The clinical guidelines for hip fracture management indicate that indwelling foley catheterization should be avoided when possible. Alternatives to indwelling catheters such as intermittent or condom catheters are recommended. Appropriate catheterization usage is important in hip fracture patients to avoid complications such as urinary tract infections (UTIs) (7–24% of patients) or post-operative urinary retention (POUR) (20–56% of patients). In this study, we aim to, (1) evaluate catheter usage in hip fracture patients at a large tertiary care centre, (2) compare current practices in catheter usage to clinical guidelines, (3) determine the incidence of POUR in hip fracture patients (4) determine the factors that increase one's risk of developing POUR. We analyzed 584 hip fracture patients between the ages of 18 and 102 admitted between November 2015 and October 2017 at a tertiary Care Hospital. Data collected included patient demographics, fracture pattern, surgical procedure, length of stay, co-morbidities and catheter use. We compared actual catheter usage to suggested guidelines to determine whether recommendations were being followed. We also investigated the incidence of POUR and risk factors associated with developing POUR. Independent samples t-test were used to compare continuous dependent variables in bivariate analyses and a logistic regression was used to determine predictors of developing POUR, catheter usage, and length of stay in multivariate analyses. T. Over three quarters (76.9%) of patients with hip fractures were treated with a catheter during their admission, 63.5% of which were inserted pre-operatively and 36.5% of which were inserted post-operatively. Indwelling catheters accounted for 92.2% of catheters used, while intermittent and catheter condoms accounted for 7.8%. POUR occurred in 98 of 584 cases (16.7%). Age (p = 0.004), gender (p=0.001), and presence of kidney disease (p=0.033) were statistically significant predictors of POUR. Fracture pattern (p=0.825), surgical procedure (p=0.298), diabetes mellitus (p=0.309) and UTI in the past 60 days (p=0.848) or on admission (p=0.999) were not statistically significant predictors of developing POUR. The development of POUR did not significantly increase length of stay (p=0.558). There was no statistically significant correlation between developing POUR and extended post-operative catheter use over 24 hours (p=0.844) or 48 hours (p=0.862). Patients who received a catheter pre-operatively or post-operatively for longer than 24 hours were not significantly more likely to develop POUR (p=0.057). Catheter use was common for all hip fracture patients and indwelling catheters were used in the overwhelming majority of cases. The high frequency of catheter usage, and specifically indwelling catheter usage, suggests that there is low compliance with the clinical guidelines for hip fracture patients. The incidence of POUR was 17%. Older, male patients were more likely to develop POUR. Although not statistically significant, more appropriate catheter use may decrease urinary complications such as POUR

Aims. Urinary catheter use in the peri-operative and post-operative phase following arthroplasty may be associated with increased risk of urinary tract infection (UTI) and deep prosthetic joint infection (PJI). These can be catastrophic complications in joint arthroplasty. We performed a systematic review of the evidence on routine use of antibiotics for urinary catheter insertion and removal following arthroplasty. Methods. Electronic databases were searched using the HDAS interface. Grey literature was also searched. From 219 citations, six studies were deemed eligible for review. Due to study heterogeneity a narrative approach was adopted. Methodological quality of each study was assessed using the CASP appraisal tool. Included studies were found to have moderate to good methodological quality. Results. A total of 4696 hip and knee arthroplasties were performed on 4578 participants across all studies. Of these 1475 (31%) were undertaken on men and 3189 (68%) on women. The mean age of the study participants was 69 years. 3489 cases (74.3%) related to hip arthroplasty and 629 of cases (13.4%) to knee arthroplasty. 578 cases (12.3%) specified either hip or knee arthroplasty. In total, 45 PJIs were reported across all studies (0.96%). Two of the studies found either no PJI or no statistical difference in the rate of PJI when antibiotic prophylaxis was not used for catheter manipulation. Where studies report potential haematogenous spread from UTIs, this association can only be assumed. Rates of bacteriuria varied greatly between studies and depend on timing of sample and gender. Increased duration of urinary catheterisation is positively associated with UTI. Conclusion. It remains difficult to justify the routine use of prophylactic antibiotics for catheter manipulation in well patients undergoing arthroplasty. Their use is not recommended for this indication

