Aim. Debridement, antibiotics and implant retention (DAIR) are considered as an optimal curative treatment option for prosthetic joint infection (PJI) when the biofilm is still immature and radical debridement is achievable. There are two main groups of patients suitable for DAIR. Those with an early acute PJI and patients with acute hematogenous PJI. However, there is also a third group of early PJI resulting from a wound healing problem or leaking hematoma. These may be either high or low grade depending on the microorganisms that infected the artificial joint “per continuitatem”. Methods. We retrospectively analysed 100 successive DAIR procedures on prosthetic hip and knee joints performed between January 2010 and January 2022, from total of 21000 primary arthroplasties implanted within the same time period. We only included PJI in primary total replacements with no previous surgeries on the affected joint. Patients data (demographics, biochemical, microbiological, histopathological results, and outcomes) were collected from hospital bone and joint infection registry. The aim of surgery was radical debridement and the mobile parts exchange. The standardized antibiotic regime based on antibiofilm antibiotics. Results. The mean age of patients was 70 years (60% women, 43 hips, 57 knees) with a mean follow-up of 3 years. 45 cases were early acute or related to wound healing problems, 55 were hematogenous PJI. 25 patients received preoperative antibiotics. 6 of these were culture negative. The mean symptom duration was 7 days. Mean age of the prosthesis was 30 days for early, and 1064 days for the hematogenous group. Conclusions. In our cohort the success rate of DAIR is 94% which indicates that the protocol is highly successful in PJI with short-lasting symptoms and “debridable” joints. Antibiotic protocol violation and duration of symptoms may have a role in failures

Abstract. Background. Distinction between foot and ankle wound healing complications as opposed to infection is crucial for appropriate allocation of antibiotic therapy. Our aim was to evaluate the diagnostic accuracy of white cell count (WCC) and C-reactive protein (CRP) as diagnostic tools for this distinction in the non-diabetic cohort. Methods. Data were reviewed from a prospectively maintained Infectious Diseases Unit database of 216 patients admitted at Leicester University Hospitals – United Kingdom between July 2014 and February 2020 (68 months). All diabetic patients were excluded. For the infected non-diabetic included patients, we retrospectively retrieved the inflammatory markers (WCCs and CRP) at the time of presentation. Values of CRP 0–10 mg/L and WCC 4.0–11.0 ×109 /L were considered normal. Results. 25 patients met our inclusion criteria. Infections were confirmed microbiologically with positive intra-operative culture results. 7 (28%) patients with foot osteomyelitis (OM), 11 (44%) with ankle OM, 5 (20%) with ankle septic arthritis, and 2 (8%) patients with post-surgical wound infection were identified. Previous bony surgery was identified in 13 (52%) patients. 21 (84%) patients did have raised inflammatory markers while 4 (16%) patients failed to mount an inflammatory response even with subsequent debridement and removal of metalwork. CRP sensitivity was 84%, while WCC sensitivity was only 28%. Conclusion. CRP had good sensitivity, whereas WCC is a poor inflammatory marker in the detection of such cases. In presence of a clinically high level of suspicion of foot or ankle infection, a normal CRP should not rule out the diagnosis of OM

