From August 2009, all doctors were subject to the European Working Time Directive (EWTD) restrictions of 48 hours of work per week. Changes to rota patterns have been introduced over the last two years to accommodate for these impending changes, sacrificing ‘normal working hours’ training opportunities for out-of-hours service provision. We have analysed the elogbook data to establish whether operative experience has been affected.

A survey of trainees (ST3-8) was performed in February 2009 to establish shift patterns in units around the UK. All operative data entered into the elogbook during 2008 at these units was analysed according to type of shift (24hr on call with normal work the following day, 24hr on call then off next working day, or shifts including nights).

66% of units relied on traditional 24hrs on call in February 2009. When compared with these units, trainees working shifts had 18% less operative experience (564 to 471 operations) over the six years of training, with a 51% reduction in elective experience (288 to 140 operations). In the mid years of training, between ST3-5, operative experience fell from 418 to 302 operations (25% reduction) when shifts were introduced.

This national data reflects the situation in UK hospitals in 2009, prior to the implementation of a maximum of 48 hours. It is expected that most hospitals will need to convert to shift-type working patterns to fall within the law. This could have significant implications for elective orthopaedic training in the UK.

Antibiotic prophylaxis for joint replacement surgery is widely recommended and has been shown to reduce infection rates. Cephalosporins have commonly been used but are associated with development of Clostridium difficile associated diarrhoea (CDAD)

The purpose of this study was to assess whether a change of protocol aimed at reducing CDAD, including a change of antibiotic prophylaxis would reduce rates of CDAD and other postoperative complications.

We studied all 7989 patients in our trust that underwent hip or knee replacement from May 2002 to March 2009. These patients fell into two cohorts, firstly those who were prescribed cefuroxime as prophylaxis and secondly those prescribed gentamicin which was introduced following national concern regarding CDAD.

Following the change of prophylaxis from cefuroxime 750mg three doses to gentamicin 4.5 mg/kg single dose the rate of CDAD reduced significantly (0.17% to 0%, p<0.03), however the rate of acute renal failure (0.29% to 0.6%, p=0.04) and pneumonia (0.71% to 1.38%, p<0.01) increased significantly. The rate of urinary tract infection (1.44% to 1.20%, p >0.05) and the overall return to theatre rate (1.86% to 2.30%, p=0.21) were not significantly changed.

The spectrum of bacteria grown from infected joint replacements in the two cohorts was also analysed. The rate of deep MRSA infection was significantly less in the group given gentamicin. The frequency of other bacteria was also different between the cohorts, but not significantly so.

We conclude that changing protocol including antibiotic prophylaxis in joint replacement patients can have the desired effect on a particular outcome namely CDAD but can also result in increased rates of other postoperative complications. It is also likely to result in a change in the bacterial spectrum of infected joint replacements.

Background

Percutaneous K-wire fixation is a well-recognised and often performed method of stabilisation for distal radius fractures. However, there is paucity in the literature regarding the infection rate after percutaneous K-wire fixation for distal radius fractures.

Background: Diagnostic and operative codes are routinely collected on every patient admitted to National Health Service (NHS) hospitals in England and Wales (hospital episode statistics, HES). The data allows for linkage of post-operative complications and primary operative procedures, even when patients are re-admitted following a successful discharge. Morbidity and mortality data on foot and ankle surgery (F& A) has not previously been available in large numbers for NHS patients.

Methods: All HES data for a 44-month period prior to August 2008 was analysed and divided into four groups – hindfoot fusion, ankle fracture surgery, ankle replacement and a control group. The control group was of first metatarsal osteotomy, which is predominantly day case surgery where no above ankle cast is used. The incidence of pulmonary embolism (PE) and all cause mortality (MR) within 90 days, and a return to theatre (RTT, as a complication of the index procedure) within 30 days was calculated for each group.

Results: 7448 patients underwent a hindfoot fusion. PE, RTT and MR were 0.11%, 0.11% and 0.12% respectively. 58732 patients had operative fixation of an ankle fracture. PE, RTT and MR were 0.16%, 0.08% and 0.35%. 1695 patients had an ankle replacement. PE, RTT and MR were 0.06%, 0.35% and zero. 35206 patients underwent a first metatarsal osteotomy. PE, RTT and mortality rates were 0.02%, 0.01% and 0.03%.

