Bone and joint infections are not only common but their management can be technically complex. They carry significant healthcare costs and are a daunting experience for patients [1]. Frequently, multiple operations are required in order to treat the infection. Each surgical intervention usually results in greater bone loss, worsening skin and soft tissue scarring and increasingly diverse and resistant micro- organisms [2]. Specialist bone infection units involving highly integrated orthopaedic and plastic surgery, as well as infection physicians, may improve patient outcomes [3–4]. However, it is difficult to determine the hierarchy of factors contributing to outcome of treatment. This problem is confounded by a lack of structured, prospective data collection in many units around the world. In 2014, we designed a modular database which allows collection of patients’ details, components of the disease, the treatment, microbiology, histology, clinical outcome and patient-reported outcome measures (PROMS). The registry was implemented in November 2014 and has already demonstrated its function as a Hospital-wide service evaluation tool. Over 200 patients have been referred to the unit and their baseline demographic information registered. Their progress through the bone infection unit patient pathway is prospectively monitored with use of the registry and data collection ongoing. We aim to present the preliminary clinical outcomes of these 200 patients including surgical procedures performed, key microbiology results, antibiotic treatment regimens and patient reported outcomes. Our goal is to demonstrate that a bone infection registry is an integral part of infection management clinical practice. It can be used for designing service provision, assist in allocating healthcare resources and expand the evidence base for specialist bone infection units in managing complex orthopaedic infections.
The number of patients undergoing total hip replacement surgery is rising and thus the number of periprosthetic fractures is set to increase. The risk factors for periprosthetic fractures include osteolysis, rheumatoid arthritis, osteoporosis and use of certain types of implants. Evidence from literature suggests that the mortality rate within one year is similar to that following treatment for hip fractures thus as surgeons it is important for us to understand the various management strategies of these fractures. Acetabular periprosthetic fractures are uncommon and classified into Type I, in which the acetabular component is radiographically stable and Type II, in which the acetabular component is unstable. It is better to prevent than to treat these fractures. Femoral periprosthetic fractures have several classifications the most commonly used is the Vancouver classification (fig 1). Type-A fractures are proximal and can involve the greater or lesser trochanter. These are often related to osteolytic wear debris and therefore revision of the bearing surface with bone grafting is recommended. AG involves the greater trochanter and AL involves the lesser, and these can usually be stabilised by cerclage wires supplemented by screws or plates if required (fig 2). Management of type B fractures is more controversial and will be discussed in depth with reference to all recent papers at the meeting and data from the Swedish Joint Registry. In summary the management is shown in fig 3. In type-C fractures, one should ensure the fixation device bypasses the femoral stem by at least 2 diaphyseal diameters. Management is as shown in fig 4.INTRODUCTION
MANAGEMENT
It has been recently suggested that hyponatraemia may be a cause of significant iatrogenic harm in orthopaedic patients. In an attempt to test this theory, this observational study was done to establish the incidence of post-operative hyponatraemia following hip fracture and evaluate its correlation with outcome. An observational study was carried out on 213 consecutive hip fracture patients. 201 patients completed the requirements of the study (Male-45, Female-156). Mean age was 80 years. Serum sodium concentrations were recorded during the first week of admission. Hyponatraemia defined as significant (Na <
130mmol/L) was identified in 9% at admission and 18% during first week of stay. Incidence of severe hyponatraemia was 3%. There were no acute complications of hyponatraemia in these patients. 78% of hyponatraemia patients had received 5% Dextrose infusion during the postoperative period as their main intravenous fluid. All hyponatraemic patients had their sodium levels restored to normal during their stay. Long term outcome measures used were mortality, change in residential status, walking ability and use of walking aids at 4 months following fracture. There was 20% mortality at 4 months in the hyponatraemic group and it was 30% in the normal serum sodium group. However this difference was not statistically significant. Hyponatraemia did not significantly influence deterioration in residential status (p<
0. 05), walking independence (p<
0. 05) or increase of walking aids (p<
0. 05). In hip fracture patients, hyponatraemia whilst common was not associated with a poor outcome and at the same time we did not find any evidence of lapse in the recognition and treatment of hyponatraemia in a general orthopaedic ward. However emphasis should be made to junior medical staff to avoid iatrogenic hyponatraemia by following a proper postoperative fluid regime.
