Introduction: The role of prophylactic antibiotics in reducing the incidence of infection following hip and knee arthroplasty is well established. The British Orthopaedic Association (BOA) published best practice guidance on the use of prophylactic antibiotics in hip and knee arthroplasty. The guidance stated that all patients should receive prophylactic antibiotics at induction of anaesthesia and that each unit should have a locally agreed policy with advice from microbiologist. The aim of this audit was to compare the practice in our unit with the BOA guidance and implement necessary changes.

Patients and Methods: A prospective audit was conducted over a one month period in 2007 and included all patients undergoing elective primary hip and knee replacements. A similar re-audit was conducted over one month period in 2008 after the initial audit recommendations were implemented.

Results: Forty patients (40) were included in the initial audit. All patients received prophylactic antibiotics at induction but the choice, dose and duration of administration of antibiotics varied widely among surgeons in the unit. After discussion with the local microbiologist, we recommended a departmental policy for prophylactic antibiotics. The policy recommended a single dose of Cefuroxime and Gentamycin for standard cases and a single dose of Teicoplanin and Gentamycin for high-MRSA risk cases. A re-audit was conducted after the new policy was agreed. The re-audit included 33 patients. All patients received prophylactic antibiotics at induction. The choice of antibiotics was concordant with the policy in 79% of cases and duration of administration was appropriate in 85% of cases. Overall, the policy was adhered to in 22 cases (67 %).

Discussion & Conclusions: The closed audit cycle resulted in improvement of our practice but the compliance rate with the new policy was lower than expected. Although it is the primary responsibility of the operating surgeon to ensure the appropriate prophylactic antibiotics are administered, more awareness of other team members is necessary to improve the compliance rate with the new policy.

We undertook a prospective study of 61 children in Malawi with septic arthritis of the shoulder. They were randomised into two groups, treated by aspiration (group 1, 31 patients) or arthrotomy (group 2, 30 patients). Both received antibiotics for six weeks. We studied the results of blood tests, microbiology, and the clinical and radiological outcome one year after diagnosis. Only one patient was sickle-cell positive and three were HIV-positive. Non-typhoidal Salmonella species accounted for 86% (19/22) of the positive joint cultures in group 1 and 73% (16/22) in group 2. Of the 33 radiographs available for review at follow-up at six months, 23 (70%) showed evidence of glenohumeral damage. There was no statistical difference in radiological outcome for the two groups. We devised and validated a scoring system, the Blantyre Septic Joint Score, for the assessment of joints based upon swelling, tenderness, function and range of movement. Despite the radiological changes only one of the 24 joints examined at one year had any deficit in these parameters. There was no statistical difference in the clinical outcome for the two treatment groups at any stage during the period of follow-up.

We reviewed 12 patients with primary glenoid dysplasia. Ten were assessed clinically and two from case notes and radiographs. We identified two groups according to the age at onset of symptoms. The first (seven patients) consisted of boys and younger men, all of whom developed symptoms before the age of 40 years. All four children were free from pain, whereas the three adults in this group had varying degrees of this. Four patients had symptoms of instability. The second group consisted of older men (five patients) all of whom had noted the onset of symptoms, in the form of pain and stiffness, after the age of 40 years. All five had radiological evidence of osteoarthritis.

Although the four children in our study had minimal symptoms, all eight adults had ongoing shoulder pain and dysfunction, despite a specific rehabilitation programme. Four patients required surgery; one had posterior stabilisation for instability and three arthroplasties of the shoulder for osteoarthritis.