Fracture related infections (FRI) are debilitating and costly complications of musculoskeletal trauma surgery that can result in permanent functional loss or amputation. Surgical treatment can be unsuccessful, and it is necessary to determine the predictive variables associated with FRI treatment failure, allowing one to optimise them prior to treatment and identify patients at higher risk. The clinical database at a major trauma centre was retrospectively reviewed between January 2015 and January 2021. FRI treatment failure was defined by infection recurrence or amputation. A univariable logistic regression analysis was performed, followed by a multivariable regression analysis for significant outcomes between groups on univariable analysis, to determine risk factors for treatment failure. In total, 102 patients were identified with a FRI (35 open, 67 closed fractures). FRI treatment failure occurred in 24 patients (23.5%). Risk factors determined by our multivariate logistic regression model were obesity (OR 2.522; 95% CI, 0.259–4.816; p = 0.006), Gustilo Anderson type 3c (OR 4.683; 95% CI, 2.037–9.784; p = 0.004), and implant retention (OR 2.818; 95% CI, 1.588–7.928; p = 0.041). Given that FRI treatment in 24 patients (23.5%) ended up in failure, future management need to take into account the predictive variables analysed in this study, redirect efforts to improve management and incorporate adjuvant technologies for patients at higher risk of failure, and implement a multidisciplinary team approach to optimise risk factors such as diabetes and obesity.

Recent studies of exosomes derived from mesenchymal stem cells (MSCs) have indicated high potential clinical applications in many diseases. However, the limited source of MSCs impedes their clinical research and application. Most recently, induced pluripotent stem cells (iPSCs) have become a promising source of MSCs. Exosome therapy based on iPSC-derived MSCs (iMSCs) is a novel technique with much of its therapeutic potential untapped. Compared to MSCs, iMSCs have proved superior in cell proliferation, immunomodulation, generation of exosomes capable of controlling the microenvironment, and bioactive paracrine factor secretion, while also theoretically eliminating the dependence on immunosuppression drugs. The therapeutic effects of iMSC-derived exosomes are explored in many diseases and are best studied in wound healing, cardiovascular disease, and musculoskeletal pathology. It is pertinent clinicians have a strong understanding of stem cell therapy and the latest advances that will eventually translate into clinical practice. In this review, we discuss the various applications of exosomes derived from iMSCs in clinical medicine.

Introduction: Open diaphyseal tibial fractures are the most common long-bone fractures and require a rapid approach to prevent devastating complications. Current literature reports the outcomes of open tibial fractures. However, there is no robust, up-to-date research on the predictive indicators of infection severity in a large open tibial fracture patient cohort. This study investigated the predictive factors of superficial infections and osteomyelitis in open tibial fractures. Materials and methods: A retrospective analysis of the tibial fracture database was carried out from 2014 to 2020. Criteria for inclusion was any tibial fracture including tibial plateau, shaft, pilon or ankle, with an open wound at the fracture site. Exclusion criteria included patients with a follow-up period of less than 12 months and who are deceased. A total of 235 patients were included in our study, of which 154 (65.6%), 42 (17.9%), and 39 (16.6%) developed no infection, superficial infection, or osteomyelitis, respectively. Patient demographics, injury characteristics, fracture characteristics, infection status and management details were collected for all patients. Results: On multivariate modelling, patients with BMI > 30 (OR = 2.078, 95%CI [1.145–6.317], p = 0.025), Gustilo-Anderson (GA) type III (OR = 6.120, 95%CI [1.995–18.767], p = 0.001), longer time to soft tissue cover (p = 0.006) were more likely to develop a superficial infection, and patients with wound contamination (OR = 3.152, 95%CI [1.079–9.207], p = 0.036), GA-3 (OR = 3.387,95%CI [1.103–10.405], p = 0.026), longer to soft tissue cover (p = 0.007) were more likely to develop osteomyelitis. Univariate analysis also determined that risk factors for superficial infection were: BMI > 35 (OR = 6.107, 95%CI [2.283–16.332], p = 0.003) and wound contamination (OR = 2.249, 95%CI [1.015–5.135], p = 0.047); whilst currently smoking (OR = 2.298, 95%CI [1.087–4.856], p = 0.025), polytrauma (OR = 3.212, 95%CI [1.556–6.629], p = 0.001), longer time to definitive fixation (p = 0.023) were for osteomyelitis. However, none of these reached significance in multivariate analysis. Conclusion: Higher GA classification is a significant risk factor for developing superficial infection and osteomyelitis, with a stronger association with osteomyelitis, especially GA 3C fractures. Predictors for superficial infection included BMI and time to soft tissue closure. Time to definitive fixation, time to soft tissue closure, and wound contamination were associated with osteomyelitis.

