Background: screw implantation technique has been used in acetabular fractures fixation. However, this procedure is technically demanding and limited by narrow bone corridors. Objectives: Assessment of the length and constriction points of the anterior and posterior columns and the ideal screws’ trajectories. Gender differences were addressed. Patients and Methods: Measurements were done using RadiAnt DICOM viewer software program (Medixant Corp., Poznan, Poland) in 31 patients with 33 acetabular fractures using standard pelvic CT scans and multi-planar reconstruction. Results: The mean length and narrowest antero-posterior diameter of the anterior column were 113.6 and 6.6 mm, respectively compared to 103.2 and 8.4 mm regarding the posterior column. The mean length of the vertical height of the anterior column at the center of the acetabulum and middle of superior pubic ramus were 6.9 and 6.2 mm, respectively. The mean angles of the anterior column screw in the coronal and axial planes were 41.3 o and 62o, respectively; while that of the posterior column screw in the coronal and sagittal planes were 15 o and 16.3 o respectively. Significant gender differences were found in all the measurements (P-values <0.001 and 0.027).; except the angle of the posterior column screw in the coronal plane. Conclusion: Knowing the constriction points and screws, trajectories reduces the risks of screws misplacements. It is safe to use 6.5 mm posterior column screws in both sexes and 6.5 and 4.5 mm anterior column screws in males and females, respectively. Keywords: Column screws, Gender differences, Column sizes.

MATERIALS AND METHODS

This is a prospective single centre study of 100 patients who underwent an elective joint replacement procedure early August 2020.
Furthermore, a COVID-modified satisfaction questionnaire was used to assess patients’ satisfaction with the service and COVID measures.
The primary outcome was the rate of COVID contraction whilst the secondary outcome was patient satisfaction of the service and their perception of safety prior to, during their hospital stay and discharge.

RESULTS

Mean patient age was 69.1(89-47). Mean BMI was 29.7(40.2-17.2). Majority of the patients were classified as ASA grade II and III and 55% fell in the medium-risk group as per the BOA risk stratification.
50% of the patients underwent primary hip and 41% primary knee and the rest were either revisions or uni-condylar knees. Mean length of stay was 3 days.

Neither of the patients contracted COVID-19 and only 1% needed to be transferred over to the main site whilst 3% were readmitted to the hospital after discharge.
Regarding the questionnaire, all the patients were happy with the length of their hospital stay and scored a mean of 8.6 on a satisfaction scale (0-10) regarding measures taken to minimize COVID contraction, the information given and quality of the service.

CONCLUSIONS/DISCUSSION

The development of a COVID-free pathway for elective orthopaedic patients resulted in great overall patient satisfaction and the safe patient environment with absent COVID transmission.
Furthermore, that yielded better the capacity for elective orthopaedic surgery catching up with the waiting list.

Background Charcot's arthropathy (CA) is a destructive rare complication of diabetes, and its diagnosis remains challenging for foot specialists and surgeons. We aimed to assess the clinical presentation and characteristics of CA and the frequencies of its various types. Methods This cross-sectional study was conducted from January 1, 2007, to December 31, 2016, and included 149 adults with diabetes diagnosed as having CA. Cases of CA were classified based on the Brodsky anatomical classification into five types according to location and involved joints. Results The mean ± SD age of the studied cohort was 56.7 ± 11 years, with a mean ± SD diabetes duration of 21.2 ± 7.0 years. The CA cohort had poorly controlled diabetes and a high rate of neuropathy and retinopathy. The most frequent type of CA was type 4, with multiple regions involved at a rate of 56.4%, followed by type 1, with midfoot involvement at 34.5%. A total of 47.7% of the patients had bilateral CA. Complications affected 220 limbs, of which 67.7% had foot ulceration. With respect to foot deformity, hammertoe affected all of the patients; hallux valgus, 59.5%; and flatfoot, 21.8%. Conclusions There is a high rate of bilateral CA, mainly type 4, which could be attributed to cultural habits in Saudi Arabia, including footwear. This finding warrants increasing awareness of the importance of maintaining proper footwear to avoid such complications. Implementation of preventive measures for CA is urgently needed.

Objectives: The aim of study is to show that patients with vertebral compression fractures can have many presentations to the Emergency department (ED) and be admitted several times with no clear consensus in diagnosis, management and follow up.

Methods: Patients referred with vertebral compression fractures over 4 months were retrospectively recorded and analyzed in a university hospital in Ireland. These referrals arrived from four different hospitals in the region. Data was collected on number of ED visits, Length of Stay (LOS), readmission rates, number of X-rays, CT scans and MRI scans.

Results: Data from 63 patients were analyzed. Patients were mostly elderly (mean age 75 years). 73% had visited the ED only once. 17.5% had visited the ED twice. 10% presented more than twice over a 120-day period. 54% were admitted to hospital, the total number of bed days was 610, the average LOS is 9.83 days. 16% of patients were readmitted to hospital due to a VCF relating complaint within 120 days. 30% of patients had appropriate orthogeriatric bloods performed at the time of referral. 95% of patients had plain radiographs. 115 x-rays in total were performed within 120 days of referral. 54% of patients had CT scans at time of referral. 20% of patients had MRI scans performed.

Conclusion: VCFs are increasingly being recognized as providing a significant burden to the health services. The lack of consensus in literature regarding the diagnosis of this condition leads to differences in the imaging modalities used and care provided.

