Aims. A multicentre, randomized, clinician-led, pragmatic, parallel-group orthopaedic trial of two surgical procedures was set up to obtain high-quality evidence of effectiveness. However, the trial faced recruitment challenges and struggled to maintain recruitment rates over 30%, although this is not unusual for surgical trials. We conducted a qualitative study with the aim of gathering information about recruitment practices to identify barriers to patient consent and participation to an orthopaedic trial. Methods. We collected 11 audio recordings of recruitment appointments and interviews of research team members (principal investigators and research nurses) from five hospitals involved in recruitment to an orthopaedic trial. We analyzed the qualitative data sets thematically with the aim of identifying aspects of informed consent and information provision that was either unclear, disrupted, or hindered trial recruitment. Results. Recruiters faced four common obstacles when recruiting to a surgical orthopaedic trial: patient preferences for an intervention; a complex recruitment pathway; various logistical issues; and conflicting views on equipoise. Clinicians expressed concerns that the trial may not show significant differences in the treatments, validating their equipoise. However, they experienced role conflicts due to their own preference and perceived patient preference for an intervention arm. Conclusion. This study provided initial information about barriers to recruitment to an orthopaedic randomized controlled trial. We shared these findings in an all-site investigators’ meeting and encouraged researchers to find solutions to identified barriers; this led to the successful completion of recruitment. Complex trials may benefit for using of a mixed-methods approach to mitigate against recruitment failure, and to improve patient participation and informed consent. Cite this article: Bone Jt Open 2021;2(8):631–637

Introduction. Surgical site infections (SSI) are related to a surgical procedure and affect the surgical wound or deeper tissues. With continuing emphasis on clinical governance and quality control, there is increasing demand from both patients and government for methods of assessing surgical results. Rates of morbidity and mortality may play important roles in these assessments. When crude comparisons between hospitals in the incidence of SSI are made, these should at least be stratified by the type of procedure. The aim of this study is to fix SSI incidence in relation to surgical procedure. Methods. This report contains data of 19.948 procedures collected from 1996 to 2008 at a Specialist Orthopaedic Hospital and analyzed by a specific software designed for the study of infection in orthopaedic and trauma surgery. The SSI surveillance is focused on categories of surgical procedure (Hip Arthroplasty, Knee Arthroplasty, Spine Surgery and Hip Fracture Surgery) with each category containing a defined set of similar procedures. A basic of demographic data and details about operation itself are collected for each procedure. Patients are followed up throughout their hospital stay and after hospital discharge. We present the incidence of SSI by risk group and surgical procedure. SSI are categorized in type, moment of diagnosis and micro-organisms reported. Analysis of the data was performed (SPSSv15.0 ®). Statistical methods used to determine significance were the independent samples t test, Pearson X2 test, Odds ratio and Spearman correlation coefficient, with a significance level of p<0,05. Results. Rates of SSI are highest in hip hemiarthroplasty after fracture and in hip and knee revision procedures. Rates of SSI increase with the number of risk factors present in the patient, especially after fracture procedures. The most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. 38% of the infections arise after one year of surveillance. Conclusions. Our results confirm difference in rates of SSI depending of surgical procedure in orthopaedic and trauma surgery. We believe that our decision to monitor infection with a long term follow up it's the better way to avoid under-reporting of infection. Our study has also demonstrated the extent to which the emerging problem of infection due to MRSA has affected orthopaedic surgery. The risk of acquiring SSI caused by MRSA was particularly high in patients after hip fracture surgery. Rates of SSI increase with the number of risk factors present in the patient, especially after fracture procedures. Globally, the most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. 38% of the infections arise after one year of surveillance