Discussion: There is controversy regarding the use of venous thrombo-embolic (VTE) prophylaxis in foot and ankle surgery. Non-fatal PE in F& A surgery has previously been reported as 0.15%. NICE guidelines recommend low molecular weight heparin (LMWH) for all inpatient orthopaedic surgery. 94% of F& A surgeons prescribe LMWH to post operative elective inpatients in plaster according to a previous British Orthopaedic foot and ankle society survey. VTE events, RTT and mortality rates for all groups were extremely low, including inpatient procedures requiring prolonged immobilisation. We question the widespread use of LMWH.

Introduction: Following successful introduction in 2007, all training programs except two across the UK participated in the examination in 2008. The examination was run along the principles of curriculum based, online delivery with immediate results and providing supportive information for the questions. It remains free of charge as long as the trainee had contributed questions. The project is supported by an educational grant from Depuy, a Johnson and Johnson Company.

Material and Methods: In 2008 trainees from various regions were appointed to a UKITE review board, which creating good quality questions with supportive information. We took on board the feedback from 2007 examination and improved the quality of questions. Some questions from the 2008 examination were reported as ambiguous. The review board met and ambiguous questions were deleted from the exam and scores were recalculated.

Results: 648 trainees took UKITE 2008. The average scores increased up to 5th year SpR and dropped in year 6. Central organisation (86%) and local organisation (90%) were acceptable. 95% felt the examination pages were easy to use. There was difficulty in accessing the examination from NHS networks in some centers on the final day. 95% found there was educational benefit and 99% would like to sit again in 2009.

In the feedback from UKITE 2008, 85% of trainees felt it was better quality than 2007. The trainees wanted more questions on clinical situations. Those approaching the FRCS examination are interested in using the database towards preparation for the real examination. Some enthusiastic trainees would like the facility to submit questions early. We aim to improve on these in 2009.

In 2009 we also aim to open the examination for other surgical specialties and international trainees through elogbook.org.

Conclusion: UKITE has made progress in 2008. We aim to improve it further in 2009.

Purpose: To assess the infection rate following Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin.

Method: All patients undergoing Total Hip and Knee replacements over six months (October 2007 to March 2008) at three participating hospitals were prospectively followed to assess perioperative infection rates using Surgical Site Surveillance(SSI) criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg. This was compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals using 3 doses of Cefuroxime 750mg. Return to theatre data was collected independently after introduction of gentamicin to compare with previous data. The change in creatinine level postoperatively was also measured in a selected group of patients.

Results: Four hundred and eight patients underwent Total Hip Replacements (THR) and 458 patients Total Knee Replacements (TKR) during the study period. This was compared with 414 and 421 patients who underwent THRs and TKRs respectively during a previous six month period. SSI was detected in 9 THRs(2.2%) and 2 TKRs(0.44%) in the study group as compared to 13 THRs(3.1%) and 12 TKRs(2.9%) in the control group. The infection rates in THRs were not significantly different between the 2 groups(p value−0.52) but were significantly reduced in the study group for TKRs(p value−0.005). The rate of Clostridium difficile infection was reduced within the hospital with the use of gentamicin, although other measures to reduce its incidence were also introduced. The return to theatre was 1.64%(23/1402) after introduction of Gentamicin as compared with 1.05%(21/2005) [p value−0.092] before this. This was a cause for concern although not significant. The day1 postoperative creatinine level increased by more than 30 units in 6% of patients on Gentamicin.

Conclusion: This study shows that the use of single dose prophylaxis using Gentamicin is effective for Lower Limb Arthroplasty. However, be wary of increased rate of return to theatre and the rise in creatinine level following use of gentamicin. Further period of evaluation and study is needed before it is recommended for routine use in present or modified form.

Introduction: In August 2007, the Department of Health initiative Modernising Medical Careers was implemented. This was a system of reform and development in postgraduate medical education and training. In preparation for the changes, the SAC for T& O outlined a new curriculum. The emphasis of early training, StR years 1 and 2, was to be trauma. We aim to identify how effectively the SAC proposals are being applied, and what difference this makes to the trainees’ operative experience? Furthermore, how do the new posts compare to the historic SHO models?

Methods: A survey carried out by BOTA allowed us to assess post compliance with the SAC recommendations. A compliant job was defined as trauma based for 50% or more of working time. Consent was obtained to evaluate the eLogbooks of trainees in compliant and non-compliant jobs, along with registrars who had previously held traditional SHO grade posts. Overall operative experience over a specified 4 month time period was examined, with focus on routine trauma procedures.

