There is high morbidity and mortality associated with infection following orthopaedic procedures. In accordance to local guidelines, most hospitals follow a set protocol for surgical prophylaxis, which expects a compliance rate of 100%.

A new protocol was introduced to the orthopaedic department of a teaching hospital in August 2013, changing from a cephalosporin, with potential C. difficile risk, to teicoplanin and gentamicin, within 30 minutes of incision.

Our aim was to audit how well the protocol was followed across 3 different time periods.

Data was collected for 3 different time periods following the introduction of the new protocol (August-November 2013, April-May 2014 & November 2014) on the choice of antibiotic. Both elective and trauma cases were included. After each cycle, the data was presented to the orthopaedic surgical and anaesthetic departments to raise awareness and draw attention to the antibiotic prophylaxis posters in theatre.

The 1st audit cycle (n=30) indicated that there was 0% compliance with the current protocol and 100% compliance with the previous protocol. The 2nd audit cycle (n=27) indicated that 0% complied with the current protocol, 54% complied with the previous protocol and that there was a combination of both protocols being used in 46% of the patients. Finally the 3rd audit cycle (n=33) indicated a 100% compliance rate in terms of antibiotic choice. However, only 9% were given the appropriate dose according to body weight and within the appropriate time based on the documented evidence.

This audit demonstrates the value of auditing and then disseminating the findings to relevant departments to influence practice. Each audit cycle demonstrated a progressive uptake in compliance with the hospital trust's antibiotic prophylaxis policy. The last audit cycle highlighted discrepancy in dosage based on weights; a further intervention will be to provide ideal body weight (IBW) vs dose tables in all orthopaedic theatres to ensure the correct antibiotic dosage is given.

Despite being one of the most common orthopaedic operations, it is still not known how many arthroscopies of the knee must be performed during training in order to develop the skills required to become a Consultant. A total of 54 subjects were divided into five groups according to clinical experience: Novices (n = 10), Junior trainees (n = 10), Registrars (n = 18), Fellows (n = 10) and Consultants (n = 6). After viewing an instructional presentation, each subject performed a simple diagnostic arthroscopy of the knee on a simulator with visualisation and probing of ten anatomical landmarks. Performance was assessed using a validated global rating scale (GRS). Comparisons were made against clinical experience measured by the number of arthroscopies which had been undertaken, and ROC curve analysis was used to determine the number of procedures needed to perform at the level of the Consultants.

There were marked differences between the groups. There was significant improvement in performance with increasing experience (p < 0.05).

ROC curve analysis identified that approximately 170 procedures were required to achieve the level of skills of a Consultant.

We suggest that this approach to identify what represents the level of surgical skills of a Consultant should be used more widely so that standards of training are maintained through the development of an evidenced-based curriculum.

Cite this article: Bone Joint J 2015;97-B:1309–15.

A feasibility study of the use of an MRI based patient specific knee arthroplasty system within the NHS.

Introducing new technologies within a public funded health system can be challenging. We assess the use and potential benefit of customised jigs for knee arthroplasty. Outcomes assessed were safety and accuracy of implantation.

Eight knee replacements using custom jigs were compared to 11 conventionally instrumented replacements matched to surgeon and operative day. Parameters measured include tourniquet time; drain output; hospital stay; adjusted change in haemoglobin; complications; and component position on post-operative long-leg alignment films

None of the parameters observed demonstrated a statistically significant difference from the conventional arthroplasty group. No complications were seen in either group. No significant differences were seen in alignment.

Our early experiences show that this technology appears safe and allows accurate implantation of the prosthesis. There was a trend for decreased stay and blood loss. The health economic benefits of navigational arthroplasty have been demonstrated in other studies and come from the lack of instrumentation of the intramedullary canal. MRI based patient specific instrumentation is considered technically easier and more convenient than intra-operative navigation. A larger study is planned to assess the health economic implications of adopting this new technology.