Purpose: Aim of this study was to analyse the incidence of infection in orthopaedic oncology after major surgical procedures for bone tumors. Materials and Methods: We included patients with primary sacral tumors treated by major surgical procedure and patients with bone tumors of the upper and lower limb treated by resection and prosthetic reconstruction. Demographic data, surgery, adjuvant treatments, type of reconstruction were analyzed. Special attention was given to the infection: incidence, classification, microbic agents, treatment and outcome. Infections in the first 4 weeks were considered “postoperative”, those in the first 6 months were judged “early”, while “late” those diagnosed after 6 months. Overall 1462 patients treated in one institution from 1076 to 2007. Were considered 1036 patients with tumors of the lower limb, 344 patients with tumors of the upper limb and 82 sacral tumors. Univariate analysis with Kaplan-Meier actuarial curves was used in evaluating risk factors and implant survival to infections. Results: In the lower limb, infection occurred in 80 cases (7.7%). Most frequent bacteria were gram positive. Infection was postoperative in 9 cases, early in 12, late in 59 cases and generally monomicrobial. Surgical treatment was “two stage” in 73 patients, “one stage” in 4 and primary amputation in 3 cases. Revisions for infection were successful in 63 pts (79%), while 17 pts were amputated (21%). In the upper limb, in 20 patients (5.8%) a revision for deep infection was required. Two infections were postoperative, 7 early and 11 late. S. Epidermidis and S. Aureo were the most frequent bacteria causing infection (45%). “Two stage” treatment of infection was performed, but a new prostheses was implanted in 3 cases. In 17 the spacer was never removed. In the sacrum, no deep infections were observed after intralesional excision for giant cell tumors. In 23/52 resections (44%) for chordoma (3 pts. died postoperatively and were excluded), infection occurred: in 16 patients postoperatively, in 7 within 6 months. Bacteria causing infection were mostly gram negative: in 74% of cases infection was multiagent. Surgical treatment consisted in one or more surgical debridements with antibiotics therapy according to coltures: infection healed in all cases. Conclusion: Infection is a severe complication in prosthetic reconstructions for tumors of the upper and lower limb. Its incidence in the extremities (7.7% and 5.8%) is lower than after sacral surgery (44%). Infections are mostly late, monomicrobial and caused by gram positive in extremities, while early, multimicrobial and caused by gram negative in the sacrum

In performing posterior cruciate ligament- retaining total knee arthroplasty (CR-TKA), the original surgical instrument was devised to obtain the range of motion and stability of the knee joint adequate for daily life of Japanese people. We have presumed the tentative joint line as intercondylar notch point of the distal femur, and performed surgery using surface replacement to resect metal width of the femoral component for the distal femur by setting the knee to the original position based on understanding of the shape of anterior curvature of the distal femur in Japanese people in case of implanting the femoral component. In order to obtain stability of the knee, we have minimally released the soft tissue and resected the anterior cruciate ligament (ACL), whereas completely preserved the posterior cruciate ligament (PCL) and maintained physiological ligament balance of the knee joint by resecting the medial condyle of the tibia (genu varus). Our surgical procedure enabled deep flexion knee (knee embracing) greater than 145 degrees in 9.7% and also allowed Japanese sitting in three different designs of total knee joints

Objectives. The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes. Methods. A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed. Results. Seven studies including 528 patients were included. The overall meta-analysis found that there was no difference in clinical outcomes. However, subgroup and sensitivity analyses found improved patient outcomes for more complex fractures managed surgically. Four-part fractures that underwent surgery had improved long-term health utility scores (mean difference, MD 95% CI 0.04 to 0.28; p = 0.007). They were also less likely to result in osteoarthritis, osteonecrosis and non/malunion (OR 7.38, 95% CI 1.97 to 27.60; p = 0.003). Another significant subgroup finding was that secondary surgery was more common for patients that underwent internal fixation compared with conservative management within the studies with predominantly three-part fractures (OR 0.15, 95% CI 0.04 to 0.63; p = 0.009). Conclusion. This meta-analysis has demonstrated that differences in the type of fracture and surgical treatment result in outcomes that are distinct from those generated from analysis of all types of fracture and surgical treatments grouped together. This has important implications for clinical decision making and should highlight the need for future trials to adopt more specific inclusion criteria. Cite this article: S. Sabharwal, N. K. Patel, D. Griffiths, T. Athanasiou, C. M. Gupte, P. Reilly. Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus: Findings of a meta-analysisBone Joint Res 2016;5:470–480. DOI: 10.1302/2046-3758.510.2000638

