Introduction. There is widespread variation in the management of rare orthopaedic disease, in a large part owing to uncertainty. No individual surgeon or hospital is typically equipped to amass sufficient numbers of cases to draw robust conclusions from the information available to them. The programme of research will establish the British Orthopaedic Surgery Surveillance (BOSS) Study; a nationwide reporting structure for rare disease in orthopaedic surgery. Methods. The BOSS Study is a series of nationwide observational cohort studies of pre-specified orthopaedic disease. All relevant hospitals treating the disease are invited to contribute anonymised case details. Data will be collected digitally through REDCap, with an additional bespoke software solution used to regularly confirm case ascertainment, prompt follow-up reminders and identify potential missing cases from external sources of information (i.e. national administrative data). With their consent, patients will be invited to enrich the data collected by supplementing anonymised case data with patient reported outcomes. The study will primarily seek to calculate the incidence of the rare diseases under investigation, with 95% confidence intervals. Descriptive statistics will be used to describe the case mix, treatment variations and outcomes. Inferential statistical analysis may be used to analyze associations between presentation factors and outcomes. Types of analyses will be contingent on the disease under investigation. Discussion. This study builds upon other national rare disease supporting structures, particularly those in obstetrics and paediatric surgery. It is particularly focused on addressing the evidence base for quality and safety of surgery, and the design is influenced by the specifications of the IDEAL collaboration for the development of surgical research

The Control of Infection Committee at a specialist orthopaedic hospital prospectively collected data on all episodes of bacteriologically-proven deep infection arising after primary hip and knee replacements over a 15-year period from 1987 to 2001.

There were 10 735 patients who underwent primary hip or knee replacement. In 34 of 5947 hip replacements (0.57%) and 41 of 4788 knee replacements (0.86%) a deep infection developed. The most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. Of the infecting organisms, 72% were sensitive to routine prophylactic antimicrobial agents.

Of the infections, 29% (22) arose in the first three months following surgery, 35% between three months and one year (26), and 36% (27) after one year. Most cases were detected early and treated aggressively, with eradication of the infection in 96% (72). There was no significant change in the infection rate or type of infecting micro-organism over the course of this study.

These results set a benchmark, and importantly emphasise that only 64% of peri-prosthetic infections arise within one year of surgery. These results also illustrate the advantages of conducting joint replacement surgery in the isolation of a specialist hospital.

Reports of infection by Clostridium sordellii associated with allograft transplantation have generated considerable interest. We report our experience in recognising clostridial contamination in cadaver donors of musculoskeletal tissue. Tissues obtained from 795 consecutive donors were excised using standard surgical techniques. Samples of blood and bone marrow were also obtained. Donors with clostridia recovered from any site were matched with the preceding donor without clostridia as a procedural and environmental control. The histories of the donors were analysed to determine which variables had a relationship to contamination by running a contingency table and chi-squared test on the variables against the event of a donor being contaminated.

Sixty-four donors (8.1%) had clostridia, most commonly C. sordellii. Clostridia were grown from the blood, marrow and tissue samples of 52, 37 and 30 donors, respectively. In eight cases, they were cultured from the tissue samples alone. There was no significant difference in age or gender between the contaminated donors and the control group. Open wounds were more common in control than in contaminated subjects, but only death by drowning in the contaminated group was statistically significant (p = 0.02). The time between death and the excision of tissue which was contaminated (16 hrs 10 mins) compared with control (11 hrs 10 mins) donors was also significant (p < 10⁻⁶).

We conclude that there is clostridial contamination in a significant number of tissue donors, particularly with increasing time between death and tissue excision. Among the most commonly encountered species is C. sordellii. Multiple microbiological cultures, including blood, are necessary in order to identify clostridial contamination.

Aims. Safety concerns surrounding osseointegration are a significant barrier to replacing socket prosthesis as the standard of care following limb amputation. While implanted osseointegrated prostheses traditionally occur in two stages, a one-stage approach has emerged. Currently, there is no existing comparison of the outcomes of these different approaches. To address safety concerns, this study sought to determine whether a one-stage osseointegration procedure is associated with fewer adverse events than the two-staged approach. Methods. A comprehensive electronic search and quantitative data analysis from eligible studies were performed. Inclusion criteria were adults with a limb amputation managed with a one- or two-stage osseointegration procedure with follow-up reporting of complications. Results. A total of 19 studies were included: four one-stage, 14 two-stage, and one article with both one- and two-stage groups. Superficial infection was the most common complication (one-stage: 38% vs two-stage: 52%). There was a notable difference in the incidence of osteomyelitis (one-stage: nil vs two-stage: 10%) and implant failure (one-stage: 1% vs two-stage: 9%). Fracture incidence was equivocal (one-stage: 13% vs two-stage: 12%), and comparison of soft-tissue, stoma, and mechanical related complications was not possible. Conclusion. This review suggests that the one-stage approach is favourable compared to the two-stage, because the incidence of complications was slightly lower in the one-stage cohort, with a pertinent difference in the incidence of osteomyelitis and implant failure. Cite this article: Bone Jt Open 2023;4(7):539–550

Aims. Tuberculosis (TB) is one of the biggest communicable causes of mortality worldwide. While incidence in the UK has continued to fall since 2011, Bradford retains one of the highest TB rates in the UK. This study aims to examine the local disease burden of musculoskeletal (MSK) TB, by analyzing common presenting factors within the famously diverse population of Bradford. Methods. An observational study was conducted, using data from the Bradford Teaching Hospitals TB database of patients with a formal diagnosis of MSK TB between January 2005 and July 2017. Patient data included demographic data (including nationality/date of entry to the UK), disease focus, microbiology, and management strategies. Disease incidence was calculated using population data from the Office for National Statistics. Poisson confidence intervals were calculated to demonstrate the extent of statistical error. Disease incidence and nationality were also analyzed, and correlation sought, using the chi-squared test. Results. Between January 2005 and July 2017, 109 cases of MSK TB were diagnosed in Bradford. Mean incidence was 1.65 per 100,000 population, per calendar year (SD 0.75). A total of 38 cases required surgical intervention. Low rates of antimicrobial resistance were encountered. A low rate of loss to follow-up was observed (four patients; 3.7%). Overall, 94.5% of patients (n = 103) were successfully treated. 67% of patients (n = 73) reported their country of origin as either India, Pakistan, or Bangladesh. These ethnicities account for around 25% of the local population. Conclusion. Bradford maintains a high prevalence of MSK TB infection relative to national data; the prevalence within the local immigrant population remains grossly disproportionate. Typical associated factors (HIV/hepatitis coinfection, drug resistance), have only modest prevalence in our dataset. However, local socioeconomic factors such as deprivation and poverty appear germane as suggested by global literature. We advocate a high degree of suspicion in treatment of atypical infection in any area with similar population factors to ensure timely diagnosis. Cite this article: Bone Jt Open 2022;3(5):432–440

Aims. Orthopaedic infection is a potentially serious complication of elective and emergency trauma and orthopaedic procedures, with a high associated burden of morbidity and cost. Optimization of vitamin D levels has been postulated to be beneficial in the prevention of orthopaedic infection. This study explores the role of vitamin D in orthopaedic infection through a systematic review of available evidence. Methods. A comprehensive search was conducted on databases including Medline and Embase, as well as grey literature such as Google Scholar and The World Health Organization Database. Pooled analysis with weighted means was undertaken. Results. Pooled analysis of four studies including 651 patients found the mean 25(OH)D level to be 50.7 nmol/l with a mean incidence of infection of 70%. There was a paucity of literature exploring prophylactic 25(OH)D supplementation on reducing orthopaedic infection, however, there was evidence of association between low 25(OH)D levels and increased incidence of orthopaedic infection. Conclusion. The results indicate a significant proportion of orthopaedic patients have low 25(OH]D levels, as well as an association between low 25(OH)D levels and orthopaedic infection, but more randomized controlled trials need to be conducted to establish the benefit of prophylactic supplementation and the optimum regimen by dose and time. Cite this article: Bone Jt Open 2021;2(9):721–727

Aims. The timing of when to remove a circular frame is crucial; early removal results in refracture or deformity, while late removal increases the patient morbidity and delay in return to work. This study was designed to assess the effectiveness of a staged reloading protocol. We report the incidence of mechanical failure following both single-stage and two stage reloading protocols and analyze the associated risk factors. Methods. We identified consecutive patients from our departmental database. Both trauma and elective cases were included, of all ages, frame types, and pathologies who underwent circular frame treatment. Our protocol is either a single-stage or two-stage process implemented by defunctioning the frame, in order to progressively increase the weightbearing load through the bone, and promote full loading prior to frame removal. Before progression, through the process we monitor patients for any increase in pain and assess radiographs for deformity or refracture. Results. There were 244 frames (230 patients) included in the analyses, of which 90 were Ilizarov type frames and 154 were hexapods. There were 149 frames which underwent single-stage reloading and 95 frames which underwent a two-stage reloading protocol. Mechanical failure occurred after frame removal in 13 frames (5%), which suffered refracture. There were no cases of change in alignment. There was no difference between refracture patients who underwent single-stage or two-stage reloading protocols (p = 0.772). In all, 14 patients had failure prevented through identification with the reloading protocol. Conclusion. Our reloading protocol is a simple and effective way to confirm the timing of frame removal and minimize the rate of mechanical failure. Similar failure rates occurred between patients undergoing single-stage and two-stage reloading protocols. If the surgeon is confident with clinical and radiological assessment, it may be possible to progress directly to stage two and decrease frame time and patient morbidity. Cite this article: Bone Jt Open 2022;3(5):359–366

