The Control of Infection Committee at a specialist orthopaedic hospital prospectively collected data on all episodes of bacteriologically-proven deep infection arising after primary hip and knee replacements over a 15-year period from 1987 to 2001. There were 10 735 patients who underwent primary hip or knee replacement. In 34 of 5947 hip replacements (0.57%) and 41 of 4788 knee replacements (0.86%) a deep infection developed. The most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. Of the infecting organisms, 72% were sensitive to routine prophylactic antimicrobial agents. Of the infections, 29% (22) arose in the first three months following surgery, 35% between three months and one year (26), and 36% (27) after one year. Most cases were detected early and treated aggressively, with eradication of the infection in 96% (72). There was no significant change in the infection rate or type of infecting micro-organism over the course of this study. These results set a benchmark, and importantly emphasise that only 64% of peri-prosthetic infections arise within one year of surgery. These results also illustrate the advantages of conducting joint replacement surgery in the isolation of a specialist hospital

This study was undertaken to evaluate the safety and efficacy of retrievable inferior vena cava filters in high-risk orthopaedic patients. A total of 58 patients had a retrievable inferior vena cava filter placed as an adjunct to chemical and mechanical prophylaxis, most commonly for a history of previous deep-vein thrombosis or pulmonary embolism, polytrauma, or expected prolonged immobilisation. In total 56 patients (96.6%) had an uncomplicated post-operative course. Two patients (3.4%) died in the peri-operative period for unrelated reasons. Of the 56 surviving patients, 50 (89%) were available for follow-up. A total of 32 filters (64%) were removed without complication at a mean of 37.8 days (4 to 238) after placement. There were four filters (8%) which were retained because of thrombosis at the filter site, and four (8%) were retained because of incorporation of the filter into the wall of the inferior vena cava. In ten cases (20%) the retrievable filter was left in place to continue as primary prophylaxis. No patient had post-removal thromboembolic complications. A retrievable inferior vena cava filter, as an adjunct to chemical and mechanical prophylaxis, was a safe and effective means of reducing the acute risk of pulmonary embolism in this high-risk group of patients. Although most filters were removed without complications, thereby avoiding the long-term complications that have plagued permanent indwelling filters, a relatively high percentage of filters had to be left in situ

It is becoming widely accepted that research which considers only the outcome and not the costs associated with new technologies in health care, is of limited value in making decisions about the use of scarce resources. Economic evaluation is becoming a standard feature of clinical research but many published economic evaluations fall short of best practice in their methodology. We have described the essential features of economic evaluation, using published studies in orthopaedics, in order to try to improve the ability of orthopaedic surgeons to read, understand and appraise such studies critically, and to encourage them to consider including economic evaluation in future investigations

It has been fascinating to trace the gradual erection of the British edifice of orthopaedics, and nostalgic to recapture a memory, however fleeting, of some of the figures who built it and taught us so much of our sum of knowledge half-way through the twentieth century—the remarkable spell of Robert Jones, the lofty, ascetic Tubby, the pugnacious Openshaw, the forceful and enthusiastic Hey Groves, the earnest but irascible Laming Evans, the equable and thoughtful Elmslie, the restless and exuberant Trethowan. It is always tempting to conclude: "those were the days." It is probably wise to do no more than record the events and leave judgment of progress to a later century. But we are being judged already and not always kindly or even truthfully. We are justified surely in priding ourselves on what has already been achieved, and on the service that orthopaedic surgery now gives to the community and promises for the future. In concern for this aspect of our work we have perhaps tended to neglect our capacity for basic research. But we are aware of this shortcoming, as witness our closer relationships with research departments of universities and royal colleges, and our increasing contacts with colleagues in the basic sciences. Finally, apart from the most intellectual snob and the pessimistic cynic, all must surely rejoice at the enthusiasm, industry and ability of our young colleagues—the orthopaedic surgeons of to-morrow

