Presence of superficial wound infection following total joint replacement (TJR) increases risk of deep prosthetic infection and revision surgery. Early identification and management are advocated.

We conducted an audit to identify the number of suspected wound infections, treatment received, and whether diagnosis was supported by microbiological evidence. Early complication data were collected for all TJRs completed in a 12-month period (2012, n=314). Medical records were reviewed for all complications and summarised data were compared with data from 2010/11.

Forty-nine complications were recorded (47 in 2010/11) with increase in number of bacteriologically confirmed wound infections (from 2 to 6) and in number of serious wound infections (n=3).

Review of medical records showed that patients were treated in the community with antibiotics despite lack of objective microbiological evidence. Two of three serious wound infections were preceded by prolonged antibiotic prescription in the community.

Analysis of these results led to a new system for management of suspected wound infection in TJR patients. A ‘wound care card’ is issued at time of discharge and early assessment by a specialist orthopaedic nurse is available. Early results indicate a beneficial effect with potential to improve patient experience and long-term outcome, and to reduce overuse of antibiotics.

Unicompartmental knee replacement (UKR) is associated with higher revision rates than total knee replacement and it has been suggested that surgeons should receive specific training for this prosthesis. We investigated the outcome of all UKR in a district general hospital over ten years.

All patients who had received UKR from 2003 to 2013 were identified from theatre records, as were all revision knee arthroplasties. We contacted all patients (or their GP) with no known revision to ascertain UKR status. A life table analysis was used for three categories: all surgeons and types of UKR, Oxford UKR only and Oxford UKR by surgeons with specific training.

There were 319 UKR (one loss to follow up), four types of prosthesis, 21 failures and a 5-year cumulative survival rate of 91.54%. There were 310 Oxford UKR with 17 failures and 5-year survival 93.56%. Surgeons with training in use of Oxford UKR completed 242 replacements with 10 failures and 5-year survival of 95.68%.

In comparison with results for Oxford UKR in 11th annual NJR report, our results are satisfactory and support continued use of this prosthesis in a non-specialist centre. Our established programme of surveillance will monitor the survival of UKR in our hospital.

The treatment of undisplaced femoral neck fracture in the elderly population is still controversial. We analysed the outcome of cancellous screw fixation for undisplaced femoral neck fracture in patients over 70 years.

The rate of homologous blood transfusion (HBT) following primary total hip replacement (THR) can be as high as 30–40% and is not without risk. Postoperative blood salvage (POS) with autologous blood transfusion may minimize the necessity for HBT but the clinical, haematological and economic benefits have yet to be clearly demonstrated for primary THR.

The aim of this randomized prospective study was, therefore, to determine if the use of post-operative salvage affects post-operative haemoglobin and haematocrit values and reduces the rate of homologous blood transfusion. Secondary outcome measures included length of hospital stay and patient satisfaction. A cost analysis was also conducted on the basis of the results obtained.

The patients were randomized during the operation (at the point of reduction of the primary THR) to receive either two Medinorm vacuum drains or the autologous retransfusion system. A power calculation estimated that 72 patients would be required in each group to detect a significant difference of 0.7 gdL-1 in post operative haemoglobin level (at 80% power with an value of 0.05). This assumed a standard deviation of 1.5 gdL-1 obtained from a previous retrospective study.

There were 82 patients in the Medinorm vacuum drain group and 76 patients in the autologous retransfusion group. In the group with the autologous system, 76% of the patients were retransfused with a mean of 252mls. There was no significant difference between the groups when comparing haemoglobin and haematocrit values. However, significantly fewer patients in the group with the autologous system had a postoperative haemoglobin value less than 9.0 gdL-1 (8% vs. 20%, p = 0.035). Furthermore, significantly fewer patients with the autologous retransfusion system required a transfusion of homologous blood (8% vs. 21%, p = 0.022). There was a small overall cost saving in this group.

This study has shown that use of an autologous retransfusion system for primary THR reduces the necessity for HBT and is cost effective. POS also results in significantly fewer patients dropping their post-operative haemoglobin level below 9.0 gdL-1. As a result our unit routinely uses the autologous retransfusion system for primary THR.

Introduction: NICE guidelines (2000) stipulated three-year follow-up data compatible with satisfactory performance at 10 years as a minimum requirement for hip implants. We reviewed the performance of two devices in use in our department which fell outside these requirements. The Cenator cup (Corin Medical) is a cemented device, and the EPF cup (Plus Orthopedics) is uncemented (equatorially expanded, screw option, polished inside, porous HA coated).

Patients and Methods: 117 Cenator and 110 EPF cups inserted during the period 12/09/2000–28/01/2003 were assessed at 3 years by the following: Oxford Hip Score, satisfaction (visual analogue scale), details of femoral component, age, sex, BMI and any complications. Radiological assessment included Charnley Grade, concentricity, superior cover, cup inclination, migration, radiolucent lines, and linear wear at 3 years. Statistical associations with radiolucent lines or linear wear were calculated.

Results: The mean age of patients with Cenator cups was 81 (range 61–102) and EPF cups 67 (39–86). Oxford Hip Scores averaged 10 (0–41)(Cenator) and 7 (0–29)(EPF). Cup inclination range was 30–65° (mean 47). Linear wear > 1mm was observed in 18 Cenator and 53 EPF cups. Early radiolucent lines behind EPF cups closed (all cases), and superior cover improved in 8%. Progressive radiolucencies > 1mm were seen behind 37 Cenator cups. One of each type was revised for deep sepsis. Four other minor reoperations occurred. Statistical association was demonstrated between superior cover and progressive radiolucencies (Cenator), and between sex, cup size and inclination and linear wear (EPF).