The comparability of studies of extra-articular proximal femur fractures is compromised by the lack of a widely accepted, simple classification system with clinical and prognostic relevance. The aim of the study is to define the complication profile as well as differences relating to age, gender and survival rate of simple trochanteric fractures (typ 1), intertrochanteric comminute (typ 2) and subtrochanteric fractures (typ 3). The records of 335 consecutive patients were analysed prospectively. Patients had a mean follow-up of 10 (0–56) months, and were treated operatively with three intramedullary nailing systems. Simple trochanteric fractures (n=67) show only wound healing problems (1.5%). Median age is m/f 76.4(45–98) years/82.7(39–101), and the two-year survival rate is m/f 50.3%/84.9%. Intertrochanteric comminute fractures (n=204) demonstrate the highest complication rates (25%) with 9.7% femur head perforations, 3.5% other hardware related problems and 11.8% wound healing problems. Median age is m/f 72.5(41–94) years/83.6(54–100), survival rate is m/f 92.7%/66.5%. We observe a complication rate of 17.0% in subtrochanteric fractures (n=64), no femur head perforation but 9.1 % other hardware problems and 7.8% wound healing problems. Median age is m/f 61.1(24–91) years/81.6(38–99), surviving rate is m/f 92.3%/67.9%. The overall complication rate is nearly twice as high in females compared to males (19% versus 10%). The 3 types of proximal extraarticular femur fractures show diferrences in epidemiological data such as median age and surviving rates. Furthermore intramedullary nail osteosynthesis of extraarticular proximal femur fractures lead to different complication patterns in simple trochanteric fractures, in comparison to inter-trochanteric comminuted fractures and subtrochanteric fractures. The recommended surgical treatment in Type 1 fractures leads to a low complication rate. Type 3 fractures exhibit an acceptable complication level; pseudarthrosis and intraoperative shaft fissures as well as wound healings problems are the main complications. Type 2 fractures represent fractures whose treatment is problematic, with the highest complication rate of hardware-related problems (13.2%), including femoral head perforation (9.7%), and the highest number of wound healing complications (11.8%), more than a third of which are infections

The optimal choice of irrigating solution or irrigating pressure in the initial management of open fracture wounds remains controversial. FLOW compared the effect of castile soap versus normal saline, and low versus high pressure pulsatile lavage on one year re-operation rates in patients with open fracture wounds. We conducted a multicentre, blinded, two-by-two factorial, pilot randomised trial of 111 patients with open fracture wounds receiving either castile soap solution or normal saline and either high or low pressure pulsatile lavage. The primary outcome, re-operation within one year, included infections, wound healing problems, and nonunions. Secondary outcomes included all operative and non-operative infections, wound healing problems, nonunion and functional outcomes. We followed the intention to treat principle. Eighty-nine patients (80.2%) completed the 12-month follow-up. As anticipated in this small-sample-size pilot study, results were compatible with substantial benefit and substantial harm. The hazard ratio (HR) for re-operation with castile soap was 0.77 (95% Confidence Interval (CI) 0.35 to 1.69, p=0.52). With low pressure lavage, the hazard ratio for the risk of re-operation was 0.56, 95% CI 0.25 to 1.27, p=0.17. Secondary outcomes showed a significant relative risk reduction for nonunion of 63% in favour of castile soap (p=0.036), and a trend for a relative risk reduction for nonunion of 44% in favour of low pressure lavage (p=0.22). Functional outcome scores showed no significant differences at any time point between groups. The FLOW pilot randomised controlled trial demonstrated the possibility that the use of low pressure may decrease the re-operation rate for infection, wound healing problems, or nonunion. Our findings provide compelling rationale for continued investigation in a pivotal FLOW trial of 2280 patients

Introduction. Femoral shaft fractures in children is a serious injury that needs hospitalization, with a high prevalence in the age group 6–8 years old. Various treatment options are available and with a comparable weight of evidence. Submuscular plating provides a dependable solution, especially in length-unstable fractures and heavier kids. We present a novel technique to facilitate and control the reduction intraoperatively, which would allow for easier submuscular plate application. Materials and Methods. We have retrospectively reviewed four boys and three girls; all were operated in one centre. Polyaxial clamps and rods were applied to the sagittally-oriented bone screws, the reduction was done manually, and the clamps were tightened after achieving the proper alignment in the anteroposterior and lateral fluoroscopy views. The submuscular plate was applied as described, then clamps and bone screws were removed. Results. The mean age at surgery was 13 years (range, 9–14). The mean body weight was 43.3 kg (range, 30–66). There were five mid-shaft fractures, one proximal third and one distal third. There were Four type A fractures, two type B and one type C. Four patients had road traffic accidents while three had direct trauma. The mean preoperative haemoglobin concentration 12.5 g/dl (range 11.3–13 g/dl). No blood transfusion was needed intraoperatively or postoperatively. The operative time averaged 122 minutes, and the mean hospital stay was one (range 1–4 days). The patients reported no pain at a mean of 1.5 weeks (range, one-three weeks). All fractures united at a mean of 8.7 weeks (range 6–12 weeks). No wound healing problems nor deep infections happened. The knee joint range of motion was full in all patients at six weeks postoperatively. There was no mechanical irritation from the inserted plate. At the final follow-up, all fractures united without malalignment nor length discrepancy. Conclusions. External fixator-assisted internal fixation of pediatric femoral fractures would facilitate the accuracy and control of fracture reduction and allow minimally invasive percutaneous osteosynthesis. Our study has shown a decrease in operative time, and an accompanying reduction in length of inpatient stay, prolonged need for analgesia and post-operative rehabilitation

