Objectives

The diagnosis of periprosthetic joint infection (PJI) is difficult and requires a battery of tests and clinical findings. The purpose of this review is to summarize all current evidence for common and new serum biomarkers utilized in the diagnosis of PJI.

Outsourcing elective surgery has become increasingly commonplace to meet increasing demand from a growing & aging population. There is concern that outsourcing was influencing the nature of residual workload that was unsuitable for treatment elsewhere. This led to the impression that our unit is operating on more complex patients orthopaedic problems, ASA and Body Mass Index (BMI). By losing a disproportionate number of straightforward patients our department's outcomes, productivity and training opportunities could be adversely affected.

Retrospective analysis of prospectively collected data of primary hip / knee arthroplasties between July & December for 2014(pre-outsourcing), 2015 and 2016(post-outsourcing). ANOVA, Tukey Honest Significant Difference(HSD) and Pearson's correlation used.

Total of 726 primary arthroplasties were performed with an almost 50 % reduction post outsourcing. Post-outsourcing, BMI and ASA were significantly worse with a ANOVA of p=0.001 and HSD p=0.003. Length of stay increased from 5.4 days in 2014 to 6.2 days in 2015 ANOVA p< 0.001 but decreased in 2016. BMI significantly affected operating time (Pearson's r =0.12, p< 0.05) and anaesthetic time (Pearson's r =0.19, p< 0.05). ASA significantly affected length of hospital stay, p< 0.01 and operation time, p=0.007 but no effect on anaesthetic time.

In conclusion, we are operating on more complex patients due to current outsourcing setup. Implications for short-term were on anaesthetic and operation time, inpatient stay and training opportunity were affected, with possible long-term implications on individual surgeon and unit outcomes (complications, patient satisfaction).

The study was designed to look at canine related injuries presenting to the orthopaedic department at a small rural district general hospital and to assess their cost to the NHS.

A retrospective review of case notes and x-rays of all dog related injuries presenting to the orthopaedic services at our hospital over a one year period starting January 2011 was undertaken. The injuries involved and the treatment provided along with the direct financial cost of these services were calculated from trust tariffs.

Dog related injuries accounted for 84 out of a total of 48,405 patients presenting to the accident and emergency services over the index period. Of these, 29 required orthopaedic input with 57% of injuries resulting from trying to restrain a dog and the rest from being attacked by a dog. 14 patients were admitted to the wards with 11 among them requiring orthopaedic interventions ranging from wound wash outs and debridement to open reduction and internal fixation of fractures. These procedures cost £38,951 to the NHS. There were a total of 38 inpatient days involved costing another £9,196. A further 28 clinic visits were billed at £4,032. The total cost for the orthopaedic services provided was £52,179. There were no mortalities associated with these injuries over the time period.

Canine related injuries are costly and avoidable. General public awareness of the problem coupled with appropriate legislation and its strict enforcement may be necessary to protect people from our canine companions.

Sitting is the main activity of daily living for the majority of patients with cerebral palsy. More than 60% of dependent sitters have hip disorders. Surgical management of hip and pelvic postural mal-alignment remains controversial.

The aim of this study was to investigate effectiveness of open hip release in patients with spastic hip deformities. Seventeen patients with spastic cerebral palsy were treated with a selective release of the adductors, hamstrings, and iliopsoas, and capsulotomy of the hip joint. There were 6 females and 9 males. Ten of the patients were nonambulatory and seven were ambulatory. The average age at operation was 6 years 4 months (4 to 14 years). The follow-up period ranges from 2 to 9 years (average of 4.8 years). The patients were evaluated clinically and radiologically. The migration and acetabular indices were measured on the pre-operative and follow-up radiographs.

The results of hip release were rated satisfactory in 12 patients and unsatisfactory in 5 patients. The latter was due to severe acetabular dysplasia and posterior instability that was later improved by acetabuloplasty.

