Outsourcing elective surgery has become increasingly commonplace to meet increasing demand from a growing & aging population. There is concern that outsourcing was influencing the nature of residual workload that was unsuitable for treatment elsewhere. This led to the impression that our unit is operating on more complex patients orthopaedic problems, ASA and Body Mass Index (BMI). By losing a disproportionate number of straightforward patients our department's outcomes, productivity and training opportunities could be adversely affected.

Retrospective analysis of prospectively collected data of primary hip / knee arthroplasties between July & December for 2014(pre-outsourcing), 2015 and 2016(post-outsourcing). ANOVA, Tukey Honest Significant Difference(HSD) and Pearson's correlation used.

Total of 726 primary arthroplasties were performed with an almost 50 % reduction post outsourcing. Post-outsourcing, BMI and ASA were significantly worse with a ANOVA of p=0.001 and HSD p=0.003. Length of stay increased from 5.4 days in 2014 to 6.2 days in 2015 ANOVA p< 0.001 but decreased in 2016. BMI significantly affected operating time (Pearson's r =0.12, p< 0.05) and anaesthetic time (Pearson's r =0.19, p< 0.05). ASA significantly affected length of hospital stay, p< 0.01 and operation time, p=0.007 but no effect on anaesthetic time.

In conclusion, we are operating on more complex patients due to current outsourcing setup. Implications for short-term were on anaesthetic and operation time, inpatient stay and training opportunity were affected, with possible long-term implications on individual surgeon and unit outcomes (complications, patient satisfaction).

Resuscitation decisions are part of routine practice and raise difficult, sensitive issues. We present experience of Do-Not-Attempt-Resuscitation (DNAR) decision-making in our unit.

Patients and staff (medical, nursing) completed a questionnaire to ascertain current practice, knowledge, and patient feeling regarding DNAR decisions.

Consultants and Registrars make DNAR decisions, junior-doctors and nurses feel they have insufficient knowledge. Senior-doctors were most familiar with BMA and Trust guidelines. The majority of all staff felt every patient should be asked. Consultants thought DNAR decision-making was least necessary.

Half of patients felt doctors had not explained the necessity of DNAR decisions and half felt conversations could have been handled better. Half said they had not been asked their opinion. Two-thirds would like more visual information.

UK-wide figures show 15% survival to discharge of in-hospital arrest; a-third of medical staff knew this. Registrars were most optimistic and consultants and ward doctors most pessimistic. All patients believed survival rate was 50%.

Important DNAR decisions are based on poor knowledge and communication. We developed an education programme for staff and information-video for patients and relatives to improve service. Video for DNAR discussions has not been previously used; it will provide a framework on which to approach this sensitive issue.

Despite the development of skeletal or mesenchymal stem cell (MSC) constructs aimed at creating viable cartilage and bone, few studies have examined the effects of cytokines present in rheumatoid arthritis (RA) and osteoarthritis (OA) synovial tissues, or inhibition of these, on such constructs. This work addresses these issues using both in vitro and in vivo approaches and examines potential ways of overcoming the effects of cytokines on the integrity of cartilage and bone constructs.

Synovial samples were obtained from RA or OA (n=10) patients undergoing elective hip or knee arthroplasty at Southampton General Hospital. Full ethical approval was obtained. Control bone marrow-derived stromal cells were obtained from patients undergoing emergency fractured neck of femur repair, cultured in basal, osteogenic (ascorbate and dexamethasone) and chondrogenic (transforming growth factor beta (TGFbeta3)) conditions. Differentiation towards bone and cartilage was assessed using alkaline phosphatase (ALP) staining, ALP and DNA biochemical assays and analysis of osteogenic/chondrogenic gene expression using real time polymerase chain reaction (rt-PCR). Exogenous interleukin-1 (IL-1) (10ng/mL), tumour necrosis factor alpha (TNFalpha) (10ng/mL) or interleukin-6 (IL-6) (100ng/mL) was added and effects on differentiation noted. RA and OA synovial samples were digested, cultured for 48 hours then centrifuged to produce supernatants. Cytokine profiles were determined using ELISA. These supernatants were then added to MSCs and their effects on differentiation assessed.

Mesenchymal cultures in osteogenic media with IL-1 showed an additive osteogenic effect on biochemical assays. TNF exerted a less marked and IL-6 no apparent effect on osteogenic differentiation. ALP expression by rt-PCR correlated with these findings. Addition of supernatants to mesenchymal cultures produced a marked osteogenic profile that was IL-1 and TNFalpha concentration dependent, correlating with lower supernatant dilutions on initial ELISA analysis.