Results: The results of the BOTA and SAC survey revealed that 45% of the new orthopaedic posts were compliant with curriculum guidelines. The eLogbooks of 92 individuals were analysed; 28 historical posts, 34 compliant and 30 non-compliant. The mean total number of recorded entries by trainees in the 4 month period was 73.2 in the historic group, 90.5 in the compliant and 87.3 in the non-compliant job group. The corresponding numbers of trauma operations were 35.7, 48.4 and 41.5.

Conclusions: Operative experience has improved since the introduction of the new curriculum. The new posts are offering more operative and in particular trauma exposure than traditional SHO jobs. If jobs can be restructured such that they all comply with the SAC, educational opportunities in the early years will be maximised.

Background: From August 2009, all doctors were subject to the European Working Time Directive (EWTD) restrictions of 48 hours of work per week. Changes to rota patterns have been introduced over the last two years to accommodate for these impending changes, sacrificing ‘normal working hours’ training opportunities for out-of-hours service provision. We have analysed the elogbook data to establish whether operative experience has been affected.

Methods: A survey of trainees (ST3-8) was performed in February 2009 to establish shift patterns in units around the UK. All operative data entered into the elogbook during 2008 at these units was analysed according to type of shift (24hr on call with normal work the following day [traditional on call], 24hr on call then off next working day, or shifts including nights).

Results: 66% of units relied on traditional 24hrs on call in February 2009. When compared with these units, trainees working shifts had 18% less operative experience (564 to 471 operations) over the six years of training, with a 51% reduction in elective experience (288 to 140 operations). In the mid years of training, between ST3-5, operative experience fell from 418 to 302 operations (25% reduction) when shifts were introduced.

Discussion: The eLogbook is a powerful resource that provides accurate data for the purpose of supporting orthopaedic training. This national data reflects the situation in UK hospitals in 2009, prior to the implementation of a maximum of 48 hours. It is expected that most hospitals will need to convert to shift-type working patterns to fall within the law. This could have significant implications for elective orthopaedic training in the UK.

Background: Diagnostic and operative codes are routinely collected on every patient admitted to hospital in England and Wales (hospital episode statistics, HES). Linked data allows post-operative complications to be associated with the primary operative procedure, even if patients are re-admitted following a successful discharge. Morbidity and mortality data on shoulder surgery have not previously been available in large numbers.

Methods: All HES data for a 42-month was analysed and divided into three groups – elective shoulder replacement (total or hemiarthroplasty), shoulder arthroscopy (all procedures), and proximal humerus fracture surgery (internal fixation or replacement). Incidence of pulmonary embolism (PE), deep venous thrombosis (DVT) and mortality within 90 days was established.

Results: For elective shoulder replacement (10735 patients), 90-day DVT, PE and mortality rates were 0.07%, 0.11% and 0.36% respectively. Mortality in patients over 75 years was 0.9%. For arthroscopic procedures (66344 patients), 90-day DVT, PE and mortality rates were 0.01%, 0.01% and 0.03%. For proximal humerus fracture surgery (internal fixation or replacement, 4968 patients) 90-day DVT, PE and mortality rates were 0.20%, 0.38% and 2.98%. Mortality in patients over 75 years old was 6.6%.

Discussion: Venous thromboembolic (VTE) prophylaxis is rarely used for upper limb surgery. PE and mortality rates for shoulder replacement and proximal humerus fracture surgery are lower those for patients receiving chemical prophylaxis after hip replacement. Further investigation into the cause of high mortality rates following fracture surgery in patients over 75 years old is required. VTE prophylaxis may be required in this age group.

Introduction: Prophylactic systemic antibiotics are commonly used peri-operatively in primary hip and knee arthroplasty in the UK. ‘Fast-Track’ (FT) peri-operative care – a multimodal concept aiming to accelerate postoperative rehabilitation and reduce general morbidity – is also becoming more common in arthroplasty surgery. There are no published reports of acute kidney injury (AKI) as a result of a single-dose prophylactic Gentamicin. The renal impact of hypotensive anaesthesia and reduced routine post-operative intravenous fluid therapy, both features of FT protocol, has not yet been reported. Aim: To evaluate the renal impact of prophylactic Gentamicin and FT perioperative care in hip and knee arthroplasty surgery.

Methods: Four hundred and eighty-four total hip/knee arthroplasty patients had their pre-operative, first and third post-operative day serum creatinine concentration measured and recorded. The first 180 patients (group A) received 1.5g Cefuroxime at induction and two further doses of 750mg at 8 hours and 16 hours post-operatively as antibiotic prophylaxis. The next 160 patients (Group B) received 5mg/kg single-dose Gentamicin at induction instead of Cefuroxime. These patients (Group A and B) were not treated as per FT protocol. The final 144 patients (Group C) received the same Gentamicin as Group B and were treated as per FT protocol. Outcome measures were overall change and an increase of > 30 μmol/L, the latter signifying an AKI.

