The December 2024 Wrist & Hand Roundup³⁶⁰ looks at: Variability in thumb ulnar collateral ligament rupture management across the UK: survey insights; Identifying five distinct hand osteoarthritis pain phenotypes highlights the impact of biopsychosocial factors; Long-term outcomes of MAÏA TMC joint prosthesis for osteoarthritis: a possible alternative to trapeziectomy; Diagnostic and management strategies for malignant melanoma of the hand; Early versus delayed surgery for distal radius fractures: comparable outcomes but higher complications in delayed treatment; Perioperative anticoagulant and antiplatelet use does not increase complications in wide-awake hand surgery; Variability in treatment of metacarpal shaft fractures highlights need for standardized care; Low-intensity pulsed ultrasound ineffective in reducing time to union for scaphoid nonunion post-surgery.

Aims

The aim of the LightFix Trial was to evaluate the clinical outcomes for one year after the treatment of impending and completed pathological fractures of the humerus using the IlluminOss System (IS), and to analyze the performance of this device.

The December 2024 Research Roundup³⁶⁰ looks at: Skeletal muscle composition, power, and mitochondrial energetics in older men and women with knee osteoarthritis; Machine-learning models to predict osteonecrosis in patients with femoral neck fractures undergoing internal fixation; Aetiology of patient dissatisfaction following primary total knee arthroplasty in the era of robotic-assisted technology; Efficacy and safety of commonly used thromboprophylaxis agents following hip and knee arthroplasty; The COVID-19 effect continues; Nickel allergy in knee arthroplasty: does self-reported sensitivity affect outcomes?; Tranexamic acid use and joint infection risk in total hip and knee arthroplasty.

In the UK, multidisciplinary teamwork for patients with hip fracture has been shown to reduce mortality and improves health-related quality of life for patients, while also reducing hospital bed days and associated healthcare costs. However, despite rapidly increasing numbers of fragility fractures, multidisciplinary shared care is rare in low- and middle-income countries around the world. The HIPCARE trial will test the introduction of multidisciplinary care pathways in five low- and middle-income countries in South and Southeast Asia, with the aim to improve patients’ quality of life and reduce healthcare costs.

Cite this article: Bone Joint J 2024;106-B(12):1369–1371.

The December 2024 Oncology Roundup³⁶⁰ looks at: Non-reversed great saphenous vein grafts for vascular reconstruction after resection of lower limb sarcoma; Detrimental effects of COVID-19 pandemic on patients with limb bone sarcoma: reference centre experience; Whole-body staging guidelines in sarcoma; Intraoperative marrow margin frozen section in limb bone sarcoma resection; Vacuum-assisted closure and paediatric oncological limb salvage; Treatment differences and long-term outcomes in adults and children with Ewing’s sarcoma; Survival, complications, and functional outcomes of uncemented distal femoral endoprosthesis with short, curved stem for patients with bone tumours.

The December 2024 Trauma Roundup³⁶⁰ looks at: Percutaneous lumbopelvic fixation is effective in the management of unstable transverse sacral fractures; A systematic review on autologous matrix-induced chondrogenesis (AMIC) for chondral knee defects; Stable clinical and radiological outcomes at medium and over five-year follow-up of calcaneus fracture open reduction internal fixation using a sinus tarsi approach; Right or left? It might make a difference; Suprapatellar versus infrapatellar tibial nailing – is there a difference in anterior knee pain and function?; Can patients safely weightbear following ankle fracture fixation?; Anterior-to-posterior or a plate fixation for posterior malleous fractures?; Audio distraction for traction pin insertion: a prospective randomized controlled study; Is intramedullary nailing of femoral diaphyseal fractures in the lateral decubitus position as safe and effective as on a traction table?

Aims

A recent study used the RAND Corporation at University of California, Los Angeles (RAND/UCLA) method to develop anatomical total shoulder arthroplasty (aTSA) appropriateness criteria. The purpose of our study was to determine how patient-reported outcome measures (PROMs) vary based on appropriateness.

