Aim. Septic arthritis is a painful infection of articular joints that is typically treated by irrigation & debridement along with antibiotic therapy. There is debate amongst the medical community whether antibiotic administration should be delayed until fluid cultures have been taken to improve culture yield. However, delaying antibiotics can also have negative consequences, including joint destruction and sepsis. Therefore, the purposes of this study were to determine: 1) whether delayed antibiotic treatment affects culture yield and prognosis and 2) if the culture yield of patients treated for septic arthritis differs for hip, knee, and shoulder based on timing of antibiotic administration. Method. A retrospective analysis was conducted on 111 patients with septic arthritis of the hip, knee, or shoulder admitted from 3/2016 to 11/2018. In patients with multiple septic joints, each joint was analyzed individually (n=122). Diagnosis was determined by the treatment of irrigation & debridement and/or a positive culture. Patients without all intervention times recorded or with periprosthetic joint infection were excluded. Demographics, laboratory tests, culture results, and intervention times were obtained through chart review. Patients were grouped based on antibiotic therapy timing: >24 hours prior to arthrocentesis (Group 1), between 24 hours and 1 hour prior (Group 2), and 1 hour prior to post-arthrocentesis (Group 3). Analysis was conducted using chi-squared tests. Results. The mean age of each group were similar: Group 1 (n=38) 55.7 years, Group 2 (n=20) 57.2 years, and Group 3 (n=64) 54.8 years. No difference was observed in culture sensitivity between groups (p=0.825) with 71.1% (27/38) positive cultures in Group 1, 75% (15/20) in Group 2, and 76.6% (49/64) in Group 3. Similarly, frequency of related readmissions within 90 days (p=0.863) did not significantly vary: 26.3% (10/38) in Group 1, 20% (4/20) in Group 2, and 25% (16/64) in Group 3. Additionally, there were no significant differences in culture sensitivity in the knee (p=0.618; Groups: 87.5%, 75%, 70.6%), shoulder (p=0.517; Groups: 77.8%, 66.7%, 90%), and hip (p=0.362; Groups: 61.9%, 80%, 80%). Conclusions. Culture sensitivities and rates of readmission were similar for all patients regardless of antibiotic administration timing. These results suggest that antibiotic administration should not be delayed in septic arthritis to improve culture yield. However, the data does not suggest that early antibiotic administration will result in better clinical outcomes by lowering readmission rates. Further research is needed to better determine the clinical benefits that early administration of antibiotics may have on patient outcomes

There is conjecture on the optimal timing to administer bisphosphonate therapy following operative fixation of low- trauma hip fractures. Factors include recommendations for early opportunistic commencement of osteoporosis treatment, and clinician concern regarding the effect of bisphosphonates on fracture healing. We performed a systematic review and meta-analysis to determine if early administration of bisphosphonate therapy within the first month post-operatively following proximal femur fracture fixation is associated with delay in fracture healing or rates of delayed or non-union. We included randomised controlled trials examining fracture healing and union rates in adults with proximal femoral fractures undergoing osteosynthesis fixation methods and administered bisphosphonates within one month of operation with a control group. Data was pooled in meta-analyses where possible. The Cochrane Risk of Bias Tool and the GRADE approach were used to assess validity. For the outcome of time to fracture union, meta-analysis of three studies (n= 233) found evidence for earlier average time to union for patients receiving early bisphosphonate intervention (MD = −1.06 weeks, 95% CI −2.01 – −0.12, I. 2. = 8%). There was no evidence from two included studies comprising 718 patients of any difference in rates of delayed union (RR 0.61, 95% CI 0.25–1.46). Meta-analyses did not demonstrate a difference in outcomes of mortality, function, or pain. We provide low-level evidence that there is no reduction in time to healing or delay in bony union for patients receiving bisphosphonates within one month of proximal femur fixation

