Introduction

Hip prosthetic joint infection (PJI) is a debilitating complication following joint replacement surgery, with significant impact on patients and healthcare systems. The INFection ORthopaedic Management: Evidence into Practice (INFORM: EP) study, builds upon the 6-year INFORM programme by developing evidence-based guidelines for the identification and management of hip PJI.

Hip prosthetic joint infection (PJI) is a debilitating complication following joint replacement surgery, with significant impact on patients and healthcare systems. The INFection ORthopaedic Management: Evidence into Practice (INFORM:EP) study, builds upon the 6-year INFORM programme by developing evidence-based guidelines for the identification and management of hip PJI.

A panel of 21 expert stakeholders collaborated to develop best practice guidelines based on evidence from INFORM \[1\]. An expert consensus process was used to refine guidelines using RAND/UCLA criteria. The guidelines were then implemented over a 12-month period through a Learning Collaborative of 24 healthcare professionals from 12 orthopaedic centres in England. Qualitative interviews were conducted with 17 members of the collaborative and findings used to inform the development of an implementation support toolkit. Patient and public involvement contextualised the implementation of the guidelines. The study is registered with the ISCRTN (34710385).

The INFORM guidelines, structured around the stages of PJI management, were largely supported by surgeons, although barriers included limited awareness among non-surgical team members, lack of job planning for multidisciplinary teams, and challenges in ensuring timely referrals from primary care. Psychological support for patients was identified as a critical gap. Advanced Nurse Practitioners and multidisciplinary team (MDT) coordinators were seen as potential bridges to address these knowledge gaps. The guidelines were also viewed as a useful tool for service development.

This study presents the first evidence-based guidelines for hip PJI management, offering a comprehensive approach to prevention, treatment, and postoperative care. Effective implementation is crucial, involving wider dissemination amongst primary and community care, as well as non-specialist treatment centres. Further resources are needed to ensure job planning for MDTs and psychological support for patients. Overall, this study lays the foundation for improved PJI management, benefiting patients and healthcare systems.

Lateral hip pain is a common problem in middle-aged females. After investigation, a group of patients remain who are given the diagnosis of ‘trochanteric bursitis’. Treatment to date has included physiotherapy, non-steroidal anti inflammatory medication and judicious use of a combined corticosteroid and local anaesthetic preparation injected into the bursa with or without imaging control. Some surgical procedures have been described. The aims of this study are to document and describe our experience with 88 patients and to raise awareness of the condition as a common cause of lateral hip pain which is amenable to surgical repair.

This study has the approval of the Western Sydney area health service. Between 2000 and 2008, 161 patients were referred to the senior author for management of lateral hip pain. 121 patients underwent surgery to repair a gluteal tendon detachment. 32 patients were excluded from the study due to concurrent or previous surgery to the area. A surgical audit was performed on the remaining 88 patients.

Assessment was performed using the Merle d’Aubigne and Postel scoring system. The average duration of symptoms was 6 – 144 months. At 6 months, 88% patients had minimal or no pain. There were also significant improvements in range of motion and ability to walk. The most significant complication was deep vein thrombosis (6%).

Based on our experience, any patient who does not respond to treatment for trochanteric bursitis should be investigated for a gluteal tendon tear. Those with a positive MRI scan of the trochanteric region can be offered surgery for gluteal tendon repair.

Rotator cuff tendons are typically reattached to the proximal humerus using either transosseous sutures or suture anchors. Their primary mode of failure is at the tendon bone interface 1. Surgical adhesives are used to bond cartilage, tendons and bone, and to close wounds. In an attempt to increase the tendon-bone interface we investigated the addition of a novel adhesive secreted from a species of Australian frog (Notaden bennetti) 2 to different methods of rotator cuff repair.

Forty two fresh frozen sheep infraspinatus tendons were repaired using 3 different techniques: transosseous sutures; two Mitek RC Quickanchors with 1 suture per anchor and two Opus Magnum anchors with 1 suture per anchor all using a mattress stitch configuration. In each group 7 shoulders were repaired with the addition of a small amount of frog glue to the infraspinatus footprint while 7 were used as control with no adhesive. Mechanical testing was performed using a mechanical tensile testing machine.

The strongest construct in the control groups was the Mitek suture anchors (mean 86±5 N) followed by the Opus suture anchor (69±6N) and transosseous repair (50±6N). This proved significant (p< 0.05) between both metallic anchors and the transosseous repair.{BR}The addition of frog glue resulted in a significant increase in load to failure and total energy required until failure in all repair techniques (p< 0.01). There was a 2 fold increase in load to failure of both the Opus Magnum (143±8N) and Mitek RC Fastin (165N±20 N) anchors while the transosseous repair (86± 8 N) had a 1.7 fold increase in its load to failure.

This data suggests that:

suture anchor fixation is a stronger construct requiring a larger amount of total force to fail than transosseous repair using a one suture repair technique, that

The unique properties of this frog glue (strong, flexible, sets in water and biocompatibility) may ultimately lead to the production of a useful adjunct for rotator cuff repair in humans.

Obesity is considered a risk factor to a successful outcome in total knee arthroplasty. The prevalence of obesity is causing concern as risks associated with obesity are well documented and the incidence of obesity is increasing in the Australian population. Previous studies have not reached a consensus on the relationship of BMI and short term outcomes of total knee arthroplasty.

The aims of this study were to evaluate the relationship between BMI and the degree of flexion achieved at discharge and to determine the influence of BMI on pre and postoperaive range of motion, duration of surgery, analgesia requirements and duration of stay.

Obesity is defined as a body mass index (BMI) of greater than 30 KG/m2. 120 consecutive patients were recruited from patients presenting for total knee arthroplasty (TKA) to two hospitals. They were classified into one of four groups based on their BMI. All patients were assessed pre and postoperatively by the surgical team. Data was collected on type of implant used, duration of surgery, type of anaesthetic, analgesia requirements and length of stay. Knee society scores were collected pre and postoperatively. Three to six month follow-up was conducted by the surgical team to record flexion, ROM and KSS. Statistical analysis was performed using statistical software.

120 patients were available for the study with 61 (50.8%) being classified as obese and 6 patients classified as morbidly obese. (BMI > 40). The average preoperative flexion results were 112.1 degrees (BMI 18.5 to 14.9), 114.0 degrees (BMI 25 to 29.9), 107.0 degrees (BMI 30 and above), while the postoperative flexion prior to discharge was 85 (BMI 18.5 to 24.9), 90.3 (BMI 25 29.9) and 88.3 (BMI 30 or above). The obese patients had a lower ROM preoperatively but there was no Significant difference at discharge. Patients with a BMI of 25–29.9 used the least amount of analgesia and had the fastest surgery time. They also spent the least amount of time in hospital. (6.3 days) Patients classified as clinically obese (BMI 30 and above) recorded the lowest KSS. As BMI increases the postoperative functional knee score decreases but there is no Significant difference at discharge and 3–6 months postoperatively.

The increasing prevalence of obesity in the Western world suggests that a Significant proportion of surgical patients will be in the obese or morbidly obese catergory. This studty suggests that BMI alone does not influence the short term outcomes of TKA. The poorer long term outcomes in TKA may be related to other factors. Further research may be appropriate.