Introduction: Between the elderly affected by femoral neck or diaphyseal fractures are emerging few serious complications as delate union, instability of osteosynthesis, re-fracture or periprosthetic fracture. In addition the co-morbidity elevate ulteriorly the risks of the new operation which is often impossible or refused. Recently it has been recommended to orthopaedic surgeons the managment and treatment of osteoporosis. The aim of this study was to consider at 2 years follow-up the functional outcome of femoral fracture in osteoporotic elderly treated with a surgical procedure followed by daily assumption of teriparatide, an anabolic agent increasing bone mineral content, density and strength. Materials and Methods: 21 compliant female between 63 and 94 years-old presenting a femoral fracture were recruited. Before operation they undergone to a routinary instrumental examins completed by bone metabolism screening. This was constituted by biochemical bone turnover markers, standard radiograms of dorsal and lumbar spine. Lumbar and contralateral femoral BMD was measured by DXA during hospitalization before the assumption of anabolic agent. They received daily subcutaneous teriparatide (20 microg) per day for 18 months, 1g of calcium and 800 UI of vitamin D3 daily as oral supplementation from day 15 by operation. All the patients repeated: xrays of affected segment at 2, 4, 6 months; biochemical bone markers 1, 3, 6, 12, 18 and 24 months; DEXA at first and second year. The evaluation of the quality of life was evaluated in terms of recovery of walking, need of re.operation, occurance of new fracture and with a questionnaire. Results: eleven lateral femoral neck fracture treated with endomedullary nail, six medial femoral neck fracture treated with cemented endoprosthesis, four periprosthetic fracture of the femur treated with plaque and screws. The healing was detected with radiograms before 4th month. The vitamin D was at lower levels at admission but the supplementation was sufficient to normalize. The other biochemical variables of bone formation and resorption peaked within the consolidation process then remained normalized for two years. Lumbar and contralateral femoral BMD were increased after 12 months and maintained at 24 months. At 2 years follow-up all patients live, walk in autonomy without or with stick and none of them have needed a re-operation or was afflicted by new vertebral or non vertebral fracture. Conclusions: The clinical relevance of the present study is the significant improvement of functional outcome and quality of life after femoral fracture in osteoporotic elderly with post-operative assumption of anbolic agent as Teriparatide

Background: Iatrogenic hallux varus is a very disappointing potential complication following hallux valgus surgery. Depending on its clinical and radiological form, a possible surgical technique is the reconstruction of the lateral components of the first metatarsophalangeal joint.

Methods: A new surgical technique of ligamentoplasty based upon the use of the abductor hallucis tendon is described. The new method was applied in 5 patients (6 feet) with a mean follow-up of 25.8 months. Four hallux varus deformities were operated by only the transplant of the abductor hallucis tendon and two were associated with the use of an osseous buttress.

Results: We found a radiographic correction of most of the factors considered as being at the origin of the iatrogenically induced deformity. All of our patients considered the result as very good and no complications were noticed.

Conclusion: This new technique is a reliable, anatomic reconstruction with the use of the tendon participating in the physiopathology of the hallux varus deformity. No other functional tendon is harvested.

Introduction: Tibial plateau fracture is an intra-articullar complex fracture. Surgery aim is to restore articular surface height, preserve knee joints stability and alignment in order to obtain maximal range of motion and to prevent future joint degenerative changes. Ilizarov external frame using ligamentotaxis, minimal invasive techniques, smooth or olive wires (sometimes augmented by screws) allows articular surface reconstruction and stabilization. In unstable fractures, bridging of the knee with slight distraction of the joint is provided by including the distal femur to the frame with an additional ring.

Study Aims: To assess the results of complex tibial plateau fracture treated with Ilizarov external fixator.

Materials and Methods: Between 1997–2005, twenty five patients with complex fractures of the tibial plateau, Schatzker type V–VI fractures (all closed), average age 45 years old (range 30–78) were treated by hybrid 3 ring Ilizarov external frames alone or in combination with another procedure. 11 out of 25 patients were treated with ligamentotaxis using extension of the frame to the femur with hinges on the center of joint rotation. Some of these patients (10 out of 11) required lateral minimal opening for joint surface elevation. 8 out of the 25 patients needed additional bone graft/ substitute supplementation. One needed 6.5 mm canulated cancellous screw augementation. Patients with below knee frame remain non-WB for 6 weeks and partial WB for another 6 weeks. Patients with above knee frame were allowed full WB. In 3 months the frame was removed under anesthesia and the knee was manipulated. Patients were placed in a brace or a cast-brace with full WB. Physiotherapy started early after the operation.