Introduction. Open fractures of the tibia are disabling injuries with a significant risk of deep infection. Treatment involves early antibiotic administration, early and aggressive surgical debridement, and may require complex soft tissue coverage techniques. The extent of disruption to the skin and soft-tissue envelope often varies, with ‘simple’ open fractures (defined by the Orthopaedic Trauma Society (OTS) open fracture severity classification) able to be closed primarily, whilst others may require shortening or soft-tissue reconstruction. This study aimed to determine whether OTS simple tibial open fractures received different rates of adequate debridement and plastic surgical presence at initial debridement, compared with OTS complex injuries, and whether rates of fracture-related infection, nonunion, or reoperation differed between the groups. Materials & Methods. A consecutive series of open tibia fractures managed at a tertiary UK Major Trauma Centre between January 2021 and November 2022 were included. Patient demographics, injury characteristics, timing of antibiotic delivery, timing and method of definitive fixation, and frequency of plastic surgical presence at initial debridement were retrospectively collected. The delivery of bone ends at initial debridement was used as a proxy for adequacy of surgical debridement. The primary outcome measure was rate of fracture-related infection, secondary outcomes included rates of reoperation, nonunion, and amputation. Chi2 Tests and independent samples T-tests were used to assess nominal and continuous outcomes respectively between simple and complex injuries. Ordinal data was assessed using nonparametric equivalent tests. Results. 79 patients with open fractures of the tibia were included. 70.8% of patients were male, with mean age 50.4 years (SD 19.2) and BMI 26.4 Kg/m2 (SD 6.0). Injuries were mostly sustained by low-energy falls (n = 28, 35.4%) and from road traffic accidents (n = 26, 32.9%). 27 (34.2%) were OTS simple open fractures. Simple open fractures were most commonly Gustillo-Anderson grade 1 (38.5%), or 2 (30.8%), whilst complex open fractures were mostly grade 3B (66.7%) (p < 0.001). Fracture-related infection rates in OTS simple and complex open fractures were 25.9% and 25.5% respectively (p = 0.967), and nonunion rates were 32% and 37.8% (p = 0.637). Primary amputation was less common in simple (0%) than in complex open fractures (20%, p = 0.012), there were no differences in delayed amputation rates (7.4% and 6% respectively, p = 0.811). Simple open fractures were less likely to have plastic surgeons present at initial debridement compared to complex open fractures (18.5% and 44%, p = 0.025), and less likely to have bone ends delivered through the skin at initial debridement (25.9% and 61.2%, p = 0.003). There were no differences in patient age, delays to antibiotic administration, or reoperation rates between OTS simple and OTS complex fractures (p > 0.05). Conclusions. Despite involving less significant soft tissue injury, OTS simple open tibia fractures had comparable deep infection and nonunion rates to complex fractures and received early plastic surgical input and adequate debridement less frequently. The severity of open fractures with less significant soft tissue injury may be underrecognized and therefore undertreated, although further prospective study is needed

Aims

Prophylactic antibiotic regimens for elective primary total hip and knee arthroplasty vary widely across hospitals and trusts in the UK. This study aimed to identify antibiotic prophylaxis regimens currently in use for elective primary arthroplasty across the UK, establish variations in antibiotic prophylaxis regimens and their impact on the risk of periprosthetic joint infection (PJI) in the first-year post-index procedure, and evaluate adherence to current international consensus guidance.

Aims

The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI).

In treating open long bone fractures our current policy includes early administration of intravenous antibiotics and surgery on a scheduled trauma list. We have reviewed our infection rates 6 years following the initiation of this policy. 220 fractures were studied. Our records included time of administration of antibiotics, time to theatre and seniority of surgeon. We identified cases of superficial or deep infection. Surgical debridement occurred within 6 hours of injury in 45% of cases and after 6 hours in 55%. Overall infection rates were 11% and 15.7% respectively. Intravenous antibiotics were administered within 3 hours of injury in 80% of cases and after 3 hours in 20% of cases. Overall infection rates were 14% and 12.5% respectively. Infection rates where the most senior surgeon present was a consultant were 9.5% compared to 16% with the consultant absent. Our results suggest that the change in policy may have contributed to an improvement of the deep infection rate to 4.3% from the previous figure of 8.5%, although this decrease was not statistically significant. Time to theatre has not adversely affected the infection rate, and presence of a senior surgeon may have improved infection rates, although both trends were not statistically significant

