Background and purpose: Patients with external fixators are at risk of pin-site infection. A tool for objective monitoring of pin sites for evolving signs of infection is warranted. We aimed to investigate the temperature (MaxTp) difference between clean and visually inflamed pin sites using thermography and to establish the optimal cut-off value of MaxTp using thermography as a screening tool for inflammation detection.Methods: This was a cross-sectional study performed in the USA and Denmark of patients with circular external fixators. Pin sites were visually judged by a surgeon or a nurse as clean or as showing signs of inflammation. The MaxTp was obtained at the pin site by thermographic imaging using an infrared camera (FLIR T540).Results: We included 1,970 pin sites from 83 patients. The mean MaxTp for clean pin sites (n = 1,739) was 33.1°C (95% confidence interval [CI] 32.8–33.4) and the mean MaxTp for visual inflamed pin sites (n = 231) was 34.0°C (CI 33.6–34.3). The mean difference, when adjusted for repeated observations of patients and pin sites, was statistically significant with a difference of 0.9°C (CI 0.7–1.1) (P < 0.001). The area under the receiver operating characteristic curve for MaxTp as a screening tool to detect visual signs of inflammation was 0.71 (CI 0.65–0.76). The empirically optimal cut-off value was 34.1°C with a sensitivity of 65%, a specificity of 72%, a positive predictive value of 23%, and a negative predictive value of 94%.Conclusion: We found a statistically significant difference in mean temperature between pin sites with and without visual signs of inflammation. Thermography could be a promising tool for future point of care technology for monitoring inflammation around pin sites.

Objectives A grading system deployed for continuous at-home monitoring of pin sites would potentially increase the chances of early detection of pin-site infections and the commencement of early treatment. The first five grades of the Modified Gordon Pin Site Classification Scheme (MGS) meet the criteria for a visual-only, digital assessment-based grading system. The aim of this study was to assess the inter- and intra-rater reliability of the first five grades of the MGS from digital images.Methods We graded 1082 pin sites from 572 digital photographs of patients who underwent external fixator treatment for various conditions using the first five grades of the MGS classification scheme. Percent agreement and kappa values were calculated to determine the inter- and intra-rater agreement. Results were also grouped into two categories: "good" consisting of MGS grades 0-2 and "bad" made up of grades 3 and 4 for sensitivity analysis. We also analyzed reliability based on color only using MGS grades 0 and 2.Results A total of 843 of the 1082 pin sites were scored by all raters. There was moderate reliability between raters with a Fleiss kappa value of 0.48 [CI 0.45, 0.51]. The reliability remained moderate based on grouping into "good' versus "bad" and based on color with Fleiss kappa values of 0.48 [CI 0.45, 0.52] and 0.45 [CI 0.42, 0.49], respectively. Intra-rater reliability demonstrated substantial agreement with kappa values of 0.63.Conclusion Scoring pin sites from digital images with the MGS demonstrated only moderate inter-rater reliability. Modifying the use of digital photos is needed for at-home monitoring of pin sites.

Assessment of wounds based on visual appearance has poor inter- and intra-rater reliability and it is difficult to differentiate between inflammation and infection. Thermography is a user-friendly quantitative image technique that collects the skin surface temperature pattern of the wound area and immediately visualizes the temperatures as a rainbow coloured diagram. The aim of this scoping review is to map and summarize the existing evidence on how thermography has been used to assess signs of inflammation in humans and animals with surgical or traumatic wounds. The method follows the Joanna Briggs Institute methodology. The databases searched were PubMed, Embase, CINAHL and Cochrane Library. 3798 sources were identified, 2666 were screened on title and abstract, 99 on full text and 19 studies were included for review. We found that the literature is diverse and originates from a variety of scientific fields. Thermography has been used to detect and predict inflammation and infection in surgical wounds. Grading systems based on the visual appearance correlate to temperature patterns detected with thermography. The general tendency is that thermography detects the temperature in a wound with inflammation to be warmer than a reference area or the same skin area before surgery. In a surgical wound the temperature is elevated 1-2 weeks after surgery due to natural physiological inflammation that induces healing, after 2 weeks the temperature of the wound area slowly and steady decreases to baseline over 1-3 months. If a secondary temperature peak happens during the healing phase of a surgical wound, it is likely that infection has occurred. Modern handheld thermographic cameras might be a promising tool for the clinician to quickly quantify the temperature pattern of surgical wounds to distinguish between inflammation and infection. However, firm evidence supporting infection thermography surveillance of surgical wounds as a technique is missing.