Introduction: Systemic sclerosis of the hand is an uncommon form of arthritis that can cause significant functional loss in the hand. Because of decreased microcirculation, wound-healing problems are feared and surgical interventions avoided. We report the results after operations performed on the hand and forearm of patients with systemic sclerosis with special reference to wound healing problems. Material and methods: This retrospective study evaluates the results of 41 consecutive operations performed in 19 patients between 1985 and 2000 at our unit. The mean age was 50 years (14 – 84 years). Sixteen patients were female and 3 male. Twelve patients were operated twice or more. Operations were elective in 27 cases, with excision of calcinosis in 8 patients, excision of calcinosis plus skin transplant in 2 patients, neurolysis of median, radial or ulnar nerve in 7 patients, wrist procedures (fusion or implant) in 3 patients and other procedures (e. g. finger joint fusion, removal of osteosynthetis material, finger osteotomy) in 7 patients. In 14 cases the operations were indicated in reason of spontaneous skin necrosis or defects. These operations were: amputation with or without flap in 3 cases, wound revision in 6 cases, wound revision and flap in 5 cases (including skin transplantation in 3 of these patients). Results: One wound healing problem occurred in the 27 elective operations. The patient operated with an arthrodesis of the small finger PIP-joint had to have both the cerclage wire and K-wire removed to obtain complete wound healing. Seven of 14 patients in the group with spontaneous skin necrosis healed uneventfully after operation. Two patients had consecutive wound infections that caused a longer healing period of 5 months; another patient also had a longer healing period but his wounds healed shortly after he quit smoking. Four patients had necrosis/infections, which required additional surgery. Conclusion: In systemic sclerosis, surgery performed in elective operations does not seem to have an increased rate of infections or other wound healing problems. Even larger operations like wrist arthrodesis or wrist prosthesis can be performed. In non-elective cases with spontaneous skin necrosis, in critically ischaemic fingers, the wound healing is not always easy and several operations can be necessary, however a good end result, without need for amputations, can be achieved

Wound complications are much more common following knee arthroplasty compared to hip arthroplasty. This is because of the precarious blood supply which contributes to the infection rate which is about twice as high. Many, if not most, infections are related to wound problems. Avoiding wound problems is a critical issue in joint replacement, more so in the knee than the hip. The volume of these procedures is growing rapidly. Infection continues to be a major complication. The incidence is not decreasing and infections are becoming more difficult to treat, because of resistant organisms. Also, the increasing number of procedures in patients with obesity and other risk factors makes wound management a major issue in knee replacement. Many wound problems are avoidable and can be minimised by care to detail by the surgeon. Salvaging the problem wound is a major issue in total knee replacement currently in order to minimise infection, which remains a major issue and is frequently related to wound healing problems. The first step is identifying the patient at risk and either deferring surgery or optimising the patient to minimise the risk of wound healing problems and subsequent infection. Secondly, is appropriate soft tissue handling with careful attention to choosing the optimal skin incision. Third is taking steps to facilitate primary wound healing and absolutely minimising the risk of persistent drainage, particularly through the very judicious use of anticoagulants. Finally, the delayed wound healing and persistent drainage must be identified early and treated aggressively in order to minimise the risk of infection