Results: All fractures united with an average time of 12 weeks. 22 patients had full extension with 100 degree of flexion or more. 3 patients had extension lag of 10–20 degree, one of them had 20 degree of posterior slop of the tibial plateau. All patients had normal axial alignment, except one case resulted in mild valgus alignment due to osteoporotic bone (70 years old patient). One had mild unstable knee. One patient developed posttraumatic osteoarthrosis. There were no cases of postoperative infection, septic arthritis or neuro-vascular complications were reported. Pin site infection was resolved locally.

Conclusion: The use of Ilizarov external fixation in the management of complex tibial plateau fractures results in satisfactory out come as an alternative to the traditional tibial plateau open surgery. This minimal invasive intervention allowed the surgeons to reduce and fixate the tibial articular surface with out further damaging the soft tissue envelope.

Introduction: Treating tibial plateau fractures extreme care should be given to restore articular surface height preserving knee joint stability to be able to obtain maximal range of movement and to prevent future joint degenerative changes. Preoperative evaluation with CT and 3-D reconstruction is mandatory to understand the topography of the fracture for surgical planning. Traditional bone grafting techniques together with newer bone substitutes should be utilized in addition to ligamentotaxis when necessary. Fixation with smooth or olive wires (in occasions with washers for wider contact), sometimes augmented by screws is used with the Ilizarov external frame for stabilization avoiding extended incisions. In unstable fractures, bridging of the knee with slight distraction of the joint is provided by including the distal femur to the frame with an additional ring. Guided by these principles, complex tibial plateau fractures were treated in our department and the results are reported.

Materials and Methods: Ten patients 40.6 years old on average (30–70) with Schatzker type V–VI fractures (all closed) were treated by hybrid 3 ring Ilizarov external frames alone or in combination with another procedure. Six were treated by ligamentotaxis and Ilizarov fixation alone and minimal opening for joint surface elevation when needed. The remaining 4 needed 6.5 mm canulated cancellous screw augmentation and 2 of them additional bone graft supplementation. Two patients needed extension of the frame to the femur with hinges on the center of joint rotation. All patients remain non-WB for 6 weeks and partial WB for another 6 weeks. Within 3 months the frame was removed and replaced by a brace or a cast-brace with full WB. Physiotherapy started early after the operation.

Results: The results were analyzed over an average follow-up period of 22.6 months (range 3–53). All fractures healed in an average of 12 weeks. Range of motion in all patients included full extension with 90° of flexion or more. No postoperative infections, septic arthritis or neurovascular complications were reported. Pin site infection was resolved locally. One case resulted in mild valgus alignment due to osteoporotic bone (70 years old patient).

Discussion: Ilizarov external fixation for complex tibial plateau fractures offers the advantage of minimal invasive interventions with a high level of functionality since the early post operative period. The combination with minimal invasive opening for joint surface elevation and additional screws or bone graft extends even more the scope of the treatment. Functional results were similar to previous reported series. The good observance of traditional tibial plateau surgery principles should guide the surgeons when using this modality of treatment for optimal results.

Introduction: The use of a trans-physeal, trans-articular suture anchor across a joint as a means of internal stabilisation has not previously been described. This study assesses the damage caused by the procedure to the immature porcine hip.

Methods: Six twelve week old pigs underwent unilateral hip surgery. Anteroposterior pelvic radiographs were taken preoperatively and six weeks post-operatively. The acetabular index and diameter of the femoral head ossific nucleus of both hips were measured and compared. Specimens were analysed macroscopically for femoral head diameter, acetabular dimensions and for evidence of gross chondrolysis. Histological analysis was performed to assess the presence of articular chondrolysis and proximal femoral physeal arrest.

Results: In four out of six specimens the rate of change of the acetabular index slowed as compared to the unoperated side, though none worsened. The diameter of the femoral ossific nucleus continued to increase in size at a similar rate to the unoperated side on radiological examination. Similar findings were seen with the macroscopic analysis. Gross and histological analysis of the articular cartilage showed only local areas of chondrolysis, related to the drilling. Metaphyseal growth at the proximal femoral physis was unaffected by the procedure.

Discussion: The use of a trans-articular suture-anchor across the hip appears to cause marginal retardation of acetabular development in the normal hip. The trans-physeal approach to the hip does not appear to affect proximal femoral physeal or epiphyseal growth in the short-term, and the presence of a bioabsorbable suture within the joint did not result in chondrolysis.