Introduction: There is currently no accepted upper level for subsidence in cemented, polished taper-slip stems, despite their widespread use and increasing popularity. In this meta-analysis, we review the literature on the subsidence levels of polished taper-slip stems at different time intervals. Methods: A literature review was performed to identify all studies reporting on the subsidence, over time, of polished taper-slip stems. Patient demographics, stem design, subsidence and radiological findings were collected and the results analysed to identify patterns of subsidence and to establish any features leading to increased subsidence. Results: 28 papers of relevance were identified. 3090 hips were initially recruited into the studies with 2099 hips available for radiological analysis at final follow-up. The average age of patients included in this review was 68. Females represented 60.4% of the population and the average BMI was 27.4 kg/m2. Mean subsidence at one, two, five and 10 years was 0.97mm, 1.07 mm, 1.47 mm and 1.61 mm respectively. Double-tapered stems subsided more than triple-tapered stems at all time points. Remarkably, of the 28 papers included, only 23 documented the type of cement used and only 18 specified cementing technique. Conclusion: Whilst we cannot state a threshold beyond which failure is more likely, this review highlights the levels of subsidence at which clinical outcomes and survivorship remain excellent. Further studies are needed into the longer term subsidence of triple-tapered stems, but given the similarity in clinical outcomes between triple-tapered and double-tapered stems, the subsidence levels presented here can be applied to both.

Osteoarticular infection is a common pathology in children. However, given the overprescription of antibiotics, the epidemiological profile of the germs has changed leading to modifications in the management of the disease.
The objective of our study was to describe the epidemiological profile of osteoarticular infections in children in our region.
We conducted a retrospective descriptive study over an 11-year period, including patients with osteoarticular infections admitted in our orthopedics and traumatology department.
The mean age of acute osteomyelitis (AOM) was five years while children with septic arthritis (SA) had an average age of six years, with male predominance. The rural environnement and the low socioeconomic status were associated to osteoarticular infections occurrence. Trauma was observed in 28% of patients with AOM and in 31% of SA. The most common location for AOM was the metaphysis of the long bones of the lower limbs and the knee for SA. Staphylococcus aureus and Kingella kingae were the most frequently isolated germs. The most commonly used antibiotic therapy consists of amoxicillin-clavulanate associated to gentamicin. Surgery was performed in 61.1% of patients with AOM and in 79.6% of patients with SA. The average hospital stay was seven days in case of AOM and eight days for SA. Complete remission was noted in the majority of patients.
Because of its misleading presentation, the diagnosis and treatment of osteoarticular infection in children are challenging. A well-conducted medical and surgical treatment can insure complete remission of the infection.

Chronic osteomyelitis is a long-lasting infection of bone which can progress to necrosis and sequestrum formation. Diagnosis can be challenging as signs and symptoms are oftentimes vague or absent. It can be classified as exogenous or hematogenous, the former resulting from direct inoculation of bacteria in the bone during trauma or surgical treatment of bone fractures. The infection may persist for years with periods of recurrence and remission of disease and frequent therapeutic failure. Staphylococcus aureus is the main causative organism. We present the case of a 14-year-old boy with a past history of a supracondylar humerus fracture that had occurred 8 years prior and was managed with open reduction and internal fixation with Kirschner wires. Three weeks after surgery the fracture had healed but local wound drainage had developed which was followed by Kirschner wire removal and oral antibiotherapy. On November 2020, in a time at which the COVID-19 pandemic was well underway, the adolescent was brought to the hospital with severe limitation of elbow movement and painful swelling which had persisted for 6 months. Magnetic resonance study revealed a large abscess adjacent to the distal humerus, which displayed signs of osteomyelitis. Surgical drainage and debridement were promptly performed and intraoperative cultures revealed a Staphilococcus aureus. After 3 months of antibiotic treatment, clinical and analytical parameters showed no signs of infection. Elbow mobility was restored almost completely.

Heterotopic ossification (HO) represents formation of bone tissue in atypical extra-skeletal regions. Main triggers are trauma, neurological injury and arthroplasty. Chronic low-grade infections have also been described as possible triggers. We present a case of a total knee arthroplasty (TKA) with chronic infection stigmata and HO. A 76-year-old man underwent right TKA in 2003 for primary osteoarthritis. In 2020 an infection of his TKA was identified with several fistulous paths and active purulent drainage. Imaging studies exhibit a massive, progressive HO of the collateral ligaments, extensor mechanism and posterior capsule. He was admitted for extraction of prosthetic material, placement of a vancomycin and gentamicin impregnated cement spacer and intravenous antibiotics. Intraoperative cultures confirmed the presence of a methicillin-sensitive Staphylococcus aureus. The patient performed three weeks of directed intravenous antibiotics followed by three weeks of oral antibiotics. At 9 months postoperatively, the patient is pain free and ambulates with one walking aid. The fistulae and surgical wound healed without further complications. Radiologic findings of HO overlap the pre-operative description. This report raises two main questions, the first of which concerns the initial phenomenon that triggered the TKA failure: infection (as a cause of HO) or primary HO, also described as a risk factor for infection. The second point is to highlight which definitive treatment is best for this patient: observation, arthrodesis or revision TKA. This impressive case of HO in an infected TKA had a good response to the first phase of a planned two stage procedure.

