Leonard Charles Marais

Background: Fracture-related infection (FRI) represents one of the most challenging complications in trauma care and disproportionately affects patients in low-resource settings, where diagnostic capacity, surgical infrastructure, and access to microbiology and reconstructive expertise are limited. Methods: An expert group was convened through the African Bone and Joint Infection Network (ABJIN) under the auspices of the European Bone and Joint Infection Society (EBJIS) and with support from the AO Alliance. Recommendations were developed through a three-step process: (1) a two-part survey assessing current practice and priority needs among clinicians from African countries, (2) an in-person multidisciplinary consensus meeting during the COSECSA Congress (Harare, 2024), and (3) an iterative collaborative review by a wider panel of clinicians from 14 countries. Results: The group produced context-adapted recommendations covering prevention, terminology, diagnosis, investigations, holistic patient optimization, antimicrobial therapy, local antibiotic delivery, and surgical management of FRI in low-resource settings. Key themes include the following: management of open fractures; diagnostic pathways prioritizing clinical criteria and intra-operative sampling; antimicrobial strategies reflecting local microbiology and drug availability; affordable local antibiotic carriers; and the importance of soft-tissue management, multidisciplinary collaboration, and centralization of complex cases. Barriers specific to low-resource settings – delayed presentation, restricted microbiology services, limited implant availability, and high burdens of comorbidities – were integrated into the recommendations. Conclusion: These consensus-based, context-specific recommendations provide practical guidance for FRI in low-resource settings. They aim to support clinicians in delivering safe, cost-effective care, accepting structural limitations while promoting standardization and audit. Further clinical research from low- and middle-income countries is needed to strengthen the evidence base and refine these recommendations.

Lifelong learning (LLL) is a core competency in medical education, reflecting the need for clinicians’ knowledge and skills to remain current. While

Chikungunya virus (CHIKV) is a mosquito borne alphavirus that causes chikungunya disease, which is characterized by debilitating arthritis. While the acute phase is marked by fever and joint pain, many patients develop chronic arthritis that persists for years. The pathogenesis of chikungunya arthritis (CA) is not fully understood, prompting us to perform an updated review of the literature to describe the mechanisms contributing to this condition. A comprehensive search was conducted on numerous electronic databases for all studies relating to pathogenesis of CA. The search strategy included the key word search “pathogenesis”, “chikungunya”, “arthritis”. Two reviewers independently determined eligibility, rated study quality, and extracted data. The methodology followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. The data from included articles were charted and a qualitative thematic analysis formulated. A total of 623 records were identified from the electronic database search. This was narrowed to 63 records which were eligible after excluding by title and then by Following the surveying of 58 available full texts, 35 articles were eligible for inclusion, from which data was extracted. Key mechanisms identified for chronic CA included host risk factors, viral component persistence in joints, a robust pro-inflammatory cytokine response, the resulting joint destruction from pannus formation and the activation of matrix metalloproteases (MMPs) and osteoclasts. This scoping review extrapolates factors that contribute to the pathogenesis for developing chronic CA. Namely host factors and the ability of CHIKV to establish persistence within synovial fibroblasts. The inflammatory mediators and signalling pathways triggered by the host fibroblast synoviocytes, the secretion of MMPs, and promoting of osteoclastogenesis, contribute to ongoing inflammatory immune response and joint destruction. Thus, this review synthesizes evidence for a multifactorial pathogenesis of chronic CA, paralleling mechanisms of rheumatoid arthritis and highlighting targets for potential therapeutic intervention.