Background

Despite studies into patient consent and their understanding of the potential risks of trauma surgery, no study has looked at the patient's understanding of the procedure involved with neck of femur fracture surgery.

Aim. There are no studies in literature that analyze the effectiveness of closed-incisional negative pressure wound therapy (ciNPWT) in the treatment of bone and joint infections (BJI). The aim of the study was to evaluate the efficacy and the safety of the application of ciNPWT in the postsurgical wound management of patients with osteoarticular infections. Method. We conducted a perspective single-center study on patients with BJI treated between 01/2022 and 10/2022 with ciNPWT dressing application at the end of the surgical procedure. All patients were treated by a multidisciplinary team (MDT) approach and operated by the same surgical equipe. Inclusion criteria were: presence of periprosthetic joint infection (PJI), fracture-related infection (FRI), osteomyelitis (OM), septic arthritis (SA) surgically treated, after which ciNPTW was applied over the closed surgical wound. 30 patients (19M, 11F) have been analyzed with mean age of 56,10±17,11 years old; BJIs were all localized in the lower limb (16 PJI, 12 FRI, 1 SA, 1 OM). Results. We considered the following clinical local pre-operative parameters: presence of fistula (10 patients, 33,33%), presence of erythema (18 patients, 60%), presence of previous flap in the incisional site (7 patients, 23,33%). In 11 cases (36,67%) more than 3 previous surgical procedures were performed in the surgical site. The following surgical procedures were performed: 8 debridement and implants removal, 7 DAIR, 3 one-stage exchange, 6 two-stage exchange, 3 spacer exchange, 3 resection arthroplasty. Nineteen patients (63,34%) showed no occurrence of any local post-operative complication (erythema, hematoma, wound breakdown, wound blister, necrosis). Seven (23,33%) patients showed the presence of one or more postoperative complications that didn't require additional surgery. We observed four (13,33%) failures, defined as the need for further surgical procedures following the onset of a local complication: two patients had a wound breakdown before wound closure and two had a recurrence of infection after an uneventfully wound closure. All failures were within the group of joint infection (PJI+SA) and were affected by a multi drug resistant pathogen. Conclusions. In our series four patients required further surgery, but only two cases were related to incisional wound problems, that is consistent with aseptic joint revision surgeries data that are available in literature (3.4%-6.9%)[1-2]. Patients affected by BJI are a group with significant high risk of failure and therefore the use of ciNPWT should be considered. However, randomized clinical trials are needed to establish the superiority of the ciNPWT dressing over the standard one

Proximal humerus fractures (PHF) are common, accounting for approximately 5% of all fractures. Approximately 30% require surgical intervention which can range from open reduction with internal fixation (ORIF) to shoulder arthroplasty (including hemiarthroplasty, total shoulder arthroplasty, (TSA) or reverse total shoulder arthroplasty (RTSA)). The aim of this study was to assess trends in operative interventions for PHF in an Australian population. Data was retrospectively collected for patients diagnosed with a PHF and requiring surgical intervention between January 2001 and December 2020. Data for patients undergoing ORIF were extracted from the Medicare database, while data for patients receiving arthroplasty for PHF were obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Across the study period, ORIF was the most common surgical procedure for management of PHFs. However, since 2019, RTSA has surpassed ORIF as the most common surgical procedure to treat PHFs, accounting for 51% of operations. While the number of RTSA procedures for PHF has increased, ORIF and shoulder hemiarthroplasty has significantly reduced since 2007 (p < 0.001). TSA has remained uncommon across the follow-up period, accounting for less than 1% of all operations. Patients younger than 65 years were more likely to receive ORIF, while those aged 65 years or greater were more likely to receive hemiarthroplasty or RTSA. While the number of ORIF procedures has increased during the period of interest, it has diminished as a proportion of overall procedure volume. RTSA is becoming increasingly popular, with decreasing utilization of hemiarthroplasty, and TSA for fracture remaining uncommon. These trends provide information that can be used to guide resource allocation and health provision in the future. A comparison to similar data from other nations would be useful