There is no consensus on how to evaluate and grade pin site infection. A precise, objective and reliable pin site infectious score is warranted. The literature was reviewed for pin site infection classification systems, The Modified Gordon Score (MGS) grade 0-6 was used. The aim was to test the reliability of The Modified Gordon Infection Score. The observed agreement and inter-rater reliability were investigated between nurse and doctors. MGS was performed in the outpatient clinic at Aalborg University Hospital, Denmark on 1472 pin sites in 119 patients by one nurse and one of three orthopaedic surgeons blinded to each other's judgement. The data was stored in a Red Cap Database for further statistical analysis. The observed agreement between the nurse and the 3 orthopaedic surgeons was evaluated with a one-way random-effect model with interclass correlation with absolute agreement. Furthermore the observed agreement for each of the 3 surgeons with the nurse was calculated. The distribution of MGS infection grade in the 1472 pin sites was: Grade 0; n=1372, Grade 1; n=32, Grade 2; n=39, Grade 3; n=24, Grade 4; n=5, Grade 5; n=0, Grade 6; n=0. The observed agreement between the nurse and the surgeons was calculated as 98%. The ICC estimated between nurse and the surgeons was 0,8943 (ICC >0,85 = reliable). The grading was done by three different doctors with an agreement with the nurse as follows. Rater1 (n=416) =99,5 %, Rater2 (n=1440) =97,4%, Rater3 (n=1440) =96,6%. A limitation to this study is that the dataset represents mostly clean pin sites with MGS 0. Only 100 pin sites had signs of superficial infection MGS 1-4 none above 4. We found that the MGS infection score is highly reliable for low grade infections but we cannot conclude on reliability in severe infections.

To detect early signs of infection infrared thermography has been suggested to provide quantitative information. Our vision is to invent a pin site infection thermographic surveillance tool for patients at home. A preliminary step to this goal is the aim of this study, to automate the process of locating the pin and detecting the pin sites in thermal images efficiently, exactly, and reliably for extracting pin site temperatures. A total of 1708 pin sites was investigated with Thermography and augmented by 9 different methods in to totally 10.409 images. The dataset was divided into a training set (n=8325), a validation set (n=1040), and a test set (n=1044) of images. The Pin Detection Model (PDM) was developed as follows: A You Only Look Once (YOLOv5) based object detection model with a Complete Detection Intersection over Union (CDIoU), it was pre-trained and finetuned by the through transfer learning. The basic performance of the YOLOv5 with CDIoU model was compared with other conventional models (FCOS and YOLOv4) for deep and transition learning to improve performance and precision. Maximum Temperature Extraction (MTE) Based on Region of Interest (ROI) for all pin sites was generated by the model. Inference of MTE using PDM with infected and un-infected datasets was investigated. An automatic tool that can identify and annotate pin sites on conventional images using bounding boxes was established. The bounding box was transferred to the infrared image. The PMD algorithm was built on YOLOv5 with CDIoU and has a precision of 0.976. The model offers the pin site detection in 1.8 milliseconds. The thermal data from ROI at the pin site was automatically extracted. These results enable automatic pin site annotation on thermography. The model tracks the correlation between temperature and infection from the detected pin sites and demonstrates it is a promising tool for automatic pin site detection and maximum temperature extraction for further infection studies. Our work for automatic pin site annotation on thermography paves the way for future research on infection assessment using thermography.