Aim. The objective of this systematic review is to evaluate the current evidence for or against this up-and-coming treatment modality. Method. A comprehensive literature search in accordance with the Preferred Reporting Items for Systematic review and Meta-analysis (PRISMA) guidelines was conducted using PubMed, Embase, MEDLINE and Cochrane databases. Exclusion criteria included patients < 18 years of age, follow-up <11 months, and a score < 6 on the National Institute of Health quality assessment tool. Results. 15 articles, encompassing 631 PJIs in 626 patients, were included in the final analysis, all level IV case series. The quality of many studies was impeded by a retrospective design (14/15), a relative small study population (10 out of 15 studies had less than 50 patients), selection bias, and remarkable heterogeneity in terms of catheter type, antibiotic type, dose and duration of IA antibiotics and techniques of surgical revision. 347 were chronic infections, 66 acute infections and 218 unknown. The majority was treated with single-stage revision with adjuvant IA antibiotic infusion (499/631, 79.1%). The remaining PJIs were treated with stand-alone IA antibiotic infusion (77/631, 12.2%), DAIR with adjuvant IA antibiotic infusion (36/631, 5.7%) or two-stage revision with adjuvant IA antibiotic infusion (19/631, 3.0%). Mean duration of IA antibiotic infusion was 19 days (range 3–50), although most patients received a combination of both IA and systemic (IV or PO) antibiotics. An overall failure rate (defined as failures of infection eradication/total PJIs) of approximately 11% was found. The use of IA antibiotic infusion as a stand-alone treatment was associated with a higher failure rate. In total 117 complications occurred in 631 cases (18.5%). Of these, 71 were non-catheter-related (60.7%) and 46 were catheter-related (39.3%). The most common catheter-related complications were premature loss of the catheter (18/46), developing a fistula (5/46), and elevated blood urea nitrogen (BUN) and creatinine levels (12/46). Conclusions. Due to the lack of comparative studies the (added) benefit of IA antibiotic infusion in the treatment of PJI remains uncertain. From a theoretical point of view it seems likely that is should not be used as a stand-alone treatment. A prospective randomized controlled trial using a well-described infusion protocol is needed to see if the potential benefits justify the increased costs, labour and catheter-related complications of this treatment modality

Introduction: Adequate analgesia following hindfoot surgery can be difficult and conventional analgesics have significant side effects. A single bolus popliteal block of the neurovascular bundles is effective but short-lived. We have been using a retained perineural catheter with continuous local anaesthetic infusion for pain relief post-operatively. Materials and Methods: This 2 cohort observational study compares pain relief following single bolus dose popliteal block and retained continuous infusion peri-neural catheter. With the patient supine in the anaesthetic room a nerve stimulator identified the tibial and peroneal branches of the sciatic nerve which were blocked with 20mls 0.5% marcaine. In 31 patients a perineural catheter was left in situ and connected to a Stryker “Pain Pump” infusing 0.25% bupivacaine at a rate of 4 ml/hour with 1 ml/hour patient controlled boluses. Following discharge the catheter was removed by the district nurse at 72 hours post-operatively. Results: Patients were asked to fill in Visual Analogue Scores for 72 hours post operatively. The mean pain score for the single block group was 4.9 (range 0–9). The mean pain score for the popliteal catheter group was 1.03 (range 0–5). One patient had an air-lock in the infusion tubing leading to pain once the initial block wore-off. One patient experienced a patch of numbness in the lower leg which resolved by the 2 week follow-up. There were no other complications, such as infection, from placement of the retained popliteal catheter. All patients were satisfied with their post-operative pain control. Conclusion: We recommend this novel technique as an effective method of pain relief after ankle and hindfoot surgery. To confirm our findings we are running a randomised, double blinded, placebo controlled trial to study this method of pain relief