The Victorian state government introduced a trial electronic scooter sharing scheme on 1. st. February 2022 in inner city Melbourne. Despite epidemiological data from other jurisdictions that show these devices are associated with significant trauma. This is a descriptive study from the largest trauma centre in Victoria demonstrating the “scope of the problem” after introduction of this government-approved, ride sharing scheme. Retrospective case series. Our hospital orthopaedic department database was searched from 1/1/2021 to 30/6/22 to identify all presentations associated with electronic scooter trauma, the mechanism of injury and admission information was confirmed via chart review. Data collected included: mode of arrival, alcohol/drug involvement, hospital LOS, injury severity score, ICU admission, list of injuries, operations undertaken, surgical procedures, discharge destination, death. In the 12 months prior to and 5 months since introduction of the ride share scheme, 43 patients were identified. 18 patients (42% of our cohort) presented in the 5 months since ride sharing was introduced, and 25 patients in the preceding 12 months. 58% were found to be alcohol or drug affected. All patients were admitted to hospital, 14% of which included ICU admission. 44% were polytrauma admissions. Median hospital length of stay was 2 days. The longest individual hospital stay was 69 days. No patients in this series died. There were 49 surgical procedures in 35 patients including neurosurgical, plastics and maxillofacial operations. Mean Injury Severity Score was 10. Despite data demonstrating their danger in other jurisdictions, the Victorian state government approved a trial of an electronic scooter ride share scheme in inner Melbourne in February 2022. These devices are associated with a significant trauma burden and the rate has increased since the introduction of the ride-sharing scheme. This data may be combined with other hospital data and could be used to inform policy makers

In 2019, the incidence of fractures were 178 million globally, South Africa accounting for close to 600 000 of these fractures, an 18.53% increase since 1990. South Africa does not have the public infrastructure to adequately facilitate the optimal surgical management of this burden. This forces intensive labour practices among orthopaedic surgeons, often performing complex surgeries throughout the night. There is a direct correlation between “after-hour”operations and the increase in morbidities. A retrospective review of the orthopaedic surgical cases and orthopaedic surgical emergencies done at a tertiary institution in Johannesburg between 8th of August 2021 to 12th December 2022. The nature of the orthopaedic interventions, the date of booking of the surgical procedures, date of surgical procedures, as well as start and end time of the orthopaedic interventions were analysed. “After-Hours” orthopaedic interventions were defined as interventions done between 16:00 and 07:00. Orthopaedic emergencies were defined as: Open fracture debridements, external Fixator insertion, arthrotomies, fasciotomies and the insertion of steinmann pins. 1483 (27.92%) of 5310 operative cases done on the emergency board were orthopaedic cases. 1098 (74.04%) hardware-related cases and 535 (36.08%) orthopaedic emergencies were done. 854 (57.58%) cases were done “After-Hours” of which 433 (29.20%) cases were done during “Dead-Hours” (23:00–07:00). Of these 433 cases, only 173 (39.95%) were true orthopaedic emergencies. Although the proportion of emergencies done after hours were greater than during working hours, there is still a large proportion of intricate orthopaedic cases done between 16:00– 07:00 that should not be prioritized, due to an associated higher morbidity. Enhanced strategic planning is advisable in future in order to prioritize complex hardware cases during working hours, and due to the burden, prioritize minor relooks and simple skin- grafts for the latter aspects of the night. A dedicated Orthopaedic Trauma theatre is recommended

Introduction. The management of pathologic fractures (PF) following osteomyelitis (especially acute subtype) has not been widely investigated. This is challenging due to the infection-induced destructive process causing bone architecture defects. Therefore, this study aims to assess a stepwise treatment plan for the acute incidence of PF in long bone following pediatric acute Hematogenous osteomyelitis(AHO) (the most common mechanism in children). Method. This case series was conducted in a tertiary pediatric center. Patients with fracture incidence within the first 10 days after AHO diagnosis were included. Patients’ characteristics were retrospectively reviewed. Result. Nine patients (7 boys, involved bone: the femur(4), tibia(3), Radius(1), and Ulna(1)) were included, with a mean age of 52.56±66.18 months (7-216) and a follow-up time of 11.62±3.61 years (6.5-16 years). The etiology in all patients was hematological(Methicillin-resistant Staphylococcus aureus). Our stepwise treatment plan was as follows:. 1. Intravenous antibiotics until ESR<20, then oral to ESR<5. 2. Debridemnt surgery was performed if abscesses were detected. 3. Fracture type determined initial fixation: external fixation (4 patients, 2 unions) or casting (2 patients, both unions). 4. If the union was not obtained, internal fixation (with (2 patients) or without (2 patients) bone graft) was applied (all obtained union). 5. Circular external fixation was applied if the union was not obtained or leg length discrepancy occurred (1 case). A mean of 3.2 surgical procedures (1-6) was required to control the infection, and 1.4 surgical procedures (0-4) were required to obtain union. Except for one patient who died of septic shock, all other patients (88.8%) reached complete recovery (average length of hospital stay of 19.2 days (5-35).), and the union was obtained (the average union time of 17.25 months(4-36)) without long-term sequelae of osteomyelitis. Conclusion. The outcome of the stepwise plan in this study suggests that acute PF following AHO in pediatrics can be managed efficiently