Preliminary studies indicate that exogenous IL-1 and TNFalpha modulate the osteogenic phenotype in MSCs in vitro. OA and RA synovial supernatants affect skeletal cell differentiation. Variations in cytokine profiles between supernatants require analysis for potential confounders. A larger study is underway to investigate these effects, the effects of cytokines on skeletal cell differentiation on commercially available scaffolds both in vitro and in an in vivo murine model of bone formation.

Background

Unicameral bone cysts (UBCs) are difficult to treat and have a high recurrence rate. Their pathogenesis is unknown making targeted therapies difficult. Attributed causes include venous and interstitial fluid obstruction, oxygen free radicals, lysosomal enzymes, prostaglandins and genetic factors. Skeletal stem cells (SSCs) are osteoblast precursors critical to bone formation and cyst fluid may influence their growth, however the association between SSCs and cyst fluid has never been investigated.

Statement of Purpose

Our experience with Taylor Spatial Frame correction of complex foot deformities in children.

Persistent foot deformity in congenital talipes equinovarus is a challenge. Open surgery is associated with complications including difficulty in achieving acute corrections in stiff, scarred feet. Gradual correction using the Ilizarov circular frame has been described as an alternative and we present the experience using a computer assisted hexapod gradual frame correction with the Taylor Spatial Frame (TSF).

A retrospective audit of sequential patients treated by TSF was performed. Technique, outcome, complications and key learning points were recorded.

21 paediatric patients underwent 27 treatments with a Taylor Spatial frame for complex foot deformity correction. Average age 11 years with majority diagnosis of congenital talipes equinovarus. The deformities severity meant acute correction would result in either neurovascular or soft tissue compromise.

Plantigrade feet with good function was achieved in 22 feet. 3 feet were deemed as failures. 2 feet have residual deformity but acceptable function. According to Paley's classification, there were 4 complications, 7 obstacles and 35 difficulties (pin tract infection and pain management). Complications did contribute to poorer outcomes. The key learning points were: protection of the ankle joint and distal tibial physis; staged osteotomy reduces swelling and complication rates; and consideration of further procedures at frame removal is important. Finally a thorough preoperative counselling programme should be instituted and patients warned of the time commitment and high difficulty rates associated with treatment. Managing patient expectation with goals is as important as meticulous surgery.

Although complication rates were high, the majority of treatment goals were met, therefore the TSF is valid in the treatment of complex deformities in the foot. Most patients with severe deformity can achieve a plantigrade functional foot but residual stiffness and need for minor orthotics is almost universal.

The aim of this study was to investigate the risk factors, financial costs and outcomes associated with infection after hip fracture surgery.

Prospective hip fracture data from the University Hospital, Nottingham, was analysed, assessing patients with either deep or superficial wound infections admitted over a five year period.

3605 patients underwent hip fracture surgery. 2.3% of these patients developed a wound infection of which 1.2% were deep wound infections. 75% of infections were due to Staphylococcus aureus and 50% of all infections were caused by methicillin-resistant Staphylococcus aureus.

No statistically significant risk factors for the development of infection were identified in this study.

Length of stay, cost of treatment and pre-discharge mortality were all increased with deep infection. Deep wound infection increased the average length of stay from 28 days to 100 days. This quadrupled the ward costs. The mean overall hospital cost of treating a hip fracture complicated by deep wound infection was £34903 compared to £8979 fro those who did not develop infection. Pre-discharge mortality increased from 24.2% in the control group to 30% in the infected group (p<0.006).

MRSA significantly increased costs, LOS, and pre-discharge mortality compared with non-MRSA infection.

These results show the huge impact that infection after hip fracture surgery has both on mortality and hospital costs.

From 1998 to July 2003 admissions for elective arthroplasty surgery in Derriford Hospital were nursed alongside other orthopaedic and general medical patients. Since August 2003 a policy of pre-operative MRSA screening and a unit reserved exclusively for MRSA-free joint replacement patients have been used. No transfers from other wards were allowed. Patients positive on screening underwent eradication and were admitted to a different ward where they received teicoplanin on induction (in addition to standard policy cephradine). All post-operative wound infections following THR & TKR were monitored (NINSS surveillance system). Infections within 3 months were recorded. A control of non-screened hip hemi-arthroplasty patients was used to ensure a departmental wide reduction in MRSA was not occurring.

