Living in biofilms is probably the most common condition for bacteria and fungi and biofilm-related infections account for the majority of bacterial infectious diseases worldwide.Among others biofilm-related infections, those associated with implanted biomaterials have an enormous and still largely underestimated impact in orthopaedics and trauma, cardio-surgery and several other surgical disciplines.Given the limited efficacy of existing antibiotics in the prevention and treatment of bacterial biofilms, new strategies are needed to protect implants and host tissues, overcoming the striking ability of the microorganisms to adhere on different surfaces and to immediately protect themselves by forming the biofilm matrix.Adhesion is a necessary first step in microbial colonization and pathogenesis and provides a potential target for new preventive and treatment approach.Among various polymers, tested as antibacterial coatings, hyaluronic acid and some of its composites do offer a well-established long-term safety profile and a proven ability to reduce bacterial adhesion and biofilm formation.Aim of the present review is to summarize the available evidence concerning the antiadhesion/antibiofilm activity of hyaluronic acid and some of its derivatives to reduce/prevent bacterial adhesion and biofilm formation in various experimental and clinical settings.

Implant-related infection is one of the leading reasons for failure in orthopaedics and trauma, and results in high social and economic costs. Various antibacterial coating technologies have proven to be safe and effective both in preclinical and clinical studies, with post-surgical implant-related infections reduced by 90% in some cases, depending on the type of coating and experimental setup used. Economic assessment may enable the cost-to-benefit profile of any given antibacterial coating to be defined, based on the expected infection rate with and without the coating, the cost of the infection management, and the cost of the coating. After reviewing the latest evidence on the available antibacterial coatings, we quantified the impact caused by delaying their large-scale application. Considering only joint arthroplasties, our calculations indicated that for an antibacterial coating, with a final user’s cost price of €600 and able to reduce post-surgical infection by 80%, each year of delay to its large-scale application would cause an estimated 35 200 new cases of post-surgical infection in Europe, equating to additional hospital costs of approximately €440 million per year. An adequate reimbursement policy for antibacterial coatings may benefit patients, healthcare systems, and related research, as could faster and more affordable regulatory pathways for the technologies still in the pipeline. This could significantly reduce the social and economic burden of implant-related infections in orthopaedics and trauma. Cite this article: C. L. Romanò, H. Tsuchiya, I. Morelli, A. G. Battaglia, L. Drago. Antibacterial coating of implants: are we missing something? Bone Joint Res 2019;8:199–206. DOI: 10.1302/2046-3758.85.BJR-2018-0316.

While implant-related infections continue to play a relevant role in failure of implantable biomaterials in orthopaedic and trauma there is a lack of standardised microbiological procedures to identify the pathogen(s). The microbiological diagnosis of implant-related infections is challenging due to the following factors: the presence of bacterial biofilm(s), often associated with slow-growing microorganisms, low bacterial loads, previous antibiotic treatments and, possible intra-operative contamination. Therefore, diagnosis requires a specific set of procedures. Based on the Guidelines of the Italian Association of the Clinical Microbiologists (AMCLI), the World Association against Infection in Orthopaedics and Trauma has drafted the present document. This document includes guidance on the basic principles for sampling and processing for implant-related infections based on the most relevant literature. These procedures outline the main microbiological approaches, including sampling and processing methodologies for diagnostic assessment and confirmation of implant-related infections. Biofilm dislodgement techniques, incubation time and the role of molecular approaches are addressed in specific sections. The aim of this paper is to ensure a standardised approach to the main microbiological methods for implant-related infections, as well as to promote multidisciplinary collaboration between clinicians and microbiologists.

Orthopedic injuries commonly affect children during earthquakes, but reports about them are rare. This setting may lead to different standards of care, but guidelines are still missing in this field. A systematic review was performed to: (1) assess type and body distribution of pediatric earthquake-related injuries, treatment performed, length of stay, and complications; and (2) identify starting points to define standards of care.PubMed database was researched for papers (1999-2014 period) in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. Inclusion criteria were: English, French, Spanish, or Italian language and data reported about orthopedic lesions in children (≤18 years old). Reviews, letters, commentaries, editorials, and single case reports were excluded. Two independent reviewers selected articles after abstract and full-text reading.Traumatic injuries caused child hospital admissions ranging from 46.9% to 100.0%; 16% to 53% suffered fractures. Lower limbs mostly were involved. Soft-tissue injuries affected 55% of patients. Debridement and external fixation (EF) were the most frequent surgical treatments. Amputation rates varied from 5% to 11%.This study revealed that field hospitals should be prepared to: (1) treat mainly lower extremities fractures in children; and (2) use especially EF techniques. The presence of orthopedic surgeons familiar with pediatric traumatology should be considered. Morelli I , Sabbadini MG , Bortolin M . Orthopedic injuries and their treatment in children during earthquakes: a systematic review. Prehosp Disaster Med. 2015;30(5):478–485.

Introduction: Earthquake-related trauma results in crush injuries and bony- and soft-tissue trauma. There are no systematic reviews analyzing the typical injury patterns and treatments in “Mega-Mass-Casualty” earthquakes. The characterization of an injury pattern specific to disaster type, be it natural or manmade, is imperative to build an effective disaster preparedness and response system.Methods: The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search strategy was developed to identify all publications relating to earthquakes and the orthopedic treatment in adult patients. The following databases were searched: PubMed (Medline; US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), Ovid (Ovid Technologies; New York, New York USA), Web of Science (Thomson Reuters; New York, New York USA), and The Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom).Results: The searches identified 4,704 articles: 4,445 after duplicates were removed. The papers were screened for title and abstract and 65 out of those were selected for full-text analysis. The quality of data does not permit a standard-of-care (SOC) to be defined. Scarcity and poor quality of the data collected also may suggest a low level of accountability of the activity of the international hospital teams. Qualitatively, it is possible to define that there are more open fractures during daytime hours than at night. Excluding data about open and closed fractures, for all types of injuries, the results underline that the higher the impact of the earthquake, as measured by Richter Magnitude Scale (RMS), the higher is the number of injuries.Discussion: Regarding orthopedic injuries during earthquakes, special attention must be paid to the management of the lower limbs most frequently injured. Spinal cord involvement following spine fractures is an important issue: this underlines how a neurosurgeon on a disaster team could be an important asset during the response. Conservative treatment for fractures, when possible, should be encouraged in a disaster setting. Regarding amputation, it is important to underline how the response and the quality of health care delivered is different from one team to another. This study shows how important it is to improve, and to require, the accountability of international disaster teams in terms of type and quality of health care delivered, and to standardize the data collection. Bortolin M , Morelli I , Voskanyan A , Joyce NR , Ciottone GR . Earthquake-related orthopedic injuries in adult population: a systematic review. Prehosp Disaster Med. 2017;32(2):201–208.