Introduction

Non-union is an unfortunate outcome of the fracture healing process for some patients; with an estimated annual incidence of 17.4- 18.9 per 100,00. The management of these patients depicts a significant clinical challenge for surgeons and financial burden to health services. External ultrasound stimulation devices (Exogen^TM) have been highlighted as a novel non invasive therapy to achieve union in cases of delayed and non-union. The aim of the current study was to assess the rate of union in patients using Exogen^TM therapy for delayed fracture union in a district general hospital.

Local antimicrobial therapy is an integral aspect of treating orthopaedic device related infection (ODRI), which is conventionally administered via polymethylmethacrylate (PMMA) bone cement. PMMA, however, is limited by a suboptimal antibiotic release profile and a lack of biodegradability.

In this study, we compare the efficacy of PMMA versus an antibioticloaded hydrogel in a single- stage revision for chronic methicillin-resistant Staphylococcus aureus (MRSA) ODRI in

sheep. Antibiofilm activity of the antibiotic combination (gentamicin and vancomycin) was determined in vitro. Swiss alpine sheep underwent a single-stage revision of a tibial intramedullary nail with MRSA infection. Local gentamicin and vancomycin therapy was delivered via hydrogel or PMMA (n = 5 per group), in conjunction with systemic antibiotic therapy. In vivo observations included: local antibiotic tissue concentration, renal and liver function tests, and quantitative microbiology on tissues and hardware post-mortem.

There was a nonsignificant reduction in biofilm with an increasing antibiotic concentration in vitro (p = 0.12), confirming the antibiotic tolerance of the MRSA biofilm. In the in vivo study, four out of five sheep from each treatment group were culture negative. Antibiotic delivery via hydrogel resulted in 10–100 times greater local concentrations for the first 2–3 days compared with PMMA and were comparable thereafter. Systemic concentrations of gentamicin were minimal or undetectable in both groups, while renal and liver function tests were within normal limits.

This study shows that a single-stage revision with hydrogel or PMMA is equally effective, although the hydrogel offers certain practical benefits over PMMA, which make it an attractive proposition for clinical use.

The decision to undertake total hip replacement (THA) in a child is complex and daunting. This is augmented by the paucity of data on potential quality of life (QoL) improvement and functional outcomes. Therefore, the aim of this study was to ascertain whether outcomes after surgery are influenced by the nature of the primary diagnosis.

This was a prospective, consecutive cohort study of patients under the age of 18 years undergoing THA by a single arthroplasty surgeon in collaboration with colleagues at a regional paediatric hospital. Patient electronic notes, radiographs and PROMS (EQ5D-Y, Oxford Hip Score (OHS) and modified Harris Hip Score(mHHS)) were reviewed.

Twenty-two THAs were performed in patients less than 18 years (median 15 (range 10.7–17.9), with 7 patients undergoing bilateral surgery. Mean follow-up was 2 years. Thirteen of the THAs were undertaken for systemic conditions effecting multiple joints (Mucopolysaccharidoses, Mucolipidosis and Scwachman-Diamond syndrome) with the hip the worst affected joint and 9 for single joint disease (AVN, Perthes, dysplasia and idiopathic chondrolysis). PROMS scores showed reliable improvements with no differences between the two groups. Health related QoL was calculated from EQ5D-Y and indicated an overall improvement of 1.06(0.879–1.25). 6 patients were wheelchair users preop. All patients were independent walkers at follow-up. One patient underwent successful revision surgery for aseptic acetabular loosening. There were no other complications.

THA in children leads to a significant positive impact on QoL as measured with validated PROMS scores. Patients with systemic conditions can benefit just as much as those with single joint disease. Further follow-up is required to understand the long-term outcomes.

The decision to undertake THA in a child is complex and surgery challenging. Pre-operatively patients' typically have significant pain and mobility restriction. Little is published on the functional gains after THA in this group.

The aim of this study was therefore to measure the impact THA had on the PROMS in our young patients undergoing THA, to determine QoL improvement.

This was a prospective, consecutive cohort study of patients under the age of 17 years undergoing THA by a single surgeon in a tertiary referral centre. Patient electronic notes, radiographs, and PROMS (EQ5D-Y, Oxford Hip Score (OHS) and modified Harris Hip Score (mHHS)) were reviewed.

12 children (8 females and 4 males) underwent THA before their 17th birthday, with 5 undergoing bilateral operations (17 THA total). The mean age was 14.6 years (10.75–16.9) and mean follow-up 1.5 years. Nine of the THA were undertaken for congenital syndromes, 4 for AVN, 2 for Perthe's disease and 1 for dysplasia and idiopathic chondrolysis. The mean pre-operative OHS was 15 (1–33) improving to 31 (19–39) at 6-weeks, 44 (42–46) at a year and 48 (47–48) at 3 years. mHHS improved from a pre-operative mean of 25 (0–56) to 60 (37–92) at 6-weeks, 65 (38–84) at a year and 91 (91) at 3 years. The EQ-VAS mean score pre-operatively was 35 (8–100) improving at 6-weeks to 73 (55–96), 84 (76–96) at a year and 92 (76–100) at 3 years. All patients achieved MCID or higher for OHS. 6 patients were wheelchair users preop. All patients were independent walkers at follow-up. There were no complications.

