Greater tuberosity fractures of the humerus: complications and long-term outcomes after surgical treatment.

BACKGROUND: Isolated greater tuberosity (GT) fractures typically occur in younger patients following high-energy trauma compared to humeral neck fractures. Surgical treatment is indicated when superior displacement is > 5 mm. This study aimed to assess the complications and long-term outcomes of surgically-treated GT fractures. METHODS: A retrospective review of 39 patients who underwent surgery from 2010 to 2014 was conducted. The cohort comprised 54.6% females, with an average age of 56.74 years and a median follow-up of 6.71 years. Only 25 patients returned for reevaluation, with functional outcomes assessed using Constant-Murley score. RESULTS: Women were older than men (63.00 ± 12.15 vs. 48.65 ± 16.93, p = 0.006). 18/39 patients (46.1%) sustained avulsion-type, 1 patient out of 39 (2.6%) depression-type, and 20/39 patients (51.3%) split-type fractures. The mean Constant-Murley score was 84.08 ± 18.36, with higher scores observed in men (p = 0.021). Avulsion-type fractures were related to higher postoperative scores compared to split fractures (p = 0.069). Post-surgical complications occurred in 20.5% of patients, with no differences noted between sexes, fracture types, or procedures. CONCLUSION: This study enhances understanding of the long-term outcomes of surgically-treated GT fractures, aiding in treatment selection. Interfragmentary screws may be preferable in younger male patients, but are associated with the higher risk of reintervention, particularly in fragile bone. Prospective multicentric studies are warranted to further elucidate long-term results and treatment strategies.

Comparative analysis of proximal humerus fracture management in elderly patients: complications of open reduction and internal fixation by shoulder surgeons and non-shoulder surgeons-a retrospective study.

BACKGROUND: Open reduction and internal fixation (ORIF) with a locking plate is a popular surgical treatment for proximal humeral fractures (PHF). This study aimed to assess the occurrence of complications in elderly patients with PHF treated surgically using ORIF with a locking plate and to investigate the potential differences between patients treated by shoulder surgeons and non-shoulder surgeons. METHODS: A retrospective study was conducted using a single-center database to identify patients aged ≥70 years who underwent ORIF for PHF between January 1, 2011, and December 31, 2021. Data on the Neer classification, follow-up, occurrence of avascular necrosis of the humeral head, implant failure, and revision surgery were also collected. Statistical analyses were performed to calculate the overall frequency of complications according to the Neer classification. RESULTS: The rates of implant failure, avascular osteonecrosis, and revision surgery were 15.7%, 4.8%, and 15.7%, respectively. Complications were more common in patients with Neer three- and four-part fractures. Although the difference between surgeries performed by shoulder surgeons and non-shoulder surgeons did not reach statistical significance, the rate of complications and the need for revision surgery were nearly two-fold higher in the latter group. CONCLUSIONS: PHF are highly prevalent in the elderly population. However, the ORIF surgical approach, as demonstrated in this study, is associated with a considerable rate of complications. Surgeries performed by non-shoulder surgeons had a higher rate of complications and a more frequent need for revision surgery. Future studies comparing surgical treatments and their respective complication rates are crucial to determine the optimal therapeutic options. Level of evidence: III.

Improved outcomes of older patients with acute and displaced proximal humerus fractures treated with window bone ingrowth fracture-specific stem reverse shoulder arthroplasty.

BACKGROUND: The optimal treatment of displaced proximal humerus fractures (PHFs) in the older people population remains controversial. Reverse shoulder arthroplasty (RSA) is a popular surgical treatment option that provides improved and reproducible results. However, the relevance of fracture-specific stem designs for RSA to improve tuberosity consolidation and shoulder function remains debatable. METHODS: This study included all patients 70 years or older with acute and displaced PHFs primarily treated with RSA at a single institution in Portugal, between January 2010 and December 2019 who participated in a minimum follow-up of 2 years. RESULTS: A total of 112 patients (15 men and 97 women) with a median clinical follow-up of 52 months were included. The mean age at the time of fracture was 78.6 years. All fractures were classified as Neer types 3 and 4 (n = 50 and n = 62, respectively). A window bone ingrowth fracture-specific stem was used for 86 patients, and a conventional humeral stem was used for 26 patients. Regarding the tuberosity fixation technique, 76 tuberosities were attached using technique A (according to Boileau's principles), 36 tuberosities were attached using technique B (not following Boileau's principles) and 11cases were classified as technique C (if fixation was not possible). The overall survival rate during the 2-year follow-up was 88.2%; however, this decreased to 79% at 5 years. Only three patients had complications (two infections and one dislocation) requiring revision surgery. In the multivariable analysis, the tuberosity fixation technique (P = 0.012) and tuberosity anatomical consolidation (P < 0.001) were associated with improved Constant scores (median Constant Score 62.67 (technique A), 55.32 (technique B), 49.70 (technique C). Fracture-specific humeral implants (P = 0.051), the tuberosity fixation technique (P = 0.041), tuberosity anatomical consolidation (P < 0.001), and dementia influenced the achievement of functional mobility (P = 0.014). Tuberosity anatomic consolidation was positively associated with bone ingrowth fracture-specific humeral implants (P < 0.01) and a strong tuberosity fixation technique (P < 0.01). CONCLUSION: RSA is used for complex and displaced fractures of the proximal humerus in older patients. Dementia was negatively correlated with functional outcomes. A window bone ingrowth fracture-specific stem combined with strong tuberosity fixation can yield better clinical and radiological results. LEVEL OF EVIDENCE: Level II; prospective comparative study; treatment study.

