The purpose of the study was to retrospectively assess the patients treated to date with the vac ulta system using a technique of antibiotic instillation.

The vac ulta system is licensed for use with anti-septic instillation fluid but we have now treated a number of patients with antibiotic instillation under the guidance of the microbiology department. All patients being treated with the vac ulta system were included in the study. There were no exclusions. Pathology treated, infecting organism, antibiotic used and length of treatment were all recorded. Any antibiotic related complications were noted. Treatment was judged successful with resolution of presenting symptoms, normalization of inflammatory markers and three negative foam cultures.

There were 21 patients included in the study. There were 13 male and 8 female patients. Length of treatment ranged from 1 week to 10 weeks with a mean of 4.2 weeks. Follow up ranged from 1 month to 42 months with a mean follow up of 17.9 months

The most common pathogen was Staph. Aureus(11 cases). Enterobacter, ESBL, Strep. Milleri, MRSA and Citrobacter were also treated. Antibiotics instilled included flucloxacillin, meropenem, gentamicin, vancomycin, meropenem and teicoplanin. There were no antibiotic reactions/allergies. Pathologies treated included osteomyelitis, two stage amputations for infection, infected non-union and infected metalwork. Infection recurred in 2 of 21 patients (10%), with one recurring at 18 months and one at 2 years.

The 90% treatment success rate is highly encouraging in this notoriously difficult group of patients to treat. In this series vac instill was an effective treatment of infection and allows antibiotic treatment to be targeted to the infected tissues. There were no adverse reactions seen.

Larger series with longer follow up are no needed but we believe this technique is safe, successful and easily administered can be cautiously adopted on a wider basis.

With the recent reductions in junior doctor hours levels of staffing have become ever more critical as clinical duties are covered with fewer junior doctors available on a daily basis. Trainees also have to meet specific requirements of the curriculum and thus need to be allocated to posts with suitable opportunities. There is little evidence available to account for the allocation of posts to individual trusts and departments with training post numbers seem driven by historical allocation, rather than based on trainee and local population needs.

‘SHO’ tier numbers were obtained for each orthopaedic department within the Yorkshire deanery through direct contact with the departments. Data was also obtained to establish the workload of these departments. Information was gathered from the national neck of femur database, hospital episode statistics, the national joint registry, the trauma audit and research network (TARN) and finally Dr Foster and the national census. The workload data was then analysed and compared to the staffing levels in each department.

Data was obtained for fourteen trusts across the Yorkshire Deanery. The percentage of SHO tier doctors in training posts ranged from 0 to 78% (mean 37%) across the trusts surveyed, with wide variation in make up of the SHO tier in each department.

Workload was standardised using the unit of cases/SHO/annum. The workload for neck of femur fractures ranged from 8 to 52 cases/SHO/annum (mean 36). General trauma admissions ranged from 199 to 383 cases/SHO/annum (mean 288). Elective arthroplasty admissions ranged from 11 to 174 (mean 70). Pearson correlation coefficients were 0.5 for elective arthroplasty and neck of femur admissions and 0.8 for trauma admissions.

There is wide variation in workload between trusts when standardised for the number of SHO's with weak to moderate correlations between the number of juniors and workload in each department. This wide variation will impact on patient care, but also the training opportunities available in different posts – where workload is higher it is likely there will be an increased need for ward based work away from clinics and theatre lists.

The introduction of the foundation programme and MMC has changed the structure of the SHO grade at a time when the EWTD introduction has also had a profound impact on working patterns and hours. At this time we believe there is a need for a review of trainee allocations nationally with comparison to workload in each trust, trainee logbook data and data on curriculum competencies met. With the proposed reductions in trainee numbers now is the time for a centrally led review of these posts via the Royal College, BOA and BOTA to ensure high quality training, maintain high standards of patient care and secure the future of the orthopaedic profession.