The Joint-Specific BACH classification: A predictor of outcome in prosthetic joint infection.

BACKGROUND: There is currently no commonly accepted method of stratifying complexity of prosthetic joint infection (PJI). This study assesses a new classification, the Joint-Specific, Bone involvement, Anti-microbial options, Coverage of the soft tissues, Host status (JS-BACH) classification, for predicting clinical and patient reported outcomes in PJI. METHODS: Patients who received surgery for PJI at two centres in the UK between 2010 and 2015 were classified using JS-BACH as 'uncomplicated', 'complex' or 'limited treatment options'. Patient reported outcomes were recorded at 365-days following the index operation and included the EuroQol EQ-5D-3L index score and the EQ-visual analogue score (VAS). Clinical outcome data were obtained from the most recent follow-up appointment. FINDINGS: 220 patients met the inclusion criteria. At 365-days following the index operation, patients with 'uncomplicated' PJI reported similar EQ-index scores (0.730, SD:0.326) and EQ-VAS (79.4, SD:20.9) compared to the age-matched population. Scores for 'uncomplicated' PJI were significantly higher than patients classified as having 'complex' (EQ-index:0.515 SD:0.323, p = 0.012; EQ-VAS:68.4 SD:19.4, p = 0.042) and 'limited treatment options' PJI (EQ-index:0.333 SD:0.383, p < 0.001; EQ-VAS:60.2, SD:23.1, p = 0.005). The median time to final follow-up was 4.7 years (inter-quartile range 2.7-6.7 years) where there were 74 cases (33.6%) of confirmed recurrence. Using death as a competing risk, the Cox proportional-hazards ratio of recurrence for 'complex' versus 'uncomplicated' PJI was 23.7 (95% CI:3.23-174.0, p = 0.002) and having 'limited options' verses 'uncomplicated' PJI was 57.7 (95% CI:7.66-433.9, p < 0.001). INTERPRETATION: The JS-BACH classification can help predict likelihood of recurrence and quality of life following surgery for PJI. This will aid clinicians in sharing prognostic information with patients and help guide referral for specialist management of PJI.

Insights into patient preferences for elective surgery during the COVID-19 pandemic.

AIMS: To investigate factors that contribute to patient decisions regarding attendance for arthroplasty during the COVID-19 pandemic. METHODS: A postal questionnaire was distributed to patients on the waiting list for hip or knee arthroplasty in a single tertiary centre within the UK. Patient factors that may have influenced the decision to attend for arthroplasty, global quality of life (QoL) (EuroQol five-dimension three-level (EQ-5D-3L)), and joint-specific QoL (Oxford Hip or Knee Score) were assessed. Patients were asked at which 'COVID-alert' level they would be willing to attend an NHS and a "COVID-light" hospital for arthroplasty. Independent predictors were assessed using multivariate logistic regression. RESULTS: Of 540 distributed questionnaires, 400 (74.1%; 236 awaiting hip arthroplasty, 164 awaiting knee arthroplasty) complete responses were received and included. Less than half (48.2%) were willing to attend for hip or knee arthroplasty while a UK COVID-19 epidemic was in circulation (COVID-alert levels 3 to 5). Patients with worse joint-specific QoL had a preference to proceed with surgery at COVID-alert levels 3 to 5 compared to levels 1 and 2 (hip arthroplasty odds ratio (OR) 1.54 (95% confidence interval (CI) 1.45 to 1.63); knee arthroplasty OR 1.16 (1.07 to 1.26)). The odds of patients with worse joint-specific QoL being willing to attend for surgery at COVID-alert levels 3 to 5 increased further if surgery in a private, "COVID-light" hospital was available (hip arthroplasty OR 3.50 (95% CI 3.26 to 3.71); knee arthroplasty OR 1.41 (95% CI 1.29 to 1.53). CONCLUSION: Patient decisions surrounding elective surgery have been influenced by the global COVID-19 pandemic, highlighting the importance of patient involvement in ensuring optimized provision of elective surgery during these challenging times. Cite this article: Bone Jt Open 2021;2(4):261-270.

The microbiology of chronic osteomyelitis: Changes over ten years.