Introduction: Adequate analgesia following hindfoot surgery can be difficult and conventional analgesics have significant side effects. A single bolus popliteal block of the neurovascular bundles is effective but short-lived. We have been using a retained perineural catheter with continuous local anaesthetic infusion for pain relief post-operatively. Materials and Methods: This 2 cohort observational study compares pain relief following single bolus dose popliteal block and retained continuous infusion perineural catheter. With the patient supine in the anaesthetic room a nerve stimulator identified the tibial and peroneal branches of the sciatic nerve which were blocked with 20mls 0.5% marcaine. In 31 patients a perineural catheter was left in situ and connected to a Stryker “Pain Pump” infusing 0.25% bupivacaine at a rate of 4 ml/hour with 1 ml/hour patient controlled boluses. Following discharge the catheter was removed by the district nurse at 72 hours post-operatively. Results: Patients were asked to fill in Visual Analogue Scores for 72 hours post operatively. The mean pain score for the single block group was 4.9 (range 0–9). The mean pain score for the popliteal catheter group was 1.03 (range 0–5). One patient had an air-lock in the infusion tubing leading to pain once the initial block wore-off. One patient experienced a patch of numbness in the lower leg which resolved by the 2 week follow-up. There were no other complications, such as infection, from placement of the retained catheter. All patients were satisfied with their post-operative pain control. Conclusion: We recommend this novel technique as an effective method of pain relief after ankle and hindfoot surgery. To confirm our findings we are running a randomised, double blinded, placebo controlled trial to study this method of pain relief

Introduction: Intra-Discal Electrothermal Therapy (IDET) has been used to treat chronic discogenic low back pain. A novel intradiscal decompression catheter has been developed to reduce local disc bulging in cases of contained prolapse. This new catheter is inserted percutaneously into a disc and advanced under radiographic control into a postero-lateral position targeting the herniation. The decompression catheter uses more focused heating and higher temperatures than previous devices and is intended to provide a local decompression of the disc through a thermally mediated reduction in nuclear volume. The purpose of this study was to investigate changes in internal stress profiles following use of the new catheter. Methods: Five cadaveric lumbar ‘motion segments’ were dissected from two spines (age 64–84 yrs). Each segment was compressed, normally to 1 kN, while a miniature pressure transducer was withdrawn from posterior to anterior across the mid-sagittal diameter of the disc producing a baseline stress profile. A decompression catheter was inserted into the disc and its position confirmed with plain radiography. The temperature of the catheter was increased to 90°C over a period of 14 minutes. Stress profiles were then repeated. Results: Stress profiles in three of the five segments showed changes consistent with degenerative change. In these discs stress profiles following ‘treatment’ showed up to a 35% reduction in the magnitude of stress peaks in the posterior annulus. There was very little change in the distribution of stress in the two non-degenerate discs. Stress in the nucleus appeared unchanged in all discs. Conclusions: Treatment of degenerate discs with the decompression catheter lead to a measurable alteration in annular stress peaks associated with degenerative discs, while non-degenerate discs were unaffected. These preliminary findings of an ongoing study suggest that the novel decompression catheter has a biomechanical effect in certain classes of disc

Introduction: Intra-Discal Electrothermal Therapy (IDET) has been used to treat chronic discogenic low back pain. Proposed mechanisms of action include denervation of the posterior annulus and collagen denaturation. Previous authors have reported on changes in internal disc mechanics following IDET including reduction in stress concentrations possibly leading to a more even distribution of load across the end-plate. 1. A novel intradiscal decompression catheter has been developed to reduce local disc bulging in cases of contained prolapse. This new catheter is inserted percutaneously into a disc and advanced under radiographic control into a postero-lateral position targeting the herniation. The decompression catheter uses more focused heating and higher temperatures than previous devices and is intended to provide a local decompression of the disc through a thermally-mediated reduction in nuclear volume. The purpose of this study was to investigate changes in internal stress profiles following use of the new catheter. Methods: Five cadaveric lumbar ‘motion segments’ were dissected from two spines (age 64–84 yrs). Each segment was compressed, normally to 1 kN, while a miniature pressure transducer was withdrawn from posterior to anterior across the mid-sagittal diameter of the disc producing a baseline stress profile. A decompression catheter was inserted into the disc and its position confirmed with plain radiography. The temperature of the catheter was increased to 90°c over a period of 14 minutes. Stress profiles were then repeated. Results: Stress profiles in three of the five segments showed changes consistent with degenerative change. In these discs stress profiles following ‘treatment’ showed up to a 35% reduction in the magnitude of stress peaks in the posterior annulus. There was very little change in the distribution of stress in the two non-degenerate discs. Stress in the nucleus appeared unchanged in all discs. Conclusions: Treatment of degenerate discs with the decompression catheter lead to a measurable alteration annular stress peaks that have been associated with degenerative disc disease, while non-degenerate discs were unaffected. These preliminary findings of an ongoing study suggest that the novel decompression catheter has a biomechanical effect in certain classes of disc

