Introduction

Acute kidney injury is a recognised post-operative complication in primary joint replacement. Recently it has been demonstrated that antibiotic regimen can significantly impact on the proportion of patients who develop acute kidney impairment post-operatively. Within our unit an increased rate of acute kidney injury had been noted post-operatively over the last 5 years. This increase followed the introduction of a rapid recovery protocol for arthroplasty patients. Our aim was determine whether we could identify a causative factor or those who were at increased risk of post-operative renal impairment.

Introduction

Needle guided biopsy of a suspected musculoskeletal malignancy has become increasingly popular as an effective modality for diagnosis. Biopsy performed in a safe manner should be performed in a centre which is also capable of performing the definitive management of such conditions. Our aim was to determine accuracy and success rates of the image guided biopsies performed by our service.

Introduction:

When having to remove broken or embedded metal implants using high speed burrs, the consequence is often a significant amount of metal debris which becomes embedded in the soft tissues. This may then act as a source for a foreign body inflammatory reaction or as a third body wear in the situation of joint arthroplasty. We describe a simple, cheap and effective method of reducing this debris using only a sterile water-based lubricating gel.

Deep infection represents one of the most devastating complications of total knee arthroplasty. Commonly implicated organisms are gram positive bacteria such as staphylococcus aureus, staphylococcus epidermidis and group B streptococcus. Occasionally, infection may be caused by rare organisms, particularly in the immunocompromised host.

We present a case of infected total knee arthroplasty in a penicillin allergic patient, caused by Pasteurella multocida, 13 weeks after the initial surgery. This was treated by open debridement and change of insert as well as aggressive antibiotic therapy. The patient admitted contact with a cat and three dogs at home.

Pasteurella multocida is a facultatively anaerobic gram negative coccobacillus. It is a commensal in the nasopharygeal tract of domestic pets such as cats and dogs. Human infection can often be attributed to a bite or scratch. Prosthetic joint infection caused by Pasteurella is uncommon. Only a few cases have been reported in the literature.

Our case has several learning points: (1) It is very important to definitively identify Pasteurella because standard therapy for prosthetic joint infection (e.g. flucloxacillin or vancomycin) is not optimal for this species.(2) Pasteurella are susceptible to penicillin, but the optimal antibiotic therapy for infections in patients allergic to beta lactam antibiotics is uncertain. A combination of ciprofloxacin and linezolid is recommended. (3) There is no consensus regarding appropriate management. There are reports of washout and antibiotic therapy alone, single and two stage revision procedures. In our case, at five months follow up, open debridement and change of insert along with antibiotic treatment appears to have been effective, although more long term follow up is required. (4)Post arthroplasty, all patients with pets at home should be advised to seek medical attention following any bite or scratch so that timely prophylaxis can be administered before sepsis becomes deep-seated.

Fifth metatarsal fractures are common and the majority unite regardless of treatment. A sub-type of these fractures carries a risk of non-union and for this reason many centres follow up all 5^th metatarsal fractures. In 2011, a standardised protocol was introduced to promote weight-bearing as pain allowed with a tubigrip or Velcro boot according to symptoms. No routine fracture clinic appointments were made from A&E but patients were provided with information and a help-line number to access care if required. Some patients still attended fracture clinics, but only after review of their notes/X-rays by an Orthopaedic Consultant, or after self-reported “failure to progress” using the special help-line number.

Audit of a year prior to the introduction of the protocol and the year following it was performed. All x-rays taken at presentation in A&E were reviewed and classified independently (KBF/JM) for validation.

During 2009/2010, 279 patients presented to A&E with a 5^th metatarsal fracture and were referred to a fracture clinic. 106(38%) attended 1 appointment, 130(47%) attended 2 appointments and 31 (11%) attended 3 or more appointments – 491 appointments in total. 3% failed to attend the clinic. Operative fixation was performed in 3 patients (1.07%).

In 2011/2012, of 339 A&E fractures, only 63 (19%) attended fracture clinic. 37 (11%) attended 1 appointment, 12 (4%) 2 and 9 (3%) 3 or more appointments – 96 appointments in total. Four patients (1.17%) required operative fixation.

Our study did not demonstrate any added value for routine outpatient follow-up of 5^th metatarsal fractures. Patients can be safely allowed to weight bear and discharged at the time of initial presentation in the A&E department if they are provided with appropriate information and access to a “help line” run by experienced fracture clinic staff. The result is a more efficient, patient-centred service.

The aim of this study is to assess the discrepancy between weight bearing long leg radiographs and supine MRI alignment. There is currently increasing interest in the use of MRI to assess knee alignment and develop custom made cutting blocks utilising this data. However in almost all units MRI scans are performed supine and it is recognised that knee alignment can alter with weight bearing. 46 patients underwent MRI scans as pre-operative planning for Biomet signature total knee replacement and the measure of varus or valgus deformity on MRI was obtained from the plan produced by Biomet Signature software system. 41 of these patients had long leg weight bearing radiographs performed. 37 of these radiographs were amenable to measuring the knee alignment on the picture archiving and communication system (PACS). These measurements were performed by two assessors and inter-observer reliability was satisfactory. There was a significant difference between the alignment as measured on supine MRI compared with weight bearing long leg films. In knee arthroplasty one of the aims is to correct the biomechanical axis of the knee and one of the appeals of custom made cutting blocks is that this can be achieved more easily. However it is important to realise that alignment is not a static value and thus correcting supine alignment may not necessarily result in correction of weight bearing alignment.

