An interesting case with excellent accompanying images, highlighting the significance of tourniquets in controlling exsanguination, whilst also raising the issue of amputation versus reconstruction in severely injured limbs.

A 39 year old male motorcyclist was BIBA to the Midland Regional Hospital in Tullamore, following a head-on collision with a bus at high velocity. On arrival, he was assessed via ATLS guidelines; A- intubated, B- respiratory rate 32, C - heart rate 140bpm, blood-pressure 55/15 and D- GCS 7/15. Injuries included partial traumatic amputation of the right lower limb with clearly visible posterior femoral condyles, a heavily comminuted distal tibial fracture and almost complete avulsion of the skin and fat at the popliteal fossa. Obvious massive blood loss at the scene had been tempered by a passer-by who applied a beach towel as a makeshift tourniquet. CT Brain demonstrated extra-dural and subarachnoid haemorrhages with gross midline shift. Unfortunately, the neurosurgical team in Beaumont concluded that surgical intervention would be inappropriate. However, his kidneys had not sustained ATN and were made available for donation.

Two vital surgical issues were featured in this case. Firstly, it highlighted the importance of tourniquets in controlling exsanguination in a trauma situation¹. Secondly, it raised the critical issue of amputation versus reconstruction in severely injured limbs^2,3.

Without prompt placement of a make-shift tourniquet by a passer-by, this patient would have almost certainly died at the scene of the accident. Two kidneys were successfully donated as a result.

The importance of appropriate tourniquet use cannot be overstated. This case highlights its potential life or limb-saving capabilities in emergency trauma situations. It also raises the critical issue of amputation versus reconstruction in acute emergency situations.

Hip fractures are a major cause of morbidity and mortality in the elderly and are thought to represent an increasing cohort of our patients. It is estimated that the cost of caring for each patient for their hospital admission is €10,000. There is significant regional and international variation in the incidence rates of such injuries, depending on age, sex and ethnic variations in populations. Recent Irish literature would suggest that the rates in Ireland are exponentially increasing while in the US the rate may be decreasing. The length of stay of such patients is also an important issue especially in the current economic environment. The aim of this study was to define the incidence of hip fractures in the South East. The aim was also to examine any changes to their length of stay that have occurred in a 11 years period.

Independent searches of the operating theatre register and the HIPE (hospital in-patient enquiry scheme) database were undertaken for the time period. Population data was obtained from central census office and the HSE South East offices.

The combined incidence of hip fractures in 2008 and 1998 was 96.06 and 100.90 per 100,000 respectively. The male to female ratio in 2008 was 1:2.67, while in 1998 it was 1:3.04. 13% of the patients in 2008 where under 65 years of age, while in 1998 this figure was 8%. In 1998 the mean length of stay was 17.15. By 2008 this had increased to 23.95 days. The dramatic increase in acute hospital length of stay over the period was estimated to have a burden of more than 14 million euros on health board fund.

This study provides data on a large patient group which is of paramount importance. Health service resources can be allocated appropriately in the future in terms of acute and step-down care based on this data set and results.

Introduction

The incidence of osteochondral lesions following ankle fractures varies in the literature between 17-70%. They are commonly associated with chronic pain and swelling in patients diagnosed with such pathology. There is less evidence about the relationship between OCL and the development of post-traumatic osteoarthritis, the most common type of ankle arthritis.

The cement-in-cement femoral revision is a possible method of reducing complications. During recent research on this revision it was observed that a number of the inner cement contained macropores. It was hypothesized that porosity of the mantle influenced the subsidence and inducible displacement of the revision stems. The aim was to calculate the porosity and assess its relationship to the above factors.

Primary cement mantles were formed by cementing a stem into sections of tubular steel. At this stage, the specimen was chosen to be in a test or a control group. If in the test group, it underwent a fatigue of 1 million cycles. This was carried out in a fatigue machine mounted with a specifically designed rig. If in the control group, no such fatigue was undertaken. Into these fatigued and unfatigued mantles, the cement-in-cement procedure was performed. Both groups underwent a fatigue of again 1 million cycles. Subsidence and inducible displacement was recorded. The composites were then sectioned and photographed. The images underwent image analysis to calculate the porosity.