Periprosthetic joint infection (PJI) represents a complex challenge in orthopaedic surgery associated with substantial morbidity and healthcare expenditures. The debridement, antibiotics, and implant retention (DAIR) protocol is a viable treatment, offering several advantages over exchange arthroplasty. With the evolution of treatment strategies, considerable efforts have been directed towards enhancing the efficacy of DAIR, including the development of a phased debridement protocol for acute PJI management. This article provides an in-depth analysis of DAIR, presenting the outcomes of single-stage, two-stage, and repeated DAIR procedures. It delves into the challenges faced, including patient heterogeneity, pathogen identification, variability in surgical techniques, and antibiotics selection. Moreover, critical factors that influence the decision-making process between single- and two-stage DAIR protocols are addressed, including team composition, timing of the intervention, antibiotic regimens, and both anatomical and implant-related considerations. By providing a comprehensive overview of DAIR protocols and their clinical implications, this annotation aims to elucidate the advancements, challenges, and potential future directions in the application of DAIR for PJI management. It is intended to equip clinicians with the insights required to effectively navigate the complexities of implementing DAIR strategies, thereby facilitating informed decision-making for optimizing patient outcomes.

Cite this article: Bone Joint J 2024;106-B(12):1377–1384.

Hip fractures pose a major global health challenge, leading to high rates of morbidity and mortality, particularly among the elderly. With an ageing population, the incidence of these injuries is rising, exerting significant pressure on healthcare systems worldwide. Despite substantial research aimed at establishing best practice, several key areas remain the subject of ongoing debate. This article examines the latest evidence on the place of arthroplasty in the surgical treatment of hip fractures, with a particular focus on the choice of implant, the use of cemented versus uncemented fixation, and advances in perioperative care.

Cite this article: Bone Joint J 2024;106-B(12):1372–1376.

Aims

Frailty has been gathering attention as a factor to predict surgical outcomes. However, the association of frailty with postoperative complications remains controversial in spinal metastases surgery. We therefore designed a prospective study to elucidate risk factors for postoperative complications with a focus on frailty.

The December 2024 Shoulder & Elbow Roundup³⁶⁰ looks at: Predicting recurrence of instability after a primary traumatic anterior shoulder dislocation; Predictors of surgery and long-term outcomes in nonoperative management of full-thickness rotator cuff tears; Reverse shoulder arthroplasty viable despite acquired acromial compromise, but higher infection risk noted; LP-PRP reduces retear rates in rotator cuff repair but shows no functional outcome advantage; Long-term clinical outcomes of arthroscopic supraspinatus tendon repair using the single anchor tension band technique – minimum five-year follow-up; Arthroscopic stabilization for anterior shoulder dislocation shows low recurrence rates regardless of prior dislocations; ORIF outperforms arthroplasty for complex radial head fractures: mid-term outcomes; Routine use of surgical helmet systems may not reduce infection risk in shoulder arthroplasty.

Aims. Calcaneal osteomyelitis remains a difficult condition to treat with high rates of recurrence and below-knee amputation, particularly in the presence of severe soft-tissue destruction. This study assesses the outcomes of single-stage orthoplastic surgical treatment of calcaneal osteomyelitis with large soft-tissue defects. Methods. A retrospective review was performed of all patients who underwent combined single-stage orthoplastic treatment of calcaneal osteomyelitis (01/2008 to 12/2022). Primary outcome measures were osteomyelitis recurrence and below-knee amputation (BKA). Secondary outcome measures included flap failure, operating time, complications, and length of stay. Results. A total of 30 patients (14 female, 16 male; mean age 53.7 years (95% CI 48.0 to 59.5)) underwent combined orthoplastic surgical treatment for BACH “complex” calcaneal osteomyelitis with a median follow-up of 31 months (IQR 11.75 to 49.25). Of these, 19 received a local flap and 11 received a free flap. The most common causes were fracture-related infection (n = 12; 40%) and ulceration (n = 10; 33%); 21 patients (70%) had already undergone at least one operation elsewhere. Osteomyelitis was eradicated in 23 patients (77%). There were seven patients who developed recurrent osteomyelitis (23%), all in the local flap group. One patient required a BKA. Univariate analysis revealed that local flap reconstruction (OR 13.5 (95% CI 0.7 to 269.7); p = 0.029) and peripheral vascular disease (OR 16.5 (95% CI 1.35 to 203.1); p = 0.008) were associated with increased risk of recurrence. Free flap reconstruction took significantly longer intraoperatively than local flaps (mean 481 minutes (408 to 554) vs mean 168 minutes (119 to 216); p < 0.001), but without significant differences in length of stay or frequency of outpatient appointments. Conclusion. In our study involving 30 patients, single-stage orthoplastic management was associated with 77% (n = 23) eradication of infection and only one amputation in this complex and comorbid patient group. Risk factors for failure were peripheral vascular disease and local flap reconstruction. While good outcomes can be achieved, this treatment requires high levels of inpatient and outpatient care. Cite this article: Bone Joint J 2024;106-B(12):1443–1450