Results: Mean creatinine change at day 1 was −4.63 in Group A, −3.95 in Group B and 4.19 in Group C. Mean creatinine change by day 3 was −5.28 in Group A, −2.53 in Group B and 8.89 in Group C. No patients in Group A, 4 patients (2.56%) in Group B and 9 patients (6.66%) in Group C had a rise of > 30 μmol/L in day 1 creatinine concentrations.

Conclusions: Comparing the groups, there was no statistically significance change in the day 1 creatinine when Gentamicin replaced Cefuroxime (p=0.625,) however this became significant once FT was also introduced (p=0.001.) In terms of an important creatinine rise (AKI,) the change to Gentamicin produced a statistically significant rise in the number of patients with a day 1 creatinine rise > 30 μmol/L (p=0.048.) By day 3 there is no significant difference in the number of patients with a creatinine rise > 30 μmol/L.

Discussion: FT protocol aims to encourage haemostatic surgery and early ambulant patients (free from drip stands) at the expense of mild hypovolaemia. When these patients are also receiving Gentamicin, the kidneys are concentrating urine and Gentamicin in the tubules thus causing and AKI in some cases. It appears that Gentamicin and FT are cumulative in their effect on renal function.

Since 2003 Trauma and Orthopaedic trainees in the UK and Ireland have routinely submitted data recording their operative experience electronically via the eLog-book. This provides evidence of operative experience of individuals and national comparisons of trainee, trainer, hospital and training programme performance. We have analysed trauma surgery data and established standards for training.

By January 2008 there were over 4 million operations logged. Operations performed and uploaded since 2003 have been included. Each trainee’s work is analysed by ‘year-in-training’. Data on levels of supervision, missed opportunities (where the trainee assisted rather than performed the operation) was analysed. The average number of trauma operations performed annually by trainees was 109, 120, 110, 122, 98 and 84 (total 643) for YIT one (=ST3) to six (=ST8) respectively. There were only 22% of missed opportunities throughout six years of training. A high level of experience is gained in hip fracture surgery (121 operations) and forearm (30), wrist (74) and ankle (47) operative stabilisation over the six years. However, the average number of tibial intra-medullary nails (13), external fixator applications (12) and childrens’ elbow supracondylar fracture procedures (4) performed is low. We are also able to identify trainees performing fewer operations than required during their training (two standard deviations or more below the mean for their YIT). We expect a trainee to have performed at least 255, 383, 473, and 531 trauma operations at the end of YIT three to six respectively.

The eLogbook is a powerful tool which can provide accurate information to support in-depth analysis of trainees, trainers, and training programmes. This analysis has established a baseline which can be used to identify trainees who are falling below the required operative experience.

The first United Kingdom In-training Examination (UKITE) was held in 19 training programmes during December 2007. The aims of the project are to offer a national, online examination (providing immediate results to trainees) and to allow practice for the ‘real’ FRCS T& O examination with similarly formatted questions based on the UK T& O curriculum. All Speciality training years (StR2, StR3 and above, and all SpRs) and all deaneries will participate in the future. A total of 450 trainees sat this first examination. This is an online exam (accessed through the eLogbook/OCAP website) which is voluntary and has no bearing on RITA outcomes. To take part in the exam trainees were asked to provide 3 questions for a bank which can be used in subsequent years for both UKITE and the FRCS T& O examination.

The exam was 3 hours and questions were of multi-choice (MCQ) and extended matching question (EMQ) style covering all aspects of orthopaedics. Correct answers and explanations were available to the trainee after their answer had been submitted. Final scores ranged from 35% to 92%. Mean scores increased from 48% (StR2) to 73% in SpR year 5 (StR7 equivalent). This was followed by a drop off in performance in the final year of training. Three candidates had equal top scores at 92%. 97% stated they would sit the UKITE again and 93% felt there was educational benefit. The length and level of difficulty of the exam was felt to be satisfactory. Improvements were suggested for question quality. The UKITE is a powerful tool for self-assessment of trainees. This analysis establishes a baseline for future years.

Introduction: Following successful introduction in 2007, all training programs except two participated in 2008. The examination was run along the principles of curriculum based, online delivery with immediate results and providing supportive information for the questions. The examination remains free of charge for the trainees and is supported by an educational grant from Depuy.