Pyogenic arthritis of the hip in childhood despite improved antibiotic therapy remains a serious disorder which demands early diagnosis and prompt treatment. The most serious complication of the pyogenic arthritis of the hip in childhood and especialy in newborns and infants is the avascular necrosis of the femoral head which can lead to partial or complete destruction of the capital femoral epiphysis or the growth plate or both. This destruction may lead to hip joint deformity, leg length discrenpancy and dysfunction. The PURPOSE of this study was an effort to determine the factors which affect the outcome of the hip joint in pyogenic arthritis.In the present study included 37 children, 24 boys and 13 girls, with 37 involved hips. Their ages ranged from 10 days to 1 year old in 17 children and from 1y–11 years old in 20 children. All patients were hospitalized and treated in our Orthopaedic Department with proven pyogenic arthritis. All children were suspected to have pyogenic arthritis of the hip from the history, clinical features, laboratory and imaging findings and were confirmed with positive aspiration in 35 patients. In two negative aspirations the pyogenic arthritis was confirmed of the performed surgical interventions. The treatment consisted of I.V. and oral administration of appropriate antibiotics and cast immobilization for about six weeks. In 23 only patients was performed immediate incision and surgical drainage with debridement of the hip joint, wipping the panus of the cartilage. The length of the follow up was 2–9 years. The hips were classified according to radiographic findings into 3 groups. TYPE I (31 Patients, 84%) Normal overgrown femoral head. TYPE II (3 Patients, 8%) Deformed femoral head. TYPE III (3 Patients, 8%) Partial or complete destruction of the proximal femoral epiphysis. The evaluation and analysis of the results revealed primarily that the delayed diagnosis lead in delayed treatment especialy in neonates and infants. Other factors which have unfavorable outcome in the pyogenic hip arthritis are the multiple location, osteomyelitis of the hip region and the causative organism. Of course the rapid diagnosis followed of immediate aspiration with surgical drainage and early administration of apropriate antibiotics lead to good or excellent results

Pyogenic arthritis of the hip in childhood despite improved antibiotic therapy remains a serious disorder which demands early diagnosis and prompt treatment. The most serious complication of the pyogenic arthritis of the hip in childhood and especialy in newborns and infants is the avascular necrosis of the femoral head which can lead to partial or complete destruction of the capital femoral epiphysis, the growth plate or both. This destruction may lead to hip joint deformity, leg length discrenpancy and dysfunction. The PURPOSE of this study was an effort to determine the factors which affect the outcome of the hip joint in pyogenic arthritis. The present study included 37 children, 24 boys and 13 girls, with 37 involved hips. Their ages ranged from 10 days to 1 year old in 17 children and from 1y-11 years old in 20 children. All patients were hospitalized and treated in our Orthopaedic Department during 1983–1995 with proven pyogenic arthritis. All children were suspected to have pyogenic arthritis of the hip from the history, clinical features, laboratory and imaging findings and were confirmed with positive aspiration in 35 patients. In two negative aspirations the pyogenic arthritis was confirmed after surgical intervention. The treatment consisted of I.V. and oral administration of appropriate antibiotics and cast immobilization for about six weeks. In only 23 patients was immediate incision and surgical drainage performed with debridement of the hip joint, and removal of the panus on the cartilage. The length of the follow up was 7–16 years. The hips were classified according to radiographic findings into 3 groups. TYPE I (31 Patients, 84%) Normal overgrown femoral head. TYPE II (3 Patients, 8%) Deformed femoral head. TYPE III (3 Patients, 8%) Partial or complete destruction of the proximal femoral epiphysis. The evaluation and analysis of the results revealed primarily that delay in diagnosis lead to delayed treatment particularly in neonates and infants. Other factors which have an unfavorable outcome in the pyogenic hip arthritis are the multiple location, osteomyelitis of the hip region and the causative organism. Rapid diagnosis followed by immediate aspiration with surgical drainage and early administration of an appropriate antibiotics lead to good or excellent results

