Intramedullary application of local antibiotic bullets for the treatment of long bone fracture related infection.

PURPOSE: The optimal means of local antibiotic delivery for fracture related infection is unknown. Until now, intramedullary application of calcium sulphate based local antibiotics has been challenging. We report on the use of a newly available mode of preparation and delivery: the Stimulan Bullet Mat and Introducer (Biocomposites Ltd, Staffordshire, England). METHODS: A retrospective analysis of prospectively collected data for infection cases at two separate tertiary referral institutions was performed. We included cases of long bone FRI with a retained intramedullary nail, treated with a single stage protocol of metalwork removal, debridement, local antibiotic application using the novel mould and applicator, with additional bony stabilisation and soft tissue reconstruction where required. RESULTS: All 13 patients achieved infection remission rate with an average follow-up of 19.7 months (range 12-28). All 6 patients with infection around an unhealed fracture achieved union at an average 8 months (range 4-12) from debridement. No patients developed aseptic wound leak. CONCLUSIONS: Antibiotic impregnated calcium sulphate can be used safely as part of a single stage treatment protocol for the treatment of long bone fracture related infection following intramedullary nailing. We have demonstrated high rates of infection remission and union, using a newly available intramedullary applicator.

A major trauma centre experience with gentamicin-coated tibial intramedullary nails (ETN PROtect™) in acute primary open fracture fixation and complex revision surgery.

PURPOSE: Fracture-related infections (FRI) following intramedullary nailing for tibial shaft fractures remain challenging to treat with associated high patient morbidity and health care costs. Recently, antibiotic-coated nails have been introduced as a strategy to reduce implant related infection rates in high-risk patients. We present the largest single-centre case series on ETN PROtect® outcomes reporting on fracture union, infection rates and treatment complications. METHODS: Fifty-six adult patients underwent surgery with ETN PROtect® between 01/09/17 and 31/12/20. Indications consisted of acute open fractures and complex revision cases (previous FRI, non-union surgery and re-fracture) with a mean of three prior surgical interventions. We report on patient demographics, union rates and deep infection. Minimum follow-up was one year. RESULTS: One (1.8%) patient developed a deep surgical infection and associated non-union requiring further surgery. In addition, we identified three cases (5.4%) of aseptic non-union following facture treatment with ETN PROtect®. Of the five patients who underwent staged complex revision surgery for established FRI with ETN PROtect®, all had treatment failure with ongoing symptoms of deep infection requiring implant removal and further treatment. CONCLUSION: Use of the ETN PROtect® nail in high-risk patients (open fractures and those initially treated with external fixation) and in those patients with aseptic non-unions, demonstrates promising outcomes in the prevention of implant-related infection. In our limited series we have failed to observe any benefit over uncoated nails, when used in treating cases of previously established FRI/osteomyelitis and would therefore advise caution in their use, especially in view of the high cost.

Mesenchymal stromal cells and platelet-rich plasma promote tendon allograft healing in ovine anterior cruciate ligament reconstruction.

