Aim. Swedish guidelines on antibiotic prophylaxis in arthroplasty surgery recommend cloxacillin in fixed doses that pay little attention to the patient's renal function and weight. Nevertheless, there are no studies on whether the resulting free prophylactic cloxacillin in vivo concentrations are optimal. We aimed to evaluate whether the current recommended prophylactic dosage of cloxacillin is adequate. Method. We performed a prospective two-centre study, measuring the free (active) cloxacillin concentrations in plasma throughout surgery, in patients subject to primary hip and knee prosthetic joint replacements, aiming at 100 patients per centre. To account for plasma-bone exposure differences, concentrations were considered adequate if twice the epidemiological cut-off value for cloxacillin concerning wild type Staphylococcus aureus whereas two-three times were labelled threshold values. The two enrolling hospitals are acute care hospitals in central Sweden, also performing 600 - 1200 primary hip and knee joint arthroplasties annually. All patients scheduled for elective primary hip or knee replacements from January 2022 to April 2024 were eligible for participation. Exclusion criteria were allergy towards penicillins, cognitive disorders leading to inability to sign informed consent, and an absence of interpreter in case of a patient not speaking Swedish or English. Results. We present results from the first 49 patients included. Four patients had free cloxacillin concentrations below cut-off (8.2%). These four cases had prolonged surgeries of 77-100 minutes. An additional 5/49 (10.2%) had threshold values. Conversely 5/49 (10.2%) cases had concentrations exceeding 15 times the needed. No cases with threshold or low cloxacillin concentrations were attributable to a lack of concerning timing and dosing of cloxacillin. All concentrations were above or equal to our cut-off at the start of surgery. Eighteen percent of patients were of normal of weight (BMI 18.5- 25). Of the rest 4% were morbidly obese (BMI >40), 41% obese (BMI 30-40) and 37% overweight (BMI 25-30). Twenty seven percent (43/159) had diabetes and 45% suffered cardiac disease. Conclusions. Some patients in our cohort had insufficient active cloxacillin levels at the end of prosthetic
The Journal of Bone and
Foot and ankle is a well-established and growing sub specialty in orthopaedics. It accounts for 20 to 25 per cent of an average department's workload. There are two well established foot and ankle specialist journals but for many surgeons the Journal of Bone and Surgery (JBJS) remains the preeminent journal in orthopaedics and a highly sought after target journal for publication of research. It is our belief that foot and ankle surgery is underrepresented in the JBJS. We undertook a study to test this hypothesis. We analysed all JBJS (British and American editions) volumes over a 10 year period (2001 to 2010). We recorded how many editorials, reviews, original papers and case reports were foot and ankle related.Introduction
Methods
From 1998 to July 2003 admissions for elective arthroplasty surgery in Derriford Hospital were nursed alongside other orthopaedic and general medical patients. Since August 2003 a policy of pre-operative MRSA screening and a unit reserved exclusively for MRSA-free joint replacement patients have been used. No transfers from other wards were allowed. Patients positive on screening underwent eradication and were admitted to a different ward where they received teicoplanin on induction (in addition to standard policy cephradine). All post-operative wound infections following THR & TKR were monitored (NINSS surveillance system). Infections within 3 months were recorded. A control of non-screened hip hemi-arthroplasty patients was used to ensure a departmental wide reduction in MRSA was not occurring. 1.9% MRSA carriage rate was detected over the study. Before screening, 0.59% of 3386 cases were acutely infected with MRSA. After institution of screening and a dedicated MRSA free unit, 0.10% of 1034 were acutely infected. This was a 6-fold decrease (p<0.05). The infection noted was in a patient treated outside the ringfenced unit on High Dependency. In fact the infection rate on the ringfenced unit was zero. MRSA infection in the control was statistically unchanged during this period. A policy of MRSA screening and an MRSA free joint replacement ward reduces the incidence of acute MRSA infections.Conclusion
Randomised controlled trials (RCT) published in the British volume of the JBJS from United Kingdom based institutes have been analysed to review the level of involvement of junior doctors over the past 25 years (1988 to 2012) which included three different training eras: Pre-Calman (1988 to 1995), Calman (1996 to 2006), and MMC (2007 to 2012). Authors were divided into: Senior doctors, Registrars, Fellows, Senior House Officers/ Foundation Doctors, and Others. The level of involvement has been identified as being first author, senior author or co-author. One hundred and fifty nine RCTs have been identified with a total of 705 authors. Eighty eight registrars, 32 fellows and 19 SHO/ Foundation doctors have been involved in RCT published over the last 25 years (19.7%). Registrars constituted 15% of all authors in the pre-Calman, 12% in the Calman and 11% in the MMC periods. They constituted 33% of all first authors in the pre-Calman, 21% in the Calman, and 12% in the MMC periods. With regards to SHO/ Foundation doctors, they were only 2% of all authors in the pre-Calman, 3% in the Calman, and 4% in the MMC periods. They were not the first author in any RCT in the pre-Calman period, rising to 7% in both the Calman and MMC periods. Our study shows that registrars involvement was at its highest in the pre-Calman era with gradual decline in their involvement in the subsequent training eras. SHO/Foundation doctors involvement remains very low, however showing increasing rate in the MMC era.
