In bone and joint infections, several materials can be used for local antibiotic elution at site of infection. Polymethylmethacrylate (PMMA) cement is often used. Recently the use of antibiotic impregnated dissolvable synthetic pure calcium sulphate beads [Stimulan R]1 has been used as an alternative, due to several perceived advantages.

We present our experience of using Calcium sulphate beads in infections involving the upper limb.

From Jan 2012 to Jan 2015, we used Calcium sulphate beads in 7 complex upper limb infections including 1 elbow replacement, 2 infected non unions, 2 shoulder replacement, 1 wrist fusion and I ORIF elbow.

We used combination of Vancomycin and Gentamicin in the beads, using manufacturer's mixing guide for optimum setting.

Arthroplasty infections underwent explantation, addition of antibiotic impregnated calcium sulphate beads in the joint space, followed by a second stage, and systemic antibiotics. Fracture non-union cases had surgical debridement, calcium sulphate beads and systemic antibiotics

Follow up (6months to 2 years) indicate no recurrence of infection in any case.

The most common organisms isolated were Coagulase negative staphylococcus and Staphylococcus aureus. Others included Group B Streptococcus, Serratia marscesens and Corynebacterium spp.

In 2 of 7 cases there was significant drainage from the wound. This settled without further input.

For fracture non-union fixation, there was no need to do second procedure to remove beads as they dissolve. In cases of staged revisions, the beads were inserted at first stage with microbiological clearance at 2nd stage

At present there are no reports in the literature of the use of this product in the upper limb. Our experience suggests use of dissolvable pure Calcium sulphate beads impregnated with selected antibiotics, is an effective adjunct to current treatments.

Aseptic drainage has been reported and this was seen in some of our cases. It is postulated that the use of Calcium sulphate beads in more superficial joints may lead to more drainage. It may be necessary to avoid packing any beads in the subcutaneous spaces and using lower volumes in upper limb.

Further work will include long-term follow up and any evidence of relapse or recurrence of infection.

The JRI cemented total hip replacement consisted of an acetabulum with a gamma irradiated UHMW polyethylene cup encased in a titanium metal shell, a 32 mm titanium head, and forged titanium alloy stem. Revision of this implant for failure, in particular that of the acetabulum, and the lack of published survivorship prompted a retrospective review of the local series. Data was compiled from theatre log books, patient records and X-rays.

During the period 1989–1997 a single surgeon performed 304 total hip replacements using this JRI prosthesis through an anterior lateral approach. The average age was 70 (48–96), with 186 (61%) female and 85% performed for osteoarthritis. Complete data was available in 236 cases to allow further analysis. The average follow up was 9.3 (1–17) years. During this period 37 hips had to be revised: 28 for a loose acetabulum, both components were loose in 5, and 3 had revision for infection. The mean time to revision was 7.4 (1–17) years.

This data provides a revision rate of at least 16% at ten years. This data does not take potential earlier radiographic failure nor patient function into account. This prosthesis therefore fails to comply with modern benchmarks for survivorship of implants. Furthermore this study highlights the importance of ongoing review of patients who have undergone joint replacement, in particular those with implants that have problems with design, as has been demonstrated in other metal backed components.

We set out to ascertain if there is a consensus in elective orthopaedic practice for the screening and management of MRSA. A questionnaire was distributed to all British Orthopaedic Association Linkmen, with prepaid return envelopes.

A response rate of 60% (159 of 250) was recorded. 62% do have a screening policy in practice: all admissions (44%), high risk patients only (22%), only patients for joint replacement (12%), both patients for joint replacement and patients at high risk of carriage (21%). Eradication therapy is used in a MRSA - positive patient prior to joint replacement surgery by 91%, following which the MRSA status would be checked by 88%. The efficacy of eradication would be confirmed by obtaining: one set (29%), two sets (13%), and three sets (49%) of negative swabs, prior to proceeding with surgery. A 2nd generation Cephalosporin (77%), followed by Teicoplanin/Vancomycin (16%) are in routine use for antibiotic prophylaxis.

The majority of responders have adopted a practice of screening patients; however, significant differences exist in the population that is selected for screening. Eradication in MRSA positive patients is a common practice, but there is variation in the number of subsequent screens performed. Cephalosporins remain the antibiotic of choice for prophylaxis but first line therapeutic agents are also being used which may have implications for resistance. These variations can be partly attributed to the lack of evidence from which practical guidelines can be drafted, as highlighted by national guidelines published in 1998. Until further research is done into the cost effectiveness of screening and the further management of MRSa we have to rely on strict adherence to infection control practices, and appropriate use of antibiotics.