PURPOSE: The effect of bone marrow mesenchymal stromal cells (BMSCs) and platelet-rich plasma (PRP) on tendon allograft maturation in a large animal anterior cruciate ligament (ACL) reconstruction model was reported for the first time. It was hypothesised that compared with non-augmented ACL reconstruction, BMSCs and PRP would enhance graft maturation after 12 weeks and this would be detected using magnetic resonance imaging (MRI). METHODS: Fifteen sheep underwent unilateral tendon allograft ACL reconstruction using aperture fixation and were randomised into three groups (n = 5). Group 1 received 10 million allogeneic BMSCs in 2 ml fibrin sealant; Group 2 received 12 ml PRP in a plasma clot injected into the graft and bone tunnels; and Group 3 (control) received no adjunctive treatment. At autopsy at 12 weeks, a graft maturation score was determined by the sum for graft integrity, synovial coverage and vascularisation, graft thickness and apparent tension, and synovial sealing at tunnel apertures. MRI analysis (n = 2 animals per group) of the signal-noise quotient (SNQ) and fibrous interzone (FIZ) was used to evaluate intra-articular graft maturation and tendon-bone healing, respectively. Spearman's rank correlation coefficient (r) of SNQ, autopsy graft maturation score and bone tunnel diameter were analysed. RESULTS: The BMSC group (p = 0.01) and PRP group (p = 0.03) had a significantly higher graft maturation score compared with the control group. The BMSC group scored significantly higher for synovial sealing at tunnel apertures (p = 0.03) compared with the control group. The graft maturation score at autopsy significantly correlated with the SNQ (r = - 0.83, p < 0.01). The tunnel diameter of the femoral tunnel at the aperture (r = 0.883, p = 0.03) and mid-portion (r = 0.941, p = 0.02) positively correlated with the SNQ. CONCLUSIONS: BMSCs and PRP significantly enhanced graft maturation, which indicates that orthobiologics can accelerate the biologic events in tendon allograft incorporation. Femoral tunnel expansion significantly correlated with inferior maturation of the intra-articular graft. The clinical relevance of this study is that BMSCs and PRP enhance allograft healing in a translational model, and biological modulation of graft healing can be evaluated non-invasively using MRI.

Characterisation of Novel Angiogenic and Potent Anti-Inflammatory Effects of Micro-Fragmented Adipose Tissue.

Adipose tissue and more specifically micro-fragmented adipose tissue (MFAT) obtained from liposuction has recently been shown to possess interesting medicinal properties whereby its application supports pain reduction and may enhance tissue regeneration particularly in osteoarthritis. Here we have characterised samples of MFAT produced using the Lipogems® International Spa system from eight volunteer individuals in order to understand the critical biological mechanisms through which they act. A variation was found in the MFAT cluster size between individual samples and this translated into a similar variation in the ability of purified mesenchymal stem cells (MSCs) to form colony-forming units. Almost all of the isolated cells were CD105/CD90/CD45+ indicating stemness. An analysis of the secretions of cytokines from MFAT samples in a culture using targeted arrays and an enzyme-linked immunosorbent assay (ELISA) showed a long-term specific and significant expression of proteins associated with anti-inflammation (e.g., interleukin-1 receptor alpha (Il-1Rα) antagonist), pro-regeneration (e.g., hepatocyte growth factor), anti-scarring and pro-angiogenesis (e.g., transforming growth factor beta 1 and 2 (TGFß1/2) and anti-bacterial (e.g., chemokine C-X-C motif ligand-9 (CXCL-9). Angiogenesis and angiogenic signalling were notably increased in primary bovine aortic endothelial cells (BAEC) to a different extent in each individual sample of the conditioned medium whilst a direct capacity of the conditioned medium to block inflammation induced by lipopolysaccharides was shown. This work characterises the biological mechanisms through which a strong, long-lasting, and potentially beneficial effect can be observed regarding pain reduction, protection and regeneration in osteoarthritic joints treated with MFAT.

Current concepts in the prevention, diagnosis and treatment of fracture-related infection (FRI).

Fracture-related infection (FRI) is one of the most challenging complications following operative management of fractures. It can have profound implications for the patient, can be associated with considerable morbidity and often lead to impaired outcomes. There are significant healthcare-related costs. In recent years, there has been significant progress towards developing preventative strategies. Furthermore, diagnostic algorithms and management protocols have recently been reported. Lack of a strong evidence base has previously hindered efforts to implement these and develop established standards of care. There are multiple aspects of care that need to be considered and a multi-disciplinary approach is recommended. In this narrative review, we present the most up-to-date recommendations in the prevention, diagnosis and management of FRI.

A Gender-Bias-Mitigated, Data-Driven Precision Medicine System to Assist in the Selection of Biological Treatments of Grade 3 and 4 Knee Osteoarthritis: Development and Preliminary Validation of precisionKNEE.