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. Methods. A retrospective observational study was undertaken of consecutive patients who had CSI in our local hospitals between 1 February and 30June 2020. Electronic patient medical records (EPR) and radiology information system (RIS) database were reviewed. SARS-CoV-2 RT-PCR testing, SARS-COV2 IgG antibody testing, radiological investigations, patient management, and clinical outcomes were recorded. Lung findings were categorized according to the British Society of Thoracic Imaging (BSTI) guidelines. Reference was made to the incidence of lab-confirmed COVID-19 cases in our region. Results. Overall, 1,656 lab-confirmed COVID-19 cases were identified in our upper tier local authority (UTLA), a rate of 306.6 per 100,000, as of 30June 2020. A total of 504 CSI injections were performed on 443 patients between 1 February and 30June 2020. A total of 11 RT-PCR tests were performed on nine patients (2% of those who had CSI), all of which were negative for SARS-CoV-2 RNA, and five patients (1.1%) received an SARS-CoV-2 IgG antibody test, of which 2 (0.5%) were positive consistent with prior COVID-19 infection, however both patients were asymptomatic. Seven patients (1.6%) had radiological investigations for respiratory symptoms. One patient with indeterminate ground glass change was identified. Conclusion. The incidence of positive COVID-19 infection following corticosteroid injections was very low in our cohort and no adverse clinical outcomes related to COVID-19 infection following CSI were identified. Our findings are consistent with CSI likely being low risk during the COVID-19 pandemic. The results of this small observational study are supportive of the current multi-society guidelines regarding the judicious use of CSI. Cite this article: Bone Joint Open 2020;1-9:605–611

Aims. The aetiologies of common degenerative spine, hip, and knee pathologies are still not completely understood. Mechanical theories have suggested that those diseases are related to sagittal pelvic morphology and spinopelvic-femoral dynamics. The link between the most widely used parameter for sagittal pelvic morphology, pelvic incidence (PI), and the onset of degenerative lumbar, hip, and knee pathologies has not been studied in a large-scale setting. Methods. A total of 421 patients from the Cohort Hip and Cohort Knee (CHECK) database, a population-based observational cohort, with hip and knee complaints < 6 months, aged between 45 and 65 years old, and with lateral lumbar, hip, and knee radiographs available, were included. Sagittal spinopelvic parameters and pathologies (spondylolisthesis and degenerative disc disease (DDD)) were measured at eight-year follow-up and characteristics of hip and knee osteoarthritis (OA) at baseline and eight-year follow-up. Epidemiology of the degenerative disorders and clinical outcome scores (hip and knee pain and Western Ontario and McMaster Universities Osteoarthritis Index) were compared between low PI (< 50°), normal PI (50° to 60°), and high PI (> 60°) using generalized estimating equations. Results. Demographic details were not different between the different PI groups. L4 to L5 and L5 to S1 spondylolisthesis were more frequently present in subjects with high PI compared to low PI (L4 to L5, OR 3.717; p = 0.024 vs L5 to S1 OR 7.751; p = 0.001). L5 to S1 DDD occurred more in patients with low PI compared to high PI (OR 1.889; p = 0.010), whereas there were no differences in L4 to L5 DDD among individuals with a different PI. The incidence of hip OA was higher in participants with low PI compared to normal (OR 1.262; p = 0.414) or high PI (OR 1.337; p = 0.274), but not statistically different. The incidence of knee OA was higher in individuals with a high PI compared to low PI (OR 1.620; p = 0.034). Conclusion. High PI is a risk factor for development of spondylolisthesis and knee OA. Low pelvic incidence is related to DDD, and may be linked to OA of the hip. Level of Evidence: 1b. Cite this article: Bone Joint J 2020;102-B(9):1261–1267

Aims. The aim of this study was to analyze the prevalence of culture-negative periprosthetic joint infections (PJIs) when adequate methods of culture are used, and to evaluate the outcome in patients who were treated with antibiotics for a culture-negative PJI compared with those in whom antibiotics were withheld. Methods. A multicentre observational study was undertaken: 1,553 acute and 1,556 chronic PJIs, diagnosed between 2013 and 2018, were retrospectively analyzed. Culture-negative PJIs were diagnosed according to the Muskuloskeletal Infection Society (MSIS), International Consensus Meeting (ICM), and European Bone and Joint Society (EBJIS) definitions. The primary outcome was recurrent infection, and the secondary outcome was removal of the prosthetic components for any indication, both during a follow-up period of two years. Results. None of the acute PJIs and 70 of the chronic PJIs (4.7%) were culture-negative; a total of 36 culture-negative PJIs (51%) were treated with antibiotics, particularly those with histological signs of infection. After two years of follow-up, no recurrent infections occurred in patients in whom antibiotics were withheld. The requirement for removal of the components for any indication during follow-up was not significantly different in those who received antibiotics compared with those in whom antibiotics were withheld (7.1% vs 2.9%; p = 0.431). Conclusion. When adequate methods of culture are used, the incidence of culture-negative PJIs is low. In patients with culture-negative PJI, antibiotic treatment can probably be withheld if there are no histological signs of infection. In all other patients, diagnostic efforts should be made to identify the causative microorganism by means of serology or molecular techniques. Cite this article: Bone Joint J 2022;104-B(1):183–188

Aims. The exact risk to patients undergoing surgery who develop COVID-19 is not yet fully known. This study aims to provide the current data to allow adequate consent regarding the risks of post-surgery COVID-19 infection and subsequent COVID-19-related mortality. Methods. All orthopaedic trauma cases at the Wrightington Wigan and Leigh NHS Foundation Trust from ‘lockdown’ (23 March 2020) to date (15 June 2020) were collated and split into three groups. Adult ambulatory trauma surgeries (upper limb trauma, ankle fracture, tibial plateau fracture) and regional-specific referrals (periprosthetic hip fracture) were performed at a stand-alone elective site that accepted COVID-19-negative patients. Neck of femur fractures (NOFF) and all remaining non-NOFF (paediatric trauma, long bone injury) surgeries were performed at an acute site hospital (mixed green/blue site). Patients were swabbed for COVID-19 before surgery on both sites. Age, sex, nature of surgery, American Society of Anaesthesiologists (ASA) grade, associated comorbidity, length of stay, development of post-surgical COVID-19 infection, and post-surgical COVID-19-related deaths were collected. Results. At the elective site, 225 patients underwent orthopaedic trauma surgery; two became COVID-19-positive (0.9%) in the immediate perioperative period, neither of which was fatal. At the acute site, 93 patients underwent non-NOFF trauma surgery, of whom six became COVID-19-positive (6.5%) and three died. A further 84 patients underwent NOFF surgery, seven becoming COVID-19 positive (8.3%) and five died. Conclusion. At the elective site, the rate of COVID-19 infection following orthopaedic trauma surgery was low, at 0.9%. At the acute mixed site (typical district general hospital), for non-NOFF surgery there was a 6.5% incidence of post-surgical COVID-19 infection (seven-fold higher risk) with 50% COVID-19 mortality; for NOFF surgery, there was an 8.3% incidence of post-surgical COVID-19 infection, with 71% COVID-19 mortality. This is likely to have significance when planning a resumption of elective orthopaedic surgery and for consent to the patient. Cite this article: Bone Joint Open 2020;1-9:556–561

Aims. Despite the COVID-19 pandemic, incidence of hip fracture has not changed. Evidence has shown increased mortality rates associated with COVID-19 infection. However, little is known about the outcomes of COVID-19 negative patients in a pandemic environment. In addition, the impact of vitamin D levels on mortality in COVID-19 hip fracture patients has yet to be determined. Methods. This multicentre observational study included 1,633 patients who sustained a hip fracture across nine hospital trusts in North West England. Data were collected for three months from March 2020 and for the same period in 2019. Patients were matched by Nottingham Hip Fracture Score (NHFS), hospital, and fracture type. We looked at the mortality outcomes of COVID-19 positive and COVID-19 negative patients sustaining a hip fracture. We also looked to see if vitamin D levels had an impact on mortality. Results. The demographics of the 2019 and 2020 groups were similar, with a slight increase in proportion of male patients in the 2020 group. The 30-day mortality was 35.6% in COVID-19 positive patients and 7.8% in the COVID-19 negative patients. There was a potential association of decreasing vitamin D levels and increasing mortality rates for COVID-19 positive patients although our findings did not reach statistical significance. Conclusion. In 2020 there was a significant increase in 30-day mortality rates of patients who were COVID-19 positive but not of patients who were COVID-19 negative. Low levels of vitamin D may be associated with high mortality rates in COVID-19 positive patients. Cite this article: Bone Joint J 2021;103-B(4):782–787

Aims

This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures.