Material and methods: In 2008 a UKITE review board was appointed to create good quality questions with supportive information. We took on board the feedback from 2007 examination. Some questions from the 2008 examination were reported as ambiguous. The review board met and ambiguous questions were deleted from the examination and the scores recalculated.

Results: 648 trainees took UKITE 2008. Central organisation (86%) and local organisation (90%) were acceptable. 95% felt the examination pages were easy to use. There was difficulty in accessing the examination from NHS networks in some centers on the final day. 95% found there was educational benefit and 99% would like to sit again in 2009.

In the feedback from UKITE 2008, 85% of trainees felt it was better quality than 2007. The trainees approaching the FRCS examination are interested in using the database towards preparation.

In 2009 we aim to open the examination for SAS doctors, other surgical specialties and international trainees through elogbook.org.

Conclusion: UKITE has made progress in 2008. We aim to improve it further and open it to SAS doctors, other specialties and international trainees in 2009.

National Institute for Clinical Excellence (NICE) guidelines on venous thromboembolic (VTE) prophylaxis for patients undergoing orthopaedic surgery recommend that all inpatients be offered a low molecular weight heparin (LMWH).

Linked hospital episode statistics of 219602 patients were examined to determine the rates of complications following lower limb arthroplasty for the 12-month periods prior to and following the publication of these guidelines. This was compared with data from the National Joint Register (England and Wales) regarding LMWH usage during the same periods.

There was a significant increase in the reported use of LMWH (59.5 to 67.6%, p< 0.01) between the two periods. However, 90-day VTE events increased following both total hip (THR, 1.67% to 1.84%, p=0.06) and knee replacement (TKR, 1.99% to 2.04%, p=0.60). 30-day return to theatre rate for infection fell following TKR, but increased after THR. In addition, there were increases in rates of thrombocytopenia, which was significant following THR (p=0.03).

Recommendations from NICE are based on predicted reductions in VTE events, reducing morbidity, mortality and costs to the National Health Service. Early results in orthopaedic patients are unable to support these predictions.

Aim: To assess the infection rate following Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin.

Material and Methods: All patients undergoing Total Hip and Knee joint replacements over 6 months (October 2007 to March 2008) at 3 participating hospitals were prospectively followed up to assess perioperative infection rates. Joint replacements were defined as having infection by the UK Health Protection Agency Surgical Site Surveillance criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg body weight adjusted for body mass index.

This group of patients were compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals for infection rates in Lower Limb Arthroplasty using 3 doses of Cefuroxime 750mg as antibiotic prophylaxis.

Results: 408 patients underwent Total Hip Replacements (THR) and 458 patients underwent Total Knee Replacements (TKR) during the study period. This was compared with 414 patients who underwent THR and 421 patients who underwent TKR during a 6 month period over 2 years.

Surgical site infection was detected in 9 THRs (2.2%) and 2 TKRs (0.44%) in the study group as compared to infection in 13 THRs (3.1%) and 12 TKRs (2.9%) in the control group.

Using the Fisher Exact test the infection rates in THRs were not significantly different between the 2 groups (p value – 0.52) but the infection rates were significantly reduced in the study group for TKRs (p value – 0.005).

There were no complications with the use of Gentamicin as antibiotic prophylaxis.

Cefuroxime is known to promote Clostridium difficile infection and was removed from the hospital pharmacy to help meet a UK government targets to reduce the incidence. The rate of Clostridium difficile infection was reduced within the hospital with the use of single dose antibiotic prophylaxis although other measures to reduce its incidence were also introduced.

Conclusions: This study shows that the use of single dose antibiotic prophylaxis using Gentamicin is effective for elective Lower Limb Arthroplasty.

This is recommended for routine use in all elective joint replacements as it is safe, effective and easy to administer.

Background: There are no large comparative metal ion studies of commercially available hip resurfacing devices which have taken into account the effects of femoral size and cup inclination and anteversion.

Patients and methods: Metal ion analysis is carried out routinely at our independent centre. We present the metal ion results of 95 unilateral ASR patients and 70 unilateral BHR patients. For all patients, acetabular cup orientation was assessed using EBRA software. Patients with other metallic implants and those within 12 months of surgery were excluded.

Results: Whole blood/serum chromium (Cr) and cobalt (Co) concentrations were inversely related to femoral component size in both the ASR and BHR group (p< 0.05). Cr and Co levels were only seen to increase in the BHR group when the cup was implanted with an inclination greater than 55°. A significant relationship was identifed between the anteversion of the BHR cup and Cr and Co (p< 0.05 for Co, Spearman Rank correlation), with an increase in ions observed at anteversion angles > 17°. Cr and Co were more strongly influenced by cup position in the case of the ASR, with an increase in metal ions observed at inclinations greater than 45° and anteversion angles of < 10° and > 20°.

