Subacromial corticosteroid injections are a well-recognised management for chronic shoulder pain and are routinely used in general practice and musculoskeletal clinics. Mycobacterium tuberculosis (TB) of a joint is a rare presentation in the United Kingdom. International literature exists for cases of reactivated latent tuberculosis following intra-articular corticosteroid injections in a knee; however there are no reports of a primary presentation of undiagnosed TB in a joint following therapeutic corticosteroid injections.

A seventy-four year old lady presented with a one-year history of a painful shoulder, which clinically manifested as a rotator cuff tear with impingement syndrome. Following three subacromial depo-medrone injections, the patient developed a painless “cold” lump which was investigated as a suspicious, possibly metastatic lesion. This lump slowly developed a sinus and a subsequent MRI scan identified a large intra-articular abscess formation. The sinus then progressed to a large intra-articular 5×8 cm cavity with exposed bone (picture available). The patient had no diagnosis of TB but had pathogen exposure as a child via her parents.

The patient underwent three weeks of multiple débridement and intravenous amoxicillin/flucloxacillin to treat Staphylococcus aureus grown on an initial culture. Despite best efforts the wound further dehisced with a very painful and immobile shoulder. Given the poor response to penicillin and ongoing wound breakdown there was a suspicion of TB. After a further fortnight, Mycobacterium tuberculosis was eventually cultured and quadruple antimicrobial therapy commenced. Ongoing débridement of the rotator cuff and bone was required alongside two months of unremitting closed vacuum dressing. The wound remained persistently open and excision of the humeral head was necessary, followed by secondary wound closure. There were no extra-articular manifestations of TB in this patient. At present the shoulder is de-functioned, the wound healed and shoulder pain free.

This unique case study highlights that intra-articular corticosteroid can precipitate the first presentation of Mycobacterium tuberculosis septic arthritis. The evolution of symptoms mimic many other shoulder complaints making confident diagnosis a challenge. The infective bone and joint destruction did not respond to the management described in the current literature. There remains a further management issues as to whether arthroplasty surgery can be offered to post-TB infected shoulder joints.

Taking a TB exposure history is indicated prior to local immunosuppressant injection, particularly in the older age group of western populations and ethnicities with known risk factors.

Introduction

Infection is disastrous in arthroplasty surgery and requires multidisciplinary treatment and debilitating revision surgery. Between 80-90% of bacterial wound contaminants originate from colony forming units (CFUs) present in operating room air, originating from bacteria shed by personnel present in the operating environment. Steps to reduce bacterial shedding should reduce wound contamination. These steps include the use of unidirectional laminar airflow systems and the introduction of theatre attire modelled on this principle (e.g. total body exhaust suits). Our unit introduced the use of the Stryker Sterishield Personal Protection System helmet used with laminar flow theatre systems. This study compares an enclosed helmet system used with standard gowns, with standard hood and mask attire.

Background

Patients with diabetes who sustain an ankle fracture are at increased risk for complications including higher rates of in-hospital mortality, in-hospital post-operative complications, length of stay and non-routine discharges.

The 2004 United Kingdom (UK) National Health Service (NHS) Improvement Plan stated that: “By 2008, no one will have to wait longer than 18 weeks from GP referral to hospital treatment.” Over the same time period, on the other side of the Atlantic, the provincial government of British Columbia (BC) allocated funding for a specialist centre accommodating 2 new operating rooms and a 38 bed inpatient ward. The centre was designed to augment existing surgical capacity for hip and knee joint replacement by 1600 cases per year to help achieve the Canadian waiting time target of 26 weeks. Core design principles were:

to improve patient flow through a centralised joint clinic designed to assess patients with osteoarthritis and related disorders;

Analysis of the programme's results showed:

1609 and 1602 joint replacements were performed during each of the first two respective years of operation – an additional 16% of provincial capacity, thus achieving the headline target;

By maintaining the patient/surgeon relationship and adhering to other key principles a high standard of care has been achieved in this programme with high rates of patient and surgeon satisfaction and a low complication rate.

Purpose

There has been recent interest in gender-specific arthroplasty implant design but little evidence to support their use. We hypothesised that outcomes among arthroplasty patients are affected by gender.

Introduction

The articulating surfaces of a new metal-on-metal (MoM) hip prosthesis system were modified with the ceramic Titanium-Niobium-Nitride (TiNbN) by Physical Vapor Deposition (PVD). The purpose of the study was to investigate whether the elevation of the ion levels of chromium and cobalt, normally seen in the blood of patients after MoM hip arthroplasty, can be prevented by ceramic engineering of the articulating metal surfaces.