Aims. COVID-19 represents one of the greatest global healthcare challenges in a generation. Orthopaedic departments within the UK have shifted care to manage trauma in ways that minimize exposure to COVID-19. As the incidence of COVID-19 decreases, we explore the impact and risk factors of COVID-19 on patient outcomes within our department. Methods. We retrospectively included all patients who underwent a trauma or urgent orthopaedic procedure from 23 March to 23 April 2020. Electronic records were reviewed for COVID-19 swab results and mortality, and patients were screened by telephone a minimum 14 days postoperatively for symptoms of COVID-19. Results. A total of 214 patients had orthopaedic surgical procedures, with 166 included for analysis. Patients undergoing procedures under general or spinal anaesthesia had a higher risk of contracting perioperative COVID-19 compared to regional/local anaesthesia (p = 0.0058 and p = 0.0007, respectively). In all, 15 patients (9%) had a perioperative diagnosis of COVID-19, 14 of whom had fragility fractures; six died within 30 days of their procedure (40%, 30-day mortality). For proximal femoral fractures, our 30-day mortality was 18.2%, compared to 7% in 2019. Conclusion. Based on our findings, patients undergoing procedures under regional or local anaesthesia have minimal risk of developing COVID-19 perioperatively. Those with multiple comorbidities and fragility fractures have a higher morbidity and mortality if they contract COVID-19 perioperatively; therefore, protective care pathways could go some way to mitigate the risk. Our 30-day mortality of proximal femoral fractures was 18.2% during the COVID-19 pandemic in comparison to the annual national average of 6.1% in 2018 and the University Hospital Coventry average of 7% for the same period in 2019, as reported in the National Hip Fracture Database. Patients undergoing procedures under general or spinal anaesthesia at the peak of the pandemic had a higher risk of contracting perioperative COVID-19 compared to regional block or local anaesthesia. We question whether young patients undergoing day-case procedures under regional block or local anaesthesia with minimal comorbidities require fourteen days self-isolation; instead, we advocate that compliance with personal protective equipment, a negative COVID-19 swab three days prior to surgery, and screening questionnaire may be sufficient. Cite this article: Bone Joint Open 2020;1-9:520–529

Aims

Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set.

Aims. The first death in the UK caused by COVID-19 occurred on 5 March 2020. We aim to describe the clinical characteristics and outcomes of major trauma and orthopaedic patients admitted in the early COVID-19 era. Methods. A prospective trauma registry was reviewed at a Level 1 Major Trauma Centre. We divided patients into Group A, 40 days prior to 5 March 2020, and into Group B, 40 days after. Results. A total of 657 consecutive trauma and orthopaedic patients were identified with a mean age of 55 years (8 to 98; standard deviation (SD) 22.52) and 393 (59.8%) were males. In all, 344 (approximately 50%) of admissions were major trauma. Group A had 421 patients, decreasing to 236 patients in Group B (36%). Mechanism of injury (MOI) was commonly a fall in 351 (52.4%) patients, but road traffic accidents (RTAs) increased from 56 (13.3%) in group A to 51 (21.6%) in group B (p = 0.030). ICU admissions decreased from 26 (6.2%) in group A to 5 (2.1%) in group B. Overall, 39 patients tested positive for COVID-19 with mean age of 73 years (28 to 98; SD 17.99) and 22 (56.4%) males. Common symptoms were dyspnoea, dry cough, and pyrexia. Of these patients, 27 (69.2%) were nosocomial infections and two (5.1%) of these patients required intensive care unit (ICU) admission with 8/39 mortality (20.5%). Of the patients who died, 50% were older and had underlying comorbidities (hypertension and cardiovascular disease, dementia, arthritis). Conclusion. Trauma admissions decreased in the lockdown phase with an increased incidence of RTAs. Nosocomial infection was common in 27 (69.2%) of those with COVID-19. Symptoms and comorbidities were consistent with previous reports with noted inclusion of dementia and arthritis. The mortality rate of trauma and COVID-19 was 20.5%, mainly in octogenarians, and COVID-19 surgical mortality was 15.4%. Cite this article: Bone Joint Open 2020;1-7:330–338

Aims

Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier.

Aims. This study aims to define the epidemiology of trauma presenting to a single centre providing all orthopaedic trauma care for a population of ∼ 900,000 over the first 40 days of the COVID-19 pandemic compared to that presenting over the same period one year earlier. The secondary aim was to compare this with population mobility data obtained from Google. Methods. A cross-sectional study of consecutive adult (> 13 years) patients with musculoskeletal trauma referred as either in-patients or out-patients over a 40-day period beginning on 5 March 2020, the date of the first reported UK COVID-19 death, was performed. This time period encompassed social distancing measures. This group was compared to a group of patients referred over the same calendar period in 2019 and to publicly available mobility data from Google. Results. Orthopaedic trauma referrals reduced by 42% (1,056 compared to 1,820) during the study period, and by 58% (405 compared to 967) following national lockdown. Outpatient referrals reduced by 44%, and inpatient referrals by 36%, and the number of surgeries performed by 36%. The regional incidence of traumatic injury fell from 5.07 (95% confidence interval (CI) 4.79 to 5.35) to 2.94 (95% CI 2.52 to 3.32) per 100,000 population per day. Significant reductions were seen in injuries related to sports and alcohol consumption. No admissions occurred relating to major trauma (Injury Severity Score > 16) or violence against the person. Changes in population mobility and trauma volume from baseline correlated significantly (Pearson’s correlation 0.749, 95% CI 0.58 to 0.85, p < 0.001). However, admissions related to fragility fractures remained unchanged compared to the 2019 baseline. Conclusion. The profound changes in social behaviour and mobility during the early stages of the COVID-19 pandemic have directly correlated with a significant decrease in orthopaedic trauma referrals, but fragility fractures remained unaffected and provision for these patients should be maintained. Cite this article: Bone Joint Open 2020;1-6:182–189

Introduction. Studies have addressed the issue of increasing prevalence of work-related musculoskeletal (MSK) pain among different occupations. However, contributing factors to MSK pain have not been fully investigated among orthopaedic surgeons. Thus, this study aimed to approximate the prevalence and predictors of MSK pain among Saudi orthopaedic surgeons working in Riyadh, Saudi Arabia. Methods. A cross-sectional study using an electronic survey was conducted in Riyadh. The questionnaire was distributed through email among orthopaedic surgeons in Riyadh hospitals. Standardized Nordic questionnaires for the analysis of musculoskeletal symptoms were used. Descriptive measures for categorical and numerical variables were presented. Student’s t-test and Pearson’s χ2 test were used. The level of statistical significance was set at p ≤ 0.05. Results. The response rate was 80.3%, with a total number of 179 of Saudi orthopaedic surgeons (173 males and six females). Of our sample, 67.0% of the respondents complained of having MSK pain. The most commonly reported MSK pain was lower back (74.0%), followed by neck (58.2%). Age and body mass index were implicated in the development of more than one type of MSK pain. Increased years of experience (≥ 6 years) was linked to shoulder/elbow, lower back, and hip/thigh pain. Smoking is widely associated with lower back pain development, whereas physicians who do not smoke and exercise regularly reported fewer pain incidences. Excessive bending and twisting during daily practice have been correlated with increased neck pain. Conclusion. MSK pain was found to be common among Saudi orthopaedic surgeons. Further extensive research should be conducted to understand and analyze the risk factors involved and search for possible improvements to avoid further complications. However, ergonomics education during surgical training could be effective at modifying behaviors and reducing MSK pain manifestations

Aims. The current global pandemic due to COVID-19 is generating significant burden on the health service in the UK. On 23 March 2020, the UK government issued requirements for a national lockdown. The aim of this multicentre study is to gain a greater understanding of the impact lockdown has had on the rates, mechanisms and types of injuries together with their management across a regional trauma service. Methods. Data was collected from an adult major trauma centre, paediatric major trauma centre, district general hospital, and a regional hand trauma unit. Data collection included patient demographics, injury mechanism, injury type and treatment required. Time periods studied corresponded with the two weeks leading up to lockdown in the UK, two weeks during lockdown, and the same two-week period in 2019. Results. There was a 55.7% (12,935 vs 5,733) reduction in total accident and emergency (A&E) attendances with a 53.7% (354 vs 164) reduction in trauma admissions during lockdown compared to 2019. The number of patients with fragility fractures requiring admission remained constant (32 patients in 2019 vs 31 patients during lockdown; p > 0.05). Road traffic collisions (57.1%, n = 8) were the commonest cause of major trauma admissions during lockdown. There was a significant increase in DIY related-hand injuries (26% (n = 13)) lockdown vs 8% (n = 11 in 2019, p = 0.006) during lockdown, which resulted in an increase in nerve injuries (12% (n = 6 in lockdown) vs 2.5% (n = 3 in 2019, p = 0.015) and hand infections (24% (n = 12) in lockdown vs 6.2% (n = 8) in 2019, p = 0.002). Conclusion. The national lockdown has dramatically reduced orthopaedic trauma admissions. The incidence of fragility fractures requiring surgery has not changed. Appropriate provision in theatres should remain in place to ensure these patients can be managed as a surgical priority. DIY-related hand injuries have increased which has led to an increased in nerve injuries requiring intervention

Aims. This study aimed to identify patients receiving total hip arthroplasty (THA) for trauma during the peak of the COVID-19 pandemic in the UK and quantify the risks of contracting SARS-CoV-2 virus, the proportion of patients requiring treatment in an intensive care unit (ICU), and rate of complications including mortality. Methods. All patients receiving a primary THA for trauma in four regional hospitals were identified for analysis during the period 1 March to 1 June 2020, which covered the current peak of the COVID-19 pandemic in the UK. Results. Overall, one of 48 patients (2%) contracted COVID-19 during their admission. Although they required a protracted stay in hospital, they did not require ICU treatment. Two patients did require ICU support for medical problems but not relating to COVID-19. Complications were no greater than expected given the short follow-up. There were no mortalities. Conclusion. There is a paucity of evidence to guide restarting elective joint arthroplasties following the COVID-19 pandemic. Although THAs for trauma are by no means a perfect surrogate, the results of this study show a low incidence of contracting COVID-19 virus during admission and no significant sequalae during this period. Cite this article: Bone Joint Open 2020;1-7:438–442