THA in children is safe and leads to a significant positive impact on QoL as measured with validated PROMS scores. Wheelchair users can reliably gain independent walking. Further follow-up is required understand the long-term outcomes.

Aim

Implant-associated osteomyelitis is a devastating complication with poor outcomes following treatment, especially when caused by antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA). A large animal model of a two-stage revision to treat MRSA implant-associated osteomyelitis has been developed to assess novel treatments. A bioresorbable, thermo-responsive hyaluronan hydrogel (THH) loaded with antibiotics has been developed and our aim was to investigate it´s in vivo efficacy as a local antibiotic carrier compared to the current standard of care i.e. antibiotic-loaded polymethylmethacrylate (PMMA) bone cement.

Introduction: An extensive review of the literature has found no evidence supporting the routine use of antibiotic prophylaxis in patients with prosthetic joints undergoing dental treatment. A working party of the British Society for Antimicrobial Chemotherapy have stated that “patients with prosthetic joint implants (including total hip replacement) do not require antibiotic prophylaxis for dental treatment” and that “it is unacceptable to expose patients to the adverse effects of antibiotics when there is no evidence that such prophylaxis is of any benefit”.

Method: A postal questionnaire containing both open and closed questions regarding prescribing habits and protocols with respect to antibiotic prophylaxis in patients with prosthetic joints undergoing dental treatment was sent to all General Dental Practitioners and all Consultant Surgeons in Northern Ireland. Response rates of 72% and 97.5% were obtained from the two groups.

Results: The majority of Dentists (82–96%) routinely prescribe antibiotic cover in patients with structural heart defects but not in those who have had a joint replacement (24%) with Penicillin being the most frequently used antibiotic. 43% of Dentists have however, been asked by an Orthopaedic Surgeon to give cover with 216 of these 242 having given it. Responding Orthopaedic Surgeons indicated that the majority (63%) prefer their patients to have cover during dental extractions. A Cephalosporin is the most commonly suggested antibiotic(25%). Only one of the Surgeons given advice to his patients to ask for antibiotic cover during dental procedures.

Conclusion: We conclude that current practice, particularly amongst Orthopaedic Surgeons with regard to antibiotic prophylaxis in patients undergoing dental extraction following joint replacement does not adhere to national recommendations and that dissemination of the guidelines is essential.

The Austin Moore Prosthesis (AMP) is a recognised treatment option in the management of displaced intracapsular femoral neck fractures in elderly patients. Peri-prosthetic femoral fractures are a potential complication of both cementless and cemented hemiarthroplasty and can occur intra-operatively or at any stage following implant insertion.

Over a two-year period, 244 patients underwent hemiarthroplasty for a displaced intracapsular femoral neck fracture. Seventy patients had an AMP inserted whilst 174 patients were treated using a cemented Thompson stem. All of the AMP’s were inserted by, or under the supervision of an orthopaedic consultant.

Five patients (7%) from the AMP group sustained a periprosthetic femoral fracture. Four required revision surgery. The remaining case was managed non-operatively.

When compared to the cemented Thompson hemiarthroplasties performed over the same time period, despite the operating time being significantly less, the number of periprosthetic femoral fractures was significantly greater with the AMP. Furthermore, the early mortality rate was significantly higher for the AMP group who, were also significantly older and more likely to require postoperative blood transfusion. There was no significant difference in gender or ASA grade between the two groups.

These findings suggest that for displaced intracapsular femoral neck fractures in elderly patients, when hemiarthroplasty is the treatment of choice, a cemented prosthesis is preferable.

Objective: This study evaluates the use of the Isola Growing Rod System for scoliosis in a group of skeletally immature patients with predominantly neuromuscular disorders. Our series of patients was unsuitable for definitive anterior and posterior fusion due to poor respiratory function.

Design: We reviewed the case notes and x-rays of eighteen patients who had undergone instrumentation with the Isola Growing Rod System. The Cobb angles on the pre-operative and subsequent post-operative X-rays were measured. Complications were noted.

Subjects: Eighteen children with scoliosis.

Outcome measures: Curve correction and complications.

Results: Two patients had idiopathic scoliosis, four patients had spinal muscular atrophy with the remainder having varied diagnoses. Eight patients were fully ambulant, the remainder being wheelchair bound pre-operatively. The average age at rod insertion was eight years, three months. The average number of lengthenings was four. The mean pre-operative Cobb angle was 76 degrees, the mean most recent Cobb angle 28 degrees. One patient required definitive fusion. Two patients required revision procedures due to implant failure.

Conclusion: Our study shows that progressive scoliosis associated with neuromuscular disorder can be controlled with the growing rod system, thus avoiding both anterior release and the ‘crankshaft’ phenomenon, until the optimal time for definitive spinal fusion.