Discussion: The increased tolerance of the BHR cup to inclinations between 45–55° is likely due to the larger BHR cup providing greater protection against edge loading. When the cohort was divided by gender, the median Cr concentrations of the male ASR patients were significantly lower than those of the BHR males (p< 0.001). This suggests that in larger components positioned at more satisfactory angles of inclination and anteversion, the lower clearance of the ASR proves more significant than the extra coverage provided by the BHR cup. The BHR appears to be more sensitive to changes in anteversion than inclination.

Aim: To assess the infection rate following Primary Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin.

Material And Methods: All patients undergoing primary Total Hip and Knee joint replacements over 6 months (October 2007 to March 2008) at 3 participating hospitals were prospectively followed up to assess perioperative infection rates. Joint replacements were defined as having infection by the UK Health Protection Agency Surgical Site Surveillance (SSI) criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg body weight adjusted for body mass index.

This group of patients were compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals for infection rates in Lower Limb Arthroplasty using 3 doses of Cefuroxime 750mg as antibiotic prophylaxis.

Return to theatre data was collected independently after introduction of gentamicin to compare with previous data.

Results: 408 patients underwent Total Hip Replacements (THR) and 458 patients underwent Total Knee Replacements (TKR) during the study period. This was compared with 414 patients who underwent THR and 421 patients who underwent TKR during a 6 month period over 2 years.

Surgical site infection was detected in 9 THRs (2.2%) and 2 TKRs (0.44%) in the study group as compared to infection in 13 THRs (3.1%) and 12 TKRs (2.9%) in the control group.

Using the Fisher Exact test the infection rates in THRs were not significantly different between the 2 groups (p value – 0.52) but the infection rates were significantly reduced in the study group for TKRs (p value – 0.005).

There were no complications with the use of Gentamicin as antibiotic prophylaxis.

The return to theatre was 2.42% (28/1157) after introduction of Gentamicin as compared with 1.85% (37/2005) [p value – 0.172] before this. This was a cause for concern, although not a significant difference.

Cefuroxime is known to promote Clostridium difficile infection and was removed from the hospital pharmacy to help meet a UK government targets to reduce the incidence. The rate of Clostridium difficile infection was reduced within the hospital with the use of single dose antibiotic prophylaxis although other measures to reduce its incidence were also introduced.

Conclusions: This study shows that the use of single dose antibiotic prophylaxis using Gentamicin is effective in preventing SSI as defined in the HPA definition. It is safe to use and reduces rate of Clostridium difficile associated diarrhoea.

However, be wary of increased rate of return to theatre following use of gentamicin.

Further period of evaluation and study is needed before it is recommended for routine use in present or modified form.

Background and objective: in 2003 in its publication ‘Care of fragility fracture patients’ The British Orthopaedic Association highlighted the orthopaedic surgeon’s role in assessment and management of patients at high risk from osteoporosis. In general such secondary prevention of osteoporosis is carried out poorly by orthopaedic surgeons. This audit aimed to determine if software which identifies patients at high risk from osteoporosis from clinic letters, improves orthopaedic surgeons’ referral rates for DEXA.

Methods: two audit cycles were carried out using local guidelines. The audits concerned patients over 50 years having sustained a fragility fracture of the distal radius. According to local guidelines all such patients should undergo DEXA. Patients were identified from hospital records and the number referred for DEXA determined. Those who had undergone DEXA in the year prior to fracture were excluded. The baseline audit was from April to June 2004 inclusive followed by closure of the loop between October and December 2004 following reinforcement of guidelines. Following continued poor referral rates at this point the software programme was introduced. It identifies patient age and key words in dictated clinic letters when they are being printed, for example distal radial fracture. Appropriate patients have computer generated osteoporosis advice included at the bottom of the general practitioner letter along with a DEXA referral form which General Practitioners complete. A further audit using similar methods was carried out 3 months after the software introduction (January 2006).

Results: baseline audit identified forty-three patients (36 women and 7 men) with a mean age of 73 years, 3 were referred for DEXA (7%). Following reinforcement of guidelines fifty-two patients were identified (46 women and 6 men) with a mean age of 68 years, 16 (31%) were referred. At re-audit (following the introduction of the software programme) 45 patients were identified (38 women and 7 men) with an average age of 71 years. 30 (67%) were referred for DEXA. This is a significant improvement using a Chi squared analysis.