Introduction: Host factors affecting pin site infections were selected by The Pin site Consensus Group, using a modified Delphi approach, to be one of the top 10 priorities to investigate how to reduce rates of pin site infections, improve clinical management, and inform research. The aim of this study was to perform a systematic literature review of the association between host factors and pin site infection, focused on age, smoking, body mass index, and comorbidities, in particular diabetes. Materials and Methods: The literature search strategy was developed as advised in the Cochrane Handbook for Systematic Reviews of Interventions following the PRISMA guidelines with the help from a scientific librarian. The protocol was registered in the International Register of Systematic Reviews, PROSPERO (ID: CRD42021273305). The literature search was executed in three electronic bibliographic databases, including Embase MEDLINE (1111 hits) and CINAHL (2066 hits) through Ovid and Cochrane Library CENTRAL (387 hits). Results: A total of 3564 titles were found. 3162 records were excluded by title and abstract screening. 140 studies were assessed for full-text eligibility. All excluded studies were not reporting specific numbers of patients with pin site infection and the associations of interest. 11 studies were included for data extraction. The included studies were all designed retrospective, and the risk of bias assessment was done using Joanna Briggs Institute risk appraisal tool. The extracted data are presented as results in tabular summaries. This review reveals an increased risk of pin site infection associated with increased HbA1C level in diabetic patients and congestive heart failure in diabetic patients. An increased risk of pin site infection was associated with a lower ASA score. None of the included studies found any association between pin site infection and smoking, age, or body mass index. Conclusion: This systematic literature search identified a surprisingly low number of studies examining the association between pin site infection and the specific host factors. Thus, this review most of all serves to demonstrate a gap of evidence about the correlation between host factors and risk of pin site infection, and further studies are warranted.

Background:Patients with severe bone fractures and complex bone deformities are treated by orthopedic surgeons with external fixation for several months. During this long treatment period, there is a high risk of inflammation and infection at the superficial skin area (pin site). This can develop into a devastating, sometimes fatal, and always costly condition of deep bone infection.Objective:For pin site infection surveillance, thermography technology could be the solution to build an objective and continuous home-based remote monitoring tool to avoid frequent nursing care and hospital visits. However, future studies of infection monitoring require a preliminary step to automate the process of locating and detecting the pin sites in thermal images reliably for temperature measurement, and this step is the aim of this study.Methods:This study presents an automatic approach for identifying and annotating pin sites on visible images using bounding boxes and transferring them to the corresponding thermal images for temperature measurement. The pin site is detected by applying deep learning-based object detection architecture YOLOv5 with a novel loss evaluation and regression method, control distance intersection over union. Furthermore, we address detecting pin sites in a practical environment (home setting) accurately through transfer learning.Results and conclusion:The proposed model offers the pin site detection in 1.8 ms with a high precision of 0.98 and enables temperature information extraction. Our work for automatic pin site annotation on thermography paves the way for future research on infection assessment on thermography.

Background: Bone-lengthening nails result in various complications with different severity and origin. However, no universal reporting system for complications has been agreed upon, making it difficult to compare different nail designs and patient populations. This study aimed to assess the inter-and intra-rater agreement of a classification system of complications according to severity and origin. Materials and methods: Four orthopaedic surgeons assessed 48 complications retrieved from patient charts in a single-centre cohort and 49 literature complications cases. Complications were classified according to severity grading (I, II, IIIA and IIIB) from Black et al. and origin with eight main types and 33 subtypes. A blinded independent assessment was performed twice at least six weeks apart. Cohen/Congers kappa estimated for the inter-and intra-rater agreement was interpreted after Svanholm et al. Results: The surgeons had a good inter-rater agreement for complication severity with a kappa value of 0.68 [95% confidence interval (CI): 0.56-0.79] and complication origin with a kappa value of 0.63 (CI: 0.53-0.73), respectively, on the cohort cases. In literature cases, a good agreement on complication severity and origin grading was shown by kappa values of 0.64 (CI: 0.53-0.75) and 0.74 (CI: 0.65-0.83). The intra-rater assessment of complication severity and origin grading had good to excellent agreement with kappa values ranging from 0.51 to 0.97. Conclusion and clinical significance:The study presents the first structured complication classification on severity and origin in intramedullary bone-lengthening nails. A good reproducibility agreement in both severity and origin was found between four orthopaedic surgeons for both cohort and literature complication cases. For clinical and research purposes, a shared language for communicating complications is essential. We encourage future studies to use a structured and validated complication classification.