Background: Lifelong learning (LLL) is a core competency in postgraduate medical education (PGME), yet little is known about how registrar programmes teach it. Although LLL is prominent in policy and discourse, knowledge of best-practice educational strategies during registrar training remains limited. Aim: This study aimed to map and synthesise the empirical research of strategies designed to foster LLL in registrar training. Setting: The study was carried out at postgraduate orthopaedic training institutions in South Africa. Method: A scoping review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses extension for scoping review (PRISMA-ScR) guidelines to identify educational strategies that promote LLL in PGME. Searches of MEDLINE, EMBASE, Web of Science, and the Cochrane Library were performed from database inception to November 2025 using medical subject headings (MeSH) terms including ‘lifelong learning’ and ‘registrar’, supplemented by reference screening. Bibliographic data were tabulated, and strategies synthesised into three overarching categories. Results: Of the 492 records screened, eight studies met the inclusion criteria. Strategies clustered into three groups: (1) goal-setting; (2) reflection, self-assessment, and feedback; and (3) evidence-based medicine (EBM) training. The vehicles for delivering these strategies included individualised learning plans, portfolios, goal-setting requirements, and EBM training courses. Conclusion: The review identified eight studies describing strategies to foster LLL in registrar training, concentrated in North America, and non-surgical disciplines. The paucity and heterogeneity of published evidence highlight the need for intentional incorporation and evaluation of the impact of LLL in postgraduate curricula across diverse contexts. Contribution: This review provides the first mapped synthesis of explicit LLL educational strategies in PGME, identifying gaps and informing future curriculum design.

Aims: Periprosthetic joint infections (PJIs) pose significant challenges to patients and healthcare systems worldwide. The aim of this study was to estimate the health-economic burden of reimbursement payment in Europe for PJIs following primary hip and knee arthroplasty.Methods: The calculation was based on health-economic modelling using data on primary hip and knee arthroplasties for the year 2019 from the Statistical Office of the European Union (Eurostat) and published infection rates to estimate the total number of hip and knee PJIs in 30 European countries. Revision procedures were stratified into: 1) debridement, antibiotics, and implant retention (DAIR); 2) one-stage exchange; and 3) two-stage revision procedures. The cases were then multiplied by the respective healthcare system reimbursement payments. Payment data were acquired from a survey of 13 countries (Austria, Croatia, France, Germany, Italy, Lithuania, Netherlands, Norway, Portugal, Slovenia, Switzerland, Turkey, and the UK) and extrapolated for the remaining countries.Results: In 2019, a total of 2,048,778 primary total joint replacements were performed (total hip arthroplasty (THA) = 1,147,316 and total knee arthroplasty (TKA) = 901,462), with an estimated 20,416 cases of PJIs (11,131 hip and 9,285 knee) in Europe. This results in an estimated total reimbursement burden of €346,262,026 for European healthcare systems. The breakdown for hip PJI reimbursement was €197,230,953 (€9,751,962 for DAIR procedures, €45,135,894 for one-stage revisions, and €142,343,097 for two-stage revisions). For knee PJIs, the analysis yielded a total reimbursement of €149,031,073 (€9,335,075 for DAIR procedures, €48,058,479 for one-stage revisions, and €91,637,518 for two-stage revisions).Conclusion: This is the first study to evaluate the health-economic burden of PJIs in Europe, revealing a substantial impact on healthcare systems with an estimated case load of 20,414 cases and overall reimbursement of €346,262,026 for primary THAs and TKAs performed in 2019.Cite this article: Bone Jt Open 2025;6(3):298–311.