Few studies of wound complications following limb salvage surgery for soft tissue sarcomas separate anatomical compartments. Forty-nine patients with adductor compartment sarcomas underwent limb salvage surgery, 43% developing significant wound complications, 25% requiring further surgery and 20% had delays in adjuvant radiotherapy as a result. Prior surgery by non tumour surgeons and previous radiotherapy led to an increased risk of wound healing problems. In this particular group of patients, special attention should be made to prevent wound healing complications, possibly involving plastic surgeons at an earlier stage of management

The purpose of this study is to compare the healing progress in cases with wound healing complications with or without VAC assistance. From 2005 to 2008, 32 patients with a mean 56 years of age had wound healing complications necessitating for further operative intervention. 26 cases were classified as stage III and 6 cases were classified as stage IV according to the National Pressure Ulcer Advisory Panel. The mean extent of wounds was 7cm2. 17 cases (group A) were treated with repeated removal of necrotic debris. In 15 cases (group B) the VAC device was applied (75mmHg). The 2 groups were compared on the basis of total hospital stay, need for additional operation, and re-infection rates. Mean hospital stay was 25.2 days in group A and 16.5 days in group B (p< 0.05). 7 cases needed re-operation in group A comparing to 2 in group B (p< 0.05). Re-infection appeared in 5 cases of group A comparing to 1 case of group B (p< 0.05). 1 patient of group B used VAC therapy in lower negative pressure (50mmHg) 6 days post application due to unrelenting pain. Negative pressure wound therapy is safe and effective. It minimises the total hospital stay, it is associated with lower recurrence, re-infection and re-operations rates, and lowers total cost of therapy

Multiple newer wound closure techniques have been recently developed with the goals being reducing closure time, enhancing cosmesis, and decreasing wound healing problems including infections. Among these techniques are the zipper-like closure, absorbable dermal staples, scaffold devices, and others. Each of these techniques propose certain advantages. Nevertheless, this comes at an added cost and careful weighing of the cost/benefit should be considered in an evidence-based manner, in order to guide future recommendations for using these techniques

Purpose: The optimal choice of irrigating solution or irrigating pressure in the initial management of open fracture wounds remains controversial. FLOW compared the effect of castile soap versus normal saline, and low versus high pressure pulsatile lavage on one year re-operation rates in patients with open fracture wounds. Method: We conducted a multicenter, blinded, two-by-two factorial, pilot randomized trial of 111 patients with open fracture wounds receiving either castile soap solution or normal saline and either high or low pressure pulsatile lavage. The primary outcome, reoperation within one year, included infections, wound healing problems, and nonunions. Secondary outcomes included all operative and non-operative infections, wound healing problems, nonunion and functional outcomes. We followed the intention to treat principle. Results: Eighty-nine patients (80.2%) completed the 12-month follow-up. As anticipated in this small-sample-size pilot study, results were compatible with substantial benefit and substantial harm: the hazard ratio (HR) for reoperation with castile soap was 0.77, 95% CI 0.35 to 1.69, p=0.52; with low pressure lavage, the hazard ratio for the risk of reoperation was 0.56, 95% CI 0.25 to 1.27, p=0.17. Secondary outcomes showed a significant relative risk reduction for nonunion of 63% in favour of castile soap (p=0.036), and a trend for a relative risk reduction for nonunion of 44% in favour of low pressure lavage (p=0.22). Conclusion: The FLOW pilot study suggests the possibility of an important reduction in reoperation rates for both castile soap and low pressure pulsatile lavage. Our findings provide compelling rationale for continued investigation in a pivotal FLOW trial of 2280 patients