Introduction: Osteoarticular Tuberculosis (TB) constitutes 1-3% of the cases of extrapulmonary TB, of which about 10% involve the foot and ankle region. In the foot, the calcaneus is the most commonly affected bone. The classical constitutional symptoms of TB such as evening rise of temperature and weight loss are absent in many cases of foot and ankle TB. As calcaneus TB is rare, its awareness among surgeons is low and diagnosis is often delayed. Case Report: A 21-year-old male presented with pain, swelling in the right heel for 5 months, and difficulty in walking for 2 months. Plain X-ray (axial) view of calcaneus showed a lytic lesion in the calcaneus. The magnetic resonance imaging (MRI) of the right ankle shows hypointense and hyperintense lesions on T1- and T2-weighted images. Plain radiographs of the chest were normal. A biopsy was done under local anesthesia and histologic examination revealed a characteristic granuloma, caseous necrosis, and Langhans giant cells which confirmed our diagnosis. The patient was treated with anti-TB chemotherapy for 12 months. Radiographs at 18 months follow-up showed a healed lesion. At present, the patient is comfortable with no complaints. Discussion and Conclusion: TB calcaneus is a rare condition and a high index of clinical suspicion along with imaging studies helps in diagnosis. Conservative management with anti-TB chemotherapy for an adequate duration helps incomplete resolution of the infection with good functional results.

Fragility fractures are defined as fractures involving a low energy mechanism and usually predict higher risk for future fractures. Most fragility fractures occur at the distal radius, hip or vertebral spine. Since they are associated with a significant morbidity and mortality rate, the prevention, diagnosis and treatment of these fractures should be a priority. Understanding osteoporosis risk factors, known to cause decreased bone mineral density (BMD), is vital in the development of strategies to reduce existing risk, limit the impact of this type of fracture and decrease the probability of secondary fractures. Osteoporosis is diagnosed either by the presence of a fragility fracture or by dual-energy x-ray absorptiometry (DXA) derived BMD of ≤2.5 standard deviations (SD) below the mean of a young, healthy reference population. This review gives us an opportunity to remind orthopaedic surgeons that, apart from the fracture fixation, a more preventive approach, beyond surgery, is of crucial importance. Therefore, our aim is to review the most recent scientific updates on the prevention of osteoporosis and associated fractures, the appropriate timing of treatment initiation, duration and dose.

Charcot-disease, caused occasionally by syphilis, is characterized by severe joint destruction, pathological fractures, instability and combined with peripheral neuropathy. Syphilis is thought to be an almost erased condition, nevertheless its incidence is slowly rising according to recent statistics. The authors present the case of a patient with neuroarthropathy affecting the hip and knee joints. Due to the different occurrence of the disease, surgical treatment was performed in the hip, while the two months later an atraumatic, pathological intraarticular knee joint fracture occurred, which was treated conservatively. The therapy of the affected joints were challenging, but finally both were healing with satisfying results, despite the current suboptimal healing patterns. The literature mentions several therapy methods, but our final, considered choice was the conservative management. A review of the corresponding literature highlighting the pathophysiology and management of the disease is also given, next to the aim to plant suspicion in the surgeon's mind in case of meeting with arthropathy.

Pyogenic flexor tenosynovitis (PFT) is an infection of the flexor tendon sheath that should be managed urgently. It presents an incidence between 2.5 to 9.4% of all hand infections. The authors present a case of a 37-year-old male patient, who was admitted to the Emergency Department for inflammatory signs at the level of the 4th finger of his right hand with 3 weeks of evolution.: he presented tenderness to palpation of the flexor tendon sheath, a resting flexed posture, pain with attempted extension and fusiform swelling of the 4th digit, with progression to the hand and cutaneous necrosis of the anterior face of the finger. CT showed thickening and swelling subcutaneous tissue along the 4th finger, compatible with PFT. Minimally invasive irrigation of the flexor tendon sheath was performed. After the procedure, the patient had uncontrollable violent pain associated with distal cyanosis and thickening swelling: he presents a circular volar hematoma with impaired venous return functioning as a local compartment syndrome. Emergent decompression surgery was performed and two drains were left. Although an open debridement was considered the gold standard, closed-catheter irrigation has gained popularity. In this case, as it was an infection with 3 weeks of evolution, the minimally invasive technique was not the best choice. In addition, we should have left a drain on the initial approach to prevent the formation of a circular hematoma. This case was undoubtedly challenging: initially because we used a new surgical minimally invasive technique followed by the need for emergent decompression surgery.

To evaluate the outcome of a novel, combined endoscopic and mini-open repair (CEMR) of a chronic
complete retracted proximal hamstring tendon avulsion (PHA). A retrospective case series of a single-surgeon
database for all patients, with a minimum of 1-year follow-up, who underwent CEMR between July 2015 and
September 2019 was performed. Patients were evaluated for their functional outcome using the Perth Hamstring
Assessment Tool (PHAT). At the latest follow-up, patients were evaluated for their muscle strength, subjective
satisfaction and post-operative complications. Twelve patients who underwent endoscopic surgery for chronic
PHA were identified, of which seven patients underwent CEMR. After exclusion of one patient from the study
due to an open claim for health insurance, six patients (five males) with a mean age of 48 years (range 20–
61 years) were evaluated. The mean time from injury to surgery was 12 months (range 2–43 months). At a mean
follow-up of 28 months (range 12–55 months), the average PHAT score was 73 (range 70–80). The mean subjective
activity level percentage improved from 34 (range 20–50) pre-surgery to 81 (range 75–90) post-surgery.
The mean strength of the quadriceps, hamstring at 30, and hamstring at 90 of the operated leg compared to the
uninjured leg did not differ significantly. One patient underwent adhesiolysis 1 year after the index procedure for
treatment of subcutaneous adhesions. CEMR is a viable and safe option for the treatment of chronic complete
proximal hamstring tears, with good to excellent short-term functional outcome.