Objectives: To describe a new method of catheter insertion in Intradiscal Electrothermal Therapy (IDET), when and adequate catheter position cannot be achieved with standard technique. Intradiscal Electrothermal Therapy is a new technique developed in 1998 for treatment of chronic low back pain. Adequate catheter position is of vital importance to the outcome of this procedure. If adequate position is not achieved with the standard technique, the recommendation is to reinsert a new cannula into the contralateral side. This requires more local anaesthesia, further discomfort for the patient and additional X-ray exposure. The “Pig Tail” Technique described here, eliminates the need for reinsertion of the cannula and catheter from the contralateral side in those patients in whom optimal positioning is not achieved with the standard technique. This new technique has not been described before. Methods: In those patients in whom adequate catheter position cannot be achieved with the standard technique, instead of withdrawing the cannula after the initial treatment, we recommend rotating the cannula 180° through its long axis. This will allow the catheter to hit the anterior annulus and deflect backwards towards the cannula. It can then be negotiated across the midline to adequately thermally treat the whole posterior annulus. Results: We have performed our technique in thirty two consecutive patients in whom initial navigation was difficult. This new method proved to be simple and did not cause patients additional discomfort. Conclusion: “Pig Tail” Technique is safe and effective in IDET of those patients with difficult navigation. It avoids the need for second needle insertion therefore avoiding the use of more local anaesthsia, further discomfort for the patient and additional X-ray exposure

Aims. Prompt and sufficient broad-spectrum empirical antibiotic treatment is key to preventing infection following open tibial fractures. Succeeding co-administration, we dynamically assessed the time for which vancomycin and meropenem concentrations were above relevant epidemiological cut-off (ECOFF) minimal inhibitory concentrations (T > MIC) in tibial compartments for the bacteria most frequently encountered in open fractures. Low and high MIC targets were applied: 1 and 4 µg/ml for vancomycin, and 0.125 and 2 µg/ml for meropenem. Methods. Eight pigs received a single dose of 1,000 mg vancomycin and 1,000 mg meropenem simultaneously over 100 minutes and 10 minutes, respectively. Microdialysis catheters were placed for sampling over eight hours in tibial cancellous bone, cortical bone, and adjacent subcutaneous adipose tissue. Venous blood samples were collected as references. Results. Across the targeted ECOFF values, vancomycin displayed longer T > MIC in all the investigated compartments in comparison to meropenem. For both drugs, cortical bone exhibited the shortest T > MIC. For the low MIC targets and across compartments, mean T > MIC ranged between 208 and 449 minutes (46% to 100%) for vancomycin and between 189 and 406 minutes (42% to 90%) for meropenem. For the high MIC targets, mean T > MIC ranged between 30 and 446 minutes (7% to 99%) for vancomycin and between 45 and 181 minutes (10% to 40%) for meropenem. Conclusion. The differences in the T > MIC between the low and high targets illustrate how the interpretation of these results is highly susceptible to the defined MIC target. To encompass any trauma, contamination, or individual tissue differences, a more aggressive dosing approach may be considered to achieve longer T > MIC in all the exposed tissues, and thereby lower the risk of acquiring an infection after open tibial fractures. Cite this article: Bone Joint Res 2022;11(2):112–120

The recent introduction of intra-articular local anaesthetic techniques following total joint arthroplasty have demonstrated improvements in post-operative pain control, early joint mobilisation and may contribute to early discharge. Following intra-operative infiltration, the CALEDonian Technique requires ropivicaine to be administered postoperatively via an epidural catheter and filter, 20 to 40 ml over 60 seconds, on three occasions. Epidural filter catheters are used to prevent bacterial contamination during injection and have demonstrated 100% efficacy when intact. However, on internal departmental audit we have become aware of a filter membrane rupture rate approximating 10%. We therefore investigated the variables of syringe size and rate of administration in the occurrence of filter ruptures. Using a standard primed epidural catheter set (Perifix B Braun), pressure measurements were taken pre- and post-filter. Recordings using the filter with attached catheter tubing were undertaken using 5 ml, 10 ml and 20 ml syringes (n=10) during infusion of a standard 5 ml volume. Controlled (over 1 min and following departmental protocol) and forced (over less than 15 seconds) infusions were undertaken manually and the experiment also undertaken using an automated syringe driver with 40 ml infused at a rate of 400 ml/hr. Each experiment was repeated ten times. Infusion pressures were measured and filters examined for evidence of rupture. Using departmental protocol, controlled infusions independent of syringe size generated consistently low pressures, averaging 115 kPa, with no filter ruptures. Forced administration, independent of syringe size, generated pressures averaging 625.1 kPa. This is above the filter threshold and resulted in almost universal filter rupture. An automated device infusing at a rate of 400 ml/hr again generated low pressures and no filter ruptures. Our study demonstrates low infusion pressures and no filter ruptures, independent of syringe size, when departmental protocol is adhered to suggesting that a human element may be in-part responsible for filter rupture. Although the technique currently used is safe, our audit has raised awareness of a potential difficulty and has lead to re-education of staff involved in this process. Consideration is being given to the possibility of automating infusions in the future and a process of re-audit of filter rupture will be undertaken