1.9% MRSA carriage rate was detected over the study. Before screening, 0.59% of 3386 cases were acutely infected with MRSA. After institution of screening and a dedicated MRSA free unit, 0.10% of 1034 were acutely infected. This was a 6-fold decrease (p<0.05). The infection noted was in a patient treated outside the ringfenced unit on High Dependency. In fact the infection rate on the ringfenced unit was zero. MRSA infection in the control was statistically unchanged during this period.

Introduction: The open treatment of hip impingement is now a well-recognised technique with numerous publications about pathogenesis and surgical technique. There are very few publications of very small series discussing surgical results.

We present the results of 148 hips at a mean follow-up of 20 months (range 4 – 55).

Methods: This is a two surgeon series of sequential patients including the early learning curve. Patients were treated for impingement through a Ganz trochanteric osteotomy and open surgical hip dislocation. Patient data, operative findings and methods, complication and clinical follow up were recorded as a prospective audit and include Oxford and McCarthy Non Arthritic Hip scores.

Results: The patient demographics are as follows:

141 patients, 148 hips.

We have had the following complications: 4 trochanteric non unions requiring revision fixation, 2 deep vein thrombosis, 2 haematomas, 1 superficial infection, no deep Infections.

Life table survival curve with revision to arthroplasty defined as failure.

Discussion: The early to midterm results of this innovative procedure are encouraging even when including the decision making and surgical technique learning curves. We will present the hip scores and discuss the failures in detail to warn others embarking on this surgery which cases are more likely to lead to unsatisfactory outcomes.

Prospective data on hip fracture from 3686 patients at a United Kingdom teaching hospital were analysed to investigate the risk factors, financial costs and outcomes associated with deep or superficial wound infections after hip fracture surgery.

In 1.2% (41) of patients a deep wound infection developed, and 1.1% (39) had a superficial wound infection. A total of 57 of 80 infections (71.3%) were due to Staphylococcus aureus and 39 (48.8%) were due to MRSA.

No statistically significant pre-operative risk factors were detected. Length of stay, cost of treatment and pre-discharge mortality all significantly increased with deep wound infection. The one-year mortality was 30%, and this increased to 50% in those who developed an infection (p < 0.001). A deep infection resulted in doubled operative costs, tripled investigation costs and quadrupled ward costs.

MRSA infection increased costs, length of stay, and pre-discharge mortality compared with non-MRSA infection.

Since Aug‘03 pre-operative MRSA screening & a ward reserved exclusively for MRSA free joint replacement patients has been used. All postoperative wound infections within 3 months following THR & TKR were monitored.

Before screening, 0.59% of 3386 were acutely infected with MRSA. After institution of study policy, 0.10% of 1034, were infected with MRSA.. This was a 6 fold decrease (p< 0.05). The rate of MRSA infection in a control of hemiarthroplasties was unchanged during this period.

A policy of MRSA screening & an MRSA free joint replacement ward reduces the incidence of acute MRSA infections.

Introduction and Aims: A phenotypic and proteomic approach has identified novel targets for the development of a DNA vaccine to prevent Staphylococcus aureus infection in orthopaedics.

Approximately 1% of joint replacement operations are complicated by infection. Thirty percent of these infections are due to S.aureus, which is often difficult to treat because of antibiotic resistance. As treatment of these infections is challenging, prevention with a vaccine is a very attractive option.

Method: To infect a joint replacement, bacteria must first adhere to its surface. This adherence is mediated by specific adhesion proteins; the expression of which is controlled by virulence regulator genes within the bacterial cell. A DNA vaccine is being developed which targets this regulatory apparatus, thus preventing bacterial adhesion, allowing the immune system to rapidly clear any potential S.aureus infection.

Results: Mutations of the agr,sar and sae virulence regulator genes have been made. Their properties have been explored using a flow cell system, which uses a scanning confocal laser microscope and image analysis software to accurately provide quantitative data in real-time of biofilm formation. We have shown that the sae mutant does not form biofilm in the same was as wild-type S.aureus. We have also shown that it does not adhere to steel as well as its wild-type counterpart.

Conclusion: For such a dramatic difference in biofilm forming properties to be evident, there must be a difference in the adhesion proteins produced by the wild-type and the mutant bacteria. Gel-electrophoresis has compared protein expression of sae mutant and wild-type bacteria and identified differences. Those proteins which are not expressed in the non-biofilm-forming mutant are sequenced and from the protein sequences, DNA sequences are identified that will form part of the candidate DNA vaccine.