DAIR procedure is well established for Prosthetic Joint Infection (PJI) in acute setting after total hip and knee replacements. We present our experience of DAIR following hip and knee replacements in a District General Hospital (DGH), where we delivered comparable results to leading tertiary centres in short to mid-term followup.

We undertook a retrospective study involving 14 patients, who underwent DAIR in our DGH between August 2012 and December 2015. Patient cohort included primary, complex primary and revision hip and knee replacements. Microbiological support was provided by a Microbiologist with interest in musculoskeletal infections.

14 patients [9 males, 5 females; age 62 to 78 years (Mean 70.7); BMI 22 to 44.2 (Mean 33.8)] with multiple comorbidities underwent DAIR procedure within 3 weeks of onset of symptoms. 12 out of 14 grew positive cultures with two growing Vancomycin resistant Enterococci. Intravenous antibiotics were started after multiple samples intraoperatively and continued in six patients after discharge, while 8 were discharged with oral antibiotics. One patient died of overwhelming intraoperative septic shock in postoperative period. Another patient died of myocardial infarction subsequently. 12 (85.7%) patients were doing well with regular followup (Mean 20 months).

With good patient selection, DAIR is a far simpler solution and a safe and reproducible surgical option for early PJI following hip and knee replacements compared to one or two stage revisions. But published data in contemporary literature is predominantly from specialised centres. Our small series provides a perspective of comparable early to mid-term results of DAIR from DGH.

OBJECTIVE

Debridement, Antibiotics and Implant Retention (DAIR) procedure is well established for Prosthetic Joint Infection (PJI) in acute setting after total hip and knee replacements. We present our perspective of DAIR in a relatively a small cohort following hip and knee replacements in a District General Hospital (DGH) in United Kingdom, where we delivered comparable results to leading tertiary centers in short to mid-term followup.

Debridement Antibiotics Implant Retention (DAIR) is a recognised procedure in the management of acute prosthetic joint infection (PJI). We present an experience of DAIR following hip and knee replacements in a District General Hospital.

A retrospective review of 14 patients who underwent DAIR procedures between August 2012 and December 1015 were collated. The cohort included primary, complex primary and revision hip and knee replacements. All patients received multidisciplinary care with surgery performed by one of two arthroplasty surgeons.

9 males and 5 females with age 62 − 78 years (Mean 70.7) and BMI 22–44.2 (Mean 33.8) with various co-morbidities underwent DAIR. Surgical criteria required DAIR to be performed within 3 weeks of the onset of symptoms of infection. The time from index surgery however ranged from 15 days to 58 months. 12 of 14 grew positive cultures including two growing Vancomycin Resistant Enterococcus. Intravenous antibiotics were commenced after intraoperative samples and tailored OPAT. Antibiotic schedule varied from six weeks to eight months. 12 (85.7%) patients remain under follow up. Mean follow is 20 months (RANGE 6months-3years10months) with no recurrence of infection or reoperation.

With appropriate patient selection, DAIR is safe and reproducible surgical option in PJI in hip and knee replacements, avoiding the implications of a one or two stage revision. Published Data in contemporary literature is predominantly from specialised centres. Our small series provides a perspective of early to mid term results of DAIR to DGH. Interestingly each procedure is categorised as a failed implant on the National Joint Register.

Patellofemoral unicompartmental joint replacement is a controversial subject with a relatively small evidence base. Of the 50,000 total knee arthroplasties performed each year in the UK, approximately 10% are performed for predominantly patellofemoral arthritis. There are several patellofemoral unicompartmental prostheses on the market with the National Joint Registry recording 745 such prostheses used in 2007. Most evidence in favour of this procedure comes from experience with the Avon prosthesis (Stryker) predominantly from designer-surgeons.

The FPV patellofemoral joint replacement (Wright Medical) has been in use in Europe for several years. The instruments have recently been redesigned and the device marketed in the UK. In 2007 the FPV had 5.9% market share (n=44). We present our early experience with the FPV patellofemoral joint replacement, which to our knowledge, is the first clinical outcome series for this prosthesis.

33 consecutive FPV joint replacements in 29 patients were performed between April 2007 and September 2009 for unicompartmental patellofemoral OA. All cases were performed or directly supervised by the senior author. Results are presented with a minimum follow-up of six months.

Oxford and American Knee Society scores (AKSS) were obtained on all patients preoperatively and at subsequent outpatient visits. Mean preoperative AKSS knee score was 49.7 points and postoperative scores at 6 months and 1 year were 82.5 and 86.4 respectively. Mean Oxford score preoperatively was 30.4 (37%) and at 6 months and 1 year were 21.3 (56%) and 11.2 (77%) respectively.

There were no complications related to the implant. One knee required a secondary open lateral release due to inadequate balancing at the index procedure.