Purpose. The evolution of locked anatomical clavicular plating in combination with evidence to suggest that fixation of clavicle fractures yields better outcome to conservative treatments has led to an increasing trend towards operative management. There is no evidence however to compare early fixation with delayed reconstruction for symptomatic non- or mal-union. We hypothesize that early intervention yields better functional results to delayed fixation. Methods. Between August 2006 and May 2010, 97 patients were managed with operative fixation for their clavicular fracture. Sixty eight with initial fixation and 29 delayed fixation for clavicular non- or mal-union. Patients were prospectively followed up to radiographic union, and outcomes were measured with the Oxford Shoulder Score, QuickDASH, EQ5D and a patient interview. Mean follow-up was to 30 months. All patients were managed with Acumed anatomical clavicular plates. Results. The radiographic and clinical outcomes were available for all patients. Scores were available for 62 (62/97). There were no statistically significant differences in age (p>0.05), sex (p>0.05), energy of injury (p>0.05), number of open fractures (p>0.05) between the two groups. The mean quickDASH was 8.9 early, 9.1 delayed (p< 0.05), Oxford Shoulder score was 15.7 early, 16.1 delayed (p< 0.05). In the early fixation group 5 patients had wound healing complications, and 8 went on subsequently to have removal of prominent metalwork. In the delayed fixation group 2 had wound healing complications and 4 had removal of prominent metalwork. There were no statistically significant differences in the EQ5D quality of life questionnaire. Conclusion. There are no statistically significant differences in shoulder performance, wound or operative complications between early and delayed fixation of clavicular fractures. Our series does not support early fixation of clavicular fractures, as results for delayed intervention in those who become symptomatic appear comparable

Introduction: Recent studies suggest that preservation of the calcaneocuboidal joint and a single medial approach may lead to equally good results as a conventional triple arthrodesis for painful malalignment or arthritis of the hindfoot. The theoretical advantage of a single medial approach for subtalar and talonavicular fusion is a lower risk for postoperative wound healing problems. The aim of our study was to assess the capability of the modified triple arthrodesis to correct hindfoot malalignment. Methods: We retrospectively measured radiological parameters in 36 consecutive feet in 34 patients who underwent a modified triple arthrodesis. All operations were done with a single medial incision using rigid internal fixation with screws. Radiological evaluation was done at a mean of 15 months (range 6 to 34) postoperatively. Results: The following angles showed a significant (p< 0.001) improvement: the talonavicular coverage from 23° (range,−51 to 51°) to 10° (range, −13 to 32°), the dorsoplantar talar-first metatarsal angle from 18° (range, −19 to 76°) to 9° (range, −11 to 28°), the lateral talo-calcaneal angle from 38° (range, 14 to 57°) to 28° (range, 12 to 44°), and the lateral talar-first metatarsal angle from −15° (range, −51 to 23°) to −4°(range, −18 to 22°). We encountered neither primary wound healing problems, nor bony nonunion. Conclusions: In our study all radiological parameters improved postoperatively. We therefore believe that this is a safe and effective technique in the management of hindfoot deformity with predictable outcome even in patients with severe malalignment

Introduction. Enhanced pain and rehabilitation protocols have significantly improved patient recovery following primary TKR. Little has been written on how the protocols have affected the revision TKR patient. We report on a matched group of revision and primary TKR patients treated with the identical pain and rehab program. Materials and Methods. 40 aseptic RTKR patients who underwent a full femoral and tibial revision were matched by age, sex, and BMI to a group of patients who underwent a cemented tri-compartmental primary TKR. All revision knees had uncemented stemmed femurs and tibias. All 40 patients had either a metaphyseal sleeve on either the femur or tibia or both. Patients in both groups were treated with an identical post op pain protocol (Spinal anesthetic, local infiltrative analgesia and multimodal oral pain management along with rapid rehabilitation). All patients were mobilized on POD1 and allowed weight bearing as tolerated. Patients were followed for a minimum of 1 year. KSS at 6 weeks and 1 year were recorded for both groups. Results. There was no significant difference in length of stay between the RTKR and the primary TKR (1.2 days versus 1.1 days). Average oral morphine equivalents used during the hospitalization was 38 for the RTKR and 42 for the primary group. There was 1 readmission in each group: GI distress in the RTKR and urinary retention in the primary group. There no were reoperations, wound healing problems, identified thromboembolic events or manipulations under anesthesia in either group. KSS for the RTKR group averaged 87.3 at 6 weeks (range 45 to 99) and 89.1at minimum 1 year (range 52 to100). KSS for the primary group averaged 89.9 (range 71 to 100) at 6 week follow-up and 93.2 (range 54 to 100) at minimum follow-up. Range of motion at final follow up averaged1.2 (0–10) to 114.1 (55–135) for the RTKR group and 1 (0–8) to 121.3 (85–140) for the primary group. Conclusion. Despite more complex surgery in the revision total knee patient, enhanced pain and rehabilitation protocols have enabled the RTKR patient to have a similar recovery and outcome compared to the primary TKR patient. For figures, tables, or references, please contact authors directly