Continuous neuraxial or deep peripheral nerve blockade used to provide postoperative analgesia after major orthopaedic surgery is associated with a risk of spinal or perineural haematoma, especially in patients concomitantly receiving anticoagulants. Limited data on the use of fondaparinux in surgical patients in whom this procedure is performed are available. The EXPERT trial was an observational international study in patients undergoing major orthopaedic surgery designed to evaluate the overall efficacy and safety of once-daily 2.5 mg fondaparinux initiated 6 to 12 hours post-operatively and administered for 4±1 weeks after surgery. A 48-hour “therapeutic window” was applied in patients in whom a neuraxial/deep peripheral indwelling catheter was placed: one of the planned doses of fondaparinux was omitted, the catheter was removed 36 hours after the previous fondaparinux dose, and the next fondaparinux dose administered 12 hours after catheter removal. The primary endpoints were symptomatic venous thromboembolism (VTE) and major bleeding 5±1 weeks after surgery. These events were validated by an independent adjudication committee. Overall, 5704 patients (mean age ± SD: 66 ± 12 years) were recruited between July 2003 and October 2004. They underwent surgery for total hip replacement (52%, n=2941), knee replacement (40%, n=2263), hip fracture (6%, n=353), or other indications (3%, n=148). Fondaparinux was given for a median of 35 (range: 1–105) days. Many operations (62%) were performed under regional anaesthesia only. A neuraxial or deep peripheral nerve block catheter was placed in 29% (n=1630) of patients. It was removed between one and two days after surgery in 43% (706/1626), and between three and six days after surgery in 57% (920/1626). Overall, the rate of symptomatic VTE was 1.0% (54/5387); it was 0.8% (13/1535) in patients with catheter and 1.1% (41/3852) in patients without catheter, giving an odds ratio of 0.79 (95% CI: 0.42 to 1.49) in favour of patients with a catheter. The upper limit of the 95% CI being below the predetermined non-inferiority margin of 1.75, the efficacy of fondaparinux in patients with a catheter was therefore not inferior to that observed in patients without a catheter. The rate of major bleeding was 0.8% (42/5382) overall, 0.5% (7/1532) in patients with catheter and 0.9% (35/3850) in patients without catheter. No spinal or perineural hematomas or nerve damage were reported. At 5±1 weeks, 23 (0.4%) patients had died. In conclusion, 2.5 mg fondaparinux given daily for 4±1 weeks after major orthopaedic surgery was both effective and safe in routine practice. This benefit-risk ratio was similar in 1630 patients with a neuraxial/ deep peripheral indwelling catheter in whom a 48-hour “therapeutic window” was applied

Shoulder surgery is associated with moderate to severe post-operative pain. A pain free post-operative period is desirable and appreciated by both patients and therapists and is essential for early rehabilitation. Analgesia can be provided either locally or systemically or by combining the two. A prospective, randomised double blind study was designed to assess the effectiveness of an existing postoperative local analgesic method: using Marcaine through subacromial catheter. Thirty-nine patients were included in the trial. All patients had simple arthroscopic subacromial decompression and no additional pathology to the shoulder. At the end of the operation a standard epidural catheter was inserted into the subacromial space under visual control. Sixteen patients had 0.25% Bupivacaine and 23 patients had normal Saline given in 10 ml boluses six hourly, until required. All patients had access to conventional pain relief (paracetamol, non-steroids, minor opioids, morphine). VAS scores were taken before and one hour after the study bolus was given. In addition the patients were assessed for quality of sleep, opinion about the analgesia provided by the catheter and VAS of pain prior to and post physiotherapy sessions. The physiotherapist also recorded the active forward flexion of the operated shoulder. The number of doses required and all additional analgesic medication were recorded. The use of subacromial local anaesthetic provides significantly better pain relief (P=0.029). However, patients with subacromial local anaesthetic