Objective To identify key variables predictive of patient responses to microfragmented adipose tissue (MFAT) treatment in knee osteoarthritis (KOA) and evaluate its potential to delay or mitigate the need for total knee replacement (TKR). Methods We utilised a dataset comprising 329 patients treated with MFAT for KOA, incorporating variables such as gender, age, BMI, arthritic aetiology, radiological grade, and Oxford Knee Scores (OKS) pre- and post-treatment. We employed random forest regressors for model training and testing, with gender bias mitigation and outlier detection to enhance prediction accuracy. Model performance was assessed through root mean squared error (RMSE) and mean absolute error (MAE), with further validation in a TKR-suitable patient subset. Results The model achieved a test RMSE of 6.72 and an MAE of 5.38, reflecting moderate predictive accuracy across the patient cohort. Stratification by gender revealed no statistically significant differences between actual and predicted OKS improvements (p-values: males = 0.93, females = 0.92). For the subset of patients suitable for TKR, the model presented an increased RMSE of 9.77 and MAE of 7.81, indicating reduced accuracy in this group. The decision tree analysis identified pre-operative OKS, radiological grade, and gender as significant predictors of post-treatment outcomes, with pre-operative OKS being the most critical determinant. Patients with lower pre-operative OKS showed varying responses based on radiological severity and gender, suggesting a nuanced interaction between these factors in determining treatment efficacy. Conclusion This study highlights the potential of MFAT as a non-surgical alternative for KOA treatment, emphasising the importance of personalised patient assessments. While promising, the predictive model warrants further refinement and validation with a larger, more diverse dataset to improve its utility in clinical decision-making for KOA management.

A Quantum-Enhanced Precision Medicine Application to Support Data-Driven Clinical Decisions for the Personalized Treatment of Advanced Knee Osteoarthritis: The Development and Preliminary Validation of precisionKNEE_QNN.

Background Quantum computing and quantum machine learning (QML) are promising experimental technologies that can improve precision medicine applications by reducing the computational complexity of algorithms driven by big, unstructured, real-world data. The clinical problem of knee osteoarthritis is that, although some novel therapies are safe and effective, the response is variable, and defining the characteristics of an individual who will respond remains a challenge. In this study, we tested a quantum neural network (QNN) application to support precision data-driven clinical decisions to select personalized treatments for advanced knee osteoarthritis. Methodology After obtaining patients' consent and Research Ethics Committee approval, we collected the clinicodemographic data before and after the treatment from 170 patients eligible for knee arthroplasty (Kellgren-Lawrence grade ≥3, Oxford Knee Score (OKS) ≤27, age ≥64 years, and idiopathic aetiology of arthritis) treated over a two-year period with a single injection of microfragmented fat. Gender classes were balanced (76 males and 94 females) to mitigate gender bias. A patient with an improvement ≥7 OKS was considered a responder. We trained our QNN classifier on a randomly selected training subset of 113 patients to classify responders from non-responders (73 responders and 40 non-responders) in pain and function at one year. Outliers were hidden from the training dataset but not from the validation set. Results We tested our QNN classifier on a randomly selected test subset of 57 patients (34 responders, 23 non-responders) including outliers. The no information rate was 0.59. Our application correctly classified 28 responders out of 34 and 6 non-responders out of 23 (sensitivity = 0.82, specificity = 0.26, F1 Statistic = 0.71). The positive and negative likelihood ratios were 1.11 and 0.68, respectively. The diagnostic odds ratio was 2. Conclusions Preliminary results on a small validation dataset showed that QML applied to data-driven clinical decisions for the personalized treatment of advanced knee osteoarthritis is a promising technology to reduce computational complexity and improve prognostic performance. Our results need further research validation with larger, real-world unstructured datasets, as well as clinical validation with an artificial intelligence clinical trial to test model efficacy, safety, clinical significance, and relevance at a public health level.