Introduction: Silver-coatings on medical devices have shown to reduce infection rates but little is known about systemic exposure and possible side effects. The aim of the study was to report on the silver concentrations following megaprosthetic reconstruction.
Patients & Methods: Between 2004 and 2016, 46 patients received megaprostheses with a galvanised silver coating. Blood was taken from every patient within the first few days following surgery as well as at every six months at outpatient treatment. Silver levels were determined using inductively coupled plasma mass spectrometry.
Results: Overall, 33 patients were available for the determination of serum silver concentrations. During the follow-up we were able to observe an increment of silver levels within the first months and afterwards an unspecific course. The mean serum silver levels were 16.1 ppb, 34.9 ppb, 33.0 ppb and 12.5 ppb after an average follow-up of 10, 22, 63 and 120 months, respectively. Development of periprosthetic joint infection (PJI) was associated with significantly higher silver ion levels over time (p=0.048), irrespective of time from surgery (p=0.429), gender (p=0.462), or patient age (p=0.392).
Discussion: There are several studies reporting on the outcome and implant survival of silver-coated megaprostheses. In the current series we observed an overall unspecific course of silver concentrations. Presence of PJI, however, significantly increased silver ion levels over time. Yet, we could not identify any systemic complication associated to high silver levels, except local argyria. Therefore, we can state that silver-coated implants seem to be a safe solution for megaprosthetic reconstruction.

Introduction: Tuberculosis of Navicular bone is a rare entity. Osteoarticular tuberculosis of foot is uncommon and that of navicular bone is extremely rare. It is important to recognise skeletal tuberculosis in the initial stages as early treatment can effectively eliminate long-term morbidity. Case presentation: A 13 year old presented to OPD with swelling and dull aching pain over dorsum of left foot. Radiograph of foot showed focal osteopenia with patchy sclerosis in the navicular bone. Further investigations in the form of aspiration biopsy showed paucibacillary tuberculosis. Anti-Kochs treatment was started immediately and patient was treated conservatively on standard anti tubercular regimen. Last recent Follow up Radiographs show a healing lesion leading patient to toe touch pain-free ambulation. Conclusion: TB navicular bone is a very rare condition and can be treated conservatively unless associated with metastatic changes or any other complications. Conservative treatment with AKT has excellent results without any complications

Background: The information obtained from laboratory might be insufficient for definitive diagnosis of septic arthrits. This study aimed to evaluate several ratios obtained from routine blood tests (neutrophil/lymphocyte, monocyte/lymphocyte, platelet/lymphocyte and platelet count/mean platelet volume) for a possible use in the diagnosis of septic arthritis. Methods: The adult patients who were operated due to septic arthritis were identified and retrospectively evaluated. A total of 36 patients were found to be eligible for inclusion. The control group included 40 patients without any sign of infection. Receiving operating characteristics (ROC) curve analysis was made to determine the sensitivity, specificity and area under curve (AUC) values of blood parameters. Results: The cultures of joint aspiration yielded positive result in 19 patients while the cultures were negative in 17 patients. All of the analyzed parameters were significantly different between the groups (p<0.001). The AUC value was 97.3 when only CRP and sedimentation values were used but increased to 98.6 when neutrophile/ lymphocyte ratio was added and increased to 100 when all analyzed parameters were included. Conclusions: The analyzed parameters were found to increase the overall sensitivity and specificity when used together with acute phase reactants. However, when evaluated separately, CRP and sedimentation were still found as the most valuable parameters in the diagnosis of septic arthritis. In the diagnosis of septic arthritis, 35 mm/hr cut-off value for sedimentation and 10 mg/L cut-off value for CRP were found more sensitive and specific compared to standard laboratory cut-off values of 20 mm/hr and 5 mg/L.

Purpose: We aimed to compare the clinical efficacy and safety of arthroscopy-guided continuous suprascapular nerve block (AS-SSNB) and ultrasound-guided continuous interscalene block (US-ISB) in patients who underwent arthroscopic rotator cuff repair (ARCR).
Methods: A prospective study was performed. In total, 76 patients were enrolled and divided into two groups: in 38 patients of group 1 (AS-SSNB); and in 38 patients of group 2 (US-ISB). The primary outcome was the pain score measured by the visual analog scale (VAS) at postoperative 24 hours during admission. Comparisons were conducted at different time points (postoperative 4, 8, 24, and 48 hours). The secondary outcome was any of the following events: neurologic complications such as sensory/motor change in the upper extremities, hemi-diaphragmatic paresis, dyspnea, dysphonia, and Horner’s syndrome. Opioid usage until postoperative 3 weeks was compared between the groups.
Results: The VAS scores in groups 1 and 2 were comparable at each postoperative time point (p = 0.132). Neurological deficits were more common in group 2 than in group 1 (8 vs. 32 patients, p < 0.001). Decreased excursion of the diaphragm was more common in group 2 (1 vs. 29 patients, p-value < 0.001). Opioid consumption was similar in both groups (morphine milligram equivalents per kilogram; 1.75 vs 1.55, p = 0.195).
Conclusions: Our findings show that AS-SSNB is not inferior to US-ISB for postoperative pain control following ARCR while showing fewer temporary neurologic complications.

