Infection following total knee arthroplasty is a serious complication. Recently there has been increasing incidence of isolation of multi-drug resistant bacteria from peri-prosthetic infections. The aim of our study is to identify the organisms causing delayed deep infections following primary total knee arthroplasty in the current situation. We also compared the differences in outcome based on the infecting organism. We undertook a retrospective study of all the patients who presented with delayed deep infection following primary total knee replacement during a six year period between April 1998 and March 2004. Organisms were isolated in 27 of the 31 patients who presented with delayed deep infection. Forty-four % of the organisms isolated were multi-drug resistant with increasing incidence of Methicillin resistant Staphylococcus aureus and multi-drug resistant Staphylococcus epidermidis infections. Successful outcome following an infected total knee arthroplasty was lower compared to the previous studies where there were fewer multi-drug resistant organisms. The average number of surgical procedures carried out was significantly higher when the organism isolated was multi-drug resistant. The number of patients with satisfactory outcome is significantly lower when the organism isolated is multi-drug resistant.

The aim of our study is to identify the organisms causing delayed deep infections following primary total knee arthroplasty in the current situation. We also compared the differences in outcome based on the infecting organism.

We undertook a retrospective study of all the patients who presented with delayed deep infection following primary total knee replacement during a six year period between April 1998 and March 2004. We analysed the infecting organism, sensitivity of the organism to antibiotics, number of surgical procedure carried out and the outcome of the infected arthroplasty based on the infecting organism. Statistical analysis was done using Fisher’s Exact test for categorical data and Mann-Whitney U test for the non-parametric numeric data.

The mean age at the time of primary arthroplasty was 69.9 years (range 46 to 92 years, SD=10.8). The mean follow-up (time since the initial knee replacement) was 77.3 months (range 27–170 months,). The mean follow-up since the last surgical procedure to treat infection was 31 months (range 14–47 months). Organisms were isolated in 27 of the 31 patients who presented with delayed deep infection. Forty-four % of the organisms isolated were multi-drug resistant with increasing incidence of Methicillin resistant Staphylococcus aureus and multi-drug resistant Staphylococcus epidermidis infections. Successful outcome following an infected total knee arthroplasty was lower compared to the previous studies where there were fewer multi-drug resistant organisms. The number of patients with satisfactory outcome is significantly lower when the organism isolated is multi-drug resistant. Patients infected by multi-drug resistant organisms undergo higher number of surgical procedures compared to patients where the organism is not multi-drug resistant. We conclude that deep infection with MRSA and Methicillin resistant Staphylococcus epidermidis are on the rise. Outcome is significantly better when the organism isolated is non resistant Staphylococcus aureus.

Open reduction and internal fixation of comminuted, displaced intra-articular or potentially unstable fractures of the distal radius with plate and screws has increasingly become a favoured treatment. Intra-operative assessment of fixation with the help of an image intensifier has always been difficult because of the anatomy of the distal radius which has an average ulnar inclination of 22 degrees and an average volar tilt of 14 degrees. These inclination and tilt produce superimposition of images and imaging of the implants placed as distal as possible to achieve satisfactory fixation often shows the screws to be penetrating the joint.

We describe two new radiographic views of the distal radius, which we used intra-operatively in ten patients undergoing open reduction and internal fixation of distal radius fractures. These are the tangential views of the articular surface of the distal radius taken by elevating the wrist so that the forearm makes an angle to the operating table to negate the effects of natural inclination and tilt in antero-posterior and lateral views. The images were compared with the images of standard antero-posterior and standard lateral views. Screws were thought to have been penetrating the joint in the standard lateral views of all of them and in the standard antero-posterior views of eight of them. However, no screw was seen penetrating the joint in these new views.

The tangential views showed correct relation of the screws with the articular surface and a more distal placement of the plate was possible. This enabled the screws to engage the sub-chondral bone and obtain bi-cortical purchase in presence of dorsal comminution. We recommend use of these views in open reduction and internal fixation of distal radius fractures.