriage at admission, age and the pathology are all associated with an increased rate of developing MRSA wound infection. Identification of such risk factors at admission helps to target health-care resources, such the use of glycopeptide antibiotics at induction and the ‘building-in’ of increased vigilance for wound infection pre-operatively.

More than a million hip replacements are carried out each year worldwide, and the number of other artificial joints inserted is also rising, so that infections associated with arthroplasties have become more common. However, there is a paucity of literature on infections due to haematogenous seeding following dental procedures. We reviewed the published literature to establish the current knowledge on this problem and to determine the evidence for routine antibiotic prophylaxis prior to a dental procedure.

We found that antimicrobial prophylaxis before dental interventions in patients with artificial joints lacks evidence-based information and thus cannot be universally recommended.

We have analysed the management and clinical outcome of a series of consecutive patients who had a total hip replacement and developed post-operative surgical site infection (SSI) with methicillin-resistant Staphylococcus aureus. The incidence of this infection was 1% over a period of five years. We studied SSI in 15 patients (16 infections) with a mean age of 72.7 years (53 to 81). In all, 12 of the infections occurred early and half of the infections involved the prosthesis, resulting in an increase of 11-fold in the cumulative hospital stay.

Methicillin-resistant Staph. aureus was successfully eradicated in all the patients after a mean follow-up of 53.6 months (25 to 88). Superficial incisional infections resolved after antibiotic therapy alone while deep infections required multiple operative debridements. Attempted retention of the implant in early organ space infections was successful in only one of five patients. Only three patients with implant-level infections obtained a pain-free, functional prosthesis while a further three required excision arthroplasty. We have formulated a protocol of treatment which may serve as a guide in the management of these infections.

The purpose of this study was to compare the diagnostic accuracy for the detection of infection between the culture of fluid obtained by sonication (SFC) and the culture of peri-implant tissues (PITC) in patients with early and delayed implant failure, and those with unsuspected and suspected septic failure. It was hypothesised that SFC increases the diagnostic accuracy for infection in delayed, but not early, implant failure, and in unsuspected septic failure. The diagnostic accuracy for infection of all consecutive implants (hardware or prostheses) that were removed for failure was compared between SFC and PITC. This prospective study included 317 patients with a mean age of 62.7 years (9 to 97). The sensitivity for detection of infection using SFC was higher than using PITC in an overall comparison (89.9% versus 67%, respectively; p < 0.001), in unsuspected septic failure (100% versus 48.5%, respectively; p < 0.001), and in delayed implant failure (88% versus 58%, respectively; p < 0.001). PITC sensitivity dropped significantly in unsuspected compared with suspected septic failure (p = 0.007), and in delayed compared with early failure (p = 0.013). There were no differences in specificity.

Sonication is mainly recommended when there is implant failure with no clear signs of infection and in patients with delayed implant failure. In early failure, SFC is not superior to PITC for the diagnosis of infection and, therefore, is not recommended as a routine diagnostic test in these patients.

Cite this article: Bone Joint J 2013;95-B:244–9.

Objectives

To determine the morbidity and mortality outcomes of patients presenting with a fractured neck of femur in an Australian context. Peri-operative variables related to unfavourable outcomes were identified to allow planning of intervention strategies for improving peri-operative care.

Staphylococcus aureus is one of the leading causes of surgical site infection (SSI). Over the past decade there has been an increase in methicillin-resistant S. aureus (MRSA). This is a subpopulation of the bacterium with unique resistance and virulence characteristics. Nasal colonisation with either S. aureus or MRSA has been demonstrated to be an important independent risk factor associated with the increasing incidence and severity of SSI after orthopaedic surgery. Furthermore, there is an economic burden related to SSI following orthopaedic surgery, with MRSA-associated SSI leading to longer hospital stays and increased hospital costs. Although there is some controversy about the effectiveness of screening and eradication programmes, the literature suggests that patients should be screened and MRSA-positive patients treated before surgical admission in order to reduce the risk of SSI.

Cite this article: Bone Joint J 2013;95-B:4–9.

We live in troubled times. Increased opposition reliance on explosive devices, the widespread use of individual and vehicular body armour, and the improved survival of combat casualties have created many complex musculoskeletal injuries in the wars in Iraq and Afghanistan. Explosive mechanisms of injury account for 75% of all musculoskeletal combat casualties. Throughout all the echelons of care medical staff practice consistent treatment strategies of damage control orthopaedics including tourniquets, antibiotics, external fixation, selective amputations and vacuum-assisted closure. Complications, particularly infection and heterotopic ossification, remain frequent, and re-operations are common. Meanwhile, non-combat musculoskeletal casualties are three times more frequent than those derived from combat and account for nearly 50% of all musculoskeletal casualties requiring evacuation from the combat zone.

We examined patient and surgical factors associated with deep surgical site infection (SSI) following total hip replacement (THR) in a large integrated healthcare system. A retrospective review of a cohort of primary THRs performed between 2001 and 2009 was conducted. Patient characteristics, surgical details, surgeon and hospital volumes, and SSIs were identified using the Kaiser Permanente Total Joint Replacement Registry (TJRR). Proportional-hazard regression models were used to assess risk factors for SSI. The study cohort consisted of 30 491 THRs, of which 17 474 (57%) were performed on women. The mean age of the patients in the whole series was 65.5 years (13 to 97; sd 11.8) and the mean body mass index was 29.3 kg/m² (15 to 67; sd 5.9). The incidence of SSI was 0.51% (155 of 30 491). Patient factors associated with SSI included female gender, obesity, and American Society of Anesthesiologists (ASA) score ≥ 3. Age, diagnosis, diabetes and race were not associated with SSI. The only surgical factor associated with SSI was a bilateral procedure. Surgeon and hospital volumes, use of antibiotic-laden cement, fixation method, laminar flow, body exhaust suits, surgical approach and fellowship training were not associated with risk of SSI.

A comprehensive infection surveillance system, combined with a TJRR, identified patient and surgical factors associated with SSI. Obesity and chronic medical conditions should be addressed prior to THR. The finding of increased SSI risk with bilateral THR requires further investigation.