Aim

This study aimed to identify risk factors for development of deep periprosthetic joint infection (PJI) in patients following surgical treatment of neck of femur fracture.

Aim

The incidence of fractured neck of femur (FNOF) is increasing yearly. Many of these patients undergo hip hemiarthroplasty. High dose dual-antibiotic cement (HDDAC) has been shown to reduce rates of deep surgical site infection (SSI) when compared to the current standard low dose single-antibiotic cement (LDSAC) in a quasi-randomised controlled trial. Some concerns exist regarding the use of HDDAC and the development of resistance. We reviewed cases of infection in LDSAC and HDDAC bone cement with regard to causative organism and resistance profile.

INTRODUCTION

Dislocation is a major complication post total hip replacement (THR) and a common cause for revision. Jameson et al (2012) studied 35,000 cemented Exeter (Stryker) THRs demonstrating the risk of revision was significantly influenced by the acetabular component design. This led 3 surgeons in a single hospital group to make a mass move from using the hooded Exeter Low Profile (LP) cup to the better performing Contemporary Flanged (CF) component. The purpose of this study was to show whether this change was associated with a fall in dislocation rates.

In June 2012 the Orthopaedic Speciality Advisory of the Joint Committee on Surgical Training defined ‘minimum indicative numbers’ that trainees would have to meet before completion of specialist training. It has been speculated that regions have varied in their ability to provide operative opportunities to their trainees. This study aims to test the hypothesis that there are regional differences in operative training experience. The eLogbook database was interrogated for cases over a 12 month period from 7 August 2013 to 5 August 2015. Within each region, the mean of the cases registered by orthopaedic trainees in each year of training during the study period was calculated and summed to give a representative surgical experience for the years ST3-8. First surgeon only cases were analysed for 11 index procedures in 30 T&O rotations. Considerable variation in training existed across rotations. In three index procedures, including DHS, no rotation achieved the minimum indicative number required. All rotations achieved the minimum indicative number of external fixator applications. This study proves the extent of the significant regional variation in surgical training in Trauma and Orthopaedics in the UK and raises concerns regarding the volume of operative training currently achieved.

Introduction:

Symptomatic treatment of ankle osteoarthritis (OA) with corticosteroid injections is well established. Hyaluronic acid is also reported as an effective symptomatic treatment for ankle OA but these two treatments have not been compared directly.

Pre-operative variables are increasingly being used to determine eligibility for total knee replacement (TKR). This study was undertaken to evaluate the relationships, interactions and predictive capacity of variables available pre- and post-operatively on patient satisfaction following TKR. Using nationally collected patient reported outcome measures and data from the National Joint Registry for England and Wales, we identified 22 798 patients who underwent TKR for osteoarthritis between August 2008 and September 2010. The ability of specific covariates to predict satisfaction was assessed using ordinal logistic regression and structural equational modelling. Only 4959 (22%) of 22 278 patients rated the results of their TKR as ‘excellent’, despite the majority (71%, n = 15 882) perceiving their knee symptoms to be much improved. The strongest predictors of satisfaction were post-operative variables. Satisfaction was significantly and positively related to the perception of symptom improvement (operative success) and the post-operative EuroQol-5D score. While also significant within the models pre-operative variables were less important and had a minimal influence upon post-operative satisfaction. The most robust predictions of satisfaction occurred only when both pre- and post-operative variables were considered together. These findings question the appropriateness of restricting access to care based on arbitrary pre-operative thresholds as these factors have little bearing on post-operative satisfaction.

Cite this article: Bone Joint J 2013;95-B:1359–65.

The cement used for hemiarthroplasties by the authors and many other surgeons in the UK is Palacos® (containing 0.5g Gentamicin). Similar cement, Copal® (containing 1g Gentamicin and 1g Clindamycin) has been used in revision arthroplasties. We aim to investigate the effect on SSI rates of doubling the gentamicin dose and adding a second antibiotic (clindamycin) to the bone cement in hip hemiarthroplasty.

We randomised 848 consecutive patients undergoing cemented hip hemiarthroplasty for fractured NOF into two groups: Group I, 464 patients, received standard cement (Palacos®) and Group II, 384 patients, received high dose, double antibiotic-impregnated cement (Copal®). We calculated the SSI rate for each group at 30 days post-surgery. The patients, reviewers and statistician were blinded as to treatment group.