Introduction and Aims: To determine if the surface area of partial thickness (< 50%), Bursal side tears of the cuff influence outcome following Subacromial Decompression.

Method: Shoulder function using Constant score (CS) was recorded before and a minimum of one year after Arthroscopic Subacromial Decompression (ASD) in patients undergoing surgery for primary impingement. In patients who had partial thickness, Bursal side tears (BT), the length of the tear in its largest dimension (surface area) was measured. These patients were divided into two groups according to the tear surface area (≤9 mm and ≥10mm) .To determine whether having a BT (< 50% thickness) or its surface area affect pre- and post-operative CS, t-tests were performed.

Results: 110 patients underwent ASD over a one-year period for primary impingement. Twenty-two patients with partial thickness BT and 18 patients with intact rotator cuff were included in this study. In 10 patients, the BT was ≤9 mm (mean 7 mm) and in 12 patients BT was ≥10mm (mean 13 mm).

Statistical analysis of pre- and post-operative Constant scores showed that, in ≤9 mm group CS increased significantly by 21.5, p=0.02, 95% CI (4.9, 38.1). CS increased in ≥10mm group by 22.8, p< 0.01, 95%(11.5, 34.1). Comparing the change in CS between these two groups with different tears size, there was no significant difference (2-sample t-test, t=0.15, 20df, p=0.88).

To determine whether having BT tear affects pre- and post-operative Constant scores, all BTs were grouped together and compared with the group of patients with intact cuff.

In the group with BTs, average Constant scores increased significantly (paired t-test, t=5.24, 21df, p< 0.01) by 22.2 with 95% CI (13.4, 31.0).

In the group with no tears, average Constant scores increased significantly (paired t-test, t=5.17, 17df, p< 0.01) by 26.6, 95% CI (15.8, 37.5).

Comparing the levels of absolute change in Constant scores from pre- to post-operation between the two groups there is no difference in outcome between patients with a tear and those without a tear (2-sample t-test, t=1.03, 38df, p=0.31).

Conclusion: We conclude that ASD yields satisfactory results in patients with BTs involving < 50% thickness, irrespective of the surface area of the tear.

The Department of Health and the Public Health Laboratory Service established the Nosocomial Infection National Surveillance Scheme in order to standardise the collection of information about infections acquired in hospital in the United Kingdom and provide national data with which hospitals could measure their own performance. The definition of superficial incisional infection (skin and subcutaneous tissue), set by the Center for Disease Control (CDC), should meet at least one of the defined criteria which would confirm the diagnosis and determine the need for specific treatment.

We have assessed the interobserver reliability of the criteria for superficial incisional infection set by the CDC in our current practice. The incisional site of 50 patients who had an elective primary arthroplasty of the hip or knee was evaluated independently by two orthopaedic clinical research fellows and two orthopaedic ward sisters for the presence or absence of surgical-site infection. Interobserver reliability was assessed by comparison of the criteria for wound infection used by the four observers using kappa reliability coefficients. Our study demonstrated that some of the components of the current CDC criteria were unreliable and we recommend their revision.

Purpose of the study: To assess the survivability of the metal backed glenoid component, to examine its mode of failure and to measure the range of movement, specifically rotation following Total Shoulder Arthroplasty.

Patients and methods: 46 patients (55 shoulders) were prospectively followed up after Biomet biomodular Total Shoulder Arthroplasty using a metal backed glenoid component fixed with screws. 36 patients (43 shoulders) had Rheumatoid arthritis, 9 patients (11 shoulders) had Osteoarthritis and 1 patient had Psoriatic arthritis. Mean age at surgery was 58 years (range 37 to 79 years). Patients were followed up for a minimum of 5 years. Data was collected prospectively for a mean follow up of 84 months. 28 of the 46 patients had more than 10 years follow up. Range of movement including forward flexion and rotation was measured. Data was analysed by 3 independent observers. Intention to treat or revision of component was taken as failure. Paired t test comparison was carried out for statistical analysis.

Results: One failure was noted in the Osteoarthritis group at 8 years follow up. Superior head migration and eccentric wear of polyethylene liner was noted in an otherwise well fixed glenoid component. Range of external rotation improved from a mean of 18.2 to 38.2 degrees. This improvement was statistically significant (p=0.01, 95% CI= 6.3 to 35.2). The range of forward flexion improved significantly from a mean of 80.5 to 110 degrees (p= .01, 95% CI= −42.6 to −5.9)

3 failures were noted in the Rheumatoid group. 2 patients needed revision to hemiarthroplasty within 4 years of surgery for rotator cuff insufficiency with superior head migration but without loosening of glenoid. One other shoulder was revised at 11 years for glenoid component loosening with a worn out polyethylene liner. All 3 failures occurred in patients more than 60 years of age. Rheumatoid patients under 60 had a significant improvement in the range of external rotation from a mean of 24.2 to 30.6 degrees (p= 0.03, 95% CI = −21.4 to −1.1). The range of forward flexion improved from a mean of 71.2 to 73.3 degrees which was not statistically significant (p=.767). Rheumatoid patients over 60 years of age did not have a statistically significant improvement in the range of external rotation( p= 0.712) or in their range of forward flexion (p=.757).