Aims

For displaced femoral neck fractures (FNFs) in geriatric patients, there remains uncertainty regarding the effect of total hip arthroplasty (THA) compared with hemiarthroplasty (HA) in the guidelines. We aimed to compare 90-day surgical readmission, in-hospital complications, and charges between THA and HA in these patients.

The December 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Total hip arthroplasty after femoral neck fractures versus osteoarthritis at one-year follow-up: a comparative, retrospective study; Excellent mid-term survival of a monoblock conical prosthesis in treating atypical and complex femoral anatomy with total hip arthroplasty; Hip arthroscopy for femoroacetabular impingement improves sexual function; Fast-track hip arthroplasty does not increase complication rates; Ten-year experience with same-day discharge outpatient total hip arthroplasty: patient demographics changed, but safe outcomes were maintained.

Aim. Haematogenous prosthetic joint infections account for 20-35% of total prosthetic infections. Debridement, antibiotics and implant retention (DAIR) is a well-accepted treatment for these infections and probably the most desired by surgeons, since it tries to maintain a functional and stable implant. However, the risk of DAIR failure is not negligible and some risk factors have been described, and also, different scores, such as CRIME80. Nonetheless, less is known about the impact of positive blood cultures may have on DAIR treatment. The aim of our study is to analyze whether the presence of a positive culture is a risk factor for DAIR failure. Method. A retrospective cohort study of 50 late acute haematogenous TKA infections was performed from 2015 to 2023. DAIR failure was defined as the need of a subsequent intervention either a new DAIR or a revision surgery. So, patients were divided into two groups depending on the surgical outcome: successful (SG) vs failure (FG). Demographic variables including age, gender, affected side and body mass index were collected. Patient's comorbidities were also collected including chronic obstructive pulmonary disease (COPD), diabetes, rheumatoid arthritis (RA), cirrhosis and chronic renal failure, etc. Other variables, such as ones included in CRIME80 (C-reactive protein (CRP) >150mg/dl and polyethylene exchange), were also collected. Results. 30 patients had a successful DAIR outcome (60%). Age and sex do not act as risk factors [OR 0.7 (0.2-2.6) and OR 0.4 (0.1-1.3)]. Neither do COPD [OR 3.3 (0.5-2.0), p=0.2]; RA [OR 0.8 (0.2-3.1), p=0.7]; CRP value [3.2 (0.9-11.2), p=0.06]; and polyethylene exchange [OR 0.4 (0.1-2.5), p= 0.3]. Thirty-five blood cultures (70%) were obtained before surgery (20 SG and 15 FG). Nine of the obtained blood cultures were positive (25.7%), being 7 from FG (46.7%) [OR 7.6 (1.3-4.8), p=0.02]. A logistic regression was performed where positive blood cultures were the only significant variable to predict DAIR failure (OR 12, 95% CI 1.1−18, p=0.049), after adjusting for all CRIME80 variables. Skin and soft tissue origin was described in 5 of the nine positive blood cultures (55.6%). Cardiovascular system was the second most common spread (22.2%), and then followed by urogenital and digestive tract. The most common microorganism in FG was Staphylococcus aureus (57.1%) [OR 6.4 (0.2-18.0), p=0.2]. Conclusions. Positive blood cultures may be another risk factor for DAIR failure. This can be important in diagnosis and it may be taken into account in antibiotic and surgical treatment strategies

Aims

Pain is the most frequent complaint associated with osteonecrosis of the femoral head (ONFH), but the factors contributing to such pain are poorly understood. This study explored diverse demographic, clinical, radiological, psychological, and neurophysiological factors for their potential contribution to pain in patients with ONFH.