Aims. The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods. A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database. All patients who underwent primary TKA or THA between January 2012 and December 2017 were identified and stratified based upon hematocrit level. In this analysis, we defined anaemia as packed cell volume (Hct) < 36% for women and < 39% for men, and further stratified anaemia as mild anaemia (Hct 33% to 36% for women, Hct 33% to 39% for men), and moderate to severe (Hct < 33% for both men and women). Univariate and multivariate analyses were used to evaluate the incidence of multiple adverse events within 30 days of arthroplasty. Results. Following adjustment, patients in the THA cohort with moderate to severe anaemia had an increased odds of 6.194 (95% confidence interval (CI) 5.679 to 6.756; p < 0.001) for developing any postoperative complication. Following adjustment, patients in the TKA cohort with moderate to severe anaemia had an increased odds of 5.186 (95% CI 4.811 to 5.590; p < 0.001) for developing any postoperative complication. Among both cohorts, as severity increased, there was an increased risk of postoperative complications. Conclusion. Preoperative anaemia is a risk factor for complications following primary arthroplasty. There is a significant relationship between the severity of anaemia and the odds of postoperative complications. Patients who had moderate to severe anaemia were at increased risk of developing postoperative complications relative to patients with mild anaemia. When considering elective primary THA or TKA in a moderately or severely anaemic patient, surgeons should strongly consider correcting anaemia prior to surgery if possible. Cite this article: Bone Joint J 2020;102-B(4):485–494

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There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019.

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The aim of this study was to surveil whether the standard operating procedure created for the NHS Golden Jubilee sufficiently managed COVID-19 risk to allow safe resumption of elective orthopaedic surgery.

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Limb-lengthening nails have largely replaced external fixation in limb-lengthening and reconstructive surgery. However, the adverse events and high prevalence of radiological changes recently noted with the STRYDE lengthening nail have raised concerns about the use of internal lengthening nails. The aim of this study was to compare the prevalence of radiological bone abnormalities between STRYDE, PRECICE, and FITBONE nails prior to nail removal.

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Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements.

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The new COVID-19 variant was reported by the authorities of the UK to the World Health Organization (WHO) on 14 December 2020. We aim to describe the clinical characteristics and nosocomial infection rates in major trauma and orthopaedic patients comparing the first and second wave of COVID-19 infection.

Aims

This study aims to enhance understanding of clinical and radiological consequences and involved mechanisms that led to corrosion of the Precice Stryde (Stryde) intramedullary lengthening nail in the post market surveillance era of the device. Between 2018 and 2021 more than 2,000 Stryde nails have been implanted worldwide. However, the outcome of treatment with the Stryde system is insufficiently reported.

Aims

Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites.

This population-based study investigated the incidence and trends in venous thromboembolic disease after total hip and knee arthroplasty over a ten-year period. Death or readmission for venous thromboembolic disease up to two years after surgery for all patients in Scotland was the primary outcome. The incidence of venous thromboembolic disease, including fatal pulmonary embolism, three months after surgery was 2.27% for primary hip arthroplasty and 1.79% for total knee arthroplasty. The incidence of fatal pulmonary embolism within three months was 0.22% for total hip arthroplasty and 0.15% for total knee arthroplasty. The majority of events occurred after hospital discharge, with no apparent trend over the period. The data support current advice that prophylaxis should be continued for at least six weeks following surgery. Despite the increased use of policies for prophylaxis and earlier mobilisation, there has been no change in the incidence of venous thromboembolic disease

Recent recommendations by the National Institute for Health and Care Excellence (NICE) suggest that all patients undergoing elective orthopaedic surgery should be assessed for the risk of venous thromboembolism (VTE). Little is known about the incidence of symptomatic VTE after elective external fixation. We studied a consecutive series of adult patients who had undergone elective Ilizarov surgery without routine pharmacological prophylaxis to establish the incidence of symptomatic VTE. . A review of a prospectively maintained database of consecutive patients who were treated between October 1998 and February 2011 identified 457 frames in 442 adults whose mean age was 42.6 years (16.0 to 84.6). There were 425 lower limb and 32 upper limb frames. The mean duration of treatment was 25.7 weeks (1.6 to 85.3). According to NICE guidelines all the patients had at least one risk factor for VTE, 246 had two, 172 had three and 31 had four or more. . One patient (0.23%) developed a pulmonary embolus after surgery and was later found to have an inherited thrombophilia. There were 27 deaths, all unrelated to VTE. The cost of providing VTE prophylaxis according to NICE guidelines in this group of patients would be £89 493.40 (£195.80 per patient) even if the cheapest recommended medication was used. . The rate of symptomatic VTE after Ilizarov surgery was low despite using no pharmacological prophylaxis. This study leads us to question whether NICE guidelines are applicable to these patients. . Cite this article: Bone Joint J 2014;96-B:426–30

Aims

The risk to patients and healthcare workers of resuming elective orthopaedic surgery following the peak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been difficult to quantify. This has prompted governing bodies to adopt a cautious approach that may be impractical and financially unsustainable. The lack of evidence has made it impossible for surgeons to give patients an informed perspective of the consequences of elective surgery in the presence of SARS-CoV-2. This study aims to determine, for the UK population, the probability of a patient being admitted with an undetected SARS-CoV-2 infection and their resulting risk of death; taking into consideration the current disease prevalence, reverse transcription-polymerase chain reaction (RT-PCR) testing, and preassessment pathway.

Aims

To assess the impact of the declaration of the state of emergency due to the COVID-19 pandemic on the number of visits to a traumatology emergency department (ED), and on their severity.

Aims

The primary aim was to assess the rate of patient deferral of elective orthopaedic surgery and whether this changed with time during the coronavirus disease 2019 (COVID-19) pandemic. The secondary aim was to explore the reasons why patients wanted to defer surgery and what measures/circumstances would enable them to go forward with surgery.

We conducted a randomised, controlled trial to determine whether changing gloves at specified intervals can reduce the incidence of glove perforation and contamination in total hip arthroplasty. A total of 50 patients were included in the study. In the study group (25 patients), gloves were changed at 20-minute intervals or prior to cementation. In the control group (25 patients), gloves were changed prior to cementation. In addition, gloves were changed in both groups whenever there was a visible puncture. Only outer gloves were investigated. Contamination was tested by impression of gloved fingers on blood agar and culture plates were subsequently incubated at 37°C for 48 hours. The number of colonies and types of organisms were recorded. Glove perforation was assessed using the water test. The incidence of perforation and contamination was significantly lower in the study group compared with the control group. Changing gloves at regular intervals is an effective way to decrease the incidence of glove perforation and bacterial contamination during total hip arthroplasty

Introduction

The aim of this study is to report the 30 day COVID-19 related morbidity and mortality of patients assessed as SARS-CoV-2 negative who underwent emergency or urgent orthopaedic surgery in the NHS during the peak of the COVID-19 pandemic.

Aims

The safe resumption of elective orthopaedic surgery following the peak of the COVID-19 pandemic remains a significant challenge. A number of institutions have developed a COVID-free pathway for elective surgery patients in order to minimize the risk of viral transmission. The aim of this study is to identify the perioperative viral transmission rate in elective orthopaedic patients following the restart of elective surgery.

Aims

To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS).

Aims

Elective surgery has been severely curtailed as a result of the COVID-19 pandemic. There is little evidence to guide surgeons in assessing what processes should be put in place to restart elective surgery safely in a time of endemic COVID-19 in the community.

It is unusual, if not unique, for three major research papers concerned with the management of the fractured neck of femur (FNOF) to be published in a short period of time, each describing large prospective randomized clinical trials. These studies were conducted in up to 17 countries worldwide, involving up to 80 surgical centers and include large numbers of patients (up to 2,900) with FNOF. Each article investigated common clinical dilemmas; the first paper comparing total hip arthroplasty versus hemiarthroplasty for FNOF, the second as to whether ‘fast track’ care offers improved clinical outcomes and the third, compares sliding hip with multiple cancellous hip screws. Each paper has been deemed of sufficient quality and importance to warrant publication in The Lancet or the New England Journal of Medicine. Although ‘premier’ journals, they only occationally contain orthopaedic studies and thus may not be routinely read by the busy orthopaedic/surgical clinician of any grade. It is therefore our intention with this present article to accurately summarize and combine the results of all three papers, presenting, in our opinion, the most important clinically relevant facts.

Cite this article: Bone Joint Open 2020;1-6:198–202.

Aims

Healthcare systems have been rapidly restructured to meet COVID-19 demand. Clinicians are working to novel clinical guidelines, treating new patient cohorts and working in unfamiliar environments. Trauma and orthopaedics (T&O) has experienced cancellation of routine clinics and operating, with redistribution of the workload and human resources. To date, no studies have evaluated the mental health impact of these changes on the T&O workforce. We report the results of a novel survey on the impact of the pandemic on the mental health of our orthopaedic workforce and the contributory factors.