Radiological landmarks for the safe extra-capsular placement of supra-acetabular half pins for external fixation.

PURPOSE: Low anterior external fixators are constructed by placing half pins in the dense bone tunnel of the supra-acetabular region in an anterior to posterior direction. Although the placement of these pins is extra-articular, they may still breach the hip capsule on the anterior inferior iliac spine and thus be intra-capsular. We aim to provide radiological markers for the most superior fibres of the capsule to allow safe extra-capsular pin placement within the supra-acetabular bone tunnel. METHODS: Thirteen cadaveric pelves were used for this study. The supra-acetabular bone tunnel was visualised with an image intensifier. The proximal most fibres of the hip joint capsule were marked with a K-wire so that their relation to the bone tunnel could be clearly seen on the images. Once all images were acquired they were calibrated and analysed to estimate the dimensions of the supra-acetabular bone tunnel and the reflection of the hip capsule. RESULTS: The median height of the bone tunnel was 23.6 mm (18.9-33.2) and maximum width was 11.4 mm (7.6-16.3). The inferior margin of the bone tunnel was 6.7 mm (1.1-14.5) superior to the acetabular dome, and the most proximal fibres of the capsule were 9.3 mm (4.7-6.1) superior to the acetabular dome. The inferior portion of the tunnel was 3.7 mm (0.3-8.9) within the joint. CONCLUSION: Half pins for the construction of a pelvic external fixator should be placed in the upper half of the supra-acetabular bone corridor to minimise the risk of intra-capsular placement.

Fracture of the ulnar styloid process negatively influences the outcome of paediatric fractures of the distal radius.

In paediatric patients with fractures of the distal radius, the consequences of associated ulnar styloid fractures are often underestimated. These may include persisting pain or functional deficits. The aim of the present study was to report the outcome of these fractures using a modified DASH-Score. All children with distal radius fractures treated in a two years period were analysed; only patients with a concomitant fracture of the ulnar styloid were included in the study.In addition, children with a non-union of the styloid at cast removal were asked to complete a postal questionnaire; the data were compared to those in a group of patients with isolated distal radius fractures. Patients reporting problems and those with a modified DASH score over 0.5 were invited for a long-term follow-up clinical and radiological examination. A concomitant fracture of the ulnar styloid was present in 11% of all distal radius fractures. At the time of cast removal 46 patients (89%) showed a delayed union of the ulnar styloid. The modified DASH Score of these patients at an average of 31 months (range: 24-40 months) was significantly worse (3.8; range: 0-24.2) compared to 0.7 (range 0-27.7) in the patients with isolated radius fractures after a mean of 27 months (range: 21-42 months). At follow-up, 7 patients showed a non-union of the ulnar styloid. Fractures of the base of the styloid process were more likely to develop non-union compared to fractures of its tip. The presence of an ulnar styloid fracture negatively influences the outcome of distal radius fractures. Patients with lesions of the ulnar styloid should be followed until union is observed and/or they are asymptomatic.

Fractures of the pelvis in children: a review of the literature.

Trauma is the leading cause of death in children. Pelvic ring injuries account for 0.3-4% of all paediatric injuries. The pattern of fractures differs to that seen in adults as it is more ductile. Pelvic ring injuries tend to be more stable as the relatively thick periosteum restricts bony displacement. Intrapelvic viscera are not well protected and can sustain injury in the absence of pelvic fractures. These injuries have traditionally been treated non-operatively. In this paper, we comprehensively review the literature and propose a protocol for treatment taking into consideration associated organ injuries, hemodynamic status of the patient, patient's age, type of fracture and the stability of the pelvic ring.

Complications after talus fractures: A trauma centre experience.