Objective: The purpose of this study was to assess whether the use of high dose methylprednisolone (MPS) given to trauma patients with acute spinal cord injury improves neurological and long term functional outcomes. Summary of Background Data: The National Acute Spinal Cord Injury Studies (NASCIS II and III) recommend the early administration of high dose MPS in the context of acute spinal cord injury. However, controversy exists surrounding its long term benefits. Methods: A retrospective data analysis was performed using the Helicopter Emergency Medical Service (HEMS) trauma registry, medical records, and rehabilitation notes of 263 trauma patients with acute spinal injury admitted over a 6-year period. All survivors over 16 years of age with documented spinal cord injuries were selected. Frankel grade, Injury Severity Score (ISS), and Functional Independence Measure (FIM) scores (minimum FIM of 18 implies total dependence, and a maximum of 126 implies no disability) as indicators of neurological and functional morbidity were recorded at initial presentation, hospital discharge, and intervals up to 12 months post injury. Details of the age, gender, mechanism of injury, nature of injury and associated injuries were also recorded. Results: There were 139 patients (107 males and 32 women) with documented acute spinal cord injuries, of which 74 patients had neurological deficits (Frankel A–D) at presentation. 49 patients were given high dose MPS within 8 hours of injury according to a standard protocol. The remaining 25 patients with documented neurological injury did not meet criteria or failed to receive the agent within the recommended time. The mean ISS scores were shown to be comparable in both groups. 59% (29/49) of patients who were given MPS showed an improvement of one or greater Frankel grade at the time of discharge whereas 52% (13/25) of patients who did not receive MPS showed a similar improvement in Frankel grades. We had long term functional outcome data (FIM scores) on 48% (67/139) of the total number of patients. At the time of discharge, the mean FIM scores for the MPS treated group and non MPS treated group were 68 and 90, respectively. Whereas at 12 months, there was no significant difference in the mean FIM scores between the two groups (both of which were > 100). Conclusions: The Frankel grade assesses the degree of neurological impairment while FIM scores are a basic measure of the severity of disability regardless of the underlying impairment. In our study, patients given high dose MPS in the context of acute spinal cord injury showed some early improvement in Frankel grades. However, we have shown, there is no short term or long term benefit in terms of functional outcome by using MPS in trauma patients with acute spinal cord injury

Aim. Antibiotic prophylaxis is critical for the prevention of fracture related infection (FRI) in trauma patients, particularly those with open wounds. Administration of prophylactic antibiotics prior to arrival at the hospital (e.g. by paramedics) may reduce intraoperative bacterial load and has been recommended; however scientific evidence for pre-hospital administration is scarce. Methods. The contaminated rabbit humeral osteotomy model of Arens was modified to resemble the sequence of events in open fractures. In an initial surgery representing the “accident”, a 2mm mid-diaphyseal hole was created in the humerus and the wound was contaminated with a clinical Staphylococcus aureus strain (mean 1.6×106 Colony Forming Units, CFU). The animals were allowed recover for 4 hours mimicking the period from trauma to debridement. At this time, a second procedure was performed in order to debride and irrigate the wound, and to fix a complete osteotomy that was made through the initial defect. Three test groups were included (n=8 rabbits per group): 1) no antibiotic therapy; 2) standard “in-hospital” antibiotic prophylaxis (24 hours therapy starting 30 minutes before surgery); 3) “pre-hospital” antibiotics (single dose 15 minutes after the “accident”). The antibiotic used was cefuroxime and was administered in a weight-adjusted dosage. Results. In the absence of any antibiotic administration (group 1), high bacterial counts were identified at fixation (1.89×106 CFU) and at euthanasia (day 7, 7.70×107 CFU) in all rabbits. When 24 hours of antibiotics were administered commencing “in hospital” (group 2), the bacterial load during fixation surgery was slightly reduced (CFU 9.88×105) and 50% of animals were infected at euthanasia. When one single shot of antibiotics was administered in the “pre-hospital” setting (group 3), the bacterial load during fixation surgery was significantly lower than for both groups 1 and 2(CFU 2.34×103) yet all animals were infected at euthanasia. Conclusions. Early pre-hospital administration of antibiotics significantly reduced the bacterial load in the operative field at the time of debridement compared to regular prophylaxis. However, continuation of systemic antibiotics is necessary in order to prevent infection in this model