Aim. Determine therapeutic and prognostic value of three different prosthetic joint infections (PJI) staging systems – JS-Bach, McPherson and PJI-TNM. Method. Retrospective analysis of patients who received surgery for PJI between 2011 and 2022 at one single institution, including DAIR, 1-stage revision and 2-stage revision. We applied three staging systems - JS-Bach, McPherson, PJI-TNM – and categorize the results into A (less severe), B (intermediate) and C (most severe). Demographic data and comorbidities, anatomic location, type of treatment, recurrency of infection, final outcome and antibiogram were analyzed. Results. 186 patients were included, 112 (60%) were woman. Median age was 70 years old. 51% were submitted to DAIR, 10% to 1-stage revision and 39% to 2-stage revision. Recurrence of infection was found on 27% of patients after initial treatment. 10% died with complication related to PJI. Final status at last follow-up showed 96% of cases were ultimately free of infection at last follow-up. JS-BACH was associated with recurrence. All three staging systems were associated with final outcome. Conclusions. Despite all existing knowledge around risk factors for treatment failure of PJI, there is still a lack of a generally accepted classification system to accurately predict patient outcome. JS-BACH, McPherson and PJI-TNM are three different proposed classifications developed to predict clinical outcomes. To the best of our knowledge there are no studies directly comparing their performance. We retrospectively evaluated our cohort and found that all three correlated with final patient outcome but JS-BACH was the only who significantly correlated with infection recurrence after initial treatment

Aim. This study seeks to outline the clinical, laboratory, and imaging features of patients with pyogenic spondylitis. It aims to define a novel imaging sign that could indicate the severity of suppurative spondylitis, aiding in its early diagnosis and treatment. Method. This retrospective study included 137 patients from 2013 to 2023. Through the analysis and summary of imaging characteristics among all patients, we identified a distinct MRI sign known as ‘the Disc Penetration sign’ (DP). This sign is defined as an image finding on sagittal MRI depicting the anterior and posterior penetration of an abscess through the intervertebral disc space, affecting both the anterior margin of the vertebrae and the structures within the spinal canal. Observational parameters included WBC, ESR, CRP, hemoglobin, and albumin levels. Documentation of the study included location and segment of the lesion, presence or absence of spinal cord compression, and paravertebral abscesses. Results. 56 patients presented with the Disc Penetration sign(DP) and 81 did not. In both groups, there were no significant differences in gender ratio or age (P > 0.05). However, significant differences were observed in the presence of comorbid diabetes and chronic kidney disease (p < 0.05). The DP group had a significantly greater ESR level (74.30±33.79 mm/h vs. 51.46±30.46 mm/h, P < 0.001) and CRP level (47.28 mg/L vs. 26.18 mg/L, P = 0.003). Additionally, the DP group had a significantly lower Hb (100.66±19.82 g/L vs. 116.99±19.99g/L,P < 0.001) and the serum albumin level (28.81±6.59 g/L vs. 34.09±6.17 g/L,P < 0.001). Imaging results showed no significant differences in affected spinal segments or parts (p>0.05). Patients in the DP group showed a higher likelihood of developing paravertebral abscesses compared to those in the non-DP group (n = 54 [96.4%] vs. n = 33 [40.7%], P < 0.001), and also exhibited a higher incidence of spinal cord compression(n = 32 [57.1%] vs. n = 17 [21.0%], P < 0.001). Conclusions. The study suggests that the Disc Penetration sign in pyogenic spondylitis patients correlates with more severe inflammation and higher incidence of paraspinal abscess, pointing to worse stability of the spine, longer bone restructuring time, and potentially poorer prognosis. These findings enable clinicians to rapidly assess the severity of the disease and prognosticate outcomes more effectively We emphasize the need for early, pathogen-specific diagnosis and treatment, particularly considering surgical intervention for patients demonstrating substantial paraspinal abscesses or spinal instability