BACKGROUND: Talus fractures are anatomically complex, high-energy injuries that can be associated with poor outcomes and high complication rates. Complications include non-union, avascular necrosis (AVN) and post-traumatic osteoarthritis (OA). The aim of this study was to analyse the outcomes of these injuries in a large series. METHODS: We retrospectively collected data on 100 consecutive patients presenting to a single high volume major trauma centre with a talus fracture between March 2012 and March 2020. All patients were over the age of 18 with a minimum of 12 months follow up post injury. Retrospective review of case notes and imaging was conducted to collate demographic data and to classify fracture morphology. Whether patients were managed non-operatively or operatively was noted and where used, the type of operative fixation, outcomes and complications were recorded. RESULTS: The mean age was 35 years (range: 18-76 years). Open injuries accounted for 22% of patients. An isolated talar body fracture was the most frequent fracture (47%), followed by neck fractures (20%). The overall non-union rate was 2% with both cases occurring in patients with open fractures. The AVN rate was 6%, with the highest prevalence in talar neck fractures. Overall rates of post-traumatic OA of the tibio-talar, sub-talar and talo-navicular joints were 12%, 8%, and 6%, respectively. These were higher after a joint dislocation, and higher in neck or head fractures. The postoperative infection rate was 6%. The overall secondary surgery rate was 9%. There were 2% of patients who subsequently underwent a joint arthrodesis. CONCLUSION: Our study found that talar body fractures are more common than previously reported; however, talar neck fractures cause the highest rates of AVN and post-traumatic arthritis. Open fractures also carry a greater risk of complications. This information is useful during consenting and preoperatively when planning these cases to ensure adverse outcomes may be anticipated.

Functional Outcomes of Dorsal Bridge Plating for Lisfranc Injuries With Routine Implant Retention: A Major Trauma Center Experience.

OBJECTIVES: To assess medium-term functional outcomes and the complication profile for unstable Lisfranc injuries treated with dorsal bridge plate (DBP) fixation when implants are not routinely removed. DESIGN: Large single-center retrospective case series. SETTING: Level-1 Trauma Center, London, United Kingdom. PATIENTS: Consecutive cases of skeletally mature individuals with unstable Lisfranc injuries treated operatively between 2014 and 2019. INTERVENTION: Open reduction and DBP fixation with implants not routinely removed. MAIN OUTCOME MEASUREMENTS: Patient-reported outcome measures at final follow-up. The Manchester-Oxford Foot Questionnaire summary index was the primary outcome measure. The American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale, complications, and all-cause reoperation rates were secondary outcome measures. Logistic regression models were used to identify risk factors that influenced outcomes. RESULTS: Eighty-five patients were included. Mean follow-up was 40.8 months (24-72). The mean Manchester-Oxford Foot Questionnaire Summary Index was 27.0 (SD 7.1) and mean AOFAS score 72.6 (SD 11.6). The presence of an intra-articular fracture was associated with poorer outcomes, with worse MOXFQ and AOFAS scores (both P < 0.001). Eighteen patients (21%) required implants removal, with this more likely in female patients (OR 3.89, 95% confidence interval, 1.27 to 12.0, P = 0.02). Eight patients (9%) required secondary arthrodesis. CONCLUSIONS: This is the largest series of Lisfranc injuries treated with DBP fixation reported to-date and the only to routinely retain implants. Medium-term outcomes are comparable to existing literature in which implants are routinely removed. The presence of an intra-articular fracture is a poor prognostic indicator. Implant removal is more likely to be needed in female patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for authors for a complete description of levels of evidence.

Microbiological Profile of Fracture Related Infection at a UK Major Trauma Centre.