Aims

The aim of this study is to determine the effects of the UK lockdown during the COVID-19 pandemic on the orthopaedic admissions, operations, training opportunities, and theatre efficiency in a large district general hospital.

Aims

Europe has found itself at the epicentre of the COVID-19 pandemic. Naturally, this has placed added strain onto healthcare systems internationally. It was feared that the impact of the COVID-19 pandemic could overrun the Irish healthcare system. As such, the Irish government opted to introduce a national lockdown on the 27 March 2020 in an attempt to stem the flow of admissions to hospitals. Similar lockdowns in the UK and New Zealand have resulted in reduced emergency department presentations and trauma admissions. The aim of this study is to assess the effect of the national lockdown on trauma presentations to a model-3 hospital in Dublin, Ireland.

Aims

The use of technology to assess balance and alignment during total knee surgery can provide an overload of numerical data to the surgeon. Meanwhile, this quantification holds the potential to clarify and guide the surgeon through the surgical decision process when selecting the appropriate bone recut or soft tissue adjustment when balancing a total knee. Therefore, this paper evaluates the potential of deploying supervised machine learning (ML) models to select a surgical correction based on patient-specific intra-operative assessments.

Aims. Computer hexapod assisted orthopaedic surgery (CHAOS), is a method to achieve the intra-operative correction of long bone deformities using a hexapod external fixator before definitive internal fixation with minimally invasive stabilisation techniques. The aims of this study were to determine the reliability of this method in a consecutive case series of patients undergoing femoral deformity correction, with a minimum six-month follow-up, to assess the complications and to define the ideal group of patients for whom this treatment is appropriate. Patients and Methods. The medical records and radiographs of all patients who underwent CHAOS for femoral deformity at our institution between 2005 and 2011 were retrospectively reviewed. Records were available for all 55 consecutive procedures undertaken in 49 patients with a mean age of 35.6 years (10.9 to 75.3) at the time of surgery. Results. Patients were assessed at a mean interval of 44 months (6 to 90) following surgery. The indications were broad; the most common were vitamin D resistant rickets (n = 10), growth plate arrest (n = 6) and post-traumatic deformity (n = 20). Multi-planar correction was required in 33 cases. A single level osteotomy was performed in 43 cases. Locking plates were used to stabilise the osteotomy in 33 cases and intramedullary nails in the remainder. Complications included two nonunions, one death, one below-knee deep vein thrombosis, one deep infection and one revision procedure due to initial under-correction. There were no neurovascular injuries or incidence of compartment syndrome. Conclusion. This is the largest reported series of femoral deformity corrections using the CHAOS technique. This series demonstrates that precise intra-operative realignment is possible with a hexapod external fixator prior to definitive stabilisation with contemporary internal fixation. This combination allows reproducible correction of complex femoral deformity from a wide variety of diagnoses and age range with a low complication rate. Cite this article: Bone Joint J 2017;99-B:283–8

Fresh-frozen allograft bone is frequently used in orthopaedic surgery. We investigated the incidence of allograft-related infection and analysed the outcomes of recipients of bacterial culture-positive allografts from our single-institute bone bank during bone transplantation. The fresh-frozen allografts were harvested in a strict sterile environment during total joint arthroplasty surgery and immediately stored in a freezer at -78º to -68º C after packing. Between January 2007 and December 2012, 2024 patients received 2083 allografts with a minimum of 12 months of follow-up. The overall allograft-associated infection rate was 1.2% (24/2024). Swab cultures of 2083 allografts taken before implantation revealed 21 (1.0%) positive findings. The 21 recipients were given various antibiotics at the individual orthopaedic surgeon’s discretion. At the latest follow-up, none of these 21 recipients displayed clinical signs of infection following treatment. Based on these findings, we conclude that an incidental positive culture finding for allografts does not correlate with subsequent surgical site infection. Additional prolonged post-operative antibiotic therapy may not be necessary for recipients of fresh-frozen bone allograft with positive culture findings. Cite this article: Bone Joint J 2015;97-B:427–31

We performed a prospective, blind, controlled study on wound infection after implant surgery involving 41 procedures in patients infected with the human immunodeficiency virus (HIV) and 141 in HIV-negative patients. The patients were staged clinically and the CD4 cell count determined. Wound infection was assessed using the asepsis wound score. A risk category was allocated to account for presurgical contamination. In HIV-positive patients, with no preoperative contamination, the incidence of wound infection (3.5%) was comparable with that of the HIV-negative group (5%; p = 0.396). The CD4 cell count did not affect the incidence of infection (r = 0.16). When there was preoperative contamination, the incidence of infection in HIV-positive patients increased markedly (42%) compared with that in HIV-negative patients (11%; p = 0.084). Our results show that when no contamination has occurred implant surgery may be undertaken safely in HIV-positive patients

We examined the rates of infection and colonisation by methicillin-resistant Staphylococcus aureus (MRSA) between January 2003 and May 2004 in order to assess the impact of the introduction of an MRSA policy in October 2003, which required all admissions to be screened. Emergency admissions were treated prophylactically and elective beds ring-fenced. A total of 5594 admissions were cross-referenced with 22 810 microbiology results. The morbidity, mortality and cost of managing MRSA-carrying patients, with a proximal fracture of the femur were compared, in relation to age, gender, American Society of Anaesthesiologists grade and residential status, with a group of matched controls who were MRSA-negative. In 2004, we screened 1795 of 1796 elective admissions and MRSA was found in 23 (1.3%). We also screened 1122 of 1447 trauma admissions and 43 (3.8%) were carrying MRSA. All ten ward transfers were screened and four (40%) were carriers (all p < 0.001). The incidence of MRSA in trauma patients increased by 2.6% per week of inpatient stay (r = 0.97, p < 0.001). MRSA developed in 2.9% of trauma and 0.2% of elective patients during that admission (p < 0.001). The implementation of the MRSA policy reduced the incidence of MRSA infection by 56% in trauma patients (1.57% in 2003 (17 of 1084) to 0.69% in 2004 (10 of 1447), p = 0.035). Infection with MRSA in elective patients was reduced by 70% (0.56% in 2003 (7 of 1257) to 0.17% in 2004 (3 of 1806), p = 0.06). The cost of preventing one MRSA infection was £3200. Although colonisation by MRSA did not affect the mortality rate, infection by MRSA more than doubled it. Patients with proximal fractures of the femur infected with MRSA remained in hospital for 50 extra days, had 19 more days of vancomycin treatment and 26 more days of vacuum-assisted closure therapy than the matched controls. These additional costs equated to £13 972 per patient. From this experience we have been able to describe the epidemiology of MRSA, assess the impact of infection-control measures on MRSA infection rates and determine the morbidity, mortality and economic cost of MRSA carriage on trauma and elective orthopaedic wards

Aims

The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients.

Lengthening of the humerus is now an established technique. We compared the complications of humeral lengthening with those of femoral lengthening and investigated whether or not the callus formation in the humerus proceeds at a higher rate than that in the femur. A total of 24 humeral and 24 femoral lengthenings were performed on 12 patients with achondroplasia. We measured the pixel value ratio (PVR) of the lengthened area on radiographs and each radiograph was analysed for the shape, type and density of the callus. The quality of life (QOL) of the patients after humeral lengthening was compared with that prior to surgery. The complication rate per segment of humerus and femur was 0.87% and 1.37%, respectively. In the humerus the PVR was significantly higher than that of the femur. Lower limbs were associated with an increased incidence of concave, lateral and central callus shapes. Humeral lengthening had a lower complication rate than lower-limb lengthening, and QOL increased significantly after humeral lengthening. Callus formation in the humerus during the distraction period proceeded at a significantly higher rate than that in the femur. . These findings indicate that humeral lengthening has an important role in the management of patients with achondroplasia

Over a two-year period, 265 Norwegian orthopaedic surgeons working at 71 institutions performed 63 484 operations under a tourniquet. Their replies to a questionnaire revealed that they mostly followed modern guidelines in their use of the tourniquet. Most felt that the tourniquet could be left on for two hours, and that it could be re-applied after 15 minutes. A total of 26 complications (one in 2442 operations) that might have been due to the tourniquet were reported, of which 15 were neurological. Three were in the upper limb (one in 6155 operations) and 12 in the lower limb (one in 3752 operations). Two were permanent (one in 31742 operations), but the remainder resolved within six months. One permanent and one transient complication occurred after tourniquet times of three hours. The incidence of tourniquet complications is still at least as high as that estimated in the 1970s

We present a retrospective review of a single-surgeon series of 30 consecutive lengthenings in 27 patients with congenital short femur using the Ilizarov technique performed between 1994 and 2005. The mean increase in length was 5.8 cm/18.65% (3.3 to 10.4, 9.7% to 48.8%), with a mean time in the frame of 223 days (75 to 363). By changing from a distal to a proximal osteotomy for lengthening, the mean range of knee movement was significantly increased from 98.1° to 124.2° (p = 0.041) and there was a trend towards a reduced requirement for quadricepsplasty, although this was not statistically significant (p = 0.07). The overall incidence of regenerate deformation or fracture requiring open reduction and internal fixation was similar in the distal and proximal osteotomy groups (56.7% and 53.8%, respectively). However, in the proximal osteotomy group, pre-placement of a Rush nail reduced this rate from 100% without a nail to 0% with a nail (p < 0.001). When comparing a distal osteotomy with a proximal one over a Rush nail for lengthening, there was a significant decrease in fracture rate from 58.8% to 0% (p = 0.043). We recommend that in this group of patients lengthening of the femur with an Ilizarov construct be carried out through a proximal osteotomy over a Rush nail. Lengthening should also be limited to a maximum of 6 cm during one treatment, or 20% of the original length of the femur, in order to reduce the risk of complications