Purpose of the study: is to evaluate the wound healing problems following. Open reduction and internal fixation (ORIF) of calcaneal fractures. Introduction: Calcaneal fracture is challenging to all orthopaedic surgeons. It can be disabling injury with economical consequences, particularly it usually happen in men workers. ORIF is often needed to improve the final outcome of these difficult injuries. However, without careful selection of patients, time of surgery and using meticulous surgical technique, wound breakdown (the most frequent complication) can be disastrous. Material and Method: We reviewed 45 consecutive series calcaneal fractures treated by O.R.I.F. between 1996 and 2001. The mean age was 36 years (range 18 to 57) All but one fracture resulted from a fall from height. Cases were analyzed to ascertain the mechanism of injury, associated injuries, presence of medical problems e.g. Diabetes or peripheral vascular disease, smoking. Number of days elapsed before surgery, method of wound closure, and the use of drain and Saunders grade. Results: All patients were Saunders grade two& three in our study. Fourteen were smokers. No one with peripheral vascular compromise, Body mass Index was within normal limit in all of them. Average time elapsed before surgery was 8 days. All operations were done by one surgeon, who closed all wounds in layers and regularly used a drain. We had four (11%) delayed healing (more than 2 weeks). No serious wound problems needing free flaps or amputation. Conclusion: ORIF for certain calcaneal fractures greatly improve the outcome of these unpleasant injuries. Appropriate patient selection and adherence to meticulous surgical technique significantly reduces wound healing problems

Aims

This study evaluated the definitions developed by the European Bone and Joint Infection Society (EBJIS) 2021, the International Consensus Meeting (ICM) 2018, and the Infectious Diseases Society of America (IDSA) 2013, for the diagnosis of periprosthetic joint infection (PJI).

Introduction. Closed suction intraarticular drain (CSD) use after total knee arthroplasty (TKA) has been studied with regards to wound healing and range of motion, however, no data exist on how CSD use impacts knee joint effusion and quadriceps strength. The primary purpose of this study was to determine whether CSD use influences recovery of quadriceps strength. Secondary outcomes examined effects of CSD on intraarticular effusion, lower limb swelling, knee range of motion (ROM), pain and wound healing complications. Methods. Twenty-nine patients undergoing same-day bilateral TKA were enrolled in a prospective, randomized blinded study. Subjects were randomized to receive a CSD on one lower extremity while the contralateral limb had the use of a subcutaneous drain (SCDRN) without the use of suction. Isometric quadriceps strength was collected as the primary outcome. Secondary outcomes consisted of quadriceps muscle activation, intraarticular effusion measured via ultrasound, lower extremity swelling measured with bioelectrical impendence, lower extremity girth, ROM, and pain. Outcomes were assessed preoperatively and postoperatively at day 2, 2 and 6 weeks and 3 months. Differences in limbs were determined using paired t-tests or Wilcoxon signed rank tests. Results. No significant differences were identified between limbs prior to surgery for the primary or secondary outcomes. No significant differences in quadriceps strength were seen between CSD and SCDRN limbs at postoperative day 2 (p = 0.09), two weeks (p=0.7), six weeks (p=0.3), or three months (p=0.5). Secondary outcomes, of quadriceps activation battery, intraarticular effusion, lower extremity swelling, ROM, and pain were not found to significantly differ at any time point following surgery. Conclusion. The use of CSD during TKA did not influence quadriceps strength, quadriceps activation, intraarticular effusion, bioelectrical measure of swelling, ROM, or pain. The results of this study have limited drain use by the authors in primary uncomplicated TKA