Fracture Related Infection (FRI) represents one of the biggest challenges for Trauma and Orthopaedic surgery. A better understanding of the microbiological profile should assist with decision-making and optimising outcomes. Our primary aim was to report on the microbiological profile of FRI cases treated over a six-year period at one of Europe's busiest trauma centres. Secondarily, we sought to correlate our findings with existing anti-microbiological protocols and report on diagnostic techniques employed in our practice. All adult cases of FRI treated in our institution between 2016 and 2021 were identified, retrospectively. We recorded patient demographics, diagnostic strategies, causative organisms and antibiotic susceptibilities. There were 330 infection episodes in 294 patients. A total of 463 potentially pathogenic organisms (78 different species) were identified from cultures, of which 57.2% were gram-positive and 39.7% gram-negative. Polymicrobial cultures were found in 33.6% of cases and no causative organism was found in 17.5%. The most prevalent organisms were Staphylococcus aureus (24.4%), coagulase-negative Staphylococci (14%), Pseudomonas aeruginosa (8.2%), Enterobacter species (7.8%) and Escherichia coli (6.9%). Resistant gram-positive organisms (methicillin resistant Staphylococcus aureus or vancomycin-resistant Enterococci) were implicated in 3.3% of infection episodes and resistant gram-negatives (extended-spectrum beta-lactamase, ampC or carbapenemase-producing bacteria) in 13.6%. The organisms cultured in 96.3% of infection episodes would have been covered by our empirical systemic antibiotic choice of teicoplanin and meropenem. To our knowledge, this is the largest reported single-centre cohort of FRIs from a major trauma centre. Our results demonstrate patterns in microbiological profiles that should serve to inform the decision-making process regarding antibiotic choices for both prophylaxis and treatment.

Three-dimensional morphometry of the proximal ulna: a comparison to currently used anatomically preshaped ulna plates.

BACKGROUND: Anatomically preshaped plates are increasingly used for stabilization of comminuted olecranon and Monteggia fractures. The purposes of this study were to investigate the morphology of the proximal ulna and to compare morphologic findings with geometry of 4 preshaped ulna plates. MATERIALS AND METHODS: Forty human elbows (mean age, 68 years; range, 21-98 years) were measured by 2 independent observers using 64-slice computed tomography scans and 3-dimensional measuring software. RESULTS: Measurements showed a mean dorsal hook angle of 95.3° ± 9.0° (range, 74.7°-110.8°) with gender-specific differences (mean, 92.2° ± 8.1° in men and 98.3° ± 8.9° in women; P = .029); a mean distance from the tip of the olecranon to the proximal edge of the ulna of 24.7 ± 2.7 mm (range, 20-30.5 mm) with gender-specific differences (P = .00068); a mean varus angulation of 14.3° ± 3.6° (range, 5.8°-21.2°); and a mean anterior angulation (proximal ulna dorsal angulation) of 6.2° ± 2.7° (range, 1.0°-11.2°). The investigated plates offered a tolerable (± standard deviation) hook angle in 25% to 68%, an appropriate varus angulation in 0% to 20%, and an adequate anterior angulation in 23% to 88%. The intraclass correlation coefficient was between 0.74 and 0.91. CONCLUSION: The proximal ulna has a gender-specific and variable morphology. Some currently used anatomically preshaped proximal ulna plates differ significantly from these morphologic findings. In cases where reduction is not exactly possible, application of an "anatomically preshaped" plate may result in poor reduction. Especially in case of Monteggia fractures with instability of the radiocapitellar joint, surgeons could be misguided by plates that do not incorporate anterior angulation, resulting in subluxation of the radial head on the capitellum.

The influence of ultrasound guidance in the rate of success of acromioclavicular joint injection: an experimental study on human cadavers.

BACKGROUND: Injections of the acromioclavicular joint (ACJ) are performed routinely in patients with ACJ arthritis, both diagnostically and therapeutically. The aim of this prospective controlled study was to estimate the frequency of successful intra-articular ACJ injections with the aid of sonographic guidance versus non-guided ACJ injections. MATERIALS AND METHODS: A total of 80 cadaveric ACJs were injected with a solution containing methylene blue and subsequently dissected to distinguish intra- from peri-articular injections. In 40 cases the joint was punctured with sonographic guidance, whereas 40 joints were injected in the control group without the aid of ultrasound. RESULTS: The rate of successful intra-articular ACJ injection was 90% (36 of 40) in the guided group and 70% (28 of 40) in the non-guided group. Ultrasound was significantly more accurate for correct intra-articular needle placement (P = .025). DISCUSSION: The use of ultrasound significantly improves the accuracy of ACJ injection.