We concluded that a soft tissue release of spastic hip deformities improved sitting stability in nonambulatory and walking posture in ambulatory patients.

Osteogenesis imperfecta (OI) is characterised by decreased bone density and increased bone fragility.

We studied the effect of bisphosphonates on clinical features and bone mass, enrolling to the study 22 children with OI treated with these drugs. Sixteen of them received continuous oral alendronate and six received cyclical IV pamidronate. Evaluation included mobility score, fracture rate, chemistry of skeletal remodelling, iliac crest biopsy and DEXA assessment of bone mass.

After 18 months of bisphosphonate therapy, 10 patients were fully assessed. There was a definite clinical improvement, with significantly improved mobility (p =0.04), a reduction in the annualised fracture rate from 1.27 to 0.44, and significant improvement in bone mass density (p =0.01).

We treated 31 feet in 17 children with myelomeningocele by extra-articular subtalar arthrodesis. Two patients were lost to follow-up. In the rest, we assessed the correction of valgus deformity and the growth of the tarsal bones. At operation the mean age of the eight girls and nine boys was 6.3 years (3 to 9). At a mean follow-up period of 5.5 years (3 to 9) patients were evaluated clinically and radiologically. We assessed calcaneal growth by calculating the ratio of calcaneal and naviculo-metatarsal longitudinal length on the preoperative and follow-up lateral radiographs.

Results of valgus correction were good in 19 feet. In eight they were unsatisfactory owing to progressive valgus of the ankle. Orthotic fitting was difficult and pressure sores over the medial malleolus often developed. Four of the patients underwent further correction by distal tibial osteotomy. The growth ratio was increased in 15 feet, remained the same in seven and decreased in five. Extra-articular subtalar arthrodesis produced satisfactory partial correction of a complex valgus deformity and stability of the hindfoot, and did not have a detrimental effect on the growth of the calcaneus.

Talectomy was performed on 31 rigid clubfeet in 13 boys and 10 girls. Sixteen patients had myelomeningocele and seven arthrogryposis. The procedure was undertaken as a salvage operation on 22 feet. Seven patients had an additional cuboidectomy. The mean age of the patients was 3.7 years (2 to 9).

The patients were followed up for a mean of 4.5 years. Assessment included foot position, appearance and mobility, orthotic or shoe-wear fitting and walking capacity. Calcaneal position at the ankle was assessed radiologically. The results in 18 feet were good and in seven were satisfactory. There were six failures. Primary talectomy produced better results in children above the age of two years than ssecondary procedure in the older children. One of the patients developed a severe vascular complication, followed by sepsis, and required amputation of the foot. The other failures were due to recurrence of equines deformity.

Talectomy performed for severe rigid clubfoot achieved satisfactory correction in most of our patients. Excision of the talus as a salvage procedure carries a risk of incomplete correction and vascular complication.

Patients with spastic diplegia who walk with a crouched posture often suffer from anterior knee pain, thought to be due to cephalad displacement of the patella. Ambulation with flexed knees elongates the patellar tendon, which leads to development of patella alta. Our study of 57 patients with spastic diplegia aimed to determine the severity of patella alta and to investigate its correlation with spasticity and muscle imbalance at the level of the knee.

The ages of the 31 male and 26 female patients ranged from 3 months to 16 years. They were divided into two groups, one with spasticity of the hamstrings and the other with combined spasticity of the quadriceps and hamstrings. Clinical evaluation documented anterior knee pain, walking capacity, fixed deformities, hamstrings and rectus femoris shortening, and patellar mobility. Lateral radiographs were taken to measure the length of the patella and the patellar tendon. We used the method described by Insall and Salvati to calculate the patellar ratio. The clinical findings were examined for correlations with the severity of patella alta.

We found that the group of patients with quadriceps and hamstring spasticity had a higher rate of patellar displacement but less frequent anterior knee pain than the group of patients with hamstring spasticity alone.