Aims

This study aimed to assess the performance of an automated multiplex polymerase chain reaction (mPCR) technique for rapid diagnosis of native joint septic arthritis

Over a 13-year period we studied all patients who underwent major hip and knee surgery and were diagnosed with objectively confirmed symptomatic venous thromboembolism, either deep venous thrombosis or non-fatal pulmonary embolism, within six months after surgery. Low-molecular-weight heparin had been given while the patients were in hospital. There were 5607 patients. The cumulative incidence of symptomatic venous thromboembolism was 2.7% (150 of 5607), of which 1.1% had developed pulmonary embolism, 1.5% had deep venous thrombosis and 0.6% had both. Patients presented with deep venous thrombosis at a median of 24 days and pulmonary embolism at 17 days after surgery for hip fracture. After total hip replacement, deep venous thrombosis and pulmonary embolism occurred at a median of 21 and 34 days respectively. After total knee replacement, the median time to the presentation of deep venous thrombosis and pulmonary embolism was 20 and 12 days respectively. The cumulative risk of venous thromboembolism lasted for up to three months after hip surgery and for one month after total knee replacement. Venous thromboembolism was diagnosed after discharge from hospital in 70% of patients who developed this complication. Despite hospital-based thromboprophylaxis, most cases of clinical venous thromboembolism occur after discharge and at different times according to the operation performed

A two-year retrospective survey in southern Ethiopia revealed that 49 amputations had been performed, 25 of which were for gangrene following tight splintage applied by traditional bone setters. The aim of this study was to determine if it was possible to reduce this incidence of gangrene by offering one-day instructional courses to bone setters. In ten separate one-day courses 112 tradition healers attended. In addition, two-day courses were given to local health assistants, who also received written instructions for the safe care of fractures. A two-year prospective study revealed a marked reduction in amputations, from 49 to 25, with only seven rather than 25 being required for gangrene. We found that it is possible to educate traditional healers so that fewer gangrenous limbs require to be amputated

Aims

The aim of this study was to examine the association between postoperative glycaemic variability and adverse outcomes following orthopaedic surgery.

In patients who underwent autogenous iliac bone grafting we studied prospectively injury to the lateral femoral cutaneous nerve (LFCN) in relation to the size (length, depth, width) of the graft. We also examined the neurological deficit, by questioning them about numbness and/or pain in the lateral thigh. The risk of injury was significantly higher in those in whom the depth of the graft was more than 30 mm. With regard to the length of the graft the incidence of nerve injury was 20% when the graft was 45 mm long or more, 16% when it was between 30 mm and 45 mm long, and 8% when it was less than 30 mm long. We should inform patients of the possibility of such injury, and take size into consideration when harvesting grafts from the ilium

There has been an increase in the incidence of bone and joint tuberculosis (BJTB) in The Netherlands and we have carried out an epidemiological study in order to find an explanation for this increase. Data from 1993 to 2000 from The Netherlands Tuberculosis Register (NTR) were used. In 1993 there was a total of 52 patients with BJTB. This figure increased gradually to 80 in 1999 before decreasing to 61 in 2000. There was a total of 12 447 patients with tuberculosis; BJTB was found in 532, accounting for 4.3% of all cases and 10.6% of all extrapulmonary cases. Localisation in the spine occurred in 56%. Certain immigrants, in particular from Somalia, were more likely to have BJTB than other immigrants or the native Dutch population. Increased age and female gender were associated with BJTB. Only 15% of BJTB patients also suffered from pulmonary tuberculosis. The usual long delay in the diagnosis of BJTB may be shortened if physicians are more aware of tuberculosis

Aims

The aim of this paper was to present the clinical features of patients with musculoskeletal sources of methicillin-sensitive Staphylococcus aureus (MSSA) septicaemia.

We have studied prospectively the outcome of wound discharge in patients after arthroplasty of the hip and knee. Over a period of 3.5 years 530 primary arthroplasties were carried out in one hospital. Postoperative wound infections developed in 82. At a mean follow-up of two years a comparison was made between these patients and 82 with healthy wounds, in terms of symptoms and signs of deep infection. There was an incidence of 1.1% of early deep infection, within six weeks in all cases. The rate of ‘superficial’ infection was 17.3% in the hips, 10.5% in the knees and 14.3% in total. At a mean follow-up of 26 months, there were no significant differences between the patients with infected wounds and a matched group of patients with healthy wounds in terms of the ESR, level of C-reactive protein, white cell count and radiological scores, but clinical scores were significantly worse in the patients with infected knees (p < 0.05). The length of stay was also significantly longer in this group (mean 14.6 days in the healthy wound group, 19 days in the problem group; p < 0.005). There was, however, no convincing evidence that these wound infections led to deep infection and early revision in the early to medium follow-up period. A larger and longer prospective trial would be necessary to shed more light on this potential problem

Aims

Diabetes mellitus is the most common co-morbidity associated with necrotising fasciitis. This study aims to compare the clinical presentation, investigations, Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score, microbiology and outcome of management of this condition in diabetic and non-diabetic patients.

Aims

Smoking is associated with post-operative complications but smokers often under-report the amount they smoke. Our objective was to determine whether a urine dipstick test could be used as a substitute for quantitative cotinine assays to determine smoking status in patients.

Periprosthetic joint infection (PJI) complicates between 0.5% and 1.2% primary total hip arthroplasties (THAs) and may have devastating consequences. The traditional assessment of patients suffering from PJI has involved the serological study of inflammatory markers and microbiological analysis of samples obtained from the joint space. Treatment has involved debridement and revision arthroplasty performed in either one or two stages.

We present an update on the burden of PJI, strategies for its diagnosis and treatment, the challenge of resistant organisms and the need for definitive evidence to guide the treatment of PJI after THA.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):27–30.

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.

External fixation is widely used in orthopaedic and trauma surgery. Infections around pin or wire sites, which are usually localised, non-invasive, and are easily managed, are common. Occasionally, more serious invasive complications such as necrotising fasciitis (NF) and toxic shock syndrome (TSS) may occur.

We retrospectively reviewed all patients who underwent external fixation between 1997 and 2012 in our limb lengthening and reconstruction programme. A total of eight patients (seven female and one male) with a mean age of 20 years (5 to 45) in which pin/wire track infections became limb- or life-threatening were identified. Of these, four were due to TSS and four to NF. Their management is described. A satisfactory outcome was obtained with early diagnosis and aggressive medical and surgical treatment.

Clinicians caring for patients who have external fixation and in whom infection has developed should be aware of the possibility of these more serious complications. Early diagnosis and aggressive treatment are required in order to obtain a satisfactory outcome.

Cite this article: Bone Joint J 2015;97-B:1296–1300.

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.

Drug therapy forms an integral part of the management of many orthopaedic conditions. However, many medicines can produce serious adverse reactions if prescribed inappropriately, either alone or in combination with other drugs. Often these hazards are not appreciated. In response to this, the European Union recently issued legislation regarding safety measures which member states must adopt to minimise the risk of errors of medication.

In March 2014 the Medicines and Healthcare products Regulatory Agency and NHS England released a Patient Safety Alert initiative focussed on errors of medication. There have been similar initiatives in the United States under the auspices of The National Coordinating Council for Medication Error and The Joint Commission on the Accreditation of Healthcare Organizations. These initiatives have highlighted the importance of informing and educating clinicians.

Here, we discuss common drug interactions and contra-indications in orthopaedic practice. This is germane to safe and effective clinical care.

Cite this article: Bone Joint J 2015;97-B:434–41.

The use of robots in orthopaedic surgery is an emerging field that is gaining momentum. It has the potential for significant improvements in surgical planning, accuracy of component implantation and patient safety. Advocates of robot-assisted systems describe better patient outcomes through improved pre-operative planning and enhanced execution of surgery. However, costs, limited availability, a lack of evidence regarding the efficiency and safety of such systems and an absence of long-term high-impact studies have restricted the widespread implementation of these systems. We have reviewed the literature on the efficacy, safety and current understanding of the use of robotics in orthopaedics.

Cite this article: Bone Joint J 2015; 97-B:292–9.

Implant-associated infection is a major source of morbidity in orthopaedic surgery. There has been extensive research into the development of materials that prevent biofilm formation, and hence, reduce the risk of infection. Silver nanoparticle technology is receiving much interest in the field of orthopaedics for its antimicrobial properties, and the results of studies to date are encouraging. Antimicrobial effects have been seen when silver nanoparticles are used in trauma implants, tumour prostheses, bone cement, and also when combined with hydroxyapatite coatings. Although there are promising results with in vitro and in vivo studies, the number of clinical studies remains small. Future studies will be required to explore further the possible side effects associated with silver nanoparticles, to ensure their use in an effective and biocompatible manner. Here we present a review of the current literature relating to the production of nanosilver for medical use, and its orthopaedic applications.

Cite this article: Bone Joint J 2015; 97-B:582–9.

