Pitfalls preventing bone union with EXOGEN Low-Intensity Pulsed Ultrasound.

OBJECTIVES: To evaluate the efficacy of EXOGEN in achieving union and common pitfalls in its use within the Manchester Foundation Trust (MFT) and Salford Royal Foundation Trust (SRFT). METHOD: Patients receiving EXOGEN therapy between 01/01/2017 and 31/12/2019 at hospitals within MFT and SRFT were identified using EXOGEN logbooks and hospital IT systems. An equal number of patients were included from both sites. Data were retrospectively collected from clinical documents detailing clinical presentation comorbidities, and radiographic images, determining the radiological union post EXOGEN therapy. In addition, local practices were observed and compared to EXOGEN's standardized guidance for clinicians. RESULTS: Fifty-eight patients were included in the primary review, with 9 subsequently excluded based on insufficient clinical data. 47% of patients achieved radiological union following completion of EXOGEN therapy. Outcomes of the 23 patients with persistent non-union were as follows - 18 were referred for revision surgery, 5 were prescribed further EXOGEN therapy, 2 refused or were unfit for further intervention, and 1 did not have a plan documented. No significant baseline differences were present in both outcome groups. However, at MFT and SRFT, rates of union with EXOGEN are below that previously published in the literature. CONCLUSION: EXOGEN has proven successful in facilitating union in established cases of non-union without the risk and cost associated with revision surgery. Centre outcome differences may be explained by failure to educate clinicians and patients on the correct use of the EXOGEN device, failure to standardize follow-up or monitor compliance, and must be addressed to improve current services.

Comparison of Surgical Site Infection Risk Between Warfarin, LMWH, and Aspirin for Venous Thromboprophylaxis in TKA or THA: A Systematic Review and Meta-Analysis.

BACKGROUND: Infection following arthroplasty can have devastating effects for the patient and necessitate further surgery. Venous thromboembolism (VTE) prophylaxis is required to minimize the risk of deep venous thrombosis and pulmonary embolism. Anticoagulation has been demonstrated to interfere with wound-healing and increase the risk of infection. We hypothesized that different anticoagulation regimes will have differing effects on rates of periprosthetic joint infection. The aim of this study was to compare the surgical site infection risk between the use of warfarin, low-molecular-weight heparin (LMWH), and aspirin for VTE prophylaxis following total knee or hip arthroplasty. METHODS: A systematic literature search was conducted in November 2018 using the PubMed, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify studies that compared warfarin, LMWH, and/or aspirin with regard to surgical site infection rates following hip or knee arthroplasty. Meta-analyses were performed to compare the infection and VTE risks between groups. RESULTS: Nine articles involving 184,037 patients met the inclusion criteria. Meta-analysis showed that warfarin prophylaxis was associated with a higher risk of deep infection (or infection requiring reoperation) (odds ratio [OR] = 1.929, 95% confidence interval [CI] = 1.197 to 3.109, p = 0.007) and surgical site infection overall (OR = 1.610, 95% CI = 1.028 to 2.522, p = 0.038) compared with aspirin in primary total joint arthroplasty, with similar findings also seen when primary and revision procedures were combined. There was no significant difference in infection risk between warfarin and LMWH and between LMWH and aspirin. There was a nonsignificant trend for VTE risk to be higher with warfarin compared with aspirin therapy for primary procedures (OR = 1.600, 95% CI = 0.875 to 2.926, p = 0.127), and this was significant when both primary and revision cases were included (OR = 2.674, 95% CI = 1.143 to 6.255, p = 0.023). CONCLUSIONS: These findings caution against the use of warfarin for VTE prophylaxis for hip and knee arthroplasty. Further randomized head-to-head trials and mechanistic studies are warranted to determine how specific anticoagulants impact infection risk. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Erratum: A novel technique for fabricating antibiotic-coated intramedullary nails using an antibiotic-loaded calcium sulphate hydroxyapatite bio-composite, Cerament-V.

[This corrects the article DOI: 10.1093/jscr/rjz327.].

Differential diagnosis for a ring-enhancing lesion on CT/MRI brain: retained cotton ball pledget.

New or persisting symptoms require careful evaluation and investigation. We present a case report of a 58-year-old man who underwent a craniotomy for a subdural haematoma and presented a decade later with worsening neurological symptoms. Investigation revealed the cause to be a delayed foreign body reaction to a retained cotton wool pledget.

A novel technique for fabricating antibiotic-coated intramedullary nails using an antibiotic-loaded calcium sulphate hydroxyapatite bio-composite, Cerament-V.

Deformity correction in the setting of osteomyelitis is a challenge for any orthopaedic surgeon. Principles of management are well described and include staged debridement, stable fixation and a combination of local and systemic antibiotic therapy. An antibiotic-coated nail (ACN) can prove a useful tool-stabilizing bone, whilst allowing for local antibiotic elution. Typically, the surgeon will prepare these implants in the operating room using materials that are routinely at hand. Most frequently, this will involve the use of antibiotic-loaded poly-methyl methacrylate (PMMA). This method of ACN fabrication has several disadvantages. PMMA is non-degradable and can be difficult to remove surgically. There are limitations with regard to antibiotic suitability, antibiotic release as well as toxicity effects. In this case report, we present a novel technique for the preparation of ACNs for use in hindfoot surgery, using a calcium sulphate/hydroxyapatite-based bio-composite-Cerament-V.

An overview of carbapenemase producing enterobacteriaceae (CPE) in trauma and orthopaedics.

Carbapenemase resistant enterobacteriae (CPE) may be found in asymptomatic carriers. Its incidence is increasing worldwide. Surgical patients are at increased risk of immunocompromise and of carriage progressing to active infection. Active infection with CPE caries a high mortality rate, with the bacteria being resistant to many antibiotics. This article provides details on the epidemiology, screening and management of the orthopaedic patient with CPE. The guidelines advise orthopaedic staff on ways to avoid the spread of CPE amongst inpatients.