Summary:. Hamstring tendons (HT) represent a widely used autograft for ACL reconstruction. Harvesting, processing and pretensioning procedures together with the time out of the joint could theoretically hamper tendon cells (TCs) viability. The authors hypothesize that HT cells are not impaired at the end of the surgical procedures and their tenogenic phenotype may be strongly improved by exposure to PEMF. Methods. Remnants of semitendinosus and gracilis tendons were collected at the end of the surgical procedures before skin closure from 15 healthy donors who underwent ACL reconstruction with autologous hamstring tendons. To isolate TCs, the tendon was minced and digested with 0.3 % type I collagenase and the nucleated cells were plated at a density 5x10E3 cells/cm2 and cultured in chamber slides in differentiation medium composed of DMEM + 5ng/ml basic fibroblast growth factor (b-FGF) for 7, 14, 21 days. The following cell cultures were set up:. -. TCs cultured with differentiation medium + exposure to PEMF 8 h/day (PEMF generator system IGEA, intensity of magnetic field = 1.5 mT, frequency = 75 Hz). -. TCs cultured with differentiation medium without exposure to PEMF. At day 0, day 7, day 14 and day 21, immunofluorescence analysis was performed to evaluate the expression of collagen type I, collagen type VI, scleraxis and PCNA (proliferative marker). Subsequently, tendon explant cultures were set up to verify, at day 21, explant viability and the expression of collagen type I, collagen type VI, beta-catenin and PCNA. Results. The TCs from the tendon fragments at the end of the ACL reconstruction were alive and they expressed markers of proliferation and tendon phenotype at the end of the culture periods. The TCs in the presence PEMF 8h/day showed greater production of collagen type I, collagen type VI and scleraxis than that of TCs cultured without PEMF (p<0,05): the expression of this markers increased from 7 to 21 days of culture. The expression of PCNA, in the presence of PEMF stimulus, was significantly lower (p<0,05) than that of TCs cultured without PEMF. A similar behavior was surprisingly observed in tendon explant cultures. Conclusions. Hamstring tendons used for ACL reconstruction are not simple autologous tenoconductive scaffold but are a biologic structure rich in progenitor cells that show tenogenic behavior. Their tenogenic phenotype may be strongly improved by exposure to PEMF. In a future clinical perspective, the postoperative use of PEMF could be used to enhance the ligamentization processes of autologous hamstring tendons, when used as autografts for ACL reconstructions

