Introduction: Dividing the short external rotators 2 cm from their insertion into the femur should preserve the deep branch of the medial femoral circumflex artery. Our aim was to determine, prospectively, femoral head perfusion during hip resurfacing arthroplasty comparing two posterior approaches.

Methods: 20 hip resurfacing arthroplasties were performed in 20 patients by two different surgeons between September 2005 and November 2006. Patients were divided into two equal groups according to approach. One surgeon used the extended posterior approach and the other a modified posterior approach. Intravenous cefuroxime was administered in every case following capsulectomy and relocation of the femoral head. After 5 minutes the femoral head was dislocated and prepared as routine for the operation. Bone from the top of the femoral head and reamings were sent for assay to determine the concentration of cefuroxime.

Results: There was no statistical difference between the concentration of cefuroxime in bone when using the modified posterior approach (mean 5.6mg/kg; CI 3.6 – 7.8) compared to the extended posterior approach (mean 5.6; CI 3.5 – 7.8; p=0.95). In one patient, who had the operation through the posterior approach, cefuroxime was undetectable.

Discussion: The similarity in femoral head perfusion between approaches suggests the blood supply is further impaired by capsulectomy rather than by damaging the MFCA alone.

Methicillin-resistant Staphylococcus aureus (MRSA) has increased in prevalence and significance over the past ten years. Studies have shown rates of MRSA in Trauma and Orthopaedic populations to be from 1.6% to 38%. Rates of MRSA are higher in long term residential care.

It has been Department of Health policy to screen all Trauma and Orthopaedic patients for MRSA since 2001. This study audited rates of MRSA screening in patients who presented with fractured neck of femur treated with Austin Moore hemi-arthroplasty over the course of one year. Rates of MRSA carriage and surgical site infection (SSI) were derived from the computerised PAS system and review of case notes.

9.8 % of patients were not screened for MRSA at any time during their admission. The rate of MRSA carriage within the study population was 9.2%. The MRSA SSI rate was 4.2%. MRSA infections are associated with considerable cost and qualitative morbidity and mortality.

There is good evidence for the use of nasal muprocin and triclosan baths in reducing MRSA. Single dose Teicoplanin has been shown to be as effective as traditional cephalosporin regimes. There is new guidance for the use of prophylactic Teicoplanin for prevention of SSI. We should consider introducing both topical and antimicrobial MRSA prophylaxis.

The purpose of this study was to investigate the validity of exchange intramedullary nailing for the treatment of infected tibial non-union.

14 (10 male) patients with tibial fractures were treated in our institution with exchange nailing for infected tibial non-union. The mean age of the patients was 34.3 years (range 18–60) and the mean ISS was 17.5 (range 9–57). Seven fractures were originally open (grade IIIb). All patients had clinical and radiological evidence of non-union and in each case there was clinical and microbiological evidence of intramedullary infection. Following initial stabilisation, all the patients subsequently had an exchange intramedullary nail performed together with debridement and antibiotics. The mean time between original nailing and exchange nailing was 28 weeks. Antibiotics were then continued for a minimal period of 6 weeks, or longer as the clinical situation warranted. The average length of follow-up was 24 months following exchange nailing.

There were 7 positive cultures of MRSA, 4 of staph. aureus and in 3 cases multiple bacteria were grown from the samples. No further treatment was required following exchange nailing in 5/14 (35.7%) cases. 4 patients required further soft tissue debridement and a free flap to secure union. Of the remaining 5 patients, 1 required dynamisation, another required incision and drainage of peri-fracture abscess, the third patient needed iliac crest bone grafting which eventually resulted in union. The penultimate patient had numerous operations after the exchange nailing before finally uniting with bone morphogenic protein. Unfortunately the last patient developed overwhelming sepsis which necessitated below knee amputation. Overall, the mean time to union was 11.3 months (4–24).

In this series of patients the success rate of exchange nailing for septic tibial pseudarthrosis was 78.5% (11/14). We believe that exchange tibial nailing remains an effective method of treatment in the presence of deep bone sepsis.