Aim To document an outbreak of Vancomycin Resistant Enterococci in an elective Orthopaedic Unit. To describe the clinical course of the affected patients and treatment options. To describe methods employed in eradicating endemicity following the outbreak and to evaluate the lessons learnt.

Background VRE first appeared in the Microbiological literature in 1988. Very little is known about its effect in the Orthopaedic Realm. To our knowledge, this is the first report of a serious outbreak in such a unit and only the second reporting of peri-prosthetic VRE infection.

Material and methods All patients in the unit over a 1/12 unit formed the cohort for the study. Following identification of the index case, samples were taken form all in-patients. Immediately a nurse specialist in infection control oversaw sampling of all patients. Microbiological data, Clinical Data and antimicrobial therapy data was collected on all positive patients. Rapid laboratory procedure were instituted, environmental screening was preformed and a dedicated cleaning team was formed. The assistance of a Clinical Microbiologist and an Environmental Microbiologist was sought.

Results Following identification of the index case, 11 patietns had microbiological proven VRE. 1 patient had a VRE confirmed peri-prosthetic infection. This necessitated removal and appropriate anti-microbial therapy. However, this patient died. 2 pateints were found to have superficial wound infection, which resolved with oral Linezolid, while 8 patients showed colonization with the organism. No treatment was required other than clinical follow up and staged screening in these patients.

The unit was closed for 9 weeks following the outbreak and deep cleaning resulted in eradication of endemicity.

Conclusion Tracing of the index case and typing allowed us to confirm the source of the outbreak and to take steps to prevent a recurrence. Appropriate microbiological advice is essential in an outbreak situation, management of peri-prosthetic infection and follow up of affected cases. All protocols have been re-evaluated and retraining of all staff in good clinical hygiene has been undertaken. The speed of the outbreak and its devastating effect on a Joint Replacement Facility is alarming and should serve to aid other units in establishing preventative protocols and in preplanning their treatment options and an outbreak team.

Fractures of the mid-shaft of the clavicle have been treated conservatively with excellent results regarding functional outcome. Indeed some studies have indicated that open reduction and internal fixation of mid-shaft clavicle fractures by plating have superior union rates. Recent studies have indicated that early plating of the mid-shaft clavicle fractures is a stable and reliable procedure well tolerated by the patient and results in a rapid rehabilitation and better functional outcome of the shoulder. This study aims to examine the results at retrospective cases of mid-shaft clavicle fractures that underwent acute open reduction and internal fixation.

Case records and x-rays have been recorded for all the 60 patients. All patients have been informed for clinical and radiological examination. Up-to date 50% patients have attended. This gives us a mean follow-up of 9.5 years. Parameters assessed at clinical and radiological examination were Union/non-union rates, time to union, Shoulder function, time back to work and complications.

The shoulder function was assesses by using the Constant-Murley score, which has been recommended by the European Orthopaedic Association. All of the 60m mid-shaft clavicle fractures have plated with one-third tubular plate within 48 hours of the injury. All of them were immobilized in a sling for 72 hours and were the commenced physiotherapy. Skin sutures were removed on the 10th postoperative day. The mean time to radiographic union was 10 weeks. No non-union occurred. Four cases has superficial infection. Six patients had skin numbness over the incision. Average Constant-Murley score was 97% as compared to the contralateral shoulder.

In this study we analyzed our results with osteosynthesis of mid-shaft clavicle fractures using one-third tubular plate.