Synovial Fluid Biomarkers for the Diagnosis of Periprosthetic Joint Infection-A Systematic Review and Meta-Analysis of Their Diagnostic Accuracy According to Different Definitions.

BACKGROUND: Different synovial fluid biomarkers have emerged to improve periprosthetic joint infection (PJI) diagnosis. The goals of this paper were (i) to assess their diagnostic accuracy and (ii) to evaluate their performance according to different PJI definitions. METHODS: A systematic review and meta-analysis was performed using studies that reported diagnostic accuracy of synovial fluid biomarkers using validated PJI definitions published from 2010 to March 2022. A database search was performed through PubMed, Ovid MEDLINE, Central, and Embase. The search identified 43 different biomarkers with four being the more commonly studied, with 75 papers overall: alpha-defensin; leukocyte esterase; synovial fluid C-reactive protein; and calprotectin. RESULTS: Overall accuracy was higher for calprotectin, followed by alpha-defensin, leukocyte esterase, and synovial fluid C-reactive protein with sensitivities of 78 to 92% and specificities of 90 to 95%. Their diagnostic performance was different according to which definition was adopted as the reference. Specificity was consistently high across definitions for all four biomarkers. Sensitivity varied the most with lower values for the more sensitive European Bone and Joint Infection Society or Infectious Diseases Society of America definitions with higher values for the Musculoskeletal Infection Society definition. The International Consensus Meeting 2018 definition showed intermediate values. CONCLUSION: All evaluated biomarkers had good specificity and sensitivity, making their use acceptable in the diagnosis of PJI. Biomarkers perform differently according to the selected PJI definitions.

Intraoperative fluoroscopic radiation in orthopedic trauma: correlation with surgery type and surgeon experience.

Background: While fluoroscopy is widely used in orthopedic trauma surgeries, it is associated with harmful effects and should, therefore, be minimized. However, reference values for these surgeries have not been defined, and it is not known how surgeon experience affects these factors. The aims of this study were to analyze the radiation emitted and exposure time for common orthopedic trauma surgeries and to assess whether they are affected by surgeon experience. Methods: Data from 1842 trauma orthopedic procedures were retrospectively analyzed. A total of 1421 procedures were included in the analysis. Radiation dose and time were collected to identify reference values for each surgery and compared for when the lead surgeon was a young resident, a senior resident, or a specialist. Results: The most performed surgeries requiring fluoroscopy were proximal femur short intramedullary nailing (n = 401), ankle open reduction and internal fixation (ORIF) (n = 141), distal radius ORIF (n = 125), and proximal femur dynamic hip screw (DHS) (n = 114). Surgeries using higher radiation dose were proximal femur long intramedullary nailing (mean dose area [DAP]): 1361.35 mGycm2), proximal femur DHS (1094.81 mGycm2), and proximal femur short intramedullary nailing (891.41 mGycm2). Surgeries requiring longer radiation time were proximal humerus and/or humeral shaft intramedullary nailing (02 mm:20 ss), proximal femur long intramedullary nailing (02 mm:04 ss), and tibial shaft/distal tibia intramedullary nailing (01 mm:49 ss). Senior residents required shorter radiation time when performing short intramedullary nailing of the proximal femur than young residents. Specialists required more radiation dose than residents when performing tibial nailing and tibial plateau ORIF and required longer radiation time than young residents when performing tibial nailing. Conclusions: This study presents mean values of radiation dose and time for common orthopedic trauma surgeries. Orthopedic surgeon experience influences radiation dose and time values. Contrary to expected, less experience is associated with lower values in some of the cases analyzed.