Conclusion: the software programme significantly improves orthopaedic surgeon identification of patients at high risk of osteoporosis and referral rates for DEXA.

Aim: to determine the proportion of patients with fragility fractures who underwent risk assessment for osteoporosis as a result of their fracture clinic attendance prior to and following reinforcement of guidelines

Methods: The inclusion criteria were defined as: new patients fifty years of age or over sustaining a fragility fracture of their distal radius presenting during two three month periods in 2004 (April to June and October to December). Guidelines for osteoporosis risk assessment (the Northumberland guidelines) were reinforced during the interim period. Patients were identified from hospital records and the notes obtained to confirm the fracture type as fragility. The number assessed during each period was determined from outpatient referral for DEXA records and compared. Patients who had undergone DEXA scanning in the year prior to their fracture clinic attendance were excluded from the analysis.

Results: from April to June there were forty-six patients (39 women and 7 men) with a mean age of 73 years while between October and December there were fifty-four patients (48 women and 6 men) with an average age of 68 years. In the April to June cohort 3 patients had already had a DEXA scan prior to fracture clinic attendance. Of the 43 remaining patients 3 were risk assessed for osteoporosis (7%). Within the October to December group two patients had previously undergone DEXA scanning and of the remaining 52 patients 16 (31%) underwent osteoporosis risk assessment.

Conclusion: Risk assessment for osteoporosis is still carried out ineffectively by orthopaedic surgeons even following enforcement of guidelines.

i. Purpose To determine whether operating in ultra-clean vertical laminar flow and personal isolation “space suits” reduces deep infection rates in total knee replacement compared to a conventional theatre and modern disposal gowns.

ii. Method An analysis of deep infection rates in 373 patients who underwent total knee arthroplasty performed in one operating theatre prior to and after a theatre and clothing upgrade.

Results The infection rate before the introduction of ultraclean air and space suits was 6/166 (3.6%). Afterwards the rate was 1/207 (0.5%). This shows a significant reduction (p< 0.05)

iii. Conclusion Compared to conventional theatres and clothing the use of ultraclean vertical laminar flow and spacesuits significantly reduces the risk of infection in total knee arthroplasty.

Introduction: The threshold for internal fixation of thoracolumbar junction fractures is controversial. Most authorities would agree that indications would include neurological deficit and severe deformity. The definition of severe deformity many would regard as a kyphus angle of 20° or more and/or compression of more than 50% of the anterior body height. Patients are only assessed on supine films alone. The aim of this study was to ascertain whether weight-bearing films altered the deformity and if so did this subsequently alter management.

Methods: A prospective study of patients who had suffered a fracture of the thoracolumbar junction (T11- L2). All patients who had a neurological deficit or a kyphus angle of greater than 20° and/or greater than 50% anterior body collapse were excluded. Only patients with a deformity less than the above were entered into the study. These patients then had weight-bearing views (standing or sitting) as soon as they had developed trunk control. A kyphus angle of greater than 20° or more than 50% body collapse were used as a criteria for fixation.

Results: 16 patients were entered into the study over a one year period. Five (31% ) of the 16 patients had a significant increase in their deformity on weight-bearing films that caused them to pass the threshold for fixation, and subsequently had surgery .

Conclusion: The authors recommend that weight-bearing views should always be taken on fractures of the thoracolumbar spine if conservative treatment is being considered.

To determine whether resection of osteophyte at TKR improves movement, 139 TKRs were performed on knees with pre-operative posterior osteophyte. Randomisation was to have either resection of distal femoral osteophyte guided by a custom made ruler or no resection. After preparation of the femoral bone cuts the ruler measuring 19 mm was placed just proximal to the posterior chamfer cut. The proximal end of this ruler marked the bone to be resected and this was performed using an osteotome at 45 degrees. Knees randomised to no resection had no further femoral bony cuts. Three months after implantation the patients had range of motion assessed.

One hundred and fourteen suitable knees were assessed, with 59 knees (57 patients) in the resection group and 55 knees (54 patients) in the no resection group. Full extension was more likely in the resection group (62%) than the group without resection (41%)(p=0.08). Flexion to at least 110 degrees was, however, less in the resection group (37%) than the no resection group (54%) (p=0.09).

