Around 1% of total hip replacements are follow by prosthetic joint infection (PJI). There is uncertainty about best treatment method for PJI, and the most recent high quality systematic reviews in unselected patients indicates that re-infection rates following one-stage and two-stage revision arthroplasty are relatively similar. In the absence of evidence randomised controlled trials will help to identify the most clinically and cost-effective treatment for PJI. Before such trials are conducted, there is a need to establish reasons for current practice and to identify whether trials are feasible. This study aimed to deliver research that would inform trial design. Specifically, we aimed to characterise consultant orthopaedic surgeons' decisions about performing either one-stage or two-stage exchange arthroplasty for patients with PJI after hip replacement and to identify whether a randomised trial comparing one-stage with two-stage revision would be possible. Semi-structured interviews were conducted with 12 consultant surgeons from 5 high-volume National Health Service (NHS) orthopaedic departments in the UK. Surgeons were sampled on the basis that they perform revision surgery for PJI after hip arthroplasty and final sample size was justified on the basis of thematic saturation. Surgeons were interviewed face-to-face (n=2) or via telephone (n=10). The interview study took place before design of a multicentre prospective randomised controlled trial comparing patient and clinical outcomes after one-stage or two-stage revision arthroplasty. Data were audio-recorded, transcribed, anonymised and analysed using a thematic approach, with 25% of transcripts independently double-coded. Results: There is no standard surgical response to the treatment of PJI and surgeons manage a complex balance of factors when choosing a surgical strategy. These include multiple patient-related factors, their own knowledge and expertise, available infrastructure and the infecting organism. Surgeons questioned whether evidence supports the emergence of two-stage revision as a method. They described the use of loosely cemented articulating spacers as a way of managing uncertainty about best treatment method. All surgeons were supportive of a randomised trial to compare one-stage and two-stage revision surgery for PJI after hip replacement. Surgeons reported that they would put patients forward for randomisation when there was uncertainty about best treatment. Surgeons highlighted the need for evidence to support their choice of revision. Some surgeons now use revision methods that can better address both clinical outcomes and patients' quality of life, such as loosely cemented articulating spacers. Surgeons thought that a randomised controlled trial comparing one-stage and two-stage exchange joint replacement is needed and that randomisation would be feasible. The next stage of the work was to design a multi-centre randomised controlled trial, this has been achieved and the trial is now ongoing in the UK

The aim is to report a rare technique for correction of intramedullary nail acute angular deformity. Intramedullary tibial nail fixation of diaphyseal tibial fractures is the gold standard treatment allowing early mobilisation whilst preserving the soft tissues around the fracture site. Most commonly, intramedullary nails fail by metal fatigue secondary to non union, without significant deformity of the metalwork. Plastic deformity of the nail can result following new acute trauma, particularly before bone union has occurred. This is a clinical challenge as a reamed intramedullary nail is designed to achieve three point fixation with close anatomical fit, such that removal of a bent nail is technically difficult and also risks further damage to bone and soft tissues. We report a case of a 20 year old patient treated with intramedullary nail fixation of a diaphyseal right tibial fracture who was subsequently assaulted 4 weeks post operatively. This produced an unacceptable deformation of the nail into 25 degrees valgus and procurvatum. To remove the nail, the authors used a previously reported but rare technique of partial (up to 50%) nail division on the convex surface of the apex using Midas Rex High Speed Drill to weaken the nail then manipulation to correct deformity with minimal stress. The technique produced minimal metal debris and allowed simple exchange nail replacement without further complication. The authors believe this is the first reported use of the technique from the United Kingdom