Treatment of Acute Spinal Cord Injuries: A Survey Among Iberolatinoamerican Spine Surgeons - Part 1: Use of High-Dose Corticosteroids.

Objective The aim of the present study was to evaluate the current practice of using of methylprednisolone sodium succinate (MPSS) in acute spinal cord Injuries (ASCIs) among spine surgeons from Iberolatinoamerican countries. Methods A descriptive cross-sectional study design as a survey was conducted. A questionnaire composed of 2 sections, one on demographic data regarding the surgeons and MPSS administration, was sent by email to members of the Sociedad Ibero Latinoamericana de Columna (SILACO, in the Spanish acronym) and associated societies. Results A total of 182 surgeons participated in the study: 65.4% (119) orthopedic surgeons and 24.6% (63) neurosurgeons. Sixty-nine (37.9%) used MPSS in the initial management of ASCIs. There were no significant differences between countries ( p = 0.451), specialty ( p = 0.352), or surgeon seniority ( p = 0.652) for the use of corticosteroids in the initial management of ASCIs. Forty-five (65.2%) respondents reported using an initial high-dose bolus (30 mg/Kg) followed by a perfusion (5.4 mg/kg/h). Forty-six (66.7%) surgeons who used MPSS only prescribed it if the patients presented within 8 hours of the ASCI. Most of the surgeons (50.7% [35]) administered high-dose corticosteroids because of the conviction that it has clinal benefits and improves neurological recovery. Conclusion Results from the present survey show that MPSS use in ASCI is not widespread within spine surgeons and that the controversy regarding its use remains unresolved. This is probably due to the low level of evidence of the available data, to variations over the years, to inconsistencies in acute care protocols, and to health service pathways.

Treatment of Acute Spinal Cord Injuries: A Survey Among Iberolatinoamerican Spine Surgeons - Part 2 Timing to Surgery.

Objective The objective of the present study was to evaluate the current practice in terms of timing to surgery in acute spinal cord injury (ASCI) patients among spinal surgeons from Iberolatinoamerican countries. Methods A descriptive cross-sectional study design as a questionnaire was sent by an email for all members of the Sociedad Ibero Latinoamericana de Columna (SILACO, in the Spanish acronym) and associated societies. Results A total of 162 surgeons answered questions related to the timing for surgery. Sixty-eight (42.0%) considered that ASCI with complete neurology injury should be treated within 12 hours, 54 (33.3%) performed early decompression within 24 hours, and 40 (24,7%) until the first 48 hours. Regarding ASCI with incomplete neurological injury, 115 (71.0%) would operate in the first 12 hours. There was a significant difference in the proportion of surgeons that would operate ASCI within ≤ 24 hours, regarding the type of injury (complete injury:122 versus incomplete injury:155; p < 0.01). In the case of patients with central cord syndrome without radiological evidence of instability, 152 surgeons (93.8%) would perform surgical decompression: 1 (0.6%) in the first 12 hours, 63 (38.9%) in 24 hours, 4 (2.5%) in 48 hours, 66 (40.7%) in the initial hospital stay, and 18 (11.1%) after neurologic stabilization. Conclusion All inquired surgeons favour early decompression, with the majority performing surgery in the first 24 hours. Decompression is performed earlier in cases of incomplete than in complete injuries. In cases of central cord syndrome without radiological evidence of instability, there is a tendency towards early surgical decompression, but the timing is still extremely variable. Future studies are needed to identify the ideal timing for decompression of this subset of ASCI patients.

Simple and inexpensive synovial fluid biomarkers for the diagnosis of prosthetic joint infection according to the new EBJIS definition.