Aim. The intention of suppressive antimicrobial therapy (SAT) for prosthetic joint infection (PJI) is to minimise symptoms, maintain function and prevent further surgery in patients who cannot undergo further attempts at curative treatment(1). There is little high-quality evidence examining the role and efficacy of SAT for patients with PJI(1,2). The objective of this study was to describe the use of and outcomes after SAT in a large prospective PJI cohort. Methods. A pre-planned analysis of a prospective multi-centre cohort of patients with PJI. SAT was defined as antimicrobial therapy for PJI continuing 12-months after diagnosis or where there was an intention for chronic suppressive antibiotics. The primary outcome was treatment failure at 24 months, defined as any of the development of PJI symptoms, further surgery or death from PJI. Secondary outcomes included Oxford Hip and Knee Scores. Results. SAT was prescribed for 223 (31.0%) of the PJI cohort. Patients prescribed SAT for PJI were more likely to be older, have comorbidities, chronic PJI, higher CRP, a sinus tract and be treated with retention of their prosthesis than those not prescribed SAT. At 24-months, treatment failure was more common in the SAT group 75/185(40.1%) compared with the non-SAT group 85/447(19.0%). Propensity score adjusted analysis did not demonstrate an association between SAT and treatment failure in patients with chronic PJI (OR[95% CI] 1.57[0.63-3.91), late-acute PJI(1.87[0.90-3.87]), a sinus tract (2.74[0.89-8.39]), ongoing symptoms at day 90 (1.19[0.43-3.23]), treatment with DAIR(1.61[0.87-2.99]) or Staphylococcus aureus PJI (1.25[0.62-2.54]). There were similar improvements between SAT and non-SAT patients in functional joint scores (OHS median (IQR) +8.5(19.0) vs +7.0(22.0);p=0.78 and OKS +8.0(20.0) vs +7.0(22.0);p=0.53). Conclusion. SAT use for PJI is common. The lack of demonstrated evidence in this study for its benefit in controlling infection across multiple subgroups of patients but with some improvements in functional scores, suggest that the advantages of SAT are at best complex

Aim. There is controversy regarding the use of Antibiotic-loaded cement (ALBC) as compared to non-antibiotic-loaded cement (NALBC) to reduce the overall infection rate without affecting implant survival or adding additional risks on fixation for primary total knee arthroplasty (TKA). Method. To conduct the analysis, we utilized the Catalan Arthroplasty Registry (RACat) for the TKAs implanted between 2005 and 2017. The primary variable recorded was the use of cement with or without antibiotics. Other recorded variables included were age, sex, diabetes mellitus, obesity, Charlson index and type of hospital. We analyzed the effect of ALBC vs. NALBC in reducing the risk of prosthetic infection at 3, 6, 12, and 24 months as well as prosthetic survival due to mechanical causes at 1, 5, and 10 years. Univariate and multivariable analyses of risk factors were conducted. Thereby, an interactive predictive model that determines the risk of prosthetic infection based on each patient's characteristics was created. Results. A total of 28,287 TKAs from the RACat were analyzed. In that total, there were 19,788 NALBC and 8,499 ALBC. The infection rates for TKAs with NALBC vs. those with ALBC at 3, 6, 12, and 24 months were respectively: 1.69% vs. 1.39% (p=0.132); 1.81% vs. 1.56% (p=0.147); 2.14% vs. 1.73% (p=0.030); 2.51% vs. 1.86% (p=0.001). A statistically significant reduction in periprosthetic infection rate was observed in the ALBC group at 12 and 24 months. No differences were observed between the two groups in terms of prosthetic mechanical survival. Being younger, male and having had previous knee surgery or having a high comorbidity index all led to a higher risk of prosthetic revision due to infection. Conclusions. The use of ALBC as a fixation method for TKA leads to a reduction in the risk of prosthetic infection without altering the mechanical survival of the implant. The creation of a predictive model helps determine the individualized risk of prosthetic infection based on the patient's characteristics