We present the case of a patient with Rheumatoid Arthritis who underwent a right total hip replacement as a young adult. At the time of surgery there was an intra-operative femoral fracture and the prosthesis and cement breached the cortex of the proximal femur postero-medially.

The fracture was detected on the post-operative film and the patient was treated non-operatively until the fracture consolidated. Despite having rheumatoid arthritis our patient went on to an active adult life having a family and she worked full time with this hip replacement. She subsequently required a socket revision at 15 years post index surgery and at the time the femoral component was well fixed, not scratched and left in situ.

Currently, the revision socket remains satisfactory, the stem still appears well fixed and clinically the patient is well.

Discussion: This case highlights the fact that not all intra-operative fractures require surgical intervention. They are low energy events with minimal soft tissue disruption and may heal satisfactorily. This case demonstrates that it should not be assumed that loosening and failure are inevitable.

Background: Infection in total joint replacement remains one of the most devastating post operative complications. The majority of these infections are still caused by organisms normally found on the skin. The use of adhesive wound drapes has become commonplace in orthopaedic surgery but frequently these are detached from the wound edges at the end of surgery allowing contamination of the wound.

Aim: To develop a technique to improve the adherence of wound drapes.

Methods: The first part of this study was to experiment with a number of techniques to prepare the skin preoperatively. We were able to identify that a combination of initial Betadine in alcohol preparation, followed by re-preparation of the operative site with Chlorhexidine in alcohol produced the best combination of drape adherence. In a consecutive series of 100 patients we have used our original technique of preparing the wound for 50 patients followed by a further 50 patients prepared with the new technique.

Results: In the initial patient group all of the adhesive drapes were detached enough to expose the skin edges in at least one part of the wound by the end of the surgical procedure. With the new technique we have had no detachments of the adhesive drape.

There have been no complications or skin reactions related to this method of skin preparation. There has been no significant difference in the incidence of early post operative wound infection.

Conclusion: This technique of operation site preparation provides an excellent means of preventing detachment of adhesive wound drapes. We have found it reliable, safe and effective to date and it adds little to the overall procedure time. We recommend this technique as a way of ensuring that the skin edges remain covered throughout primary and revision procedures.

We present the case of an elderly lady who was treated surgically as an infant for osteomyelitis of the left distal femur. Throughout the whole of her adult life she describes episodes where the thigh has become more painful and warm followed by a watery discharge from a sinus on the upper medial aspect of the thigh. This sinus has discharged at least weekly up until the present day. No further surgery has been performed on the proximal femur since childhood.

Almost 10 years ago the patient presented with symptoms of osteoarthritis in the left hip. A total hip replacement was performed at that time without any further active measures aimed at eradication of the osteomyelitis.

Despite obvious concerns of the possibility of exacerbating the osteomyelitis and developing pan femoral disease this has not been the case. The hip replacement is symptom free, stable and there are no signs of infection clinically or radiologically.

Conclusions: Whilst we would not immediately recommend this course of action; the surgical treatment of long bone osteomyelitis if an arduous procedure for both patient and surgeon with high recurrence rates. This case demonstrates that in low demand elderly patients it may be possible to implant a hip replacement.