Further medium to long-term follow up data are required, but our initial experience with this device is encouraging.

Purpose: Anterior cruciate ligament (ACL) reconstruction techniques have traditionally focused on reconstruction only of one bundle of the ACL providing good to excellent results in most cases. Biomechanical studies have shown increased anterior and rotational stability with double bundle(DB) compared to single bundle(SB) anterior cruciate ligament(ACL) reconstruction. A systematic review and meta-analysis was performed to compare double bundle and single bundle methods of anterior cruciate ligament reconstruction.

Methods and results: Medline (1966 onwards), EMBASE (1980 onwards) and the Cochrane database were searched retrieving 8465 possible articles, but only 5 studies fulfilled all the inclusion criteria. To be included, the study had to be prospective, randomised or quasi-randomised, comparing DB and SB grafts inserted using an arthroscopically assisted technique and have a minimum 18 month follow-up for all patients.

358 patients, 190 SB and 168 DB were considered for statistical analysis from these five papers. Outcome measures assessed included pivot shift testing, KT1000 arthrometer testing and IKDC knee scores. Using Review Manager 4.2 for statistical analysis; for dichotomous data, odds ratios and 95% confidence intervals were calculated and for continuous data, weighted mean difference and 95% confidence intervals were calculated.

Patients in the double bundle group were significantly less likely to have a positive pivot shift test (P< 0.0001). KT1000 arthrometer testing demonstrated greater antero-posterior stability with the DB group (P=0.002). There was no difference between the groups in terms of IKDC score.

Conclusion: The use of a double bundle technique improved both anteroposterior and rotational stability but not the clinical IKDC score suggesting that recovery of knee stability alone is not sufficient for achieving a better outcome.

Reamed, locked intramedullary nailing is the treatment of choice for many long bone fractures, be them open or closed injuries. Certain nails used can be inserted without any locking component or reaming. However, the most biomechanically sound fixation is achieved with a reamed, locked nail, and this therefore is the preferred construct. The process of reaming is not without complication, however. Pulmonary complications secondary to embolization of intramedullary contents are of the most concern. The formation of emboli is believed to be a direct result of raised intramedullary pressures created largely by the reaming process, although nail insertion does also play a part.

The magnitude of intramedullary pressures generated during the reaming process is due, in part, to the design of the reamer itself. This study compares four different reamers currently in use in NHS hospitals today. The reamersusedincludeanolderdesign(AOUniversal(TM)) and three newer designs (Synthes Synream(TM), Biomet 5+(TM) and Stryker Bixcut(TM)).

Four different reamer head sizes were used- 9.5mm, 11.5mm, 13.5mm and 15.0mm. These were tested in vitro using a Vaseline(TM)/paraffin oil mixture to simulate intramedullary tissue and Perspex(TM) tubing of varying sizes to simulate a long bone with an intramed-ullary cavity.

The results showed that the older generation reamer produced consistently higher pressures than the newer designs of reamer with statistical significance. All the newer generation reamers produced similar pressure magnitudes, although the Biomet 5+(TM) tended to produce the lowest pressures with some statistically sig-nificant differences.

This study shows that different designs of reamer can generate different pressures and that the newer generation of reamers do produce lower pressures. This is therefore important in the prevention of complications associated with reaming and intramedullary nailing.

Aim: To evaluate patient satisfaction and the effectiveness of a telephone clinic designed to follow up patients who have received shoulder or elbow surgery.

Method: Following wound checks in the community, patients are followed up in our department at six weeks, then three and six months respectively to assess level of progress and answer any questions patients may have. As outcome measures are already assessed by physiotherapists, a telephone clinic was devised to make better use of Consultant time. Patients were contacted by telephone at a pre-determined time by an extended scope practitioner physiotherapist who used a set of standard questions to obtain information about the patients’ progress. An opportunity was then given to the patients to discuss any issues they may have with regards to their treatment so far.

Urgent hospital follow – up was arranged for patients requiring it depending on their level of progress and problems identified.

Patients’ satisfaction and opinions with regards to the use of the telephone as a method of post-operative follow -up were ascertained by an independent researcher.

Results: 50 patients were contacted over a 12-week period.

Patients were satisfied by the level of information they were provided with and their subsequent management as a result of the telephone clinic. Patients particularly commented on the advantages of getting information at home with the avoidance of problems associated with attending for a hospital appointment.

Three patients were given an urgent follow-up appointment as a result of the information gleaned during the telephone clinic. These included a patient with a stitch abscess and two with adhesive capsulitis.

Conclusion: Telephone clinic follow up is an effective and safe method for monitoring patient progress post – operatively following shoulder or elbow surgery. It is well received by patients who save the time and effort associated with attending for a hospital consultation that often only lasts a few minutes. In the subject group identified the method of questioning was sufficiently sensitive to identify problems that required further management.