AIM: This study quantified changes in the microbiology of osteomyelitis over a ten year period from a single centre within the UK with regard to infection with multi-drug resistant (MDR) bacteria and susceptibility of antimicrobial regimens. METHOD: Patients with chronic osteomyelitis undergoing definitive surgery from 2013-2017 were inluded (n = 223). Microbiology was compared to patients in a cohort from 2001-2004, using the same diagnostic criteria, and same deep tissue sampling technique (n = 157). Clinical features associated with MDR bacterial infection were analysed using logistic regression. RESULTS: Both cohorts had similar baseline characteristics. Despite a similar proportion of Staphylococcus aureus in both cohorts, the rate of methicillin resistant Staphylococcus aureus (MRSA) infection was lower in 2013-2017 compared to 2001-2004 (11.4% vs 30.8% of Staphylococcus aureus, p = 0.007). However, the proportion of MDR infections was similar in both cohorts (15.2% versus 17.2%). Metalwork was associated with MDR infection (unadjusted OR 5.0; 95% CI: 1.15 to 22.0). There was no change in resistance to glycopeptide / meropenem combination treatment (2.2% vs 2.5%, p > 0.9). CONCLUSIONS: In this centre, rates of MRSA osteomyelitis have fallen by two thirds, over the past 10 years, in line with the reducing rate of MRSA bacteraemia nationally. A history of metalwork may predict MDR infection. A glycopeptide with an anti-pseudomonal carbapenem remains the post-operative empiric systemic regimen of choice. Resistance patterns support the use of a glycopeptide with an aminoglycoside in local antibiotic therapy.

Bridging hard callus at 48 days in an open femoral shaft fracture with segmental defect treated with a first-stage Masquelet technique: I wasn't expecting that.

The Masquelet technique is a strategy for management of segmental bone defects. It is a two-stage procedure that involves inducing a synovial-like membrane that can be used for a bone graft. Segmental bone defects can occur following trauma and can accompany traumatic brain injury. There is a well-documented, albeit debated, association between traumatic brain injury and increased rate of new bone formation. Here, we present a case of unexpected callus formation in a segmental femoral fracture. The patient had a traumatic brain injury and was treated with the first stage of the Masquelet technique. Owing to the amount of large callus, a second stage of the Masquelet was not required. The patient recovered well from the injury and at 16-week follow-up was able to partially weight bear. A case similar to this has not previously been reported within the literature.

Ovarian hyperstimulation syndrome, the master of disguise?

The use of IVF has risen dramatically over the past 10 years and with this the complications of such treatments have also risen. One such complication is ovarian hyperstimulation syndrome with which patients can present acutely to hospital with shortness of breath. On admission, a series of blood tests are routinely performed, including the d-dimer. We present a case of a 41-year-old lady who had recently undergone IVF and presented with chest pain and dyspnoea. In the emergency department, a d-dimer returned as mildly elevated. Consequential admission onto MAU initiated several avoidable investigations for venous thromboembolism. Careful examination elicited a mild ascites and a thorough drug history gave recent low molecular weight heparin usage. Ultrasound scan of the abdomen subsequently confirmed the diagnosis of severe OHSS. The d-dimer should therefore be used to negate and not to substantiate a diagnosis of VTE. This case report aims to highlight the importance of OHSS as an uncommon cause of dyspnoea but whose prevalence is likely to increase in the forthcoming years. We discuss the complications of the misdiagnosis of OHSS, the physiology behind raised d-dimers, and the potential harm from incorrect treatment or inappropriate imaging.

Multiple, persistent gastropancreato-neuroendocrine tumours accompanying sigmoid bowel adenocarcinoma: A rare case report.

INTRODUCTION: Gastropancreato-neuroendocrine tumours (GETs) are rare, especially when they occur alongside colorectal adenocarcinoma. Furthermore, multiple GETs occurring within the small bowel are less frequent with only two cases described within the literature. PRESENTATION OF CASE: A healthy 58-year old woman presented with severe gastrointestinal pain and faecal incontinence. Family history revealed consanguineous parents and a brother who had recently died of a gastric GET. First biopsy showed a sigmoid adenocarcinoma. Histology of the resected sigmoid revealed both adenocarcinoma and GET. After this, she presented with small bowel obstruction secondary to multiple ileal and jejunal GETs, also treated with resection. All imaging modalities gave no evidence of extra-intestinal metastasis. The patient received multiple operations and chemotherapy but died 18 months after the original presentation. DISCUSSION: A case of such persistent and multiple small bowel GET without extra-intestinal metastasis has yet to be reported within the literature. GETs are rare and typically asymptomatic with a small proportion giving the classical carcinoid syndrome. Surgery is usually reserved for smaller GETs with high five-year survival. Despite this, surgery and chemotherapy were performed and both proved to be ineffective. Furthermore, a genetic basis for GETs is supported in this case with her brother suffering a similar fatal tumour. CONCLUSION: This case highlights a rare GET that has a likely underlying familial origin. It illustrates the non-specific presentation of these tumours and the importance of taking a thorough family history. It also demonstrates that these tumours can be fatal even in the absence of extra-intestinal metastasis.