Non-tuberculous mycobacterial (NTM) infection of the musculoskeletal tissue is a rare disease. An early and accurate diagnosis is often difficult because of the indolent clinical course and difficulty of isolating pathogens. Our goal was to determine the clinical features of musculoskeletal NTM infection and to present the treatment outcomes. A total of 29 patients (nine females, 20 males between 34 and 85 years old, mean age 61.7 years; 34 to 85) with NTM infection of the musculoskeletal system between 1998 to 2011 were identified and their treatment retrospectively analysed. Microbiological studies demonstrated NTM in 29 patients: the isolates were Mycobacterium intracellulare in six patients, M. fortuitum in three, M. abscessus in two and M. marinum in one. In the remaining patients we failed to identify the species. The involved sites were the hand/wrist in nine patients the knee in five patients, spine in four patients, foot in two patients, elbow in two patients, shoulder in one, ankle in two patients, leg in three patients and multiple in one patient. The mean interval between the appearance of symptoms and diagnosis was 20.8 months (1.5 to 180). All patients underwent surgical treatment and antimicrobial medication according to our protocol for chronic musculoskeletal infection: 20 patients had NTM-specific medication and nine had conventional antimicrobial therapy. At the final follow-up 22 patients were cured, three failed to respond to treatment and four were lost to follow-up. Identifying these diseases due the initial non-specific presentation can be difficult. Treatment consists of surgical intervention and adequate antimicrobial therapy, which can result in satisfactory outcomes.

Cite this article: Bone Joint J 2014;96-B:1561–5.

We compared the use of broth culture medium for samples taken in theatre with the standard practice of placing tissue samples in universal containers. A total of 67 consecutive patients had standard multiple samples of deep tissue harvested at surgery and distributed equally in theatre either to standard universal containers or to broth culture medium. These samples were cultured by direct and enrichment methods. The addition of broth in theatre to standard practice led to an increase in sensitivity from 83% to 95% and an increase in negative predictive value from 77% to 91%. Placing tissue samples directly into broth in the operating theatre is a simple, inexpensive way to increase the sensitivity of cultures from infected patients, and does not appear to compromise the specificity of these cultures.

Cite this article: Bone Joint J 2014;96-B:1566–70.

There has been an in increase in the availability of effective biological agents for the treatment of rheumatoid arthritis as well as a shift towards early diagnosis and management of the inflammatory process. This article explores the impact this may have on the place of orthopaedic surgery in the management of patients with rheumatoid arthritis.

Cite this article: Bone Joint J 2014;96-B:1287–9

Tendinopathy is a debilitating musculoskeletal condition which can cause significant pain and lead to complete rupture of the tendon, which often requires surgical repair. Due in part to the large spectrum of tendon pathologies, these disorders continue to be a clinical challenge. Animal models are often used in this field of research as they offer an attractive framework to examine the cascade of processes that occur throughout both tendon pathology and repair. This review discusses the structural, mechanical, and biological changes that occur throughout tendon pathology in animal models, as well as strategies for the improvement of tendon healing.

Cite this article: Bone Joint Res 2014;3:193–202.

This article presents an overview of mycetoma and offers guidelines for orthopaedic surgeons who may be involved in the care of patients with this condition.

Cite this article: Bone Joint J 2014;96-B:420–5.

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 evaluated the quality of guidelines on thromboprophylaxis in orthopaedic surgery by examining how they adhere to validated methodological standards in their development. A structured review was performed for guidelines that were published between January 2005 and April 2013 in medical journals or on the Internet. A pre-defined computerised search was used in MEDLINE, Scopus and Google to identify the guidelines. The AGREE II assessment tool was used to evaluate the quality of the guidelines in the study.

Seven international and national guidelines were identified. The overall methodological quality of the individual guidelines was good. ‘Scope and Purpose’ (median score 98% interquartile range (IQR)) 86% to 98%) and ‘Clarity of Presentation’ (median score 90%, IQR 90% to 95%) were the two domains that received the highest scores. ‘Applicability’ (median score 68%, IQR 45% to 75%) and ‘Editorial Independence’ (median score 71%, IQR 68% to 75%) had the lowest scores.

These findings reveal that although the overall methodological quality of guidelines on thromboprophylaxis in orthopaedic surgery is good, domains within their development, such as ‘Applicability’ and ‘Editorial Independence’, need to be improved. Application of the AGREE II instrument by the authors of guidelines may improve the quality of future guidelines and provide increased focus on aspects of methodology used in their development that are not robust.

Cite this article: Bone Joint J 2014;96-B:19–23.

We performed a systematic review and meta-analysis to compare the efficacy of intermittent mechanical compression combined with pharmacological thromboprophylaxis, against either mechanical compression or pharmacological prophylaxis in preventing deep-vein thrombosis (DVT) and pulmonary embolism in patients undergoing hip or knee replacement. A total of six randomised controlled trials, evaluating a total of 1399 patients, were identified. In knee arthroplasty, the rate of DVT was reduced from 18.7% with anticoagulation alone to 3.7% with combined modalities (risk ratio (RR) 0.27, p = 0.03; number needed to treat: seven). There was moderate, albeit non-significant, heterogeneity (I² = 42%). In hip replacement, there was a non-significant reduction in DVT from 8.7% with mechanical compression alone to 7.2% with additional pharmacological prophylaxis (RR 0.84) and a significant reduction in DVT from 9.7% with anticoagulation alone to 0.9% with additional mechanical compression (RR 0.17, p < 0.001; number needed to treat: 12), with no heterogeneity (I² = 0%). The included studies had insufficient power to demonstrate an effect on pulmonary embolism.

We conclude that the addition of intermittent mechanical leg compression augments the efficacy of anticoagulation in preventing DVT in patients undergoing both knee and hip replacement. Further research on the role of combined modalities in thromboprophylaxis in joint replacement and in other high-risk situations, such as fracture of the hip, is warranted.

Hyaline articular cartilage has been known to be a troublesome tissue to repair once damaged. Since the introduction of autologous chondrocyte implantation (ACI) in 1994, a renewed interest in the field of cartilage repair with new repair techniques and the hope for products that are regenerative have blossomed. This article reviews the basic science structure and function of articular cartilage, and techniques that are presently available to effect repair and their expected outcomes.

Osteoporosis is common and the health and financial cost of fragility fractures is considerable. The burden of cardiovascular disease has been reduced dramatically by identifying and targeting those most at risk. A similar approach is potentially possible in the context of fragility fractures. The World Health Organization created and endorsed the use of FRAX, a fracture risk assessment tool, which uses selected risk factors to calculate a quantitative, patient-specific, ten-year risk of sustaining a fragility fracture. Treatment can thus be based on this as well as on measured bone mineral density. It may also be used to determine at-risk individuals, who should undergo bone densitometry. FRAX has been incorporated into the national osteoporosis guidelines of countries in the Americas, Europe, the Far East and Australasia. The United Kingdom National Institute for Health and Clinical Excellence also advocates its use in their guidance on the assessment of the risk of fragility fracture, and it may become an important tool to combat the health challenges posed by fragility fractures.

We report the results of six trauma and orthopaedic projects to Kenya in the last three years. The aims are to deliver both a trauma service and teaching within two hospitals; one a district hospital near Mount Kenya in Nanyuki, the other the largest public hospital in Kenya in Mombasa. The Kenya Orthopaedic Project team consists of a wide range of multidisciplinary professionals that allows the experience to be shared across those specialties. A follow-up clinic is held three months after each mission to review the patients. To our knowledge there are no reported outcomes in the literature for similar projects.

A total of 211 operations have been performed and 400 patients seen during the projects. Most cases were fractures of the lower limb; we have been able to follow up 163 patients (77%) who underwent surgical treatment. We reflect on the results so far and discuss potential improvements for future missions.

The objective of this study was to determine the effectiveness of screening and successful treatment of methicillin-resistant Staphylococcus aureus (MRSA) colonisation in elective orthopaedic patients on the subsequent risk of developing a surgical site infection (SSI) with MRSA.

We screened 5933 elective orthopaedic in-patients for MRSA at pre-operative assessment. Of these, 108 (1.8%) were colonised with MRSA and 90 subsequently underwent surgery. Despite effective eradication therapy, six of these (6.7%) had an SSI within one year of surgery. Among these infections, deep sepsis occurred in four cases (4.4%) and superficial infection in two (2.2%). The responsible organism in four of the six cases was MRSA. Further analysis showed that patients undergoing surgery for joint replacement of the lower limb were at significantly increased risk of an SSI if previously colonised with MRSA.

We conclude that previously MRSA-colonised patients undergoing elective surgery are at an increased risk of an SSI compared with other elective patients, and that this risk is significant for those undergoing joint replacement of the lower limb. Furthermore, when an infection occurs, it is likely to be due to MRSA.

The most frequent cause of failure after total hip replacement in all reported arthroplasty registries is peri-prosthetic osteolysis. Osteolysis is an active biological process initiated in response to wear debris. The eventual response to this process is the activation of macrophages and loss of bone.

Activation of macrophages initiates a complex biological cascade resulting in the final common pathway of an increase in osteolytic activity. The biological initiators, mechanisms for and regulation of this process are beginning to be understood. This article explores current concepts in the causes of, and underlying biological mechanism resulting in peri-prosthetic osteolysis, reviewing the current basic science and clinical literature surrounding the topic.