Skeletal tuberculosis is uncommon compared to pulmonary form of tuberculosis .literature suggests incidence of <0.5% for metatarsal dactylitis .osteoarticular tuberculosis affects weight-bearing joints, non-weightbearing joints affected by tuberculosis, such as elbow, are not frequently reported in literature. mode of spread is bacillemia via blood.CASE REPORT 25-year-old female came with complaints of pain ,swelling over medial aspect of right foot since 6 months . patient noticed pus since 20 days On examination Wound of 1cm size present Over metatarsal head Past history Patient had history of pulmonary tuberculosis nine years back for which she took [AKT]anti kochs therapy.She also had history of olecranon Tubercular osteomyelitis six years back for which curretage was done by us. x-ray and CT scan foot was done ESR ,CRP increased .SURGERY Local wound debridement ,Bony curretage Done until small petecheal bleed observed from bone ,wash given And Skin sutured.microscopic examination along with Gene xpert Showed multidrug resistant tuberculosis Patient was started on{second line akt as per weight T.bedaquinine T.cycloserine T.linezolid T.clofazimine T.levofloxacuine T. pyridoxine }after 30 days postop patients wound completely healed.Followup X-ray suggested filling of the defect created by the curretage Currently patient is walking and on AKT DISCUSSION clinical manifestation consists of pain, swelling or chronic skin ulcer.radiologically osteoporosis, bone expansion with reactive sclerosis, reduced joint space,progressive destruction of joint with cystic expansion of short tubular bones named spina ventosa. CONCLUSION metatarsal and olecranon involvement is very rare entity With measures as simple as debridement and adequate Anti tubercular drugs one can treat disease.

Aim: The optimization of the ways to prevent infectious complications after arthroplasty surgeries by using the intraoperative microbiology examination of the patient. Materials and methods: It was performed 505 arthroplasty surgeries for the last five years in Kharkiv regional hospital that meant more than 100 surgeries per year. Mostly it was performed total hip arthroplasty. In 76% cases the reason of the operation was the osteoarthrosis. In 18% of patients the reason was bone fracture and in 6% it was the hip displasia. It was performed microbiology examination of the joints in all cases with analyzing it. Results: 47% of infectious agents was Staphylococcus Epidermidis, 16% – Staphylococcus Aureus, 10% – Streptococcus Viridans, 8% – Klebsiella Pneumoniae. It should also be noted that the titer of microorganisms that were found was less than 100, except the Staphylococcus Epidermidis, which concentration was 100000. It has been revealed that infectious agents in more than 50% of cases are susceptible to levofloxacin, cefoperazone, vancomycin, imipenem, amikacin, and 75% to ciprofloxacin. Conclusions: The intraoperative microbiology examination allows to decrease the diagnosing time of infectious agents that could occur and to choose the proper antibiotics therapy if it is necessary. It also allows to find out the most effective antibiotic for the the prevention of infectious complication after the arthroplasty in the hospital where surgeries are performed in.

with this study we evaluated the reliability of intraoperative assessment of leukocyte esterase (LE) in synovial fluid samples from patients undergoing reimplantation following implant removal and spacer insertion for periprosthetic joint infection (PJI). Our hypothesis was that an intraoperative LE strip test could be a better predictor of persistent infection than either serum C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR). 76 patients (47 men and 29 women) received a two-stage exchange for PJI between July 2015 and April 2020. Synovial fluid was collected before arthrotomy for LE measurement by means of enzymatic colorimetric strips. Receiver operating characteristic curves (ROC) were generated. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and area under the curve (AUC) of the three assays (LE, CRP, ESR) were calculated. the sensitivity and the specificity of the LE assay was 82% and 99%, respectively; the PPV and the NPV was 90% and 97%, respectively. ROC analysis revealed a LE threshold of 1.5, so that a grade starting from 1+ was accurate for a diagnosis of persistent infection The best thresholds for the CRP and the ESR assay were 0.825 mg/dL (82% sensitivity, 84% specificity, AUC 0.8416) and 45 mm/h (55% sensitivity, 87% specificity, AUC 0.7493), respectively. the LE strip test, when performed during second-stage procedures for PJI, proved a reliable marker to diagnose persistence of infection and outperformed the serum CRP and ESR assays. The strip test provides a valuable intraoperative diagnostic tool when deciding between reimplantation and spacer exchange.

Introduction: Upper extremity amputations are a procedure commonly done in a variety of circumstances including infection, trauma, cancer, etc. Methods: 73 years old male with personal pathological antecedents of type II diabetes, chronic kidney disease with hemodialysis needing, and hepatopulmonary syndrome who presents fungal chronic paronychia in 4th finger of the right hand despite of topic and oral treatment, associated with severe invalidating pain. Imaging tests diagnosed distal phalanx osteomielitis. Surgical treatment is proposed due to bad response to topic and oral treatment and intense pain. Trans-middle phalanx amputation surgery was performed, ocurring bad outcome and soft tissue necrosis with exposure of the bone remanent two weeks after surgery, despite of specific treatment against C. albicans identifyed in the tissue´s intrasurgical simples. In a second surgery, a trans-metacarpal 3º radius amputation was performed. Results: No wound complications, satisfactory clinic and functional progress was reported. Discussion: Fungical osteomyelitis is a rare condition, often associated with immunocompromise situations.Given the personal antecedents and vascular risk factors of the patient, a more aggresive surgery in the first place could have been proposed, in order to obtain better outcomes and avoid a second surgery , given the patient´s surgical and anesthesic risks. Conclussions: The level at which the amputation occurs can greatly impact a patient's outcomes and level of care required by health care professionals. Preserving healthy tissue is a common tendency amog hand surgeons but specific situations, a more aggresive surgery can provide good functional and clinic outcomes minimising the probabilities of subsequent surgeries.