Introduction: diagnosis of periprosthetic joint infection (PJI) is challenging, as no single test has absolute accuracy. The purpose of this study was to assess the utility of different simple synovial biomarkers in the diagnosis of PJI as defined by the European Bone and Joint Infection Society (EBJIS). Methods: we retrospectively identified all patients undergoing revision hip or knee arthroplasty from 2013 to 2019 on our prospectively maintained database. Only patients with minimum required infection diagnostic workup were included in the study. Patients with comorbidities that may influence the accuracy of synovial biomarkers were excluded. Receiver operator characteristic (ROC) curves were utilised to assess the diagnostic utility of synovial fluid white blood cell (WBC) count, polymorphonuclear leukocyte percentage (PMN %), C-reactive protein (CRP), adenosine deaminase (ADA), and alpha-2-microglobulin (A2M). Results: in total, 102 patients met the inclusion criteria. Of these, 58 were classified as infection unlikely, 8 as infection likely, and 36 as infection confirmed. Synovial WBC count (area under the curve (AUC) 0.94) demonstrated the best utility for the diagnosis of PJI, followed by PMN % (AUC 0.91), synovial CRP (AUC 0.90), ADA (AUC 0.82), and A2M (AUC 0.76). We found added value in the combined interpretation of different biomarkers. We calculated high sensitivity and negative predictive value if at least two of them are negative and high specificity and positive predictive value if at least two are elevated. Conclusion: current results show that synovial fluid investigation is a useful tool for the diagnosis of PJI, and the combined interpretation of simple and inexpensive biomarkers demonstrated improved diagnostic accuracy.

Treatment of Acute Spinal Cord Injuries: A Survey Among Iberolatinoamerican Spine Surgeons - Part 2 Timing to Surgery / Tratamento de lesões agudas da medula espinal: Uma pesquisa entre cirurgiões de coluna iberoamericanos - Parte 2: Momento da cirurgia

Abstract Objective The objective of the present study was to evaluate the current practice in terms of timing to surgery in acute spinal cord injury (ASCI) patients among spinal surgeons from Iberolatinoamerican countries. Methods A descriptive cross-sectional study design as a questionnaire was sent by an email for all members of the Sociedad Ibero Latinoamericana de Columna (SILACO, in the Spanish acronym) and associated societies. Results A total of 162 surgeons answered questions related to the timing for surgery. Sixty-eight (42.0%) considered that ASCI with complete neurology injury should be treated within 12 hours, 54(33.3%) performed early decompression within 24 hours, and 40 (24,7%) until the first 48 hours. Regarding ASCI with incomplete neurological injury, 115 (71.0%) would operate in the first 12 hours. There was a significant difference in the proportion of surgeons that would operate ASCI within ≤ 24 hours, regarding the type of injury (complete injury:122 versus incomplete injury:155; p<0.01). In the case of patients with central cord syndrome without radiological evidence of instability, 152 surgeons (93.8%) would perform surgical decompression: 1 (0.6%) in the first 12 hours, 63 (38.9%) in 24 hours, 4 (2.5%) in 48 hours, 66 (40.7%) in the initial hospital stay, and 18 (11.1%) after neurologic stabilization. Conclusion All inquired surgeons favour early decompression, with the majority performing surgery in the first 24 hours. Decompression is performed earlier in cases of incomplete than in complete injuries. In cases of central cord syndrome without radiological evidence of instability, there is a tendency towards early surgical decompression, but the timing is still extremely variable. Future studies are needed to identify the ideal timing for decompression of this subset of ASCI patients.

Resumo Objetivo O objetivo do presente estudo foi avaliar a prática atual em termos de momento de realização da cirurgia em pacientes com lesão medularaguda (LMA) entre cirurgiões de coluna de países ibero-americanos. Métodos Estudo transversal descritivo com base em um questionário enviado por correio eletrônico para todos os membros da Sociedad Ibero Latinoamericana de Columna (SILACO, na sigla em espanhol) e sociedades associadas. Resultados Um total de 162 cirurgiões responderam a perguntas relacionadas ao momento da cirurgia. Sessenta e oito (42,0%) consideraram que a LMA com lesão neurológica completa deve ser tratada em até 12 horas, 54 (33,3%) realizariam a descompressão precoce em até 24 horas e 40 (24,7%) fariam este procedimento nas primeiras 48 horas. Em relação à LMA com lesão neurológica incompleta, 115 (71,0%) operariam nas primeiras 12 horas. Houve diferença significativa na proporção de cirurgiões que fariam o tratamento cirúrgico da LMA em ≤ 24 horas quanto ao tipo de lesão (lesão completa [122] versus lesão incompleta [155]; p<0.01). Em pacientes com síndrome medular central sem evidência radiológica de instabilidade, 152 cirurgiões (93,8%) realizariam a descompressão cirúrgica: 1 (0,6%) nas primeiras 12 horas, 63 (38,9%) em 24 horas, 4 (2,5%) em 48 horas, 66 (40,7%) no internamento inicial e 18 (11,1%) após a estabilização neurológica. Conclusão Todos os cirurgiões participantes favoreceram a descompressão precoce; a grande maioria realizaria a cirurgia nas primeiras 24 horas. A descompressão é feita antes em casos de lesões incompletas do que em lesões completas. Nos casos de síndrome medular central sem evidência radiológica de instabilidade, há uma tendência à descompressão cirúrgica precoce, mas o momento de intervenção ainda é extremamente variável. Estudos futuros são necessários para identificar o momento ideal para descompressão neste subconjunto de pacientes com LMA.