Conclusion: Contrary to recent literature, in this study the metal backed glenoid component performed well in the medium to long term following Total Shoulder Arthroplasty particularly in patients with Osteoarthritis and in younger patients suffering with Rheumatoid arthritis.

To determine if the surface area of partial thickness (< 50%), Bursal side tears of the cuff influence outcome following Subacromial Decompression.

Shoulder function using Constant score (CS) was recorded before and a minimum of one year after Arthroscopic Subacromial Decompression (ASD) in patients undergoing surgery for primary impingement. In patients who had partial thickness, Bursal side tears (BT), the length of the tear in its largest dimension (surface area) was measured. These patients were divided into two groups according to the tear surface area (≤9 mm and ≥10mm) .To determine whether having a BT (< 50% thickness) or its surface area affect pre and postoperative CS, t-tests were performed.

110 patients underwent ASD over a one-year period for primary impingement. 22 patients with partial thickness BT and18 patients with intact rotator cuff were included in this study. In 10 patients, the BTwas ≤9 mm (mean7mm) and in 12 patients BTwas ≥10mm(mean13mm). Statistical analysis of Pre-& postoperative Constant scores showed that, in ≤9 mm group CS increased significantly by 21.5, p=0.02, 95% CI (4.9, 38.1). CS increased in ≥10mm group by 22.8, p< 0.01, 95%(11.5, 34.1). Comparing the change in CS between these two groups with different tears size, there was no significant difference (2-sample t-test, t=0.15, 20df, p=0.88).

To determine whether having BT tear affects pre- and post-operative Constant scores, all BTs were grouped together and compared with the group of patients with intact cuff.

In the group with BTs, average Constant scores increased significantly (paired t-test,t=5.24,21df,p< 0.01) by 22.2 with 95% CI (13.4, 31.0). In the group with no tears, average Constant scores increased significantly (paired t-test,t=5.17,17df,p< 0.01) by 26.6, 95% CI (15.8, 37.5).

Comparing the levels of absolute change in Constant scores from pre- to post-operation between the two groups there is no difference in outcome between patients with a tear and those without a tear (2-sample t-test, t=1.03, 38df, p=0.31).

We conclude that ASD yields satisfactory results in patients with BTs involving < 50% thickness, irrespective of the surface area of the tear.

The Department of Health and the Public Health Laboratory Service established the Nosocomial Infection National Surveillance Scheme (NINSS) in response to the need to standardise the collection of information about infections acquired in hospital. This would provide national data that could be used as a ‘benchmark’ by hospitals to measure their own performance. The definition of superficial incisional infection (skin and subcutaneous tissue), set by Centers of Disease Control (CDC), should meet at least one of the following criteria: I: Purulent drainage from the superficial incision. II: The superficial incision yields organisms from the culture of aseptically aspirated fluid or tissue, or from a swab, and pus cells are present. III: At least two of the following symptoms and signs of inflammation: pain or tenderness, localized swelling, redness or heat, and a. the superficial incision is deliberately opened by a surgeon to manage the infection, unless the incision is culture-negative or b. clinician’s diagnosis of superficial incisional infection.

This study assessed the interobserver reliability of the superficial incisional infection criteria, set by the CDC, in current practice.

The incisional site of 50 consecutive patients, who underwent elective primary joint arthroplasty (Hips & Knees), were evaluated independently by four observers. The most significant results of the study I: All four observers achieved absolute agreement (kappa=1) for Purulent wound discharge and clinical diagnosis of wound infection. II: The four observers obtained good agreement for pain criteria (kappa=0.76, III: There was significant disagreement (fair to poor) between all four observers for the following criteria: Localized swelling (kappa=0.34), Redness (kappa=0.33) and tenderness (kappa = 0.05).

This is the first study to assess the reliability of the criteria, as set by the CDC and recommended by NINSS, for the diagnosis of superficial incisional infection and shows the Criterion III is not reliable and we recommend it should be revised. Failure to do so could lead to inaccurate statistics regarding hospital wound infection and detrimental effect on hospital trusts in the setting of league table.