Introduction: Acute long-bone osteomyelitis is rare in adults, particularly uncommon without history of trauma or immunosuppressive pathology. S. Aureus is the most common agent due to haematological dissemination (90%). Differential diagnoses include tumours, cellulitis, deep-vein thrombosis, and septic arthritis. A clinical case of acute osteomyelitis of the femur with multiple abscesses of the thigh is described. Case Report: 46-year-old male, previously healthy, presents at ED after four days of pain in his left thigh, with fever. Physical examination: feverish; left thigh swollen, hot and painful on palpation. X-ray and CT revealed a periosteal reaction of the left femoral diaphyseal cortex in response to injury in adjacent tissues. Leucocytosis and elevated CRP. MRI showed a lesion compatible with acute osteomyelitis of the diaphysis of the femur, with multiple abscesses (largest 17cm*6cm*5.3cm). Needle-guided biopsy of the lesion was performed; growth of gram-positive cocci occurred. Empirical antibiotic therapy (clindamycin, ceftriaxone, vancomycin) was initiated. Four days later underwent abscess drainage, surgical debridement, and abundant washing. Blood cultures and intraoperative pus with no microbiology isolations. Pathological anatomy of bone fragment revealed osteomyelitis with proliferative fasciitis. Completed IV antibiotics with good clinical and analytical evolution. Discharged with prescription of 10-weeks oral antibiotics. MRI, eight-months after treatment begun, with excellent response: no tissue abscesses or spinal cord changes of the femur. Conclusion: Long-bone affected in patient without associated risk factors is a rarity. Immunological study, tuberculosis, rose bengal, all came negative. Negative blood cultures and surgical drained pus. Triple antibiotics maintained until the infection was eradicated.

Osteoarthritis is a debilitating condition that affects 7% of the global population and is characterised by symptoms of pain and joint stiffness, which significantly contribute to impaired function and reduced quality of life. Objective: To assess the efficacy and safety of monoclonal anti-nerve growth factor (anti-NGF) antibodies in improving stiffness and physical function in patients with osteoarthritis of the hip and knee. Methods: We analysed seven electronic databases following Cochrane Collaboration guidelines for the use of anti-NGF antibodies in osteoarthritis of the hip and/or knee. Included papers were RCTs that investigated the efficacy of anti-NGF antibodies in patients who were 18 years or older with a Kellgren Lawrence grade of 2 or higher. We excluded studies in which the only intervention was the administration of anti-NGF antibodies in combination with non-steroidal anti-inflammatories (NSAIDs) or other analgesics. Results: A total of 8145 patients with a diagnosis of hip and/or knee osteoarthritis from 13 studies were analysed. Anti-NGF antibodies showed significant improvements compared to placebo as rated on the Western Ontario and McMaster Universities Arthritis Index (WOMAC) scales for physical function (SMD= -0.82, 95% CI -1.09 to -0.55, P<0.00001; I2 = 94%) and stiffness (SMD= -0.88, 95% CI -1.22 to -0.54, P<0.00001; I2 = 95%). Conclusion: The role of anti-NGF antibodies in the management of symptomatic osteoarthritis extends beyond simply the management of pain, and also improves physical function and stiffness, which are two main contributors to the years lived with disability (YLD).

Introduction: Chronic tubercular osteomyelitis of the foot accounts for less than 10% of skeletal TB. TB of the foot is most commonly located in calcaneum and tarsal bones. Involvement of navicular and cuneiform bone is quite rare.Case report: 29-year-old female came with complaints of pain and swelling of the right foot for 1 year due to alleged history of slip and fall with eversion injury of right foot 1 year back. The patient then gradually developed pain and swelling over midfoot. On examination, a firm swelling of 3x2x2cms over the midfoot was noticed with local tenderness and local rise of temperature. There was no discharging sinus. Plain X-rays revealed a focal osteolytic lesion in medial cuneiform with minimal sclerosis. Local USG revealed collection in subcutaneous plane and sequestrum with cortical irregularity of medial cuneiform. CT scan was suggestive of cortical irregularity with an ill-defined lytic lesion of the medial cuneiform.Biopsy with debridement of the lesion was done. The affected bone was curetted and irrigated with hydrogen peroxide and normal saline. The curetted bone and surrounding granulation tissue were sent for histopathological examination which revealed granulomatous inflammation showing epithelioid cells and Langerhans giant cells s/o tuberculous osteomyelitis. Gene Xpert was positive for TB. The patient was managed with antitubercular drugs with complete resolution of clinical and radiological symptoms at one-year follow-up. Conclusion: Early diagnosis and treatment with debridement and anti-tubercular drugs are crucial to prevent joint involvement from periarticular bony lesions in tubercular osteomyelitis of the foot.

Introduction: Osteoarticular tuberculosis accounts for only 1-3% of all tuberculosis infections. Tubercular dactylitis is an uncommon form of musculoskeletal tuberculosis, especially after the age of 5 years without any risk factors. The hand is more commonly involved than the foot in tuberculous dactylitis. Case report: A 49-year-old male presented with pain, swelling, and discharging sinus of proximal phalanx of 3rd digit of the right hand with no constitutional symptoms for 2 years, with multiple failed treatment in form of antibiotic therapy. There were no risk factors like immunodeficiency or any debilitating conditions. The plain radiograph was suggestive of increased bone density with mild periosteal reaction; MRI was suggestive of tubercular osteomyelitis. A biopsy was performed, gene expert of the sample revealed Tuberculosis with no drug resistance. The patient was managed with antitubercular drugs with complete resolution of clinical and radiological symptoms at one-year follow-up.
Conclusion: Tuberculosis should be considered a differential in patients with chronic soft tissue or skeletal lesions even in the absence of the usual risk factors because with treatment it carries an excellent prognosis.

Negative pressure wound therapy (NPWT) is an alternative to standard treatment of acute wounds (such as traumatic or post-operative wounds) but also in that of chronic wounds (such as ulcers or stage 3 and 4 pressure ulcers). With cellular, extracellular effects and bacterial clearance, it leads to rapid formation of healthy budding granulation tissue, which provides wound bed for directed healing or secondary coverage by skin graft or flap. However, the exorbitant cost of VAC (vaccum assisted closure) devices for our limited resources health facilities, and their unavailability led us to opt for a "low cost" solution using wall suction and disposable materials readily available in all surgical departments. We present the technique used in our department and its results through a series of 3 cases with both acute and chronic lesions evolving in septic environment and where NPWT enabled us to ensure a genuine care protocol until healing while reducing the cost of therapy, the number of dressings and the length of hospital stay.