Treatment of Acute Spinal Cord Injuries: A Survey Among Iberolatinoamerican Spine Surgeons - Part 1: Use of High-Dose Corticosteroids / Tratamento das lesões agudas da medula espinal: Uma pesquisa entre cirurgiões de coluna iberoamericanos - Parte 1: Uso de corticosteroides em altas doses

Abstract Objective The aim of the present study was to evaluate the current practice of using of methylprednisolone sodium succinate (MPSS) in acute spinal cord Injuries (ASCIs) among spine surgeons from Iberolatinoamerican countries. Methods A descriptive cross-sectional study design as a survey was conducted. A questionnaire composed of 2 sections, one on demographic data regarding the surgeons and MPSS administration, was sent by email to members of the Sociedad Ibero Latinoamericana de Columna (SILACO, in the Spanish acronym) and associated societies. Results A total of 182 surgeons participated in the study: 65.4% (119) orthopedic surgeons and 24.6% (63) neurosurgeons. Sixty-nine (37.9%) used MPSS in the initial management of ASCIs. There were no significant differences between countries (p = 0.451), specialty (p = 0.352), or surgeon seniority (p = 0.652) for the use of corticosteroids in the initial management of ASCIs. Forty-five (65.2%) respondents reported using an initial high-dose bolus (30 mg/Kg) followed by a perfusion (5.4 mg/ kg/h). Forty-six (66.7%) surgeons who used MPSS only prescribed it if the patients presented within 8 hours of the ASCI. Most of the surgeons (50.7% [35]) administered high-dose corticosteroids because of the conviction that it has clinal benefits and improves neurological recovery. Conclusion Results from the present survey show that MPSS use in ASCI is not widespread within spine surgeons and that the controversy regarding its use remains unresolved. This is probably due to the low level of evidence of the available data, to variations over the years, to inconsistencies in acute care protocols, and to health service pathways.

Resumo Objetivo O objetivo do presente estudo foi avaliar a prática atual de uso do succinato sódico de metilprednisolona (MPSS, na sigla em inglês) nas lesões agudas da medula espinal (LAMEs) entre cirurgiões de coluna de países ibero-americanos. Métodos Um estudo transversal descritivo foi realizado. O questionário continha duas seções, uma sobre os dados demográficos dos cirurgiões e acerca da administração de MPSS, e foi enviado por correio eletrônico aos membros da Sociedad Ibero Latinoamericana de Columna (SILACO, na sigla em espanhol) e sociedades associadas. Resultados No total, 182 cirurgiões participaram do estudo: 65,4% (119) eram cirurgiões ortopédicos e 24,6% (63), neurocirurgiões. Sessenta e nove (37,9%) usaram MPSS no tratamento inicial da LAME. Não houve diferenças significativas entre países (p = 0,451), especialidades (p = 0,352) ou senioridade do cirurgião (p =0,652) em relação ao uso de corticosteroides no tratamento inicial da LAME. Destes, 45 (65,2%) relataram a administração de um bolus de alta dose (30 mg/kg) seguido por perfusão (5,4 mg/kg/h). Quarenta e seis (66,7%) dos cirurgiões que usam MPSS apenas o prescrevem a pacientes tratados nas primeiras 8 horas após a LAME. A maioria dos cirurgiões (50,7% [35]) administrou corticosteroides em alta dose devido à convicção de seus benefícios clínicos e melhora da recuperação neurológica. Conclusão Os resultados do presente questionário mostram que o uso de MPSS na LAME não está disseminado entre os cirurgiões de coluna e que a controvérsia sobre sua administração ainda não foi resolvida. É provável que isto se deva ao baixo nível de evidência dos dados existentes, a variações ao longo dos anos, a inconsistências nos protocolos terapêuticos agudo e a diferentes sistemas de saúde.

Unexpected Positive Cultures in Patients Who Have a History of Septic Revision in the Same Joint.