Outcome of repaired unstable meniscal tears in children and adolescents.

BACKGROUND: Unstable meniscal tears are rare injuries in skeletally immature patients. Loss of a meniscus increases the risk of subsequent development of degenerative changes in the knee. This study deals with the outcome of intraarticular meniscal repair and factors that affect healing. Parameters of interest were type and location of the tear and also the influence of simultaneous reconstruction of a ruptured ACL. METHODS: We investigated the outcome of 25 patients (29 menisci) aged 15 (4-17) years who underwent surgery for full thickness meniscal tears, either as isolated lesions or in combination with ACL ruptures. Intraoperative documentation followed the IKDC 2000 standard. Outcome measurements were the Tegner score (pre- and postoperatively) and the Lysholm score (postoperatively) after an average follow-up period of 2.3 years, with postoperative arthroscopy and MRT in some cases. RESULTS: 24 of the 29 meniscal lesions healed (defined as giving an asymptomatic patient) regardless of location or type. 4 patients re-ruptured their menisci (all in the pars intermedia) at an average of 15 months after surgery following a new injury. Mean Lysholm score at follow-up was 95, the Tegner score deteriorated, mean preoperative score: 7.8 (4-10); mean postoperative score: 7.2 (4-10). Patients with simultaneous ACL reconstruction had a better outcome. INTERPRETATION: All meniscal tears in the skeletally immature patient are amenable to repair. All recurrent meniscal tears in our patients were located in the pars intermedia; the poorer blood supply in this region may give a higher risk of re-rupture. Simultaneous ACL reconstruction appears to benefit the results of meniscal repair.

Monomeric C-Reactive Protein: Current Perspectives for Utilization and Inclusion as a Prognostic Indicator and Therapeutic Target.

Monomeric C-reactive protein (mCRP), once thought to be a figment of the imagination and whose biological activity was ascribed to its sodium azide preservative, has now pronounced itself as a critical molecule playing a direct role in mediating many of the acute and chronic aberrant pathological responses to inflammation. In this focused mini review, we describe the currently attributed pathobiological interactions of mCRP in disease, where its tissue and cellular distribution and deposition have recently been clearly characterized and linked to inflammation and other pathway-associated progression of neurological and cardiovascular complications and deleterious outcomes. and focus upon current opinions as to the diagnostic and prognostic potential of mCRP-plasma circulating protein and define the possible future therapeutics including ongoing research attempting to block CRP dissociation with small molecule inhibitors or prevention of cell surface binding directly using antibodies or modified orphan drug targeting directed towards CRP, inhibiting its cellular interactions and signaling activation. There is no doubt that understanding the full influence of the biological power of mCRP in disease development and outcome will be considered a critical parameter in future stratified treatment.

Comparison of the Effect of MFAT and MFAT + PRP on Treatment of Hip Osteoarthritis: An Observational, Intention-to-Treat Study at One Year.

Hip osteoarthritis (OA) is a major contributor to reduced quality of life and concomitant disability associated with lost working life months. Intra-articular injection of various biological materials has shown promise in alleviating symptoms and potentially slowing down the degenerative process. Here, we compared the effects of treatment of a cohort of 147 patients suffering from grade 1-4 hip OA; with either micro-fragmented adipose tissue (MFAT), or a combination of MFAT with platelet-rich plasma (PRP). We found significant improvements in both the visual analogue score for pain (VAS) and Oxford hip score (OHS) that were similar for both treatments with over 60% having an improvement in the VAS score of 20 points or more. These results suggest a positive role for intra-articular injection of MFAT + PRP as a treatment for hip osteoarthritis which may be important particularly in low body mass index (BMI) patients where the difficulty in obtaining sufficient MFAT for treatment could be offset by using this combination of biologicals.