Introduction:This study aims to evaluate the clinical safety and efficacies of a novel microdiscectomy annular repairment technique combined with autologous Platelet-Rich Plasma intradiscal injection for the treatment of lumbar disc herniation.Methods: From July 2018 to December 2019 this study recruited 18 patients with lumbar disc herniation who underwent tubular microdiscectomy and used a novel annulus fibrosus repairment device close the annular defects which was an automatic stitching and tying device.The patients underwent A-PRP 2.1±0.2 ml intradiscal injection 1week, 1month and 2 month after microdiscectomy annular repair surgery. The pre/post-operation neurological function and pain status were evaluated by VAS and ODI.The assessment also data including: operation time, the quantity of bleeding and intraoperative and postoperative complications, were recorded. Patients were followed up at intervals of preoperative, postoperative 1 week, 1 months, 3 months, last follow-up. Results:The procedure was successfully performed in all cases. Average operation time was 85 minutes, Average blood loss was 35.3±6.2mL. The preoperative symptoms were alleviated significantly after surgery. All the standardized measures improved significantly. At the last follow-up, including VAS score (7.9±1.2 to 1.1±0.5; p＜0.001) and ODI (75.3 to 9.6; p＜0.001). There was no postoperative complication and disc reherniation.Conclusion:Early results showed the use of the novel annular fibrosus repairment technique and PRP intradiscal injection are beneficial for short term outcomes demonstrating reduction in symptomatic disc reherniation with low post-operative complication rates. Direct mechanical annular repair and A-PRP biological therapy may promote degenerative intervertebral disc regeneration after MISS discectomy.

Introduction: Long bone osteomyelitis has been described as a difficult to treat condition with morbidities and adverse postoperative outcomes. The purpose of this study was to evaluate the rate and potential risk factors for postoperative outcomes in acute long bone osteomyelitis patients. Methods: The National Surgical Quality Improvement Program was retrospectively analyzed for acute long bone osteomyelitis patients. Postoperative outcomes were investigated. Logistic regression analysis controlling for the modified Charlson Comorbidity Index was used to identify risk factors for adverse postoperative outcomes. Results: 158 patients were identified. 54 (34.2%) had postoperative complications, 9 (5.7%) had a reoperation, 17 (10.8%) were readmitted, 62 (39.2%) had an extended length of stay (EOLS) (>9 days), and 2 (1.3%) had reported deaths. Logistic regression analysis showed hypoalbuminemia to be a significant risk factor for readmission (2.9 [1.0 - 8.3], p=0.049) and EOLS (2.3 [1.1 - 4.6], p=0.021). Open wound is also a significant risk factor for EOLS (3.3 [1.7 - 6.7], p=0.001). Patients with hypoalbuminemia (9.1 days vs 13.7 days; p=0.021) or open wound(s) (8.0 days vs 13.6 days; p=0.003) had significantly longer lengths of stay. Conclusion: Risk factors for adverse postoperative outcomes in patients with acute long bone osteomyelitis include open wound and hypoalbuminemia. Patients with these conditions are more likely to have an EOLS and readmission.

Introduction: Our goal was to perform a systematic review to find literature identifying common upper extremity injuries in epileptic and seizure patients and appropriate surgical and non-surgical management of injuries in these patients. Methods: The search engines PubMed, EMBASE, Cochrane, and Web of Science were systematically screened using predefined search terms. Articles not written in English and animal studies were excluded. Those discussing upper-extremity orthopaedic injuries in epileptic patients were selected. Results: Of 108,825 articles, 29 met the inclusion criteria. One article discussed increased morbidity and mortality for in-hospital epileptic patients undergoing total joint arthroplasty. All remaining 28 discussed common injuries almost exclusively found in epileptic and seizure patients compared to the general population. Two predominant injuries were discussed (posterior shoulder dislocation with/without fracture [19 articles; 65.5%] and anterior shoulder dislocation with/without fracture, [10 articles; 34.5%]). Of the 19 posterior shoulder articles, 10 (52.6%) referenced surgical techniques, while the remaining 8 articles used varied specific approaches depending on the case severity. There were 5/10 articles discussing surgical techniques in anterior shoulder injuries, the most common of which included the modified Latarjet technique and open reduction and internal fixation (each, 2 articles). Conclusion: Post-seizure patients may require unique consideration to accurately identify injuries and a standardized diagnostic protocol is necessary to ensure these injuries are diagnosed and managed accordingly. They may also need a specialized approach to treatment that accommodates the nuances of their condition.

Worldwide increases in obese and elderly populations synergistically enhance sarcopenia incidence. The accumulation of intermuscular adipose tissue (IMAT) is considered a major problem whereby obesity leads to sarcopenic obesity and thus is a promising target for treating this emerging pathological condition. However, whereas sarcopenic obesity-associated IMAT is suggested to originate from PDGFRα+ mesenchymal progenitors, processes underlying their adipogenesis remain largely unexplored. Here, we comprehensively investigated intra- and extracellular changes associated with these processes using single-cell RNA sequencing (scRNA-Seq) and mass spectrometry. Our scRNA-Seq analysis identified a small PDGFRα+ cell population in obese mice directed strongly toward adipogenesis. Proteomic analysis showed that the appearance of this cell population is accompanied by an increase in galectin-3 in interstitial environments, which was found to activate adipogenic PPARγ signals
in PDGFRα+ cells. Our findings, together with these multi-omics datasets, could unravel microenvironmental networks during muscle regeneration highlighting possible therapeutic targets for sarcopenic obesity.