Background: We determined the predictive gene expression profiles associated with chemo-response in conventional osteosarcomas (COS) within South Africa. Materials and methods: In 28 patients, we performed an RNA extraction, cDNA synthesis, and quantitative analysis using the RT-PCR 2^−∆∆CT method to determine the fold change in gene expression alongside GAPDH (housekeeping gene). Results: We observed a significant downregulation in the mRNA expression profiles of ABCB1-p-glycoprotein (p = 0.0007), ABCC3 (p = 0.002), ERCC1 (p = 0.007), p-53 (p = 0.007), and RFC1 (p = 0.003) in the COS patients compared to the healthy donors. Furthermore, ABCB1-p-glycoprotein (p = 0.008) and ABCC3 (p = 0.020) exhibited a significant downregulation in the COS tumour tissues when compared to the healthy donors. In our univariate logistic regression, the predictors of chemotherapeutic response comprised ERCC1 [restricted cubic spline (RCS) knot: OR −0.27; CI −0.504 to −0.032; p = 0.036]; osteoblastic subtype [OR −0.36; CI −0.652 to −0.092; p = 0.026); fibroblastic subtype [OR 0.91; CI 0.569 to 1.248; p < 0.001]; and mixed subtype [OR 0.53; CI 0.232 to 0.032; p = 0.032]. In our multivariable logistic regression, the significant predictors of chemotherapeutic response comprised age [RCS knot: OR −2.5; CI −3.616 to −1.378; p = 0.022]; ABCC3 [RCS knot: OR 0.67; CI 0.407 to 0.936, p = 0.016]; ERCC1 [RCS knot: OR 0.57; CI 0.235 to 0.901; p = 0.044]; RFC1 [RCS knot: OR −1.04; CI −1.592 to −0.487; p = 0.035]; chondroblastic subtype [OR −0.83; CI −1.106 to −0.520; p = 0.012]; and osteoblastic subtype [OR −1.28; CI −1.664 to −0.901; p = 0.007]. Conclusions: In this South African cohort, we observed the unique gene expression profiles of osteosarcoma tumourigenesis and chemotherapeutic responses. These may serve as prognostication and therapeutic targets. Larger-scale research is needed on the African continent.

Reconstruction of segmental bone defects with bone transport is a well-established treatment. Mechanical complications at the docking site after frame removal are common. These complications include malunion, non-union, axial deviation and refracture. A simple tool to assess the healing of the docking site is currently lacking. The aim of this study is to evaluate the use of the modified RUST (mRUST) score in the setting of bone transport and to identify factors associated with an increased risk of docking site complications. This retrospective study was conducted at a single tertiary centre in South Africa, included 24 patients with a tibial bone defect treated with bone transport and a circular frame between 2014 and 2023. Demographic data, clinical and bone transport characteristics were recorded. Mechanical complications, such as fracture, non-union, any angulation >5°, shortening >5 mm, or any other complication requiring reoperation, were recorded. The mRUST was adapted as a ratio for the purpose of this study to overcome the common occurrence of cortices being obscured by the frame. The mRUST ratio was applied before and after frame removal for each patient by three appraisers. Comparison between the groups with and without complications was performed regarding bone transport characteristics, docking site configuration and mRUST ratio. The correlation of the score between radiographs before and after frame removal was assessed. The inter-rater reliability of the mRUST was analysed using Fleiss Kappa statistics for each cortex individually and the intraclass correlation coefficient (ICC) for the mRUST ratio. In this study, 20 men and 4 women with a median age of 26 years were included. The overall rate of mechanical complications after frame removal was 21.7%. Complications were all related to the docking site, with two angulations, two fractures and one non-union. Demographics, bone transport characteristics and mRUST ratio before and after frame removal were similar between the two groups. Regarding the configuration of the docking site, an angle of 45° or more between the bone surfaces was associated with the occurrence of mechanical complications (p < 0.001). The correlation of the mean mRUST ratio before and after frame removal showed a moderate relationship, with a Spearman correlation coefficient of 0.50 (p-value 0.13). The inter-rater reliability of the mRUST was “fair” (kappa 0.21–0.40) for the scoring of individual cortices, except for one score which was “slight” (kappa 0.00–0.20). The ICC of the mRUST ratio was 0.662 on radiographs with the frame, and 0.759 after frame removal. This study did not find the mRUST or mRUST ratio useful in assessing the healing of the docking site to decide on the best time to remove the frame. However, a notable finding was that the shape and orientation of the bone ends meeting at the docking site might well be relevant to decrease complication rates. If the angle between the bony surfaces is 45° or more, it may be associated with an increased risk of complications. It may be worthwhile considering reshaping these bone ends at the time of debridement or formal docking procedure to be more collinear, in order to reduce the potential for mechanical complications such as non-union, axial deviation or refracture at the docking site. Kummer A, Nieuwoudt L, Marais LC. Application of the Modified RUST Score in Tibial Bone Transport and Factors Associated with Docking Site Complications. Strategies Trauma Limb Reconstr 2024;19(2):73–81.