1. The history of microvascular surgery is reviewed; the necessary instruments and the technique of suture are described. 2. Modern trends in the experimental and clinical applications in orthopaedic surgery and traumatology are discussed. 3. The authors emphasise the usefulness of this technique in tissue transplantation and in the reconstruction of microvascular injuries of the musculoskeletal system

We reviewed all 717 manuscripts published in the 1997 issues of the British and American volumes of the Journal of Bone and Joint Surgery and in Clinical Orthopaedics and Related Research, from which 33 randomised, controlled trials were identified. The results and sample sizes were used to calculate the statistical power of the study to distinguish small (0.2 of standard deviation), medium (0.5 of standard deviation), and large (0.8 of standard deviation) effect sizes. Of the 33 manuscripts analysed, only three studies (9%) described calculations of sample size. To perform post-hoc power assessments and estimations of deficiencies of sample size, the standard effect sizes of Cohen (small, medium and large) were calculated. Of the 25 studies which reported negative results, none had adequate power (β < 0.2) to detect a small effect size and 12 (48%) lacked the power necessary to detect a large effect size. Of the 25 studies which did not have an adequate size of sample to detect small differences, the average used was only 10% of the required number. Our findings suggest that randomised, controlled trials in clinical orthopaedic research utilise sample sizes which are too small to ensure statistical significance for what may be clinically important results

1. The orthopaedic features of 100 patients with the Ehlers-Danlos syndrome are described. 2. The significance of these findings is discussed and comment is made of their relationship to the other stigmata of the syndrome

Eight patients suffering from various forms of idiopathic dystonia are described whose initial referral was for an orthopaedic opinion. The diagnoses of these patients, who were seen over a two-year period, comprised dystonia musculorum deformans, dystonia of the foot, spasmodic torticollis and occupational cramps. Although various musculoskeletal sequelae often occur, the primary underlying neurological cause of these unusual conditions is emphasised

A retrospective survey has been made of forty children with spinal tumours. Difficulties in establishing the correct diagnosis are mentioned and the value of radiological and cerebrospinal fluid investigations discussed. The major orthopaedic disabilities are spinal deformity or instability, and paraplegia. The main factor in the development of the former is the site of laminectomy: the higher the level the greater is the likelihood of deformity or instability developing. Measures to prevent this distressing complication are discussed. The role of the orthopaedic surgeon in the management of these children is emphasised

1. Three new cases of injury to main arteries at orthopaedic operations are described, and a follow-up of two previously described cases is given. The rarity of these accidents is a credit to those engaged in orthopaedic surgery, for many orthopaedic operations are done very close to great vessels, and often under the bloodless conditions of a tourniquet. Nevertheless, it is well to have the risk of great vessel injury in mind because such an accident, although rare, may be a serious threat to life or limb. 2. It is important to repair the damaged artery rather than ligate it because the risk to the growth or viability of the limb is lessened. 3. The aim should be a return to full function with as near normal a vascular anatomy as possible

The prevalence of HIV infection in East Africa has increased rapidly in recent years. We made a prospective study of the incidence of HIV-seropositivity in patients undergoing orthopaedic procedures in a large district hospital in Bulawayo, Zimbabwe. One of our aims was to determine whether a clinically-based screening programme, derived from the Centre for Disease Control classification of HIV infection, could identify high-risk individuals before surgery. During a 3-month period, 76 patients were tested, and 12 were HIV-positive (16%). Only two of these patients (17%) had clinical features associated with HIV infection; ten (83%) were entirely asymptomatic. Our results indicate that preoperative clinical screening is unlikely to be successful in identifying seropositive patients before routine surgery