Magnetic resonance imaging (MRI) continues to become more widely accessible as an investigation, with an increasing number of scans being performed in the outpatient setting for suspected shoulder pathology.

We performed a retrospective review of all shoulder MRI scans performed in an orthopaedic outpatient setting in a district general hospital between October 2010 and October 2011. We also reviewed the medical notes for these patients. 75 MRI Shoulder scans were performed on 74 patients. In 5 cases (7%), no other form of imaging was performed prior to MRI scan. 11 patients (15%) had no provisional diagnosis included in the referral. The nature of referral, indication for MRI and subsequent management of these patients was also examined.

Our findings may support the use of guidelines for requesting MRI scans of the shoulder in outpatients.

This case report describes a patient with thoracic plasmacytoma, an uncommon haematological malignancy, who presented with neck pain. Plasmacytoma is a neoplastic proliferation of B cell lineage but is much less common than multiple myeloma. The histological examination of multiple myeloma and plasmacytoma is identical however in plasmacytoma there is a solitary lesion with negative skeletal survey, negative bone marrow aspirate and little or no myeloma protein detected in the blood. This makes it more challenging to diagnose and a high index of suspicion is required.

We present a case of a 14 year old who sustained an isolated injury to her foot while horse riding. X-rays demonstrated a medial and plantar dislocation at the level of the talo-navicular and calcaneo-cuboid joint, with associated fractures of the cuboid and navicular. This was treated initially with open reduction and fixation with kirschner wires as the injury was grossly unstable and reduction difficult to maintain with casting alone. CT scan was then performed prior which confirmed satisfactory reduction of the dislocation and fixation with the k wires so these were left in situ and the navicular fracture reduced and fixed with a barouk screw.

The Chopart joint was first described by French surgeon Francois Chopart as the talo-navicular and calcaneo-cuboid joints were a practical level for amputation. Injury here is a rare but missed in 40% at presentation. Pure dislocation occurs in 10–25% with most having concomitant fractures. The Chopart joint has critical role in balance and stability in normal gait. Early recognition allows prompt reduction and fixation of these injuries which has been associated with a better outcome. However these are severe injuries and patients should be counselled on potential long term functional impairment even with optimal management.

The aim of this study is to assess the discrepancy between weight bearing long leg radiographs and supine MRI alignment. There is currently increasing interest in the use of MRI to assess knee alignment and develop custom made cutting blocks utilising this data. However in almost all units MRI scans are performed supine and it is recognised that knee alignment can alter with weight bearing. 46 patients underwent MRI scans as pre-operative planning for Biomet signature total knee replacement and the measure of varus or valgus deformity on MRI was obtained from the plan produced by Biomet Signature software system. 41 of these patients had long leg weight bearing radiographs performed. 33 of these radiographs were amenable to measuring the knee alignment on the picture archiving and communication system (PACS). These measurements were performed by two assessors and inter-observer reliability was satisfactory. There was a significant difference between the alignment as measured on supine MRI compared with weight bearing long leg films. In knee arthroplasty one of the aims is to correct the biomechanical axis of the knee and one of the appeals of custom made cutting blocks is that this can be achieved more easily. However it is important to realise that alignment is not a static value and thus correcting supine alignment may not necessarily result in correction of weight bearing alignment.

Background: Patients undergoing elective Lower limb arthroplasty are at increased risk of deep vein thrombosis (DVT). On reviewing the literature, there is a lack of evidence about the best time to administer anticoagulants post-operatively - recommended between 6 and 12 hours. In addition the recent American College of Chest Physicians guidelines recommends that postoperative DVT prophylaxis is given for a minimum of 10 days.

The principal aim of this audit was to assess the timing and duration of thromboprophylaxis post-arthroplasty in our unit.

Methods: Data was collected prospectively. We recorded the timing of the first post operative dose of Fragmin following closure of the wound along with duration of treatment. 5 months of data were analysed; changes were suggested and implemented. This included 2 post operative Fragmin ward rounds. The first at 6pm for patients undergoing surgery in morning and a second at 10pm for those in the afternoon. All patients now receive prophylaxis for 10 days. If they were discharged before 10 days they were sent home on Fragmin. A further analysis was carried out six months later for a further five months.

Results: Initial Audit – 330 patients – primary hip or knee replacement

The timing from finishing surgery to receiving Fragmin ranged from 0:31 to 8:37. 11% received Fragmin less than 2 hours post operatively, 12% 2–4 hours post operatively, 27% 4–6 hours and 49% 6–8 hours

The Duration of prophylaxis ranged from 3 to 32 days. 54% received prophylaxis for less than 7 days.

Second Audit – 337 patients – primary hip or knee replacements

The delay from completing surgery to receiving Fragmin ranged from 2:05 to 9:38. Now only 2% received Fragmin less than 4 hours post operatively. Only 51%, however received Fragmin 6–10 hours post op.

All patients received Fragmin for a minimum of 10 days in the second audit

Discussion: The initial audit highlighted potentially dangerous practice in our venous throboprophylaxis regime. Changes were instituted.

The new protocol for post-operative Fragmin administration had little impact on the percentage of patients receiving Fragmin within 6 hours of surgery. The results, however, show that only 8 of these patients received anti-coagulation within 4 hours, a definite improvement on the initial audit.

Following the changes to Fragmin continuation at discharge, inpatient stay is now not an indicator of duration of Fragmin therapy. All patients now receive 10 days of Fragmin, either as inpatients or in the community.

Conclusion: The change in protocol has reduced the number of patients receiving anti-coagulation less than 4 hours after surgery. However there are still a significant number of patients who receive Fragmin under the recommended 6 hours post-operative.