Aims

To characterize the intracellular penetration of osteoblasts and osteoclasts by methicillin-resistant Staphylococcus aureus (MRSA) and the antibiotic and detergent susceptibility of MRSA in bone.

The purpose of this study was to evaluate the efficacy of human recombinant osteogenic protein 1 (rhBMP-7) for the treatment of fracture non-unions and to estimate the health economics aspect of its administration. Twenty-four patients (18 males, mean age 39.1 (range 18-79)) with 25 fracture non-unions were treated with rhBMP-7 in our institution (mean follow-up 15.4 months (range 6-29)). Successful completion of treatment was defined as the achievement of both clinical and radiological union. The cost of each treatment episode was estimated including hospital stay, theatre time, orthopaedic implants, drug administration, investigations, clinic attendances, and physiotherapy treatments. The total cost of all episodes up to the point of receiving BMP-7 and similarly following treatment with BMP-7 were estimated and analysed. Of the 25 cases, 21 were atrophic (3 associated with bone loss) and 4 were infected non-unions. The mean number of operations performed prior to rhBMP-7 application was 3.4, including autologous bone graft in 9 cases and bone marrow injection in one case. In 21 out of the 25 cases (84%), both clinical and radiological union occurred. Mean hospital stay before and after receiving rhBMP-7 was 26.84 days per fracture and 7.8 days per fracture respectively. Total cost of treatments prior to BMP-7 was £346,117 [£13,844.68 per fracture]. Costs incurred following BMP-7 administration were estimated as £183,460 [£7,338.4 per fracture]. rhBMP-7 was used as a bone stimulating agent with or without conventional bone grafting with a success rate of 84% in this series of patients with persistent fracture non-unions. The average cost of its application was £7,338 [53.0% of the total costs of previous unsuccessful treatment of non –unions, p<0.05). Treating non-union is costly, but the financial burden could be reduced by early rhBMP-7 administration when a complicated or persistent non-union is present or anticipated. Therefore, this study supports the view that rhBMP-7 is a safe and power adjunct to be considered in the surgeon's armamentarium for the management of such difficult cases

Introduction: To investigate the presence or absence of osteonecrosis of femoral head (ONFH) in patients undergoing massive corticosteroid therapy, we have performed magnetic resonance imaging (MRI) early after administration. In some patients, MRI revealed an increase in hip fluid. In this study, we evaluated retention of hip fluid early after massive steroid therapy by MRI. Materials and Methods: The subjects were 14 patients (28 joints) in whom oral administration of prednisolone at an initial dose of 40 mg/day or more or pulse therapy was performed. They consisted of 3 men (6 joints) and 11 women (22 joints). Ages ranged from 17 to 72 years, with a mean of 38.2 years. We evaluated retention of hip fluid in T2-weighted MRI images or T2 fat-suppressed images within 3 months after massive steroid therapy according to the joint fluid grading established by Mitchell et al and evaluated volume of hip fluid by integrating an area (by using Mac scope ver 2.58). Results: Average volume of all joints was 7.18 cm. 3. Eleven joints were evaluated as Grade 1, in which a small amount of joint fluid is noted, and their average volume was 3.98 cm. 3. Fifteen joints were evaluated as Grade 2, in which retention involves the entire femoral neck, and their average volume was 8.96 cm. 3. Two joints were evaluated as Grade 3, in which marked retention involves the excavation of the cupsula articularis, and their average volume was 11.45 cm. 3. No joint was evaluated as Grade 0, in which no joint fluid is detected. Discussion: The pathogenesis of corticosteroid-related ONFH is multifactorial; various hypotheses have been proposed, suggesting the involvement of arteriosclerosis, thrombosis, fat embolization, vascular endothelial disorder, venous return disorder, enhanced blood coagulation, fibrinolytic abnormalities, and bone tissue apoptosis. However the detailed mechanism remains to be clarified. In this survey, when regarding Grade 2 or higher joints as showing a significant increase in hip fluid, the increase was noted in 17 joints (60.7%). We understood objectively by an increase in hip fluid by estimating its volume. An increase in hip fluid early after massive steroid therapy may persistently increase intraarticular pressure, affecting influx of nutrient vessels in the femoral neck or venous return, which is considered to be a tamponade effect. This may be an etiological factor involved in ONFH