The use of journal clubs and, more recently, case-based discussions in order to stimulate debate among orthopaedic surgeons lies at the heart of orthopaedic training and education. A virtual learning environment can be used as a platform to host virtual journal clubs and case-based discussions. This has many advantages in the current climate of constrained time and diminishing trainee and consultant participation in such activities. The virtual environment model opens up participation and improves access to journal clubs and case-based discussions, provides reusable educational content, establishes an electronic record of participation for individuals, makes use of multimedia material (including clinical imaging and photographs) for discussion, and finally, allows participants to link case-based discussions with relevant papers in the journal club. The Leicester experience highlights the many advantages and some of the potential difficulties in setting up such a virtual system and provides useful guidance for those considering such a system in their own training programme. As a result of the virtual learning environment, trainee participation has increased and there is a trend for increased consultant input in the virtual journal club and case-based discussions. It is likely that the use of virtual environments will expand to encompass newer technological approaches to personal learning and professional development

The orthopaedic scooter is an alternative to crutches. It gives the patient greater freedom on level smooth surfaces and uses less energy

1. Experiments using radio-isotope techniques show that whenever an orthopaedic appliance is inserted into the body tiny fragments of the instruments used to handle it become detached and welded on to the surface of the buried metal. 2. There is evidence that these particles of non-passive tool-metal may cause a small but continuing dissolution of the stainless metal to which they are attached, and that this dissolution, although too small to be detected as visible corrosion, may produce an adverse tissue reaction. 3. In samples of human tissue taken from sites adjacent to buried metal the greatest level of tissue reaction and the highest concentration of iron were found near those parts of the appliances that had been handled with the tools and received the greatest amount of transferred metal. 4. Spectroscopic analyses of similar samples confirmed that the concentration of metal in the tissues surrounding a buried appliance correlates closely with the distribution on its surface of transferred tool metal. Particularly high concentrations of chromium, nickel, and cobalt were found near regions where the transfer had been heavy. The dissolution was not limited to the non-passive foreign metal; the stainless appliance was also dissolved in those regions. 5. The influence of the manner of handling the tools on the amount and distribution of transfer has been studied, and suggestions are made whereby the transfer might be reduced

1. The gravity of thrombo-embolic complications in orthopaedic and accident surgery has stimulated us, since 1951, to devise a means of prevention which comprises: a) the use of anticoagulants, the mode of administration of which has been determined by an experience of over 5,000 cases; and b) a method of selecting those patients most threatened by thromboembolism. 2. Although there could be no absolute guarantee of protection, these measures offered a considerable reduction in the risk of thrombotic complications

Aims

To investigate the experience and emotional impact of prosthetic joint infection (PJI) on orthopaedic surgeons and identify holistic strategies to improve the management of PJI and protect surgeons’ wellbeing.

Introduction

Studies have addressed the issue of increasing prevalence of work-related musculoskeletal (MSK) pain among different occupations. However, contributing factors to MSK pain have not been fully investigated among orthopaedic surgeons. Thus, this study aimed to approximate the prevalence and predictors of MSK pain among Saudi orthopaedic surgeons working in Riyadh, Saudi Arabia.

Most children with spastic hemiplegia have high levels of function and independence but fixed deformities and gait abnormalities are common. The classification proposed by Winters et al is widely used to interpret hemiplegic gait patterns and plan intervention. However, this classification is based on sagittal kinematics and fails to consider important abnormalities in the transverse plane. Using three-dimensional gait analysis, we studied the incidence of transverse-plane deformity and gait abnormality in 17 children with group IV hemiplegia according to Winters et al before and after multilevel orthopaedic surgery. We found that internal rotation of the hip and pelvic retraction were consistent abnormalities of gait in group-IV hemiplegia. A programme of multilevel surgery resulted in predictable improvement in gait and posture, including pelvic retraction. In group IV hemiplegia pelvic retraction appeared in part to be a compensating mechanism to control foot progression in the presence of medial femoral torsion. Correction of this torsion can improve gait symmetry and function

We report 16 orthopaedic patients who had antibiotic-associated diarrhoea (pseudomembranous colitis) after operation. There was an association with the use of cephradine and with the prolongation of prophylaxis for more than three peri-operative doses. Five cases occurred as a cluster, suggesting that the causative agent, Clostridium difficile, may be infectious in some situations