Chemical debridement is a fundamental step during Periprosthetic joint infection (PJI) surgery. Antiseptic solutions are commonly used, but evidence on the optimal antiseptic, concentration, and irrigation time is lacking. The aim of this study is to analyze and compare the anti-biofilm capacity of povidone iodine, H202, acetic acid and Bactisure™ after different exposure times, as well as their combinations. Surgical steel discs inoculated with methicillin susceptible (MSSA) and resistant Aim
Method
Since Aug‘03 pre-operative MRSA screening &
a ward reserved exclusively for MRSA free joint replacement patients has been used. All postoperative wound infections within 3 months following THR &
TKR were monitored. Before screening, 0.59% of 3386 were acutely infected with MRSA. After institution of study policy, 0.10% of 1034, were infected with MRSA.. This was a 6 fold decrease (p<
0.05). The rate of MRSA infection in a control of hemiarthroplasties was unchanged during this period. A policy of MRSA screening &
an MRSA free joint replacement ward reduces the incidence of acute MRSA infections.
The role of
The treatment of patients with osteoarthritis of the knee and associated extra-articular deformity of the leg is challenging. Current teaching recognises two possible approaches: (1) a total knee replacement (TKR) with intra-articular bone resections to correct the malalignment or (2) an extra-articular osteotomy to correct the malalignment together with a TKR (either simultaneously or staged). However, a number of these patients only have unicompartmental knee osteoarthritis and, in the absence of an extra-articular deformity would be ideal candidates for
Introduction: The majority of patients with extremity osteo-sarcoma undergo limb salvage surgery. The most common location is about the knee, where at least one half of the knee joint is usually removed. A select group of patients with proximal tibial osteosarcomas had preservation of the entire articular surface following reconstruction. Method: Since 1993, 67 patients with osteosarcoma have been treated. Sixteen patients had tibial tumors. The original MRI of five patients showed part of the condyle appeared uninvolved. These five underwent
The purpose of this single center study was to analyze the robustness and thoroughness of debridement and irrigation in first stage procedures for periprosthetic joint infections in which the latter had been confirmed by fulfilling the PJI criteria produced by the musculoskeletal infection society. After introduction of ‘a clean phase’ concept in our center, we developed a method of using new instrumentation sets and waterproof cover sheets as well as sets of gloves and aprons after thorough debridement followed by copious irrigation under a splash sheet, once the prosthetic components were removed during which several (6 to 8) tissue biopsies and cultures were harvested. ‘Clean phase’ tissue specimens ad random were again obtained and cultured and compared with ‘dirty phase’ cultures and sonication results. Our zero hypothesis was that we were not able to entirely eradicate bacterial colonization. We tested this hypothesis during a period of 18 months in a consecutive series of first stage revisions for PJI at our center after introduction of the clean phase concept.Aim
Method
Hip impingement is a diagnosis that has been increasingly recognized among young patients with hip pain. Two different types of impingement have been described. Over coverage impingement, or a “pincer” effect, occurs between the anterior wall or labrum of the acetabulum and the femoral head. This is typically due to a decrease in anteversion of the acetabulum or over-coverage of the femoral head (coxa profunda or protrusio). A so-called cam-effect impingement occurs when the femoral head-neck junction has an abnormally large radius resulting in insufficient offset. Widening of the femoral neck reduces its concavity, creating an impingement over the acetabular rim. Thus, the anterolateral junction is forced under the acetabular rim, resulting in labral injury and deterioration of the cartilage. Options for treatment of impingement include non-operative management, arthroscopic débridement, trimming of the anterior aspect of the acetabular rim after surgical dislocation of the hip, periacetabular osteotomy when impingement is secondary to an acetabular torsion abnormality, and surgical resection of a femoral neck bump and/or part of the anterolateral aspect of the neck when the primary anatomic abnormality is secondary to insufficient head-neck offset. Resection of a portion of the anterolateral aspect of the femoral head-neck junction improves the femoral head-neck ratio, increasing the range of motion before impingement occurs. Recently, surgical dislocation has been used for achieving full access to the femoral head and the acetabulum. Surgical dislocation and resection osteochondroplasty were performed in 22 hips from January 2001 to Decem-ber 2004 because of anterior impingement resulting from an idiopathic nonspherical femoral head, mild slipped capital femoral epiphysis, or poor offset at the head-neck junction. Osteonecrosis was not observed in the hips treated with this method. Pain and function markedly improved after the index operation. Two patients required hardware removal. Treatment goals in young patients with hip impingement should be pain relief and, prevention of further damage to the cartilage and subsequent osteoarthritis. Surgeons using this technique need to know the amount of bone that can be removed safely before catastrophic weakening of the femoral neck occurs.