The purpose of this study was the investigation and treatment of all the complications that may occur from the epidural postoperative analgesia in patients who have undergone major orthopaedic surgery. From October 1999 to April 2002, 200 patients ASA I- III, aged 45–90 (average 72) were studied. They all received postoperative epidural analgesia and were given a mixture of local anaesthetic and Opioid analgesic, more specifically Ropivacaine 2% 10 ml/h and Morphine 0, 1 ug/h via the epidural catheter by means of a stable infusion pump. The analgesic effect covers the patients for the first 2–3 postoperative days and permits earlier and pain free mobilization and physiotherapy. The analgesic result of this method was completely satisfactory with a mean of VAS 96. The most frequent side-effects were nausea and vomiting. Pruritus, mild hypotension, hypaesthesia and motor blockage were documented as well but in a very small percentage. No case of respiratory depression or medical toxicity was mentioned, neither epidural haematoma nor infection due to the placement of epidural catheter. The complications during the recovery phase were treated easily by discontinuation of the infusion or by symptomatic therapy. Epidural analgesia with a steady infusion pump is a secure method of analgesia. However it is of great importance that the patient is informed about the epidural anaesthesia and postoperative analgesia, in a such a way as to attain his/ her consent, participation and collaboration for the best therapeutic result

Purpose. Femoral nerve blockade (FNB) can provide prolonged postoperative analgesia and facilitate rehabilitation following major knee surgery while minimizing opioid-related adverse effects. However, anecdotal data have implicated FNB in post-operative falls, presumably due to a block-related reduction in quadriceps strength. Age, gender and knee replacement surgery have also been previously identified as risk factors for falls in the acute postoperative orthopaedic inpatient setting. We hypothesized that the use of FNB would be an independent predictor of an inpatient fall following total knee replacement (TKR). Method. We examined a cohort of 2,197 patients who underwent TKR in a single academic institution between October 2003 and March 2010. The start date was based on the separate initiation of both a comprehensive regional anesthesia database and an orthopaedic ward Falls Surveillance Program. Patients undergoing revision TKR or unicompartmental arthroplasty were excluded. Age, simultaneous bilateral TKR, gender, body mass index (BMI), and various regional nerve blocks were considered predictors of post-operative falls in a logistic regression model. The database allowed resolution of the type (i.e. femoral, sciatic) and duration (i.e. single-bolus, indwelling continuous perineural catheter) of nerve blockade. Hospital-standard dosing and insertion techniques were employed. Results. The total number of falls was 60 (rate 2.7%), 40 of which occurred within 48 hours of surgery. When compared to patients who did not fall, those who fell were significantly older (699 years vs 6611 years; p=0.03), obese [BMI >30kg/m2] (75% vs 59%; p=0.01) and had continuous catheter FNB (97% vs 86%; p=0.02). The odds ratio of having a fall was 1.04 (1.0–1.07; p=0.008) for each one-year increase in age above the mean age of 66 years, 2.4 (1.3–4.5; p=0.005) for a BMI >30kg/m2 and 4.4 (1.04–18.2; p=0.04) for continuous catheter FNB. Gender, simultaneous bilateral TKR, any sciatic nerve block or spinal anesthetic did not predict an increased risk of acute-care post-operative falls. Conclusion. This is the first study to demonstrate an increased risk of post-operative falls in obese patients and with the use of continuous catheter FNB following TKR. Careful consideration of the use of continuous catheter FNB may be warranted in patients with additional risk factors for falls such as advanced age and obesity