Discussion: Crucial markers of prognosis were observed (progressive radiolucencies and linear wear) but survivorship at three years for aseptic loosening was 100%. Our results indicate satisfactory performance at three years in accordance with NICE guidelines, and suggest acceptability of both devices. Our methods may be applicable to similar implants currently in use but not yet endorsed by suitable published outcome data.

The treatment of undisplaced femoral neck fracture in the elderly population is still controversial. We analyzed the outcome of cancellous screw fixation for undisplaced femoral neck fracture in patients over 70 years.

Materials and methods: From 1998 to 2003, ninety-seven patients with undisplaced femoral neck fracture, aged over 70 and treated with cancellous screw fixation were retrospectively identified. Full clinical data was available for 79 of the 97 patients identified. All patients had in-situ fracture fixation.

Results: Of the 79 patients, M:F was 22:57, average age was 81.3 years. The average inpatient stay was 13.2 days. The mean follow up was 12 months (1m–78m). 24 patients had Garden type I and 55 type II fractures.

26 (32.9%) patients did not return to their pre-morbid mobility status, 5 (6.3%) of which did not return to their preadmission dwelling (2 went to residential home and 3 went to nursing home).

We had documented radiographic details in 46 patients: 41 patients had a healed fracture on radiographs (89.1%), 4 patients had AVN, 4 patients had non-union and 1 patient had AVN with non-union. The failure rate was 19.6%. 15 patients had evidence of screw back out with healed fracture.

12 out of the 46 complained of pain postoperatively of which 9 (19.6%) patients had re-operation: 6 (13%) underwent revision surgery and 3 (6.5%) required screw removal.

30-day mortality was 3.7%. 1-year mortality was 23.2% of which 16 died within the first 6 months (19.5%).

Conclusion: This study shows that in our unit, cancellous screw fixation of undisplaced femoral neck fractures in patients over the age 70 has a good outcome with 19.6% re-operation rate. Radiographic failure rate is 19.6%. One third of the patients did not return to their preadmission mobility level/dwelling.

Aims: Limb sparing surgery, for selected cases of long bone primary malignancy, may be accomplished with the use of large prostheses. Conventional joint implants are known to release metal ions by corrosion or wear. The aim of this study was to determine if a specialist group of patients had elevated serum metal levels. Methods: Over a 12 month period, 20 patients who had undergone previous surgery were recruited from a bone tumour clinic. A 10ml venous blood sample was obtained and analysed for trace metals using a previously published mass-spectrometry technique. Results: Eight children (mean age 14.5 years) and 12 adults (mean age 46.5 years) were recruited a mean of 54 months and 86 months following surgery, respectively. Trace metal (aluminium, titanium, cobalt) elevation was observed in 5/8 (63%) paediatric cases and 6/12 (50%) adult cases. Three of the adults had signiþcantly raised levels, (≤ 50 times), and had undergone revision surgery for loosening. There was no observed implant loosening in the paediatric group. Conclusions: This small sample has demonstrated that many patients with long-term large tumour implants have trace metal levels below laboratory detection. Signiþcant elevation of metal levels in adults was associated with loosening or wear of implants. A signiþcant proportion of paediatric cases had slight elevations, but the signiþcance of this is unknown at present.

In a post-mortem study, we compared subjects with metal implants with and without visible wear with an age-matched control group to determine the extent and effects of dissemination of wear debris. In subjects with stainless-steel and cobalt-chrome prostheses metal was found in local and distant lymph nodes, bone marrow, liver and spleen. The levels were highest in subjects with loose, worn joint prostheses and the main source of the debris was the matt coating. Metal levels were also raised in subjects with implants without visible wear and, to a less extent, in those with dynamic hip screws. Necrosis of lymph nodes was seen in those cases with the most wear, and potential damage to more distant organs such as the bone marrow, liver and spleen in the long term cannot be discounted. The consequences for the immune system and the role of metal dissemination in the possible induction of neoplasia are discussed.

The classification of intra-articular fractures of the calcaneum described in part I is related to an operative approach which allows accurate reduction and stable fixation of the fracture fragments. An extended lateral incision is used to avoid sural nerve damage and problems of soft-tissue healing. In type 3 fractures, access to the lateral joint fragment requires an osteotomy of the lateral wall, but after this the lateral joint fragment can be rotated out of the subtalar joint to allow transcalcaneal reduction of the medial wall. Reduction of the body fragment and lateral joint fragment on to the sustentacular fragment allows the three fragments to be stabilised by a 3.5 mm Y-shaped reconstruction plate. Our early results have been successful in terms of fracture reduction and the restoration of heel shape and joint congruity, but extended follow-up will be necessary to define the indications for this difficult procedure.

The production of particulate wear debris is a recognised complication of joint arthroplasty, but interest has concentrated on local tissue reactions and a possible association with implant loosening. The fate of wear products in the body remains unknown, although some of the metals used in the construction of orthopaedic implants are known to have toxic and oncogenic properties. We report histological and electron-microscopic evidence from two cases which shows that metallic debris can be identified in the lymphoreticular tissues of the body distant from the hip some years after joint replacement. The increase in the use of total arthroplasty in younger patients, the development of new alloys and the use of porous coatings must raise concern for the long-term effects of the accumulation of wear debris in the body.

We studied 55 patients who had undergone elective removal of forearm plates between 1980 and 1986; 44 plates were removed from the radius and 37 from the ulna. Before removal only 20 patients (36%) had definite symptoms attributable to the plates, but 44 patients (80%) were advised by the surgeon to have the plates removed. In 22 cases (40%) the operation was followed by a significant complication. The complication rate was higher with junior surgeons and was permanent in 50% of cases. It is recommended that forearm plates should be removed only if they are causing significant symptoms, and that the operation should not be delegated to the most junior surgeon.