Our study failed to show a statistically significant difference if the bony osteophyte is removed. There were however sharp trends, with statistically a one in ten chance these results would be different if the trial was repeated. Although there is no indication as to the cause of improved extension this could be explained by the release of the posterior capsular structures allowing full extension. The reduction in flexion is harder to explain and this may be due to increase in perioperative trauma and resultant swelling, possibly with fibrosis. Range of movement, particularly flexion, is known to improve up to 1 year post-operatively and assessment of these groups at that stage would be beneficial.

Research is regarded as an important part of higher surgical training, and forms an important component of in training assessment. Currently, there is little planning of research at a regional level. The aim of this study was, first, to evaluate the attitude of trainees towards research in order to highlight and understand difficulties. The second aim was to determine the level of support for a proposed research database to help organise regional research activity.

All trainees in a single region (39) were asked to complete a questionnaire handed out during two regional teaching days.

28 Questionnaires were returned. Nine percent of trainees have a higher degree with a further 35% on progress. Each trainee had an average of three (range 0–6) ongoing research projects. Over half the trainees had abandoned research projects. Most trainees stated an interest in research and felt that research was an important part of training and should be assessed in the RITA. Most trainees felt that research would dictate the quality of their consultant jobs. Almost every trainee stated that changing posts every eight months, as well as distance between hospital sites, made it difficult to complete projects. Every trainee felt that the ethical committee process causes significant delays in progress. Most felt that access to statistical advice was poor. Almost all trainees would welcome a regionally co-ordinated research database.

Trainees abandon research for various reasons. We propose that a research database would serve the primary function of linking trainees with consultants with quality research projects. Junior trainees would be encouraged to join the system and choose a project. The research section of the RITA could then focus on the progress of that project(s). Secondary aims would be coordinating access to advice on funding, statistics and ethics committee applications.

The aim of this study was to establish the ability of an invasive fibre-optic probe to measure intra-muscular pH, pCO₂, pO₂, HCO₃-⁻, ambient temperature, base excess and O₂ saturation. The secondary aim was to determine the effect of elevation of the limb on these parameters.

Fibre-optic probes were introduced into the anterior compartment muscle of the leg in five volunteers via 16G cannulae. After equilibration the limb was monitored for 11min with the volunteer supine on an examination couch. The limb was elevated to 22cm (Braun frame) and then 44cm for the same time. Subsequently the leg was returned to 22cm and supine. All volunteers followed this set protocol. Continuous recording of all indices was made throughout. Data was stored to a personal computer for analysis.

Similar trends were observed across all subjects for all parameters. The mean pO₂ when lying flat was 27mmHg (S.D.7.4). Elevation to 22cm increased muscle pO₂ to 33 mmHg (S.D. 5.8). Further elevation to 44 cm resulted in a reduction in muscle pO₂ to a level below that measured when supine. When the limb was returned to 22cm the pO2 trend reversed, the level improving. Returning to the supine position the pO₂ returned to the level seen at the start of monitoring.

This novel probe gives reproducible measures of pH, pCO₂, pO₂, HCO₃⁻, ambient temperature, base excess and O₂ saturation. Results indicate that elevation to 22cm improves muscle oxygenation; a height of 44cm seems detrimental. This technique may be applicable in surveillance for compartment syndromes and muscle ischaemia.

Arthroscopic acromioplasty is said to be a difficult procedure to learn although Gartsman stated that most surgeons can reliably perform an arthroscopic decompression after instruction in 10–20 cases. We assessed the learning curve for one consultant surgeon.Patients were selected on the basis of clinical examination and all had signs of impingement at arthroscopy. Surgery was performed between February 1993 and June 1996. Patients with full thickness tears were excluded from the study. The senior author had not performed any arthroscopic acromioplasties prior to providing a service in this hospital. Each shoulder was assessed immediately prior to surgery and at follow up using the Constant and Murley method of functional assessment without the power component. Patients were asked if they would have the operation again, with the benefit of hindsight.Of 89 shoulders complete preoperative and postoperative scoring beyond 6 months was available in 71. Of these, 62 operations were performed by one consultant (ANS) and 9 by trainees under his guidance. Patient questionnaires were completed for 73 of 89 shoulders.

A standard operative technique under general anaesthesia was used for all patients.

The overall improvement in shoulder function was 10.3 (SD 12.4) points (p< 0.0001). The change in shoulder score did not vary with increasing surgical experience. The length of operation, however, shortened with increasing experience with a mean of 106 minutes and 60 minutes for the first and last five operations. Questionnaire analysis found 82% would have the operation again.

In our study operative time reached a plateau after approximately the first twenty five cases but the results of these early operations are good.