Purpose of the study: Recent data in the literature regarding intra-articular deliver of analgesics during the postoperative period have been encouraging. Patients benefit from optimal analgesia and earlier mobilisation, shortening rehabilitation time and hospital stay and limiting complications. In light of these encouraging results, our institution developed a programme designed to address all postoperative situations associated with implantation of a total knee arthroplasty (TKA). Material and methods: The programme combines pre-operative counselling and a postoperative programme for multimodal anaesthesia in addition to intra-articular analgesia for 24 hours and early mobilisation. We present here the results of this technique in patients undergoing first-intention TKA. We analysed information collected prospectively in all patients who had TKA from January to June 2008: 319 patients in six months. The operation was performed under peridural anaesthesia supplemented by intra-articular ropivacaine delivered by a catheter for 24 hours. Patients were mobilised, or verticalised, the day of surgery according to individual capacities. Data collected included: pain scores, date of the end of physical therapy, and data reviewed at six weeks. Results: A cohort of 305 patients was analysed; 36% of patients were mobilised the day of the operation and 93% on day 2. The rate of urinary catheters was 12% and administration of intravenous fluids 10%. Physical therapists determined that 58% of patients could be discharged on 3 after surgery and 85% on day 5. Eighty-percent of patients were free of nausea or vomiting and had well controlled pain. Regarding function, mean range of motion was 85° at discharge with 31% of patients requiring physical therapy. At six weeks, mean range of motion was 95° and only 5% of patients had lost amplitude (reduction > 10° of range of motion) compared to discharge values. Mean scores on the Oxford questionnaire improved from 43 preoperatively to 26 six weeks postoperatively. Discussion: This multidisciplinary approach guarantees excellent postoperative analgesia with early mobilisation and provides satisfactory results at six weeks. To this can be added the benefit of a lower rate of urinary catheters, administration of intravenous fluids, and physical therapy

To investigate the efficacy of the navigable intradiscal catheter in the treatment and relief of lumbar discogenic back pain. Twenty-three (23) consecutive patients, at this site, were enrolled into the study by this investigator from normal practice. Inclusion criteria included presentation with predominant low back pain with or without referral leg pain lasting longer than 6 months, diagnosis of DDD or IDD confirmed by plain x-rays, MRI, and positive, low pressure discography, and failure of at least 6 weeks conservative treatment. Outcomes were assessed by clinical exam and administration of the SF-36 Health Survey during the baseline, 3, 6, and 12 month visits. All treatments were performed on an outpatient basis. Following the administration of conscious sedation and local anesthetic, a 17-gauge introducer needle was placed by an extrapedicular approach into the symptomatic disc using fluoroscopic x-ray guidance. A navigable catheter was placed circumferentially to the posterior annular wall. Treatment time was 17 minutes at a maximum tissue temperature of approximately 90°C. Intradiscal antibiotics were employed post procedure and all patients were discharged the day of procedure without complications. Thirty-three (33) lumbar discs were treated. Ten patients had single levels treated; thirteen had double levels treated. Twelve month results show significant improvements in pain as measured by a visual analogue scale (56% decrease, p = 0.035), and the SF-36 sub-scales measuring Bodily Pain (93% decrease, p = 0.011 at 6 months), Physical Functioning (65% increase, p = 0.035), and Role Physical (173% increase, p = 0.020). Overall, 80% of the patients were satisfied with their outcomes (p = 0.004). The intradiscal navigable catheter has proven to be effective in the reduction of pain and an increase in functional abilities for patients who suffer discogenic low back pain due to IDD or DDD

Introduction: Treatment of discitis using conventional methods can be prolonged and unrewarding. Patients can have prolonged pain and persistently elevated Inflammatory markers. We propose a new method of treatment of severe cases, and present two cases where this method has successfully been used. Method: Once discitis has been diagnosed clinically and radiologically, a percutaneous discectomy of the infected level is performed. Matter is sent for microbiological analysis. An epidural catheter is then left in the infected disc space cavity. This is then used to administer appropriate antibiotics directly into the infected cavity. After one week the patient is converted on to intravenous antibiotics, for a further two weeks, then a prolonged course of oral antibiotics. Discussion: Discitis can be a difficult and unrewarding condition to treat. This novel method appears to be a new and effective mode of treatment, for both acute and chronic infections, although it does require further evaluation

INTRODUCTION: Treatment of discitis using conventional methods can be prolonged and unrewarding. Patients can have prolonged pain and persistently elevated Inflammatory markers. We propose a new method of treatment of severe cases, and present two cases where this method has successfully been used. METHOD: Once discitis has been diagnosed clinically and radiologically, a percutaneous discectomy of the infected level is performed. Matter is sent for microbiological analysis. An epidural catheter is then left in the infected disc space cavity. This is then used to administer appropriate antibiotics directly into the infected cavity. After one week the patient is converted on to intravenous antibiotics, for a further two weeks, then a prolonged course of oral antibiotics. DISCUSSION: Discitis can be a difficult and unrewarding condition to treat. This novel method appears to be a new and effective mode of treatment, for both acute and chronic infections, although it does require further evaluation

