In 2011 health policy dictated a reduction in iatrogenic infections, such as Clostridium difficile (C. diff), this resulted in local change to antimicrobial policy in orthopaedic surgery. Previous antimicrobial policy was Cefuroxime, this was changed to Flucloxacillin and Gentimicin. Following this change an increased number of patients appeared to suffer from acute kidney injury (AKI). We initially evaluated the incidence of AKI pre and post antibiotic change and found a correlation between the Flucloxacillin and AKI. We then made changes to antibiotic policy to mitigate the increased rates of AKI and proceeded to evaluate the outcomes. In this prospective study all patients admitted with fracture neck of femurs were identified from the National Hip Fracture database and data obtained. The degree of AKI was classified according to the validated RIFILE criteria. Evaluation showed a 4 fold decrease, from 13% to only 3%, in AKI after introduction of the modified antibiotic policy. C.difficile continues to be non-existent since this change. Flucloxacillin obviously had a significant impact on this patient group. However, we have shown that with appropriate changes to antibiotic policy AKI associated morbidity can be significantly reduced. Dose dependent antibiotics will now be given based on weight and eGFR.
In late 2011 there was a change in antimicrobial policy in orthopaedic surgery to reduce the Clostridium difficile (C. diff) rate, this was inducted top down from government, to PCT, to hospital trust. The previous antimicrobial policy was Cefuroxime, this was changed to Flucloxacillin and Gentimicin. Following this change it was noticed an increased number of patients appeared to suffer from acute kidney injury (AKI). This led us to evaluate the incidence of AKI pre and post antibiotic change and look at the causes behind this. In this retrospective study all patients admitted with fracture neck of femurs were identified from the National Hip Fracture database and data pulled. The degree of AKI was classified according to the validated RIFILE criteria. Evaluation showed 2–4 fold increase in AKI since antibiotic change. Although mortality was decreased in these patients, the incidence of AKI had increased significantly. However, C. difficile has been obliterated by this change. The investigation highlights potential problems with increased rates of AKI amongst NOF patients, since antibiotic change. Flucloxacillin may have significant impact on this patient group. Dose dependent antibiotics will now be given based on weight and eGFR. Further analysis of this new change needs to be evaluated.
The Enhanced Recovery Pathway aims to improve the patient experience as well as expediting discharge. We aim to discharge 85% of patients by day 3. This audit retrospectively looked at primary total hip replacements (THR) and total knee replacements (TKR) patients who had 7 days length of stay and evaluated the factors contributing to the delay. There were 24 patients who stayed 7 days, 12 THR and 12 TKR. There were 15 females and 7 males, the mean age was 77 years (52 to 89). Causes for the delay included patient's reluctance to engage in their rehabilitation (21/24) and Occupational Therapists (OT) identifying difficulties in patient's home circumstances on admission (12/24). Medical problems also delayed early mobilisation, particularly urethral catheterisation (9/24), investigation for venous thromboembolism (6/24) and blood transfusion (3/24). Delay in discharge is multifactorial and requires involvement of MDT. We have identified ways to enhance patient engagement, including a “patient journey” DVD shown preoperatively at “Joint School” and individual white boards for daily goal setting. Fostering greater self-efficacy in patients may improve participation in preoperative discharge planning with OTs. Specific preoperative education may help patients understand the importance of continuing their rehabilitation while medical problems are managed.
