The purpose of the study was to retrospectively assess the patients treated to date with the vac ulta system using a technique of antibiotic instillation.

The vac ulta system is licensed for use with anti-septic instillation fluid but we have now treated a number of patients with antibiotic instillation under the guidance of the microbiology department. All patients being treated with the vac ulta system were included in the study. There were no exclusions. Pathology treated, infecting organism, antibiotic used and length of treatment were all recorded. Any antibiotic related complications were noted. Treatment was judged successful with resolution of presenting symptoms, normalization of inflammatory markers and three negative foam cultures.

There were 21 patients included in the study. There were 13 male and 8 female patients. Length of treatment ranged from 1 week to 10 weeks with a mean of 4.2 weeks. Follow up ranged from 1 month to 42 months with a mean follow up of 17.9 months

The most common pathogen was Staph. Aureus(11 cases). Enterobacter, ESBL, Strep. Milleri, MRSA and Citrobacter were also treated. Antibiotics instilled included flucloxacillin, meropenem, gentamicin, vancomycin, meropenem and teicoplanin. There were no antibiotic reactions/allergies. Pathologies treated included osteomyelitis, two stage amputations for infection, infected non-union and infected metalwork. Infection recurred in 2 of 21 patients (10%), with one recurring at 18 months and one at 2 years.

The 90% treatment success rate is highly encouraging in this notoriously difficult group of patients to treat. In this series vac instill was an effective treatment of infection and allows antibiotic treatment to be targeted to the infected tissues. There were no adverse reactions seen.

Larger series with longer follow up are no needed but we believe this technique is safe, successful and easily administered can be cautiously adopted on a wider basis.

With the recent reductions in junior doctor hours levels of staffing have become ever more critical as clinical duties are covered with fewer junior doctors available on a daily basis. Trainees also have to meet specific requirements of the curriculum and thus need to be allocated to posts with suitable opportunities. There is little evidence available to account for the allocation of posts to individual trusts and departments with training post numbers seem driven by historical allocation, rather than based on trainee and local population needs.

‘SHO’ tier numbers were obtained for each orthopaedic department within the Yorkshire deanery through direct contact with the departments. Data was also obtained to establish the workload of these departments. Information was gathered from the national neck of femur database, hospital episode statistics, the national joint registry, the trauma audit and research network (TARN) and finally Dr Foster and the national census. The workload data was then analysed and compared to the staffing levels in each department.

Data was obtained for fourteen trusts across the Yorkshire Deanery. The percentage of SHO tier doctors in training posts ranged from 0 to 78% (mean 37%) across the trusts surveyed, with wide variation in make up of the SHO tier in each department.

Workload was standardised using the unit of cases/SHO/annum. The workload for neck of femur fractures ranged from 8 to 52 cases/SHO/annum (mean 36). General trauma admissions ranged from 199 to 383 cases/SHO/annum (mean 288). Elective arthroplasty admissions ranged from 11 to 174 (mean 70). Pearson correlation coefficients were 0.5 for elective arthroplasty and neck of femur admissions and 0.8 for trauma admissions.

There is wide variation in workload between trusts when standardised for the number of SHO's with weak to moderate correlations between the number of juniors and workload in each department. This wide variation will impact on patient care, but also the training opportunities available in different posts – where workload is higher it is likely there will be an increased need for ward based work away from clinics and theatre lists.

The introduction of the foundation programme and MMC has changed the structure of the SHO grade at a time when the EWTD introduction has also had a profound impact on working patterns and hours. At this time we believe there is a need for a review of trainee allocations nationally with comparison to workload in each trust, trainee logbook data and data on curriculum competencies met. With the proposed reductions in trainee numbers now is the time for a centrally led review of these posts via the Royal College, BOA and BOTA to ensure high quality training, maintain high standards of patient care and secure the future of the orthopaedic profession.

Background: Diagnostic injection plays an increasing role in the diagnosis of foot and ankle pathology. Joint communications have been reported in several studies, and it has been suggested they may impact on clinical management.

Method: We analysed the findings of 389 arthrograms of the foot and ankle, identifying any joint communications noted on imaging. A case note review was then undertaken on a subset of 153 of these patients with the aim of establishing the effect of injection findings on clinical management. All injections were performed and reported by a single consultant radiologist.

Results: Joint communications were seen in 24% of patients with an equal distribution amongst males and females. Rates of individual joint communications were consistent with those previously published.

Injection studies had an impact on subsequent management in 88% of cases. Symptoms resolved with injection alone in 28% of patients with no communication versus 8% in those with a communication. Surgical plans were changed in over 20% of cases if a joint communication was found. There were no major complications reported (Joint sepsis or contrast allergy).

Conclusion: This study confirms the presence of multiple joint communications within the foot and ankle, and highlights the importance of arthrography in the diagnosis of pathology.

We would recommend joint injection be considered in all patients, especially if joint fusion is being considered. Contrast should be used in all cases to demonstrate any potential communications, which should be taken into consideration when surgical management plans are formulated. A significant number of patients will experience resolution of symptoms from injection alone, with no further intervention needed.

Background: Accurate history and examination is often supported by radiological imaging and diagnostic injection to diagnose joint pathology. In the foot and ankle communications have previously been reported which may reduce the sensitivity of this technique.

Method: We analysed the findings of 389 arthrograms of the foot and ankle, identifying any joint communications noted on imaging. A single consultant radiologist using local anaesthetic and contrast performed all injections.

Results: Observed results were similar to those previously reported for joint communications, with 13.9% of cases showing a communication between the ankle and subtalar joints (10% reported incidence), and a 42.3% communication rate between the talonavicular and calcaneocuboid joints. We also identified previously unreported communications between the anterior subtalar and naviculocuneiform joints (8%), anterior subtalar and calcaneocuboid joints (9%) and the naviculocuneiform and tarsometatarsal joints (1.1%).

Conclusion: This study confirms the presence of multiple joint communications within the foot, and highlights the potential importance of arthrography in the diagnosis of foot and ankle pathology. These communications must be appreciated when considering joint fusion within the foot and ankle, especially where local anaesthetic injection has been used to aid diagnosis.

Introduction: The use of simultaneous bilateral knee replacement surgery remains controversial–several studies have reported increased rates of complications, and the use of the technique remains in question. However, many of these procedures are not truly simultaneous, meaning it is difficult to draw accurate conclusions on the safety of this technique from the published literature.

Method: A retrospective notes based review of all those patients undergoing bilateral knee replacement surgery between 2000 and 2005 at Harrogate District Hospital was performed. Patients undergoing both unicompartmental (UNI) and total knee replacement (TKR) were included. Procedures were performed by a consultant orthopaedic surgeon and his knee fellow with one scrub team. The post operative morbidity and mortality was assessed both 30 days post operatively and also at six month follow up.

Results: A total of 112 procedures were performed over the five year period. There were no deaths reported within the study group. Within the group there were 3 DVT’s, 2 superficial wound infections and one case of aseptic loosening at six months. Average tourniquet time was 76 minutes for the TKR group and 82 minutes for the UNI group. Average length of stay over the five year period was 8.6 nights (TKR) and 6.6 nights (UNI).

Conclusion: Bilateral truly simultaneous knee replacement surgery is a safe technique with favourable rates of complications. It offers the benefit of improved efficiency with regard to both theatre time and length of hospital stay, which is valuable in the modern climate of economic strain within health services worldwide. It also offers an excellent opportunity to the trainee to operate independently within a controlled environment, and is favoured by patients–offering a single admission and rehabilitation period.