Femoral lengthening using the Intramedullary Skeletal Kinetic Distractor is a new technique. However, with intramedullary distraction the surgeon has less control over the lengthening process. Therefore, 33 femora lengthened with this device were assessed to evaluate the effect of operative variables under the surgeon’s control on the course of lengthening. The desired lengthening was achieved in 32 of 33 limbs. Problems encountered included difficulty in achieving length in eight femora (24%) and uncontrolled lengthening in seven (21%). Uncontrolled lengthening was more likely if the osteotomy was placed with less than 80 mm of the thick portion of the nail in the distal fragment (p = 0.052), and a failure to lengthen was more likely if there was over 125 mm in the distal fragment (p = 0.008). The latter problem was reduced with over-reaming by 2.5 mm to 3 mm. Previous intramedullary nailing also predisposed to uncontrolled lengthening (p = 0.042), and these patients required less reaming.

Using the Intramedullary Skeletal Kinetic Distractor, good outcomes were obtained; problems were minimised by optimising the position of the osteotomy and the amount of over-reaming performed.

This study was undertaken to evaluate the safety and efficacy of retrievable inferior vena cava filters in high-risk orthopaedic patients. A total of 58 patients had a retrievable inferior vena cava filter placed as an adjunct to chemical and mechanical prophylaxis, most commonly for a history of previous deep-vein thrombosis or pulmonary embolism, polytrauma, or expected prolonged immobilisation. In total 56 patients (96.6%) had an uncomplicated post-operative course. Two patients (3.4%) died in the peri-operative period for unrelated reasons.

Of the 56 surviving patients, 50 (89%) were available for follow-up. A total of 32 filters (64%) were removed without complication at a mean of 37.8 days (4 to 238) after placement. There were four filters (8%) which were retained because of thrombosis at the filter site, and four (8%) were retained because of incorporation of the filter into the wall of the inferior vena cava. In ten cases (20%) the retrievable filter was left in place to continue as primary prophylaxis. No patient had post-removal thromboembolic complications.

A retrievable inferior vena cava filter, as an adjunct to chemical and mechanical prophylaxis, was a safe and effective means of reducing the acute risk of pulmonary embolism in this high-risk group of patients. Although most filters were removed without complications, thereby avoiding the long-term complications that have plagued permanent indwelling filters, a relatively high percentage of filters had to be left in situ.

Severe acute respiratory syndrome (SARS) is a newly described infectious disease caused by the SARS coronavirus which attacks the immune system and pulmonary epithelium. It is treated with regular high doses of corticosteroids. Our aim was to determine the relationship between the dosage of steroids and the number and distribution of osteonecrotic lesions in patients treated with steroids during the SARS epidemic in Beijing, China in 2003.

We identified 114 patients for inclusion in the study. Of these, 43 with osteonecrosis received a significantly higher cumulative and peak methylprednisolone-equivalent dose than 71 patients with no osteonecrosis identified by MRI. We confirmed that the number of osteonecrotic lesions was directly related to the dosage of steroids and that a very high dose, a peak dose of more than 200 mg or a cumulative methylprednisolone-equivalent dose of more than 4000 mg, is a significant risk factor for multifocal osteonecrosis with both epiphyseal and diaphyseal lesions. Patients with diaphyseal osteonecrosis received a significantly higher cumulative methylprednisolone-equivalent dose than those with epiphyseal osteonecrosis. Multifocal osteonecrosis should be suspected if a patient is diagnosed with osteonecrosis in the shaft of a long bone.

As of April 2010 all NHS institutions in the United Kingdom are required to publish data on surgical site infection, but the method for collecting this has not been decided. We examined 7448 trauma and orthopaedic surgical wounds made in patients staying for at least two nights between 2000 and 2008 at our institution and calculated the rate of surgical site infection using three definitions: the US Centers for Disease Control, the United Kingdom Nosocomial Infection National Surveillance Scheme and the ASEPSIS system. On the same series of wounds, the infection rate with outpatient follow-up according to Centre for Disease Control was 15.45%, according to the UK Nosocomial infection surveillance was 11.32%, and according to ASEPSIS was 8.79%. These figures highlight the necessity for all institutions to use the same method for diagnosing surgical site infection.

If different methods are used, direct comparisons will be invalid and published rates of infection will be misleading.

Injury to the sciatic nerve is one of the more serious complications of acetabular fracture and traumatic dislocation of the hip, both in the short and long term. We have reviewed prospectively patients, treated in our unit, for acetabular fractures who had concomitant injury to the sciatic nerve, with the aim of predicting the functional outcome after these injuries.

Of 136 patients who underwent stabilisation of acetabular fractures, there were 27 (19.9%) with neurological injury. At initial presentation, 13 patients had a complete foot-drop, ten had weakness of the foot and four had burning pain and altered sensation over the dorsum of the foot. Serial electromyography (EMG) studies were performed and the degree of functional recovery was monitored using the grading system of the Medical Research Council. In nine patients with a foot-drop, there was evidence of a proximal acetabular (sciatic) and a distal knee (neck of fibula) nerve lesion, the double-crush syndrome.

At the final follow-up, clinical examination and EMG studies showed full recovery in five of the ten patients with initial muscle weakness, and complete resolution in all four patients with sensory symptoms (burning pain and hyperaesthesia). There was improvement of functional capacity (motor and sensory) in two patients who presented initially with complete foot-drop. In the remaining 11 with foot-drop at presentation, including all nine with the double-crush lesion, there was no improvement in function at a mean follow-up of 4.3 years.

We report 79 cases of bone and joint tuberculosis between 1988 and 2005, eight of which were in the Caucasian population and 71 in the non-white population.

The diagnosis was made in the majority (73.4%) by positive bacteriology and/or histology. The mean age at the time of diagnosis was higher in the Caucasian group at 51.5 years (28 to 66) than in the South Asian group at 36.85 years (12 to 93). Only one patient had previous BCG immunisation.

The spine was the site most commonly affected (44.3%). Surgical stabilisation and/or decompression was performed in 23% of these cases because of cord compression on imaging or the presence of neurological signs.

A six-month course of chemotherapy comprising of an initial two months of rifampicin, isoniazide, pyrazinamide and sometimes ethambutol followed by four months treatment with rifampicin and isoniazide, was successful in all cases without proven drug resistance.

We have conducted a case-control study over a period of ten years comparing both deep infection with methicillin-resistant staphylococcus aureus (MRSA) and colonised cases with a control group.

Risk factors associated with deep infection were vascular diseases, chronic obstructive pulmonary disease, admission to a high-dependency or an intensive-care unit and open wounds. Those for colonisation were institutional care, vascular diseases and dementia. Older age was a risk factor for any MRSA infection. The length of hospital stay was dramatically increased by deep infection.

These risk factors are useful in identifying higher-risk patients who may be more susceptible to MRSA infection. A strategy of early identification and isolation may help to control its spread in trauma units.

Using a computer-based quality assurance program, we analysed peri-operative data on 160 patients undergoing one-stage bilateral hip or knee arthroplasties under regional anaesthesia with routine anaesthetic monitoring and only using peripheral intravenous access for peri-operative safety. We monitored defined intra-operative adverse events such as hypotension, myocardial ischaemia, arrhythmias, hypovolaemia, hypertension and early post-operative complications. We also determined post-operative hip and knee function, and patient satisfaction with different aspects of the anaesthetic management. Those patients undergoing one-stage bilateral arthroplasties were matched according to a cross-stratification which used three variables (American Society of Anesthesiologists’ physical status scoring system, age and joint replaced) to patients undergoing unilateral hip or knee arthroplasties. Serious intra-operative adverse events were, with the exception of intra-operative hypotension, very infrequent in patients undergoing bilateral (nine adverse events) as well as unilateral arthroplasties (five adverse events). Early post-operative complications were also infrequent in both groups. However, the risks of receiving a heterologous blood transfusion (odds ratio 2.5; 95% confidence interval (CI) 1.3 to 5.0, estimated by exact conditional logistic regression) or vasoactive drugs (odds ratio 3.9; 95% CI 2.0 to 7.8) were significantly greater for patients undergoing bilateral operations. Patient satisfaction with anaesthesia was high; all patients who underwent the one-stage bilateral operation would choose the same anaesthetic technique again.

The Department of Health and the Public Health Laboratory Service established the Nosocomial Infection National Surveillance Scheme in order to standardise the collection of information about infections acquired in hospital in the United Kingdom and provide national data with which hospitals could measure their own performance. The definition of superficial incisional infection (skin and subcutaneous tissue), set by the Center for Disease Control (CDC), should meet at least one of the defined criteria which would confirm the diagnosis and determine the need for specific treatment.

We have assessed the interobserver reliability of the criteria for superficial incisional infection set by the CDC in our current practice. The incisional site of 50 patients who had an elective primary arthroplasty of the hip or knee was evaluated independently by two orthopaedic clinical research fellows and two orthopaedic ward sisters for the presence or absence of surgical-site infection. Interobserver reliability was assessed by comparison of the criteria for wound infection used by the four observers using kappa reliability coefficients. Our study demonstrated that some of the components of the current CDC criteria were unreliable and we recommend their revision.

A series of 14 patients suffering from tuberculosis of the sternum with a mean follow-up of 2.8 years (2 to 3.6) is presented. All were treated with antitubercular therapy: ten with primary therapy, two needed second-line therapy, and two required surgery (debridement). All showed complete healing and no evidence of recurrence at the last follow-up. MRI was useful in making the diagnosis at an early stage because atypical presentations resulting from HIV have become more common. Early adequate treatment with multidrug antitubercular therapy avoided the need for surgery in 12 of our 14 patients.