The demographics and co-morbid conditions were statistically similar between the groups. The combined superficial and deep SSI rates were 5 % (20/394) and 1.7% (6/344) for groups I and II respectively (p=0.01). Group I had a deep infection rate 3.3 %(13/394) compared to 1.16% (4/344) in group II (p=0.082). Group I had a superficial infection rate 1.7 % (7/394) compared to 0.58% (2/344) in group II (p=0.1861). 33(4%) patients were lost to follow up, and 77 (9%) patients were deceased at the 30 day end point.

Using high dose double antibiotic-impregnated cement rather than standard low dose antibiotic-impregnated cement significantly reduced the SSI rate (1.7% vs 5%; p=0.01) after hip hemiarthroplasty for fractured neck of femur in this prospective randomised controlled trial.

Currently, the cement being used for hemiarthroplasties and total hip replacements by the authors and many other surgeons in the UK is Palacos® (containing 0.5g Gentamicin). Similar cement, Copal® (containing 1g Gentamicin and 1g Clindamycin) has been used in revision arthroplasties, and has shown to be better at inhibiting bacterial growth and biofilm formation. We aim to investigate the effect on SSI rates of doubling the gentamicin dose and adding a second antibiotic (clindamycin) to the bone cement in hip hemiarthroplasty.

We randomised 848 consecutive patients undergoing cemented hip hemiarthroplasty for fractured NOF at one NHS trust (two sites) into two groups: Group I, 464 patients, received standard cement (Palacos®) and Group II, 384 patients, received high dose, double antibiotic-impregnated cement (Copal®). We calculated the SSI rate for each group at 30 days post-surgery. The patients, reviewers and statistician were blinded as to treatment group.

The demographics and co-morbid conditions (known to increase risk of infection) were statistically similar between the groups. The combined superficial and deep SSI rates were 5 % (20/394) and 1.7% (6/344) for groups I and II respectively (p=0.01). Group I had a deep infection rate 3.3 %(13/394) compared to 1.16% (4/344) in group II (p=0.082). Group I had a superficial infection rate 1.7 % (7/394) compared to 0.58% (2/344) in group II (p=0.1861). 33(4%) patients were lost to follow up, and 77 (9%) patients were deceased at the 30 day end point. There was no statistical difference in the 30 day mortality, C. difficile infection, or the renal failure rates between the two groups.

Using high dose double antibiotic-impregnated cement rather than standard low dose antibiotic-impregnated cement significantly reduced the SSI rate (1.7% vs 5%; p=0.01) after hip hemiarthroplasty for fractured neck of femur in this prospective randomised controlled trial.

Procedure Based Assessments (PBAs) are one type of Workplace Based Assessment (WBA) introduced recently to orthopaedic training in the UK. They play an increasing role in the assessment of a trainee's surgical competence.

The study aims to determine the most valuable aspects of a PBA to a trainee, and the changes trainees suggest to improving the use of PBAs.

A link to an online questionnaire was sent by email via the eLogbook system to all orthopaedic trainees in the UK with a National Training Number (NTN). The free text responses were coded and categorised. Analysis of results was conducted using the online survey software and Microsoft Excel.

Of 668 responses, 616 met the inclusion criteria, making a response rate of 66% of all trainees with a NTN in the UK. There was a broad, representative spread of seniority and of geographical location. Trainees found the verbal feedback gained from their trainer to be most valuable (47%), followed by the assessment of competence (21%). Trainees identified the PBA form itself as the most important area for change (52.4%). This included increased numbers of PBAs (17.5%), more specific to the procedure (8.6%), more user friendly (15%), more levels of competence (4.5%) and a generic PBA (3.4%). Further suggestions included changing the role of PBAs, with 8.2% suggesting discontinuing their use entirely. Improving trainer investment in the use of PBA was also highlighted.

Trainees value PBAs to gain formal feedback more than their use as evidence of competence in a procedure. There are a number of changes suggested by trainees that could improve the use and effectiveness of PBAs, and we have incorporated these into recommendations made by the British Orthopaedic Trainees’ Association, which should inform the debate on the further development of this assessment tool, and on WBAs in general.

INTRODUCTION

Deep infection is a potentially catastrophic complication of joint replacement surgery. Early intervention in suspected prosthetic joint infection in the form of aggressive Debridement and targeted Antibiotics can lead to successful Implant Retention (DAIR). In our centre, we adopt an aggressive approach to suspected prosthetic joint infection, working in a multi-disciplinary team with microbiologists and an infection surveillance team to identify and treat suspected infected cases at the earliest opportunity.