Existing annotation tools are mainly designed for visible images to support supervised learning problems for machine learning. A few tools exist for extracting temperature information from thermal images. However, they are time and manpower consuming, require different stages of data management, and are not automated. This paper focuses on addressing the limitation of existing tools in handling big thermal datasets for annotation, temperature distribution extraction in the Region of Interest (ROI) of Orthopedic surgical wounds and provides flexibility for a researcher to integrate thermal image analysis into wound care machine learning models. We present an easy to use research tool for one click annotation of Orthopedic pin sites for extraction of thermal information, which is a preliminary step of research to estimate the reliability of thermography for home based surveillance of post-operative infection. The proposed tool maps annotations from visible registered image onto thermal and radiometric images. Mapping these annotations from visible registered images avoids manual bias in annotating thermal images. Integrating the functionality of an annotation tool by processing thermal images to acquire single-click manual annotations and extracting temperature distributions in the ROI with those acquired annotations is the novelty of the proposed work and is also crucial for research on deep learning-based investigation on surgical wound infections.

Aim and objective: The purpose of this study was to explore the capability and Intrarater reliability of thermography in detecting pin site infection. Materials and methods: This is an explorative proof of concept study. Clinical assessment of pin sites was performed by one examiner with the Modified Gordon Pin Infection Classification from grade 0 to 6. Thermography of the pin sites was performed with a FLIR C3 camera. The analysis of the thermographic images was done in the software FLIR Tools. The maximum skin temperature around the pin site and the maximum temperature for the whole thermographic picture were measured. An Intrarater agreement was established and test-retests were performed with different camera angles. Results: Thirteen (four females, nine males) patients (age 9-72 years) were included. Indications for frames: Fracture (n=4), two deformity correction, one lengthening and six bone transport. Days from surgery to thermography ranged from 27 to 385 days. Overall, 231 pin sites were included. Eleven pin sites were diagnosed with early signs of infection: five grade 1, five grade 2 and one grade 3. Mean pin site temperature for each patient was calculated, varied between patients from 29.0 degrees C to 35.4 degrees C (mean 33.9 degrees C). With 34 degrees C as cut-off value for infection, sensitivity was 73%; specificity, 67%; positive predictive value, 10%; and negative predictive value, 98%. Intrarater agreement for thermography was ICC 0.85 (0.77-0.92). The temperature measured was influenced by the camera positioning in relation to the pin site with a variance of 0.2. Conclusions: Measurements of pin site temperature using the hand-held FLIR C3 infrared camera was a reliable method and the temperature was related to infection grading. Clinical significance: This study demonstrated that digital thermography with a hand-held camera might be used for monitoring the pin sites after operations to detect early infection.