BACKGROUND: The prevalence of unexpected positive cultures (UPC) in an aseptic revision surgery of the joint with a prior septic revision in the same joint remains unknown. The purpose of this study was to determine the prevalence of UPC in that specific group. As secondary outcomes, we explored risk factors for UPC. METHODS: This retrospective study includes patients who had an aseptic revision total hip/knee arthroplasty procedure with a prior septic revision in the same joint. Patients who had less than 3 microbiology samples, without joint aspiration or with aseptic revision surgery performed <3 weeks after a septic revision were excluded. The UPC was defined as a single positive culture in a revision that the surgeon had classified as aseptic according to the 2018 International Consensus Meeting. After excluding 47, a total of 92 patients were analyzed, who had a mean age of 70 years (range, 38 to 87). There were 66 (71.7%) hips and 26 (28.3%) knees. The mean time between revisions was 83 months (range, 31 to 212). RESULTS: We identified 11 (12%) UPC and in 3 cases there was a concordance of the bacteria compared to the previous septic surgery. There were no differences for UPC between hips/knees (P = .282), diabetes (P = .701), immunosuppression (P = .252), previous 1-stage or 2-stages (P = .316), causes for the aseptic revision (P = .429) and time after the septic revision (P = .773). CONCLUSION: The prevalence of UPC in this specific group was similar to those reported in the literature for aseptic revisions. More studies are needed to better interpret the results.

Comparative clinical and radiologic evaluation between patients undergoing standard reversed shoulder arthroplasty or bony increased offset.

BACKGROUND: Modifications of the medialized design of Grammont-type reverse shoulder arthroplasty (RSA) using a bony increased offset (BIO-RSA) has shown better clinical results and fewer complications. The aim of this study is to compare the clinical results, complications, and radiological outcomes between patients undergoing standard RSA and BIO-RSA. METHODS: A retrospective review was performed of 42 RSA procedures (22 standard RSA and 20 BIO-RSA). With a minimum of 1 year of follow-up, range of motion (ROM), Constant shoulder score (CSS), visual analog scale (VAS), and subjective shoulder score (SSS) were compared. Radiographs and computed tomography (CT) scan were examined for scapular notching, glenoid and humeral fixation, and graft healing. RESULTS: At a mean follow-up of 27.6 months (range, 12-48 months), a significant difference was found for active-internal rotation (P=0.038) and for passive-external rotation (P=0.013), with better results in BIO-RSA. No other differences were found in ROM, CSS (P=0.884), VAS score, and SSS. Graft healing and viability were verified in all patients with CT scan (n=34). The notching rate was 28% in the standard RSA group and 33% in the BIO-RSA group, but the standard RSA had more severe notching (grade 2) than BIO-RSA (P=0.039). No other significative differences were found in glenoid and humeral fixation. CONCLUSIONS: Bone-graft lateralization is associated with better internal and external rotation and with less severe scapular notching compared to the standard RSA. Integration of the bone graft occurs effectively, with no relevant changes observed on radiographic evaluation.

The European Bone and Joint Infection Society definition of periprosthetic joint infection is meaningful in clinical practice: a multicentric validation study with comparison with previous definitions.

BACKGROUND AND PURPOSE: A new periprosthetic joint infection (PJI) definition has recently been proposed by the European Bone and Joint Infection Society (EBJIS). The goals of this paper are to evaluate its diagnostic accuracy and compare it with previous definitions and to assess its accuracy in preoperative diagnosis. PATIENTS AND METHODS: We retrospectively evaluated a multicenter cohort of consecutive revision total hip and knee arthroplasties. Cases with minimum required diagnostic workup were classified according to EBJIS, 2018 International Consensus Meeting (ICM 2018), Infectious Diseases Society of America (IDSA), and modified 2013 Musculoskeletal Infection Society (MSIS) definitions. 2 years' minimum follow-up was required to assess clinical outcome. RESULTS: Of the 472 cases included, PJI was diagnosed in 195 (41%) cases using EBJIS; 188 (40%) cases using IDSA; 172 (36%) using ICM 2018; and 145 (31%) cases using MSIS. EBJIS defined fewer cases as intermediate (5% vs. 9%; p = 0.01) compared with ICM 2018. Specificity was determined by comparing risk of subsequent PJI after revision surgery. Infected cases were associated with higher risk of subsequent PJI in every definition. Cases classified as likely/confirmed infections using EBJIS among those classified as not infected in other definitions showed a significantly higher risk of subsequent PJI compared with concordant non-infected cases using MSIS (RR = 3, 95% CI 1-6), but not using ICM 2018 (RR = 2, CI 1-6) or IDSA (RR = 2, CI 1-5). EBJIS showed the highest agreement between pre-operative and definitive classification (k = 0.9, CI 0.8-0.9) and was better at ruling out PJI with an infection unlikely result (sensitivity 89% [84-93], negative predictive value 90% [85-93]). CONCLUSION: The newly proposed EBJIS definition emerged as the most sensitive of all major definitions. Cases classified as PJI according to the EBJIS criteria and not by other definitions seem to have increased risk of subsequent PJI compared with concordant non-infected cases. EBJIS classification is accurate in ruling out infection preoperatively.