Pin-site Infection: A Systematic Review of Prevention Strategies.

Introduction: Circular frame fixation remains a key tool in the armamentarium of the limb reconstruction surgeon. One of the key drawbacks is the onset of pin-site infection (PSI). As a result of limited evidence and consensus of PSI prevention, a wide variation in practice remains. Aim: The principal aim of this review is to synthesise primary research concerning all aspects of treatment regarded as relevant to PSI in frame constructs. Materials and methods: Comparative studies until week 26, 2021, were included in the trial. Studies were included that concerned patients undergoing management of a musculoskeletal condition in which pin-site care is necessary for over 4 weeks. Results: Eighteen studies over a 13-year period were captured using the search strategy. Sulphadiazine and hydrogen peroxide cleansing was found to reduce PSI, with the use of low-energy fine wires and hydroxyapatite (HA)-coated pins also associated with lower infection rate. The remainder of studies found no significant improvement across interventions. Conclusion: There is no superiority between weekly and daily care. Low-energy pin-insertion technique had lower rates of infection. Sulphadiazine has positive results as a pin-care solution, but more research is necessary to determine the most effective care regime. Current literature is limited by absence of established definitions and by a lack of studies addressing all aspects of care relevant to PSI. How to cite this article: Shields DW, Iliadis AD, Kelly E, et al. Pin-site Infection: A Systematic Review of Prevention Strategies. Strategies Trauma Limb Reconstr 2022;17(2):93-104.

Percutaneous subtalar joint screw fixation of comminuted calcaneal fractures: a salvage procedure.

INTRODUCTION: Malunited comminuted calcaneal fractures result in poor function due subtalar joint arthritis and altered biomechanics. We aimed to assess whether percutaneous subtalar joint screws after fracture reduction provide good outcomes for these difficult injuries. METHODS: We retrospectively analysed 15 comminuted calcaneal fractures (in 14 patients) treated with percutaneous subtalar screw fixation. All patients had a minimum of 12 months' follow-up. Six patients had open injuries. On the preoperative and the latest postoperative radiograph, Bohlers angle, Gissane angle, calcaneal inclination, width and length, absolute foot height, and posterior facet height were measured. Preoperative computed tomography scans were used to classify the fractures by Sanders classification. Clinical outcome scores were recorded postoperatively. RESULTS: Mean age was 34.2 ± 14.2 years. Minimum follow-up was 12 months (mean 17.2 ± 4.4 months). Nine patients had a Sanders 4, 3 had a Sanders 3AB, 2 had a Sanders 3BC, and 1 had a Sanders 3AC fracture. Eighty percent of patients had their angle of Gissane, absolute foot height, calcaneal length and inclination restored by this technique. Bohlers angle was restored back into the normal range in 54% of patients. Mean postoperative AOFAS score was 74 ± 11. AOFAS scores positively correlated with postoperative Bohlers angle (Pearson's correlation coefficient 0.85; p = 0.004). One patient (7%) had a wound breakdown postoperatively and three patients (20%) had heel pain from the screws, which improved after removal. CONCLUSION: Percutaneous subtalar screws offer a reliable option to restore calcaneal anatomy in comminuted calcaneal fractures, with low complication rates. Over 80% of patients had their angle of Gissane, calcaneal length and inclination restored, and over 50% of patients had all radiological parameters restored by this technique. It offers the benefits of percutaneous reduction and fixation and this procedure may be considered an effective first stage prior to definitive subtalar fusion. Further work is needed to review the longer-term outcomes and the conversion rate to arthrodesis. LEVEL OF EVIDENCE: IV (case series), Therapeutic.