OBJECTIVE: The objective of the study was to examine the educational exposure during residency in Danish orthopedic departments.DESIGN: Questionnaire-based, cross-sectional study.SETTING: Data were gathered from January 1, 2014 to April 30, 2014 through a nationwide web-based questionnaire containing 15 questions within the areas of workload, surgical procedures, outpatient clinic, and research activities. The residents targeted worked at small-to-large hospitals and in tertiary care centers.PARTICIPANTS: Every resident in Denmark (n = 163) with at least 3 active months at a department was included. Questionnaires with less than 80% completion were excluded. In total, 152 entries were registered. Among those, 27 did not meet the inclusion criteria and 29 were excluded, leaving 96 participants, representing 22 of 26 departments, for further analysis.RESULTS: The average number of operative procedures as primary surgeon was 16 (range: 8-35) per month. In all, 18 of 22 (81%) departments offered the possibility to participate in research facilitated by the department and 38 of 96 (40%) worked for free (an average of 10 h a month [range: 3-60]) to increase the amount of surgical procedures.CONCLUSIONS: A large variation in the educational exposure was found among the Danish orthopedic departments. Numbers indicate that Danish residents, compared with their US counterparts, operate considerably less during residency. Most residents work overtime and many of them work for free to participate in more surgical procedures. ((C) 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Locking plate osteosynthesis has become the preferred method for operative treatment of clavicle fractures. The method offers stable fixation, and would theoretically be associated with a low rate of fracture-related complications and reoperations. However, this remains to be explored in a large cohort, and our purpose was to assess the overall rates of complications and reoperations following locking plate osteosynthesis of mid-shaft clavicle fractures.We identified all locking plate osteosynthesis of mid-shaft clavicle fractures operated upon in our department from January 2008 to November 2010 (n = 114). Nine patients did not attend the follow-up at our institution. The study group of 105 fractures (104 patients, 86 males) had a median age of 36 years (14-75 years). Follow-up ranged from 0.5 to 3.5 years. No patients were allowed to load the upper extremity for six weeks. By studying patient files and radiographic material, we assessed complications and reoperations.Overall, there were 31 cases (30 %) of plate removals for discomfort. There were five cases (5 %) of failure of osteosynthesis: two occurred early after approximately six weeks and three late after ten to 13 months postoperatively.The overall rate of failure of osteosynthesis is low (5 %). The burden of plate removals in approximately one third of patients should be included in the preoperative information.

Around 2000 persons are diagnosed with lymphoma in Sweden each year. There are many subgroups described for this form of cancer and the great majority is derived from B-cells. The most common subgroup is Diffuse large B-cell lymphoma (DLBCL), a highly aggressive disease where only half of the patients are cured. The lymphoma types seen in adults and children vary and the dominant form in children is the B-cell derived Burkitt lymphoma (BL). In contrast to DLBCL, high survival rates in BL are obtained but more research on normal- and tumor B-cells is needed for a better understanding of the cellular mechanisms underlying lymphoma pathogenesis. Phosphorylation and dephosphorylation of enzymes are key events in signal transduction in cells. Protein kinases phosphorylate enzymes while protein phosphatases dephosphorylate them, and these opposite actions must be carefully balanced for normal cell division to occur. The aim of this study was to characterize B-cell lymphomas with emphasis on a panel of kinases and phosphatases previously described as oncogenes (kinases) and tumorsuppressors (phosphatases) in human cancers. We analyzed DLBCL tissue and found the kinases PKC-β II and ZAP70 to be stronger expressed at protein level in a subgroup of the disease associated with poor survival. We further report enhanced activation of DLBCL cells through the B-cell receptor when ZAP70 is introduced. Also, the protein expression of the phosphatases HePTP and PTEN are weaker in BL tissue from children compared to in non-malignant pediatric controls. Our results indicate important roles for the described kinases and phosphatases in B-cell lymphomas.

Background Today, breast reconstruction with autologous tissue is most commonly done either as a free muscle sparring TRAM flap or as a DIEP flap. Studies of donor site morbidity have shown an advantage in using the DIEP flap. However, this procedure might also be associated with an increased risk of flow related complications and it is also thought to be more demanding and time consuming. A few studies have evaluated the abdominal wall strength after dissection of a TRAM flap or a DIEP flap. However, these studies do not distinguish between the various types of free TRAM flaps and they also compare TRAM procedures preformed in an early period to DIEP procedures done in a later period. Methods We used an isokinetic dynamometer to measure concentric, eccentric and isometric abdominal muscle strength in 32 patients who had had a unilateral breast reconstruction with a free MS-2 (15) or a DIEP (17) flap in the year 2003. Results No significant reduction in muscle strength was observed for concentric or isometric muscle strength. However, significant lower eccentric muscle strength was found in the TRAM compared to the DIEP group (p=0.05). There was no significant difference in abdominal strength between the two flap groups at low to moderate work intensity (isometric/concentric). At the greatest work intensity (eccentric muscle strength) the patients reconstructed with a DIEP flap had a clinical small, but significant advantage over the patients reconstructed with a MS-2 TRAM flap.