Objective

To investigate the reasons for revision of Oxford Unicondylar Knee Replacement (UKR). Does insert size used relate to requirement for revision?

Antibiotic prophylaxis aims to reduce wound and prosthetic infection, with minimal adverse effects. The 3 dose Cefuroxime regime is widely used, despite the risk of infective diarrhoea. We describe the results of single dose intraoperative Gentamicin and Amoxicillin compared to this standard regime.

We retrospectively reviewed 220 patients following hip hemiarthroplasty, creating 2 demographically matched cohorts; Group 1: 3 doses of Cefuroxime (n=113) and Group 2: single dose Gentamicin and Amoxicillin (n=107). End points were evidence of infection, length of stay and Clostridium difficile (CD) rates. results showed a significant reduction in group 2 for average length of stay (17 Vs. 13 days p=0.0432) and CD rates (7/113 Vs 0/107 p=0.0158).

Considering antibiotic therapies administered; significant reductions in group 2 for the number of patients that required post-operative antibiotics (99/113 Vs 73/107 p=0.0005), the median antibiotic DDDs (Defined Daily Doses) in 1st 2 post-operative days (0.25 Vs 0 p=0.0000) and those that received Ciprofloxacin or Cefuroxime post-operatively (82/113 Vs 24/107 p=0.0000). No significant difference was found for median antibiotic DDDs, median antibiotic DDDs from 2nd post-operative day, patients that received Flucloxacillin post-operatively.

Measured microbiological outcomes showed a significant reduction in the number of patients with confirmed growth requiring treatment with antibiotics in group 2 (21/23 Vs 12/22 p=0.0053). No difference was found between number patients with operation site swabbed and those with confirmed microbial growth.

We demonstrate single dose Gentamicin and Amoxicillin significantly reduces length of stay, CD rates and the number of patients requiring post-operative antibiotics for wound infection, inferring a reduction in the rate of wound infection. We would recommend this as an effective alternative to the 3 dose Cefuroxime regime.

Fixation of comminuted olecranon and proximal ulna fractures can be a challenge. The goal of surgery is for stable fixation to encourage union and allow early elbow movement.

Over a 3 year period, a low profile titanium, precon-toured olecranon plate (Acumed LLC, Hillsboro, Portland, Oregon) was used in 16 patients with comminuted olecranon and proximal ulna fractures, using a standard universal posterior approach to the olecranon with the patient in a lateral position and active flexion/extension of the elbow was started 48 hours postoperatively. Functional outcomes were measured during follow-up (FU), including range of movement (ROM), Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Elbow Performance Score (MEPS).

There were 9 isolated olecranon fractures, including one open fracture in a multiple injured patient and one an infected non-union and 7 with associated ipsilateral upper limb injuries. Mean age was 52 years (13 to 84) and mean FU was 12.8 months (3 to 33). All had achieved radiological union at 3 months. Overall mean ROM for both groups was 19.3 to 130.7 degrees flexion, 71.8 degrees pronation and 72.1 degrees supination. DASH was 19.1 and MEPS was 87.7.

When comparing the 2 groups, there was no significant difference in supination or pronation but all other mean outcomes measurements showed statistical significance in favour of isolated, comminuted olecranon fractures. Extension 9.4 versus 35.0 degrees (p< 0.005), Flexion 140.6 versus 117.5 (p< 0.05), DASH 7.5 versus 34.7 (p=0.0007) and MEPS 96.3 (excellent) versus 78.3 (good) (p< 0.05). There were no infections or failure of metalwork, but two patients had the metalwork removed after union as they required further surgery to their elbows.

We demonstrate this is a safe and reliable method of fixation and can expect excellent results when treating isolated comminuted olecranon/proximal ulna fractures and good results when there are associated ipsilateral injuries.

Aims: To investigate adequacy of temporary ex-fix in grade III open fractures of the tibia, prior to definitive treatment by Flap & Frame at 2 UK trauma centres.

Methods: Between 2000 and 2006 all open fractures of the tibia treated by the Ilizarov Method at our two institutions were entered onto the Flap & Frame database. The database was searched for all temporary external fixators placed prior to definitive Ilizarov fixation. Data collected – ex-fix type, whether revision was necessary, reasons for revision.

Results:

97 grade III open fractures in 95 patients

Discussion: Recently Naique and Pearse showed a revision rate of skeletal fixation of 48% in grade IIIb open fractures referred to their tertiary centre. In our series 34% of temporary external fixators needed revision. Modular systems such as Hoffman II and AO required no revision, irrespective of whether they were applied at trauma centre or DGH.

All Hoffman hybrids needed revision, due to both instability and plastics access. Significantly more non modular (Orthofix) ex-fixes required revision compared to modular (Hoffmann II/AO), due to poor plastics access.

Conclusion: We recommend modular external fixation systems such as Hoffman II or AO if problems of temporary external fixation of open tibial fractures are to be avoided. Hybrid temporary external fixation should be abandoned as temporary fixation in such an injury