Postoperative impact of rod bending in the lumbar spine fusion surgery with polyaxial screws - Validation of a study.

Introduction: In 2019, Moufid and Gille published a study in which they proposed certain radiological parameters that may justify the mismatch between the lordosis of the lumbar segment and the lordosis of the rod bar using polyaxial screws. The aim of this study is to reproduce the measurements performed by Moufid and Gille and try to validate their findings. Material and methods: A retrospective study was performed including patients submitted to L3-L5 posterior fusion with or without interbody devices using polyaxial screws and titanium rods, for degenerative disease. Radiological parameters were analysed:the distance between the posterior wall and the rod for each vertebra(the standard deviation of the three distances was called Alpha); the angle between the screw and the rod for each screw(mean of the three was called Theta); the angle between screws and superior endplate for each instrumented vertebra(mean of the three was called Lambda). The difference between post-operative segmental lordosis and the lordosis of the rod was called DiffL. Results: A total of 58 cases were included. The most frequent fusion surgery was posterolateral fusion(77.6%). The mean value of lumbar lordosis, fused segmental lordosis, pelvic incidence, Alpha, Theta, Lambda and DiffL were 48.7 ± 12.7°, 28.4 ± 9.2°, 60.7 ± 11.9°, 3.4 ± 1.6 mm, 90.5 ± 1.8°, 3.9 ± 1.8° e 9.9 ± 9.5° respectively. The mean value of rod lordosis was 20.5 ± 8.1°. DiffL varied between 0.1° (practically no mismatch) and 30.5° of mismatch. DiffL didn't correlate with gender, fusion type, age, PI and Alpha, Theta or Lambda. There was a significant positive correlation between lumbar lordosis and DiffL(ρ = 0.28; p = 0.03). No correlation was found between the radiological parameters for the cut-off point proposed by Moufid and Gille(Alpha 4.7 mm, Theta 86°, Lambda 2.8°) and the DiffL value. Conclusion: No significant factors were identified in this study to aid in achieving an ideal match between rod and segmental spine lordosis, therefore not validating the study by Moufid and Gille.

Multidisciplinary Approach to Multiple Multiresistant Agent Infection of Instrumented Spine Surgery: A Case Report.

CASE: We report the case of a patient with consecutive infections with several multidrug-resistant agents-including carbapenem-resistant strains of Klebsiella pneumoniae among others-from a surgical wound infection after lumbar spine fusion, only successfully treated after the resort to novel antibiotics (ceftazidime-avibactam) in combination therapy. CONCLUSIONS: Multidrug resistance has become a major challenge in today's medicine. Care should be taken to avoid their emergence, but when present, a multidisciplinary approach is mandatory to ensure clinically up-to-date treatment choices. Multimodal antibiotic schemes tend to show the most promising results, with which successful infection resolution can still be achieved.

Combined antibiotic therapy spacers either commercial or handmade are superior to monotherapy - a microbiological analysis at the second stage of revision.

Background: Antibiotic-loaded spacers are often used during two-stage exchange for periprosthetic joint infections (PJIs) both for its mechanical properties and as a means of local antibiotic delivery. Purpose: The main goal of this study is to compare the efficacy of different options of antibiotic(s) in spacers concerning the rate of positive cultures at the second stage. Patients and Methods: We retrospectively evaluated two-stage exchange procedures for infected hip or knee arthroplasty performed between 2012 and 2018 in which adequate (at least four deep tissue samples) culture results in both stages were available. The type of spacer and antibiotics used, in addition to several other patient, infection and treatment-related variables, were registered and correlated to microbiological findings in the second stage. Results: Fifty-eight cases were included with a 19.0 % (11/58) overall rate of positive cultures during reimplantation. With a mean follow-up of 46 months, failure rate was significantly higher at 63.6 % (7/11) in cases with positive cultures at reimplantation compared to 4.3 % (2/47) for those with negative cultures during reimplantation ( p <  0.001). The need for additional surgeries was also significantly higher (odds ratio (OR) 122.67, confidence interval (CI) 95 % 11.30-1331.32, p <  0.001). Multivariable analysis revealed antibiotics in the spacers were the main independent prognostic risk factor associated with positive cultures at the second stage with an advantage for combined antibiotics. Monotherapy is associated with failure with an OR of 16.99. Longer time between surgeries did not have statistical significance ( p =  0.05), and previous surgical treatment for PJI, presence of difficult-to-treat microorganism(s), duration of systemic antibiotic therapy or even treatment within a dedicated septic team were not shown to be independent risk factors. Among combined antibiotic spacers, there were no significant differences between the rate of positive cultures during the second stage, comparing commercially available vancomycin/gentamicin spacers to hand-mixed vancomycin/meropenem manufactured spacers (8.3 % [2/24] vs. 15.0 % [3/20], p =  0.68). Conclusions: Results show that combined antibiotic therapy spacers are advantageous when compared to gentamicin monotherapy as they produce significantly lower rates of subsequent positive cultures during the second stage. Hand-mixed high-dose vancomycin/meropenem spacers seem to perform just as well as prefabricated commercially available vancomycin/gentamicin options. Level of Evidence: Therapeutic level III.