Prevention and treatment of total joint infection is closely related to biofilm formation and concentration of antibiotics achieved in the area around the implants. Most total joint infections are caused by bacteria that enter the wound at the time of the operation. These bacteria can attach to surfaces and rapidly form biofilm that is highly resistant to antibiotics. Prophylactic antibiotics given intravenously achieve concentration of local antibiotics in the knee in response to intravenous antibiotics about 1/3 of that achieved in the serum, and the level is transient. This may be enough to treat the planktonic form of the bacteria, but far from enough to treat the biofilm. The concentration of antibiotics in the joint fluid achieved with antibiotics applied locally during surgery is 1000 times higher, and can be maintained throughout the procedure. High concentration persists in drainage fluid for 24 hours after surgery. Studies done with use of local antibiotics in spinal implant surgery indicate a major reduction in the rate of infection, and cost analysis shows remarkable monetary benefit to this effect.

Infected total joints benefit especially from direct application of antibiotics to the local area. The safety and efficacy of this protocol was evaluated in patients undergoing primary or revision TKA by measuring joint and serum levels of vancomycin following IV administration (as a prophylactic) and IA administration (as a treatment for infected TKA), and comparing the levels with each method. Therapeutic levels of vancomycin were present in the knee following IV or IA administration, but much higher levels were possible with IA administration (avg. of 6.8 and 9,242 µg/mL). Vancomycin achieved therapeutic levels in the synovial fluid of the knee with IV administration, but clearance from the knee was rapid, suggesting that the synovial fluid concentration may be sub-therapeutic for hours before the next IV dose is given. In contrast, IA delivery of vancomycin resulted in peak levels that were thousands of times higher, and trough levels remained therapeutic for 24 hours in both the joint space and in the serum (minimum trough levels of 8.4 and 4.2 µg/mL, respectively). The elimination constant (half-life) of IA-administered vancomycin was 3.1 hours.

Directly infusing antibiotics into the infected area maintains a high local concentration level while minimizing systemic toxicity. This method avoids the use of antibiotic-loaded cement and the potential for growth of antibiotic-resistant strains of bacteria. These findings support single-stage revision in cases treated with cementless revision and IA antibiotics.

Preventing and treating infection in orthopaedic implant surgery requires achieving concentrations that are above the minimal biofilm eradication concentration. This can be achieved only with direct application.

Purpose: We report an evolving technique for managing peri-operative pain relief that has enabled early mobilisation and facilitated early discharge after primary Total Knee Arthroplasty (TKA).

Methods and Results: Our organisation has instituted a regime covering all aspects of the peri-operative care for TKA. This includes: pre-operative counselling and preparation; multimodal anaesthesia and analgesia regime; intra-articular analgesia for 24 hours post-operation; early mobilisation regime. We carried out an audit of prospectively collected data of all patients undergoing primary TKA in the six months from January to June 2008 (total of 319 patients), including pain scores, discharge from physiotherapy and follow up data at six weeks.

A total of 305 TKAs with complete data sets were included in the analysis. Of these 36% were mobilised on the day of surgery and 93% by post-operative day 1. Catheterisation rates were 12% and the need for postoperative intra-venous fluids was 10%. In-house physiotherapy discharged 58% of patients by day 3 and 85% by day 5. The visual analogue pain scores (on movement) on day zero and day one were within acceptable limits (median = 3) and 80% of patients experienced no nausea or vomiting.

Functionally, the median range of movement at discharge was 85° with 31% of patients requiring out-patient physiotherapy assessment. At six weeks the median range of motion was 95° with only 5% of patients having a reduced range of motion (reduction of > 10°) when compared to discharge. The median Oxford scores improved from 43 pre-operatively to 26 at six weeks.

Conclusion: This regime offers an efficient method for post-operative pain relief and early mobilisation with the added benefit of reducing post-operative catheterisation, intra-venous fluid requirements and the need for post-operative physiotherapy. It compares very favourably with published data on other peri-operative regimes using regional anaesthesia.