Total hip replacements have been shown to give superior outcomes in patients with intracapsular fractures of the neck of femur compared with hemiarthroplasty. Collarless uncemented femoral stems give excellent long term results in elective hip replacements but there are few studies looking at their outcomes in fractured neck of femur patients. There is some concern that in trauma patients bone quality maybe inferior as most neck of femur fractures are secondary to osteoporosis. The presence of osteoporosis and subsequent widened femoral canal may compromise the mechanical stability of uncemented femoral stems and result in early subsidence, which can lead to altered leg length and decreased hip stability. The aim of this study was to assess whether early subsidence occurred when collarless uncemented stems were used to treat patients with fractures of the neck of femur. Post-operative radiographs of 33 patients, mean age 71, who underwent an uncemented collarless total hip replacement for a fracture, were reviewed. The distance from the calcar to the tip of the prosthesis was measured for each patient on the initial post operative radiograph and again on the follow-up radiograph at 6 months post operation. Any subsidence was recorded and magnification for each radiograph was calculated by measuring the diameter of the femoral head, which was known to be 36mm. Distances were then adjusted for magnification. The same procedure was performed on 36 age-matched patients, mean age 71, who underwent elective uncemented total hip replacements for osteoarthritis. Hospital notes for each patient were reviewed to assess for complications and DEXA scan results for trauma patients were also evaluated where available. The mean femoral stem subsidence was significantly greater in the fracture cohort than in elective patients (p = 0.001) with mean subsidence of 4.07mm (range 0.02–18.5mm) and 1.57mm (range 0–5.5mm) respectively. In the fracture cohort there were 3 revisions within 6 months of surgery, 1 for infection and 2 for femoral stem subsidence leading to dislocation. There were no revisions in the elective cohort. DEXA scan results were available for 21 of the 33 fracture cohort patients. All these patients had abnormal bone density with 52% being osteoporotic and 48% osteopenic. This study showed that collarless uncemented stems subsided significantly when performed for fractures and had a high early revision rate. We therefore recommend that cemented or collared femoral stems be used in patients with femoral neck fractures requiring total hip replacement to reduce the risk of femoral stem subsidence.
The purpose of our study was to assess the reproducibility and reliability of traditional radiographic methods of diagnosing trochlear dysplasia compared with the gold standard of MRI. Plain radiographs and MRI scans of 36 knees in 28 patients with proven trochlear dysplasia were compared with 18 controls in a single surgeon's practice. The sulcus angle on MRI and axial radiographs was measured. The lateral radiograph was assessed for adequacy, the crossing sign and the trochlear bump sign. The mean axial (radiograph) and MRI sulcus angles in the dysplastic group were 145° and 158° respectively (p=0.0001) compared to 135° and 138° in the control group (p=0.09). The crossing sign was present in 34 out of 36 lateral radiographs in the dysplastic group and 8 out of 18 in the control group equating to a sensitivity of 94% and specificity of 56%. The quality of the lateral radiograph did not significantly alter the sensitivity or specificity of the crossing sign (p=0.01). The bump sign was present in 22 out of 36 lateral radiographs in the dysplastic group and 1 out of 18 in the control group equating to a sensitivity of 61% and specificity of 94%. Our study shows that an increased radiographic sulcus angle is reliable in diagnosing trochlear dysplasia but underestimates it. The bump sign is a reliable predictor of trochlear dysplasia. The crossing sign is sensitive but not specific in diagnosing dysplasia.
Stable fixation with macro and micro interlock prevents early migration and therefore early failure of cemented acetabular cups. The authors describe a cementation technique in an in-vitro model that increases the interossoeous pressure by a factor of 3.5 in the ishium, 4.5 in the ilium and 5.1 in the pubis by the injection of the cement directly into the 10 mm key holes prior to insertion of the cement bolus and cup.
The passage of bacteria through surgical drapes is a potential cause of wound infection. Previous studies have shown that liquids and human albumin penetrate certain types of drapes12. We studied the passage of bacteria through seven different types of surgical drape and an operating tray. We also studied the effect of different wetting agents on the passage of bacteria through wet reusable woven drapes. Bacteria were grown on an overfilled whole horse blood agar plate. The plate was covered with the drape to be tested and a second agar plate was inverted and placed on the drape. After 30 minutes the second agar plate was removed, incubated and inspected for bacterial growth. The experiment was repeated removing the second plate at 60 minutes and then again at 90 minutes. The entire experiment was repeated for each drape and then for each wetting agent. Bacteria easily penetrated all the woven reusable fabrics within 30 minutes. The disposable non-woven drapes proved to be impermeable up to 90 minutes, as did the operating tray. Chlorhexidine and Povidone-Iodine were demonstrated to slow, but not stop the passage of bacteria through reusable woven drapes. Normal saline and human blood accelerated the passage of bacteria through reusable woven drapes. We recommend the use of non-woven disposable drapes or woven drapes with an impermeable operating tray, in all surgical cases.