Impact of COVID-19 pandemic and national lockdown in an orthopaedic and traumatology department-a comparison with the homologous period of 2019.

BACKGROUND: The coronavirus disease-2019 pandemic has forced health systems to undergo dynamic changes. This study aims to evaluate the impact of the pre-lockdown and of the lockdown period on the surgical activity of a Portuguese Orthopaedic and Traumatology Department and to compare it with the homologous period of 2019. METHODS: The surgical activity between March 2 and May 2, 2020 and that of the homologous period of 2019 were analyzed and compared. Additionally, the impact of national and institutional measures was analyzed. RESULTS: There was a decrease in elective surgeries, from 587 to 100. In 2020, 59.3% of all surgeries were urgent and 48.4% were trauma whereas in 2019 there were 25.5% urgent and 23.0% trauma surgeries (P < .001 and P < .001, respectively). There was no difference in the mean of proximal hip fractures operated per week (P = .310), even when analyzing only the lockdown period (P = .102). However, proximal hip fractures corresponded to significantly higher proportion of surgeries in 2020 (P = .04). Hand and tendon injuries significantly reduced in 2020, as were sports-related trauma surgeries. Mean number of days until surgery was significantly lower in 2020 (2020:1.6 ±â€Š2.1, 2019: 2.2 ±â€Š2.5, P = .012). CONCLUSION: Governmental and institutional measures had high impact on the production and on the epidemiology of trauma. While resumption of elective surgery is needed, lessons from these measures may help in the response to a possible second wave.

Is Preoperative Staphylococcus aureus Screening and Decolonization Effective at Reducing Surgical Site Infection in Patients Undergoing Orthopedic Surgery? A Systematic Review and Meta-Analysis With a Special Focus on Elective Total Joint Arthroplasty.

BACKGROUND: Staphylococcus aureus is a major pathogen implicated in orthopedic infections worldwide. Preoperative decolonization has been promoted but different strategies present mixed results. Thus, the goals of this study are to determine (1) whether S aureus screening and/or decolonization is effective at reducing surgical site infection in orthopedic surgery, (2) with a special focus on elective total joint arthroplasty (TJA), and (3) which preoperative S aureus screening/treatment strategy is most cost-effective for TJA. METHODS: PubMed, Ovid MEDLINE, and Cochrane databases were searched on January 1, 2020, using a systematic strategy. We included papers with data comparing surgical site infection and periprosthetic joint infection rate in orthopedic surgery and/or elective total hip and knee arthroplasty patients before/after S aureus screening and/or decolonization protocol and papers evaluating the cost-effectiveness of different S aureus screening/treatment strategies. RESULTS: A total of 1260 papers were screened, and 32 papers were ultimately included. Results showed an increased risk of developing any infection (relative risk [RR] = 1.71 ± 0.16) and S aureus infection (RR = 2.79 ± 0.45) after orthopedic surgery without previous nares and whole-body decolonization. Focusing exclusively on elective TJA, there was an increased risk of developing any infection (RR = 1.70 ± 0.17) and S aureus infection (RR = 2.18 ± 0.41) if no decolonization is performed. All strategies appeared to be cost-effective, although universal decolonization without screening seemed to be the most advantageous. CONCLUSION: Preoperative S aureus screening/decolonization protocol lowered the risk of infection after elective orthopedic and TJA surgeries. However, further studies are needed to determine optimal clinical and cost-effective methodologies.