The outcome and survivorship of osteotomy for medial compartment osteoarthritis are closely correlated to the changes in the weight bearing axis. Questions remain over the optimal correction when undertaking medial unicompartmental knee replacement (UKR).

Prospective data was collected on 50 patients (30F:20M) undergoing fixed bearing medial UKR which included pre-operative and 12 month Oxford Knee Scores and pre and post-operative weight-bearing long-leg radiographs.

The weight bearing axis was measured from the centre of the femoral head to the mid-point of the talus. The point at which this axis crossed the tibial plateau was expressed as a percentage of the width of that plateau - 0 (medial cortex) to 100% (lateral cortex).

Regression method and correlation coefficients were used to assess the relationship between the response and variables.

A significant correlation was seen between the 12 month score and the change in axis, which was maintained when the pre-operative score was adjusted for (p = 0.043 and 0.046 respectively). Larger changes in scores were seen with larger changes in axis (p = 0.046) when the pre-operative axis was adjusted for.

Higher BMIs reported worse scores at 12 months (p = 0.022) and a smaller overall change in score one year post-operatively (p = 0.037). This significance was improved when the pre-operative scores were adjusted (p = 0.017 and 0.017 respectively).

Proximity of correction of axis to the assumed contralateral normal was weakly correlated (p = 0.049) to the 12 month score, especially when BMI was corrected for.

These results suggest that the weight bearing axis and BMI do play a significant role in early patient outcomes following fixed bearing unicompartmental knee replacement.

Objectives: To determine the effect of an Orthogeriatric team (OGT) upon patient management pre-operatively after its incorporation into a regional trauma centre of a district general hospital in the UK.

Design: Prospective audit covering all patients admitted with a fractured hip for surgery one year before and one year after the establishment of an OGT.

Method: A total of 288 fractured hips were operated on during February 2004 to February 2005. From February 2005 the OGT was created, consisting of a Staff Grade and 2 Senior House Officers (junior residents), assisted part-time by a consultant. Patients were medically managed and optimised for theatre; 301 patients underwent surgery in the 1st year from Feb 2005 to 2006.

The data was collected prospectively from admission, and entered onto a database.

Results: Before the set up of the OGT only one-quarter (25%) of patients were operated on within 24hours compared to almost one-half of patients (44%) under the care of the OGT. Of the patients waiting more than 24hours, delay while waiting for special tests was similar but there was a significant difference in the percentages of patients delayed due to lack of theatre time and poor medical condition. Only 5% of patients under the care of the OGT were delayed due to medical co-morbidity compared with 44% when solely under orthopaedic care.

Conclusion: Focused high-quality medical input provided by a specialist Orthogeriatric team resulted in significantly reduced delays to theatre for patients admitted with a fractured hip. This is in the context of our hip fracture population becoming increasingly frail with increasing medical problems and continuing pressures on operating time. In the environment of financial constraint, this study confirms that reduction in time to theatre, effective, appropriate investigation and lower complication rates are likely offset the cost of the team. This may provide a model for other units.

BACKGROUND: Complex tibial peri-articular fractures are known to be challenging with high complication rates. Techniques are evolving to assist the management of these injuries and this study looks at a Trauma unit’s experience to help evaluate indications, short and mid-term outcomes and complications.

METHOD: 4 year retrospective analysis of prospectively enrolled patients diagnosed with complex peri-articular fractures. Definitive treatment with Less Invasive Stabilisation System (LISS), low contact peri-articular plates and locking condylar plates, using minimally invasive percutaneous osteosynthesis (MIPO), irrespective of initial operative management were included. Follow up:until discharge from clinic with union and full weight bearing. Outcome: peri- and post-operative complications, loss of fixation, radiographic union, and range of motion.