Introduction: The treatment of symptomatic rotator cuff rupture is a common therapeutic challenge in our ageing population with high functional demands. We reviewed our results of arthroscopic treatment (introduced in our department in October 2005) and compared the outcome with that of open repair. Material and Methods: The 73 patients of the open group were operated between October 1998 and October 2006. Treatment consisted of classic open repair done by a parasagital incision with transosseous sutures in 69 and titanium anchors in 4 cases. All patients were immobilised in an abduction splint for 6 weeks and only passive exercises were performed during this period. Strengthening exercises were allowed after 3 month. The arthroscopic group included 30 patients operated between October 2005 and June 2008. A single row repair using 1–3 titanium anchors was performed via 3 to 5 incisions. The abduction splint was used for 4 weeks and strengthening exercises were allowed after 2 month. Standard x-rays in 3 planes were performed praeop, postop and at the latest follow up examination. A praeop MRI was done in all cases. Clinical examination used the non age adapted Constant score and complications were recorded. Results: Follow up was possible for 29 men and 36 women with a mean age of 57 years (35 to 78) in the open versus 15 men and 13 women with a mean age of 59 years (44 to 74) in the arthroscopic group. Mean follow up averaged 36 month (3–102) in the open and 15 month (3–35) in the arthroscopic group. One tendon was affected in 45% versus 75%, two tendons in 45% versus 25% and three tendons in 10% versus 0% in the open and arthroscopic groups. The mean Constant score could be improved from 50 (29–68) praeop to 71 (39–97) postop in the open and 52 (28–62) praeop to 80 (45–98) postop in the arthroscopic group. If only one and two tendon ruptures were recorded in the open group the mean postop Constant score was 76. Four complications were encountered in the open group. One patient had to be revised due to deep infection and one because of wound healing problems. Two cases of frozen shoulder could be managed conservatively. In the arthroscopic group one patient showed a temporal irritation of the ulnar nerve and another a frozen shoulder. Both cases could be managed conservatively. Conclusion: Short to mid term results showed no difference in clinical outcome comparing open and arthroscopic procedures. The higher mean postop Constant score of the arthroscopic group was mainly due to the lager tears sizes of the open group. Advantages of the arthroscopic procedure are the possibility of faster rehabilitation and that the operation seems less prone to infection and wound healing problems

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.

Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a devastating complication. It is associated with high morbidity and mortality. It remains, unfortunately, one of the most common modes of failure in TKA. Much attention has been paid to the treatment of PJI once it occurs. Our attention, however, should focus on how to reduce the risk of PJI from developing in the first place. Infection prevention should focus on reducing modifiable risk factors that place patients at increasing risk for developing PJI. These areas include pre-operative patient optimization and intra-operative measures to reduce risk. Pre-operative Modifiable Risk Factors: There are several patient related factors that have been shown to increase patient's risk of developing PJI. Many of these are modifiable risk factors can and should be optimised prior to surgery. Obesity and in particular Morbid Obesity (BMI >40) has a strong association with increased risk of PJI. Appropriate and healthy weight loss strategies should be instituted prior to elective TKA. Uncontrolled Diabetes (Hgb A1C >8) and poor glycemic control around the time of surgery increases the risk for complications, especially PJI. Malnutrition should be screened for in at-risk patients. Low Albumin levels are a risk factor for PJI and should be corrected. Patients should be required to stop smoking 6 weeks prior to surgery to lower risk. Low Vitamin D levels have been show to increase risk of PJI. Reduction of colonization of patient's nares with methicillin sensitive (MSSA) and resistant (MRSA) staphylococcus should be addressed with a screen and treat program. Intra-operative Measures to Reduce PJI: During surgery, several steps should be taken to reduce risk of infection. Appropriate dosing and timing of antibiotics is critical and a first generation cephalosporin remains the antibiotic of choice. The use of antibiotic cement remains controversial with regards to its PJI prophylactic effectiveness. The utilization of a dilute betadine lavage has demonstrated decreased rate of PJI. Maintaining normothermia is critical to improve the body's ability to fight infection. An alcohol-based skin preparation can reduce skin flora as a cause of PJI. Appropriate selection of skin incisions and soft tissue handling can reduce wound healing problems and reduce development of PJI. Likewise, the use of occlusive dressing has been shown to promote wound healing and reduce PJI rates