Hemiarthroplasty and proximal femoral fixation are common procedures performed in trauma units, but there is very little information regarding post-operative pain experience. Pain control is a keystone in the successful management of hip fractures. A sound strategy of pain management is easier to implement in patients where pain levels can be predicted, allowing for an effective balanced analgesic regime.

Analysis was performed on patients presenting with a hip fracture in two hospitals. Patients with a diagnosis of dementia were excluded. Post-operative pain scores were taken from patient observation charts using a verbal analogue scale. Post-operative opiate consumption was calculated from inpatient drug charts.

357 patients were included, 205 patients underwent a cemented hemiarthroplasty (HG) and 152 had fixation with a dynamic hip screw (DG). No significant difference was found in the length of hospital stay. HG patients recorded a mean morphine requirement of 20.2mg compared with 40.3mg for the DG group. Although the early pain score difference was significant (p=0.009), after 4 days, the scores were equivalent. This may support the notion of non-surgical factors determining the total length of hospital stay.

The reason for the elevated pain scores and higher morphine requirement in the DHS group remains unclear. One theory is the fracture site still exists, and it is possible that pre-existing hip arthritis may continue to be symptomatic. It is important to recognise the difference in pain experienced between the groups and analgesia should be tailored towards the individual, allowing for improved peri-operative surgical care and patient experience.

Introduction

National Institute for Health and Clinical Excellence (NICE) guidelines recommend the use of total hip replacement (THR) for displaced intracapsular fractured neck of femur (NOF) in cognitively intact patients who were independently mobile prior to the injury. The National Joint Registry for England and Wales (NJR) has collected data on THRs performed since 2003. This retrospective cohort study explores risk factors independently associated with implant failure and perioperative mortality.

Background

Both surgeon and hospital volume influence patient outcomes following revision knee arthroplasty.

Introduction

Following in-depth analysis of the market leading brand combinations in which we identified implant influences on risk of revision, we compared revision in patients implanted with different categories of hip replacement in order to find implant with the lowest revision risk, once known flawed options were removed.

Introduction

Procedure Based Assessments (PBAs) were recently introduced for orthopaedic trainees and play an increasing role in assessment. The study aims to describe the attitudes of trainees to the educational benefit of PBAs and the factors which underlie these attitudes.

Purpose

To determine how patient characteristics; health status and pre-operative knee function effect patient reported satisfaction and operative success following total knee replacement (TKR). We hypothesised that a number of patient factors would influence the reported levels of symptomatic improvement (success) and satisfaction and that these two outcomes would represent different aspects of the patient's perception of outcome.

Since its introduction in 2007 the UKITE exam has been an annual event in the diary of Orthopaedic trainees. It aims to simulate the written FRCS (T&O) examination style and offers trainees practice, immediate feedback and an update of the progress they have made through their training. It also allows bench marking against their peers nationally. The editorial process has been overhauled to allow online editing of questions throughout the year, and this has streamlined the question selection process.

The fifth edition of UKITE was held in December 2011. 669 trainees and 35 non-trainees sat for the examination. Consistently over the five years of UKITE we have seen a similar distribution of results showing improving performance until the final year (64.5% for 2011) and a drop in the performance in the last year (56.6% for 2011). Overall 80% of the trainees felt the exam was fair and better than last year. 80% of the trainees who had sat FRCS (T&O) previously thought that the UKITE 2011 was similar in difficulty. 98% trainees want to sit it again and 95% thought there was educational value in sitting the exam. Over 93% were satisfied with central and local provisions made for the exam. Some examining centres in NHS hospitals faced server failure issues and provision was made to sit for their trainees to sit un-invigilated from home. The mean score for the invigilated examination (53.6%) was significantly (p< 0.001) lower than that of un-invigilated examination (63.6%).

UKITE continues to evolve and has become a regular feature in the post-graduate orthopaedic calendar. It is perceived as a useful way of revising and maintaining a core level of knowledge as part of the exam preparation.

Background

The most appropriate form of chemical thromboprophylaxis following knee replacement is a contentious issue. Most national guidelines recommend the use of low molecular weight Heparin (LMWH) whilst opposing the use of aspirin. We compared thromboembolic events, major haemorrhage and death after knee replacement in patients receiving either aspirin or LMWH.