Burkhloderia pseudomallei is a saprophytic pathogen causing Whitmore's disease or Melioidosis. It can cause vertebral osteitis, abscess, pneumoniae, septicaemia, arthritis etc. It is a great mimicker of pulmonary as well as vertebral Tuberculosis. Southeast Asia and Australia report most of the cases. In India, the cases have been reported mostly from the coastal belt of southern states. We report the case of a 60-year-old agriculture worker with Type 2 diabetes, with lumbago and fever 1 month, initially misdiagnosed as spinal tuberculosis with cold abscess. B. pseudomallei was isolated from the drained abscess. He recovered fully following treatment with Cotrimoxazole and Ceftazidime.

Introduction: International observerships are one of many efforts aimed at addressing disparities in orthopaedic trauma care globally. However, their impact on visiting surgeons and their home countries, as well as the challenges faced by participating surgeons, are not well-documented. Methods: A survey was distributed to overseas surgeons who participated in an orthopaedic trauma observership in North America from 2009-2020. Information gathered included the participant’s demographics and observership details; perceived impact of the program; and barriers faced before, during, and after the program. Results: 724 surveys were initially distributed, with 223 respondents, and 142 complete responses from 46 countries. Most observerships lasted either 4 weeks or less (65%) or 5-12 weeks (27%), and were sponsored by an academic institution (60%) or professional society (32%). Most observers felt that they gained relevant orthopaedic knowledge (91%) and surgical skills (68%), and nearly all (98.9%) shared this knowledge with their colleagues and trainees. Cost (85%) and housing (56%) were the most common barriers to participants before beginning their observership. During the observership, the most common barriers included cost (84%) and adapting to a new healthcare system (54%). After returning from their observership, the most common barriers to implementing changes to their practice were lack of funding (72%), equipment (78%), support staff (77%), and excessive workload (86%). Discussion: Participating in a North American orthopaedic trauma observership positively impacts the surgical and clinical skills of most visiting surgeons. However, financial constraints, resource limitations, and limited logistical support present barriers to maximizing this potential.

Septic arthritis in neonates is a debilitating disorder with a multifactorial etiology. The most frequent cause is nosocomial infection. Our hospital is tertiary referral centre for neonatal patients. We investigated a particular surge in septic arthritis of the hips during a 2 year period. The standard procedures were followed for diagnosis and treatment - which included ultrasound imaging and emergency arthrotomy, drainage of the pus and post-operative antibiotics. We profiled these patients in terms of the organisms identified from operative samples, sensitivity testing and the antibiotics used. These children were followed up after a 5 year period to see if there were any residual changes.

Arthroscopic anatomic glenoid reconstruction (AAGR) using tibial allograft is a technique used to treat recurrent anterior shoulder instability with bone loss. The original technique used screw fixation and more recently, a technique has been described using button fixation. The purpose of this study was to compare the learning curve and graft positioning of the two fixation types. We performed a retrospective review on AAGR patients with button fixation (2018-2020). These patients were compared to the first set of patients who received AAGR with screw fixation (2015-2018). All patients received AAGR from the senior author and had a short-term post-operative CT. Exclusion criteria included patients with rotator cuff pathology, multidirectional instability and fractures. Surgical times and post-operative graft positioning were compared between the two groups. There were 43 patients (Screw:27; Button: 16) who met the inclusion/exclusion criteria. The average operative time for the button and screw fixation groups were 1.35±0.22 and 1.55±0.32 hours, respectively. The button group showed a significant reduction in operative time compared to the screw group (p=0.029). The graft positioning for both groups was on the lower third (button:n=14; screw:n=24) and middle third (button:n=2; screw:n=3) with no significant difference between the groups (p=0.891). Button fixation results in good horizontal positioning with respect to medial-lateral step formation, with slightly better positioning being achieved using screw fixation (p=0.033). AAGR has a short learning curve regardless of fixation type, with button fixation resulting in a shorter operations. The surgical times for both fixation types are comparable to existing arthroscopic stabilization techniques.

Aim: To study the efficacy of absorbable calcium sulphate (STIMULAN®) in dead space management in post debridement cases of chronic osteomyelitis. Type: Prospective. Period: December 2019-February 2021. Sample Size: 10. Inclusion criteria: Patients with symptoms of osteomyelitis for more than 6 weeks. Exclusion criteria: Patients with symptoms of osteomyelitis for less than 6 weeks. Patients with uncontrolled diabetes or renal compromise. Methods: Preoperative samples were sent for culture and sensitivity. Calcium sulphate (STIMULAN®) beads were used to fill the dead space intraoperatively, post debridement and curettage. Post operative xrays were obtained at immediate post op, 2 weeks & 8 weeks follow up to compare with preoperative xrays. Scar site was checked for any remnant discharge or signs of infection. Range of motion was assessed in the affected part.

Results: Out of 10 patients, we received follow up of 7 patients, out of which, in 6 patients there was complete resorption of STIMULAN® and filling up of dead space as confirmed on follow up X rays. During interview and feedback from the patients, they reported complete return to normal day to day activities with no recurrence of any previous complaints. 1 patient presented with post operative wound dehiscence but no discharge and improved post operative xray.

Conclusion: STIMULAN® is a truly absorbable form of calcium sulphate, specially designed to complement dead space management, with no third body damage. In this study, STIMULAN® has shown promising results and has proved to be a viable option for dead space and infection management.