Despite the low incidence of pilon fractures amongst lower limb injuries, their high impact nature presents difficulties in surgical management and recovery. The high complication rate and long recovery times presents a challenge for surgeons and patients. Current literature is varied, with no universal treatment algorithm. We aim to highlight differences in outcomes and complications between open and closed pilon fractures, and between patients treated by open reduction internal fixation (ORIF) or fine wire fixator (FWF) for open and closed fracture subgroups. This retrospective study was conducted at a major trauma centre including 135 patients over a 6-year period. Primary outcome was AOFAS score at 3, 6, and 12-months post-injury. Secondary outcomes included time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time, and complications during the follow-up time. AO/OTA classification was used (43A: n = 23, 43B: n = 30, 43C: n = 82). Interobserver agreement was high for bone union time (kappa=0.882) and AO/OTA class (kappa=0.807). Higher AOFAS scores were seen in ORIF groups of both open and closed fractures, compared to FWF groups. The difference was not statistically significant apart from 12-month AOFAS score of 43C open fractures (p = 0.003) and in 43B closed fractures 3 and 6 months post-injury (p<0.001 and p<0.001, respectively). The majority of ORIF subgroups, open and closed fractures, also had shorter time to PWB, FWB, time to union, and follow-up. Statistically significant differences were seen in the following cases: ORIF-treated 43B closed fracture subgroup had shorter time to PWB and FWB (p<0.001 and p = 0.017, respectively), ORIF-treated 43C closed fractures had shorter time to union (p = 0.005). Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (24%), superficial infection (21%). All occurred more frequently in FWF-treated patients. Most ORIF-treated subgroups in either open or closed pilon fractures showed better primary and secondary outcomes than FWF-treated subgroups, yet few were statistically significant. Overall, our use of a two-staged approach involving temporary external fixation, followed with ORIF or FWF achieved low complication rates and good functional recovery.

Background: Septic arthritis (SA) is a dangerous condition that requires emergency treatment. Managed by culture-specific antibiotics, irrigation, and debridement (I&D), some patients require repeat surgical treatment. The objectives were to determine the risk factors for SA and risk factors for repeat arthroscopic I&D in SA patients. We hypothesized that variables which directly or indirectly contributed to a larger infection burden would be associated with the development of SA and the need for repeat arthroscopic I&D. Methods: All patients ≥ 18 years old presenting to the emergency department, orthopaedic and rheumatology clinics at our major trauma centre between January 2018 and January 2020 with a hot, swollen joint were retrospectively evaluated. Patients with previous trauma and metalwork in the affected joint, periprosthetic joint infection, previous joint arthroplasty surgery, soft tissue infection, missing data, transferred to another centre, diagnosis not concerning the joint, and < 24-month follow-up were excluded. Two hundred eleven patients were included (SA: 28; pseudogout: 32; gout: 50; others: 101). Variables of interest in the 3-month period preceding the diagnosis of SA were compared between SA and non-SA patients using univariable analysis. A multivariable logistic regression model was formed using covariates with corresponding univariable tests of p < 0.200. Similar analyses were performed to compare SA patients with multiple washouts/procedures with those with one washout/procedure. Results: Multivariable analysis showed multiple risk factors for SA, namely rheumatoid arthritis (RA) (OR: 3.4; 95% CI: 1.2–10.0; p = 0.023); skin infection (OR: 3.3; 95% CI: 1.2–9.0; p = 0.017), liver disease (OR: 9.9; 95% CI: 2.2–43.9; p = 0.003), knee joint involvement (OR: 3.5; 95% CI: 1.3–9.4; p = 0.014), and use of immunosuppressive medication (OR: 3.5; 95% CI: 1.2–10.6; p = 0.027). Risk factors for multiple washouts included synovial WBC levels > 10.5 × 10⁹ cells/L (OR: 3.0; 95% CI: 2.3–38.8; p = 0.009) and RA (OR: 3.5; 95% CI: 1.9–66.3; p = 0.017). Conclusions: These findings suggest that prophylactic actions against septic arthritis should be targeted at patients with liver disease, RA, or skin infection. Repeat arthroscopic I&D of septic joints may be needed, especially in patients with synovial WBC levels > 10.5 × 10⁹ cells/L and RA. Key Points• The risk factors for septic arthritis determined in this study are rheumatoid arthritis, skin infection, liver disease, knee joint involvement, and immunosuppressant usage.• Some septic arthritis patients need multiple rounds of arthroscopic irrigation and debridement. The risk factors for this are a synovial WBC count > 10.5 × 10⁹ cells/L and rheumatoid arthritis.

Background: Charcot arthropathy is a progressive, non-infectious, destructive inflammatory process. Charcot arthropathy of the knee (CK) is rare and diagnosis is often delayed, resulting in detrimental outcomes. This scoping review aims to investigate the literature on CK, present the pathognomonic features of CK to aid early diagnosis, and suggest gaps in the literature for future research.Methods: A systematic search of PubMed, EMBASE, Web of Science for literature relevant to CK was performed. Primary studies such as case reports, case series, retrospective studies were included. Review articles and animal studies were excluded.Results: Of the 513 results, 58 were included in qualitative synthesis. Average time from symptom onset to CK diagnosis was 50.5 months. Eighteen and twenty-one studies included patients who had diabetes mellitus and syphilis, respectively. Twenty-one studies reported pain as a presenting complaint, but the degree of pain didn’t correspond with the level of destruction. Oedema and joint effusion were noticed in 34 studies. Twenty-nine studies reported lower limb hypoesthesia and 17 studies reported decreased tendon reflex. Twenty-eight studies reported initial conservative treatment, often in a knee brace with minimal weight bearing, 9 of which needed subsequent surgical management. Twelve studies utilised arthrodesis, with fracture at the intramedullary nail entry site being the most common complication. Twenty-four studies utilised TKA.Conclusion: The literature on CK remains sparse, with most publications being case reports. Given that CK dramatically reduces quality of life, increases morbidity of patients, there is need for more literature on evidence-based options for early diagnoses and management.