Periprosthetic joint infection (PJI) causes significant morbidity. Methicillin sensitive Staphylococcus Aureus (MSSA) is the most frequent organism, and the majority are endogenous. Nasal MSSA colonisation is a proven risk factor for S. aureus infection. Decolonisation reduces PJIs but there is a paucity of evidence comparing treatments. Aims; compare 3 nasal decolonisation treatments at (1) achieving MSSA decolonisation, (2) preventing PJI.

Our hospital trust introduced MSSA screening and decolonisation prior to hip and knee arthroplasty in 2010. Data was prospectively collected since 2013, including all MSSA carriers, decolonisation treatment received, MSSA status at time of surgery and all PJIs. Prior to 2017 MSSA carriers received nasal mupirocin or neomycin, from August 2017 until August 2019 nasal octenidine was used.

During the study period 15,958 primary hip and knee replacements were performed. 3,200 (20.1%) were MSSA positive at preoperative screening and received decolonisation treatment, 698 mupirocin, 1,210 neomycin and 1,221 octenidine. Mupirocin (89.1%) and neomycin (90.9%) were more effective at decolonisation than octenidine (50.0%, P<0.0001). There was no difference in S. aureus PJI rates (P=0.452). Of those negative at original screening 9.1% were positive on the day of surgery (1,164/12,758).

MSSA decolonisation is an effective method to decrease PJI rates but there is little research into the best treatment. Both mupirocin and neomycin are more effective than octenidine at achieving MSSA decolonisation. There was poor correlation between the MSSA status after treatment and PJI rates. There is debate if treatment should be targeted by screening or if all patients she be treated without screening. Global decolonisation without screening is supported by the 26.7% of carriers that were negative at original screening in our study.

Further research is needed comparing decolonisation treatments to reduce PJI rates and avoid the risk of drug resistance.

Aims

We assessed the difference in hospital based and early clinical outcomes between the direct anterior approach and the posterior approach in patients who undergo total hip arthroplasty (THA).

Introduction

The Direct Anterior Approach (DAA) offers potential advantages of quicker rehabilitation compared to posterior approach THR. The aim of this study was to compare hospital based and early clinical outcomes between these two groups with utilisation of Enhanced Recovery After Surgery (ERAS) protocol.

Introduction The Zweymuller tapered cementless titanium femoral stem has been in widespread use since 1986.1 Stress shielding of the proximal femur has been a concern with pressfit cementless femoral stems. Radiolucent lines (RLLs) are signs of stress shielding and possibly over time, may lead to aseptic loosening.2

Aim To evaluate the longterm radiographic bone response in the femur following Zweimuller total hip replacements.

Study Design Consecutive case study (serial radiographic analysis)

Material and Methods 49 Total Hip Replacements in 42 patients (M:F=25:17) with a mean age of 59 years (range 49–70 years), were included in the study. All patients were operated on by the senior surgeon (JRW). 28 Alloclassic and 21 Endoplus stems were implanted. AP and Lateral radiographs were assessed. A gap of 1mm or more at the bone prosthesis interface was recorded as positive for RLLs in the Gruen zones. The mean duration of follow-up was 46 months (range 24–140 months). 17 patients had follow up of more than 5 years. Other measurements included subsidence, bone remodelling and heterotropic ossification.

Results After 2 years there were distinct radiological changes (RLLs), mainly in Gruen zones 1 and 7, in 18/49(36%) femora. Though there was evidence of RLLs in zones 2 and 6, the numbers were insignificant. Subsidence of more than 3mm was noted in 16 stems (33%). Heterotropic ossification was found in 4 patients (8%), one of whom required excision. Persistent pain due to trochanteric bursitis was noted in 10 patients. 4 patients needed revision due to reasons other than aseptic loosening. There were two dislocations, which needed revision of the acetabular component.

RLLs were more common in the Endoplus group (10/21) compared to the Alloclassic group (8/28). There was no clinical compromise (all had pain free mobility) in these patients and no progression of RLLs was noted.

Conclusion Proximal femoral stress shielding following Zweimuller femoral stem implantation is observed in significant number of patients. The RLLs do not correlate with symptoms and patient satisfaction.

Aim: A study to determine the results of tibial tubercle osteotomy in a series of revision and difficult primary total knee replacements.

Method: A consecutive series of total knee replacements in which tibial tubercle osteotomy was performed were reviewed retrospectively. 18 revision knees and 5 primary knee replacements were identified. All of the operations performed were by the senior author.

The technique was the same in all cases, involving 9cm osteotomy with screw fixation. In cases with marked restricted flexion and patella baja, the tubercle was deliberately moved proximally to gain length in the extensor mechanism.

Results: All osteotomies had united by 8–12 weeks as assessed on a lateral radiograph.

Range of movement increased on average 45° in the revisions, and by 60° in the primaries.

An active extensor lag in 4 cases (all deliberate proximalisations) post operatively which all recovered.

5 patients underwent MUA for stiffness at 12 weeks.

Conclusion: Tibial tubercle osteotomy allows predictable extensile exposure in primary and revision total knee replacement. It also allows lengthening of a contracted extensor mechanism. Union rate was excellent and complications low. It allows preservation of the quadriceps mechanism and a normal post-operative rehabilitation.

Aim: Long term results of the Stanley& Winson procedure on the elbow.

Material: 15 patients in the last 10 years. 2 lost to follow-up and 13 were evaluated with Andrews and Carson scoring system. The mean time for follow-up was 2.3 years. Primary OA in 8, post-traumatic arthritis in 4 and rheumatoid arthritis in 1 patient was responsible for the symptoms.

Results: Before operation, the mean pain score was 9.23 (range 5–20) out of 60 on the Andrew Carson rating scale. Postoperatively this score increased to 18 (range 10–25) i.e. 50% beneþt of pain.

Changes in ROM of Elbow: All patients returned towork in mean of 6.5 weeks (range 4–24). Postoperatively 2 patients developed haemarthrosis, which was aspirated. Conclusion: O-K procedure has good to excellent results, it is technically simple, has low morbidity and avoids extensive release for stiff elbows.

Aim: The purpose of this study was to determine the long-term results of tibial tubercle osteotomy in a series of revision and difþcult primary total knee replacements. Method: A consecutive series of total knee replacements in which tibial tubercle osteotomy was performed were reviewed retrospectively. 18 revision knees and 5 primary knee replacements were identiþed. All of the operations performed were by the senior author. The technique was the same in all cases, involving 9cm osteotomy with screw þxation. In cases with marked restricted ßexion and patella baja, the tubercle was deliberately moved proximally to gain length in the extensor mechanism. In 3 revisions the index component had a porous in-growth stem. The osteotomy facilitated explantation. Results: All osteotomies had united by 8–12 weeks. Range of movement increased on average 45û in the revisions, and by 60û in the primaries. An active extensor lag in 4 cases (all deliberate proximalisations) post operatively which all recovered.5 patients underwent MUA for stiffness at 12 weeks. Conclusion: Tibial tubercle osteotomy allows predictable extensile exposure in primary and revision total knee replacement. It also allows lengthening of a contracted extensor mechanism. Union rate was excellent and complications low. It allows preservation of the quadriceps mechanism and a normal postoperative rehabilitation.

We report three cases of avulsion of the ischial tuberosity with marked chronic disability after delay in diagnosis and non-union of the fracture. All were treated by open reduction and internal fixation with return to full function, allowing in one case, athletic performances of Olympic standard. We also report one patient with an acute apophyseal avulsion treated by early reduction and internal fixation with restoration of full function.