The purpose of our study was to evaluate several specific methods of skeletal stabilisation and soft-tissue treatment of open fractures in the orthopaedic department in a district hospital. After stabilisation of the patient and diagnosis of concomitant injuries, the basic initial evaluation of the fracture type, soft-tissue laceration, and neurovascular status is made. Deformities of the legs are realigned promptly. Sterile wound dressing and early intravenous administration of antibiotics are applied. Prophylaxis against tetanus is considered. Radiograph diagnostics are made and the Tscherne, Gustilo and Anderson classifications of open fractures are used. All devitalised tissue is removed in the operating theatre. The following methods of bone stabilisation are used: immobilisation in a cast, external fixation, and intramedullary nailing. Repeated debridement of soft-tissue is carried out. Postoperatively, time duration for bone-healing and deep infections were analysed. During the past five years, 159 patients with a tibial shaft fracture were treated. Twenty-six were open fractures Type I (8), Type II (9), Type IIIA (7), and Type IIIB (2). Methods of stabilisation were cast (5), external fixation (7) and intramedullary rod (14). Deep infection in Type III fractures was reported in two cases and a non-union in one case. Bone grafting was performed in two cases. Nailing followed short-term use of an external fixator in three cases. No amputations were necessary. The average time (in months) for union was 5 (Type I), 5.8 (Type II), and 8 (Type III). Our experience agrees with the principle that the method of choice is intramedullary nailing that may follow the short-term use of an external fixation. Open fractures of the tibial shaft represent a limb-threatening and potentially life-threatening emergency. Optimum treatment involves appropriate initial evaluation, the administration of antibiotics, urgent operative debridements, skeletal stabilisation, and early soft-tissue closure or flap-coverage. The type of treatment depends on the individual characteristics of the fracture and the concomitant soft-tissue injury. Fractures with a higher degree of comminution and soft-tissue laceration have more complications

Blast and ballistic weapons used on the battlefield cause devastating injuries rarely seen outside armed conflict. These extremely high-energy injuries predominantly affect the limbs and are usually heavily contaminated with soil, foliage, clothing and even tissue from other casualties. Once life-threatening haemorrhage has been addressed, the military surgeon’s priority is to control infection.

Combining historical knowledge from previous conflicts with more recent experience has resulted in a systematic approach to these injuries. Urgent debridement of necrotic and severely contaminated tissue, irrigation and local and systemic antibiotics are the basis of management. These principles have resulted in successful healing of previously unsurvivable wounds. Healthy tissue must be retained for future reconstruction, vulnerable but viable tissue protected to allow survival and avascular tissue removed with all contamination.

While recent technological and scientific advances have offered some advantages, they must be judged in the context of a hard-won historical knowledge of these wounds. This approach is applicable to comparable civilian injury patterns. One of the few potential benefits of war is the associated improvement in our understanding of treating the severely injured; for this positive effect to be realised these experiences must be shared.