Aim. To describe the management of PJI due to S. aureus in CRIOAcs in 2019 and to particularly focus on the evaluation of the efficacy of DAIR regarding control of infection and risk factors for failure up to 12 months. Method. Thirteen CRIOAcs were selected to participate to the study. Data concerning the management of all the PJI in the year 2019 were retrospectively collected and registered in eCRFs. Inclusion criteria were: ≥ 18 years old patients with S. aureus ± other bacteria (in per surgical procedure sample); knee or hip PJI and with clinical signs of infection. Patients treated with bacteriophages were excluded. All eligible patients were notified by an information letter. Patients treated by the DAIR procedure were selected, and rate of control of infection (no inflammatory local signs or no new surgical procedure or no S. aureus in case of puncture) was analyzed using Kaplan Meier method and risk factors for failure at 12 months were assessed using Cox regression model. Results. A total of 978 PJI were managed in the 9 CRIOAcs, including 238 hip and knee PJI due to S. aureus and 79 to S. aureus plus another bacteria. Among all of them, 154 were managed with DAIR, and 100 fulfilled inclusion criteria, notifying no opposition to their data collection. The median age was 73.0 years; 57% were male, the median Charlson score was 4.0; 66% had hip PJI. A total of 45 failure were observed during the period studied. At 12 months, the control rate was 58. 7% [36.5–75.4], 49.3% [34.3–62.7] in in early and late PJI respectively according to Tsukuyama classification and 49.6% [30.5–66.1], 54.1% [37.7 – 68.0] in early and delayed/late PJI respectively according to Zimmerli classification, 56.6% [39.5–70.5] in case of mobile part exchange, 53.4% [35.3–68.5] for MRSA PJI and 63.4% [50.5–73. 8] in patients treated with rifampicin. No rifampicin intake was the only significative risk factor for failure in univariate analysis (HR=0.31 (0.17–0.57), p=0.0002), and remained significant after adjustment on Charlson score (aHR=0.34 (0.18–0.64), p=0.0008). Conclusions. The DAIR procedure is frequently performed in patients with acute and late PJI, and is associated with a high rate of failure, especially for patients who cannot receive rifampin. There is a strong rational to assess the use of bacteriophages during the DAIR, as bacteriophages have antibiofilm activity in vitro, and could improve the efficacy of the DAIR to control the disease

The Trauma Triage clinic (TTC) is a Virtual Fracture clinic which permits the direct discharge of simple, isolated fractures from the Emergency Department (ED), with consultant review of the clinical notes and radiographs. This study details the outcomes of patients with such injuries over a four-year period. All TTC records between January 2014 and December 2017 were collated from a prospective database. Fractures of the radial head, little finger metacarpal, fifth metatarsal, toe phalanges and soft tissue mallet finger injuries were included. Application of the direct discharge protocol, and any deviations were noted. All records were then re-assessed at a minimum of three years after TTC triage (mean 4.5 years) to ascertain which injuries re-attended the trauma clinic, reasons for re-attendance, source of referral and any subsequent surgical procedures. 6709 patients with fractures of the radial head (1882), little finger metacarpal (1621), fifth metatarsal (1916), toe phalanges (920) and soft tissue mallet finger injures (370) were identified. 963 (14%) patients were offered in-person review after TTC, of which 45 (0.6%) underwent a surgical intervention. 299 (4%) re-attended after TTC direct discharge at a mean time after injury of 11.9 weeks and 12 (0.2%) underwent surgical intervention. Serious interventions, defined as those in which a surgical procedure may have been avoided if the patient had not undergone direct discharge, occurred in 1 patient (0.01%). Re-intervention after direct discharge of simple injuries of the elbow, hand and foot is low. Unnecessary deviations from protocol offer avenues to optimise consumption of service resources

Aims. Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria. Methods. Data from 11,270 patients with PFFs, treated surgically (osteosyntheses, n = 6,435; endoprostheses, n = 4,835) at Austrian hospitals within a one-year period (January to December 2021) was retrieved from the Leistungsorientierte Krankenanstaltenfinanzierung (Achievement-Oriented Hospital Financing). The 30-day and one-year readmission rates were reported. Readmission risk for any complication, as well as general medicine-, internal medicine-, and surgery/injury-associated complications, and factors associated with readmissions, were investigated. Results. The 30-day and one-year readmission rates due to any complication were 15% and 47%, respectively. The 30-day readmission rate (p = 0.001) was higher in endoprosthesis than osteosynthesis patients; this was not the case for the one-year readmission rate (p = 0.138). Internal medicine- (n = 2,273 (20%)) and surgery/injury-associated complications (n = 1,612 (14%)) were the most common reason for one-year readmission. Regardless of the surgical procedure, male sex was significantly associated with higher readmission risk due to any, as well as internal medicine-associated, complication. Advanced age was significantly associated with higher readmission risk after osteosynthesis. In both cohorts, treatment at mid-sized hospitals was significantly associated with lower readmission risk due to any complication, while prolonged length of stay was associated with higher one-year readmission risks due to any complication, as well as internal-medicine associated complications. Conclusion. Future health policy decisions in Austria should focus on optimization of perioperative and post-discharge management of this vulnerable patient population. Cite this article: Bone Jt Open 2024;5(4):294–303