RESULTS: 25 (15 proximal,10 distal tibial) operations by senior authors (RAB, SDD) over 4 years with a 16–88 year age (mean 44). Poly-trauma:7 (28%) of cases and 6 (24%) of the entire group were open fractures. Ten patients (40%): preceding damage-limitation procedure prior to definitive treatment (MIPO) and found to be over twice as likely to experience a complication compared to patients who did not. 3 (12%) of 10 had failed those alternative modalities. Overall infection rate was 24% (6 patients:2 deep wound infections; 4 open fracture wound infections). Infection was successfully managed with the use of debridement, flaps and antibiotics in 2 patients (8%); antibiotics alone on one (4%); in 3 patients with the delayed plate removal (12%), usually after union (1 revised with an intramedullary nail). Six plates (24%) were removed: 3 (12%) for infection; 2 (8%) for pain; 1 (4%) for plate fracture (revised). Other complications:2 (8%) significant wound breakdowns, one of whom required local flap cover. No mal-alignment issues; 1 patient developed common peroneal nerve neuropraxia. Patients who were operated after a week or more from injury were half (33%) as likely to suffer from a complication than those operated within a week (57%); P < 0.05 Chi-Square.

All progressed to union with 5 patients (20%) having metal work out at that end point and 8 (32%) healing without complication, further surgery or irritation. There were 18 re-operations in total in 9 (36%) of the patients.

CONCLUSION: Complex peri-articular fractures of the tibia continue to have a high re-operation rate with significant infection risk especially in open injury. Such techniques do provide a lower morbidity and short-term complication profile when compared with frames/hybrids and formal open fixation. The timing of minimal approach surgery is crucial and has yet to be fully defined. Within a department this type of fixation should be restricted to those with a specific interest, experience and training.

Background: The implications of clinical governance, changing epidemiology, financial restraints alongside the increasing demands of the informed consumer-patient mean we must continually adapt our practice to efficiently meet expectations.

As a busy regional Trauma and Orthopaedics Unit of a District General Hospital we are increasingly affected by economic agendas and have noted an increase in the presenting frailty of our fracture hip patients.

Our practice has already changed by the use of an Orthogeriatrics Team (OGT): optimising patient status pre-operatively and ensuring maximum post-operatively continuity. The OGT has significantly reduced time to theatre. With appropriate investigation and lower complication rates it will offset the cost of the team.

We wanted to see if the care of fractured hip patients could be further focused.

On this basis, a four-part clinical stratification system was devised for patients undergoing fractured hip repair:

Complex 0 (C0): Hip repair of a non-complex fracture pattern in an otherwise fit, healthy patient.

Patients and Methods: The first 50 patients operated on across the same three months in both 2004 and 2005 were retrospectively assessed from prospectively collected data.

Patients were grouped accordingly and age, length of stay, time to theatre and reason for delay, mental state examination score (MSE) on admission, and number of co-morbidities were also recorded.

Chi-square was performed on co-morbidity, MSE and theatre times with AVOVA used for age and length of stay data.

Results: No significant difference between groups for age.

Two fold increase in stay (2004 paired classes C0+I vs CII+III; P< 0.003).

Chance of more than 2 co-morbidities (C0+I vs CII+III): 52% vs 96% (2004) and 56% vs 92% (2005).

MSE with a positive dementia score: 26% vs 82% (2004; P0.001) and 39% vs 70% (2005; P< 0.05).

Time delays to theatre greater than 24hrs were seen 24% vs 92% (P< 0.001) in 2005. The correlating values in 2004 were 63% vs 87%.

Active treatment delaying theatre in the C0+I group 24% vs 57% (CII+III) in 2004 and 0% vs 78% 2005 (P< 0.001).

Conclusion: The benefit of the OGT can be seen clearly in most parameters and this classification system correlates and quantifies increasing hip fracture complexity with increasing post-operative burden even under their care.

Stratifying patients for pre- and postoperative planning, risk counselling, and surgeon selection can identify patient groups likely to incur greater cost during their treatment.

The classifications are easily reproducible and can be applied to larger patient groups via institutional or national joint registries.