Multiple regression and a general linear model showed subsidence was inversely correlated to the porosity of the “fresh cement” in Gruen zones 3 and 5 (p = 0.021, R2 = 0.36). This relationship was not expected. The reason could be related to the fact that the migration of the stems in each separate direction was not monitored. Inducible displacement was inversely correlated to porosity of the inner cement, again in Gruen zones 3 and 5 (p = 0.001, R2 = 0.61). A possible explanation is that the stem was able to subside more due to the higher porosity and find a more stable position.

The subsidence and inducible displacement of these stems is influenced by porosity, specifically by the porosity of the distal inner cement.

One method of reducing intra-operative complications in revision hip surgery is the cement-in-cement technique. Some concern exists regarding the retention of the existing fatigued cement mantle. It was hypothesised that leaving the existing fatigued cement mantle does not degrade the mechanical properties of the cement in cement revision construct. The aim of this research was to test this hypothesis using in vitro fatigue testing of analogue cement in cement constructs.

Primary cement mantles were formed by cementing a large polished stem into sections of tubular stainless steel using polymethylmethacrylate with Gentamicin. At this stage, the specimen was chosen to be in the test group or the control group. If in the test group, it underwent a fatigue of 1 million cycles. This was carried out in a specifically designed rig and a fatigue testing machine. Into these fatigued and unfatigued primary mantles, the cement in cement procedure was carried out. Both groups underwent a fatigue of again 1 million cycles. Subsidence of the stems and their inducible displacement was recorded. A power calculation preceded testing.

Completion of a Mann Whitney test on the endpoints of the subsidence curves revealed that there is no statistical difference between the data sets (means 0.51, 0.46, n=10 + 10, p = 0.496). This data was also calculated for the inducible displacement. Again, there was no statistical difference in the separate groups for this parameter (means 0.38, 0.36, p = 0.96). This methodology produces a complex 3 dimensional reconstruction of the cement in cement revision which replicates the in vivo structure. This reconstruction has undergone fatigue testing. Neither of these two aspects has been produced for the study of cement in cement revision before.

A fatigued primary cement mantle does not appear to degrade the mechanical properties of the cement in cement revision construct

Aim To document an outbreak of Vancomycin Resistant Enterococci in an elective Orthopaedic Unit. To describe the clinical course of the affected patients and treatment options. To describe methods employed in eradicating endemicity following the outbreak and to evaluate the lessons learnt.

Background VRE first appeared in the Microbiological literature in 1988. Very little is known about its effect in the Orthopaedic Realm. To our knowledge, this is the first report of a serious outbreak in such a unit and only the second reporting of peri-prosthetic VRE infection.

Material and methods All patients in the unit over a 1/12 unit formed the cohort for the study. Following identification of the index case, samples were taken form all in-patients. Immediately a nurse specialist in infection control oversaw sampling of all patients. Microbiological data, Clinical Data and antimicrobial therapy data was collected on all positive patients. Rapid laboratory procedure were instituted, environmental screening was preformed and a dedicated cleaning team was formed. The assistance of a Clinical Microbiologist and an Environmental Microbiologist was sought.

Results Following identification of the index case, 11 patietns had microbiological proven VRE. 1 patient had a VRE confirmed peri-prosthetic infection. This necessitated removal and appropriate anti-microbial therapy. However, this patient died. 2 pateints were found to have superficial wound infection, which resolved with oral Linezolid, while 8 patients showed colonization with the organism. No treatment was required other than clinical follow up and staged screening in these patients.

The unit was closed for 9 weeks following the outbreak and deep cleaning resulted in eradication of endemicity.

Conclusion Tracing of the index case and typing allowed us to confirm the source of the outbreak and to take steps to prevent a recurrence. Appropriate microbiological advice is essential in an outbreak situation, management of peri-prosthetic infection and follow up of affected cases. All protocols have been re-evaluated and retraining of all staff in good clinical hygiene has been undertaken. The speed of the outbreak and its devastating effect on a Joint Replacement Facility is alarming and should serve to aid other units in establishing preventative protocols and in preplanning their treatment options and an outbreak team.