To elaborate upon the complex variety of successful reconstructive techniques for limb salvage surgery for the management of aggressive juxta-articular and peri-acetabular bone tumors. Limb sparing surgery, while complex, continues to gain wider acceptance among an increasing number of highly specialised musculoskeletal oncology surgeons. The collective experience of the Musculoskeletal Sarcoma Group at The University of Calgary has utilised a variety of limb and joint salvage techniques in its armamentarium for reconstruction of such cases. Whether malignant or benign, aggressive lesions occur at or near the joint resulting in marked subchondral bone destruction or pathologic fractures. comprehensive stepwise plan can result in a stable, pain free and functional joint with limb sparing. The author has utilised local tumor removal and cementation with polymethylmethacrylate with and without secondary internal fixation. ome cases have been amenable to massive osteoarticular allografts, and more recently, tumor endoprostheses. The North American experience with massive oncology prostheses is growing, resulting in increased opportunities for limb and
It has been proposed that scoring systems could be nationally used, initially on a secondary care level as a method of prioritising patients on waiting lists for hip and knee arthroplasty. If this were to be successful, scoring systems could be used as a way of tackling the ever increasing waiting list times for surgery which currently stand at around 15 months on the NHS. I studied and compared the New Zealand and Oxford Hip and Knee Scores, collecting data from 79 patients over a period of seven weeks. I found that generally, patients who scored highly were recommended for surgery; however I also found that in the group of patients recommended for surgery there was a wide range of scores obtained. There was also a great deal of overlap between the scores obtained by those who were recommended for surgery and those who were not. This means that it would be very difficult to predict a decision for an individual patient based purely on their scores. In addition, many confounding variables can affect the wide range of scores obtained. I concluded that there was too much variation between the scores obtained by patients undergoing surgery to be able to consistently and fairly prioritise them. In order to implement the use of scoring systems in this country, nationally approved criteria and priority banding categories need to be established. Scoring systems need to be modified to be clearer and to cover more variables. Larger studies need to be conducted with more patients and over a longer period of time; and further work could be done into the proposal that GP’s could use these systems as a tool for referral to consultant out-patient clinics.
Hip arthroscopy is a relatively new procedure and evidence to support its use remains limited. Well-designed prospective clinical trials with long-term outcomes are required, but study design requires an understanding of current practice. Our aim was to determine temporal trends in the uptake of non-arthroplasty hip surgery in England between 2001 and 2011. Using procedure and diagnosis codes, we interrogated the Hospital Episode Statistics (HES) Database for all hip procedures performed between 2001 and 2011, excluding those relating to arthroplasty, tumour or infection. Osteotomy procedures were also excluded.Introduction
Methods
Total joint replacement (TJR) was one of the most revolutionary breakthroughs in
Pacific people in New Zealand experience significant disparity in health outcomes. There is little known about the burden of arthritis within this community or difficulties accessing specialist orthopaedic care. This qualitative study evaluated the experiences of Pacific patients who underwent hip or knee arthroplasty with a goal to identify barriers to accessing arthroplasty for this community. We interviewed Pacific patients within the Bay of Plenty region who had received either elective hip or knee arthroplasty between 2013 and 2022. Interviews were centred on perceptions of arthritis severity, duration of symptoms, primary care and specialist interactions. Patients were encouraged to offer feedback on ways to improve this experience. We identified 6087 publicly funded primary joints performed in Tauranga hospital and 58 patients were of Pacific ethnicity. After exclusion criteria was applied, we successfully interviewed 20 patients eligible for our study. Pacific patients represented 2.9% of the of the BOP catchment but only received 0.43% of the publicly funded joints. Most reported reluctance to seek help from primary care until symptoms were present for at least a year. Most commonly cited reasons for not seeking help were fear of hospital services and lack of awareness in the community about osteoarthritis. We identified a lack of community awareness of osteoarthritis and arthroplasty among Pacific. This may result in delayed presentation to primary care and decreased utilisation of publicly funded
Background. The diagnosis of periprosthetic joint infection (PJI) remains a challenge in clinical practice and the analysis of synovial fluid (SF) is a useful diagnostic tool. Recently, two synovial biomarkers (leukocyte esterase (LE) strip test, alpha-defensin (AD)) have been introduced into the MSIS (MusculoSkeletal Infection Society) algorithm for the diagnosis of PJI. AD, although promising with high sensitivity and specificity, remains expensive. Calprotectin is another protein released upon activation of articular neutrophils. The determination of calprotectin and joint CRP is feasible in a routine laboratory practice with low cost. Purpose. Our objective was to evaluate different synovial biomarkers (calprotectin, LE, CRP) for the diagnosis of PJI. Methods. In this monocentric study, we collected SF from hip, knee, ankle and shoulder joints of 42 patients who underwent revision or puncture for diagnostic purposes. Exclusion criteria included a