Deep infection was identified as a serious complication in the earliest days of total hip arthroplasty. It was identified that airborne contamination in conventional operating theatres was the major contributing factor. As progress was made in improving the engineering of operating theatres, airborne contamination was reduced. Detailed studies were carried out relating airborne contamination to deep infection rates.

In a trial conducted by the United Kingdom Medical Research Council (MRC), it was found that the use of ultra-clean air (UCA) operating theatres was associated with a significant reduction in deep infection rates. Deep infection rates were further reduced by the use of a body exhaust system. The MRC trial also included a detailed microbiology study, which confirmed the relationship between airborne contamination and deep infection rates.

Recent observational evidence from joint registries has shown that in contemporary practice, infection rates remain a problem, and may be getting worse. Registry observations have also called into question the value of “laminar flow” operating theatres.

Observational evidence from joint registries provides very limited evidence on the efficacy of UCA operating theatres. Although there have been some changes in surgical practice in recent years, the conclusions of the MRC trial remain valid, and the use of UCA is essential in preventing deep infection.

There is evidence that if UCA operating theatres are not used correctly, they may have poor microbiological performance. Current UCA operating theatres have limitations, and further research is required to update them and improve their microbiological performance in contemporary practice.

Cite this article: Bone Joint J 2018;100-B:1264–9.

A case of pencil-gore granuloma occurring 45 years after the initial injury is described. The clinical and radiological presentation was suggestive of a soft-tissue sarcoma. The diagnosis was confirmed by biopsy, which also revealed foreign body fragments which, on spectometric analysis, had high concentrations of carbon and aluminium

Aims

The aim of the study was to analyze the results of primary tendon reinsertion in acute and chronic distal triceps tendon ruptures (DTTRs) in the general population.

Aims

A high rate of suicide has been reported in patients who sustain fractures, but the association remains uncertain in the context of other factors. The aim of this study was to examine the association between fractures and the risk of suicide in this contextual setting.

Injection or aspiration of the ankle may be performed through either an anteromedial or an anterolateral approach for diagnostic or therapeutic reasons. We evaluated the success of an intra-articular puncture in relation to its site in 76 ankles from 38 cadavers. Two orthopaedic surgical trainees each injected methylene blue dye into 18 of 38 ankles through an anterolateral approach and into 20 of 38 through an anteromedial. An arthrotomy was then performed to confirm the placement of the dye within the joint. Of the anteromedial injections 31 of 40 (77.5%, 95% confidence interval (CI) 64.6 to 90.4) were successful as were 31 of 36 (86.1%, 95% CI 74.8 to 97.4) anterolateral injections. In total 62 of 76 (81.6%, 95% CI 72.9 to 90.3) of the injections were intra-articular with a trend towards greater accuracy with the anterolateral approach, but this difference was not statistically significant (p = 0.25). In the case of trainee A, 16 of 20 anteromedial injections and 14 of 18 anterolateral punctures were intra-articular. Trainee B made successful intra-articular punctures in 15 of 20 anteromedial and 17 of 18 anterolateral approaches. There was no significant difference between them (p = 0.5 and p = 0.16 for the anteromedial and anterolateral approaches, respectively). These results were similar to those of other reported studies. Unintended peri-articular injection can cause complications and an unsuccessful aspiration can delay diagnosis. Placement of the needle may be aided by the use of ultrasonographic scanning or fluoroscopy which may be required in certain instances

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Gastrocnemius tightness predisposes to musculoskeletal pathology and may require surgical treatment. However, it is not clear what proportion of patients with foot and ankle pathology have clinically significant gastrocnemius tightness. The aim of this study was to compare the prevalence and degree of gastrocnemius tightness in a control group of patients with a group of patients with foot and ankle pathology.

We describe an unusual injury to the upper cervical spine sustained during ejection from an aircraft. MRI provided an accurate and direct diagnosis of the severe ligamentous injuries

We present four patients who had sustained a traumatic dislocation of the atlanto-occipital joint. The diagnosis was initially missed in two patients. One patient, who was neurologically intact, was treated non-operatively. The remaining three recovered neurologically after an occipitocervical fusion. Early recognition of the injury, especially in multiply-injured patients with head injuries, and timely management may improve survival and neurological recovery

There have been no previous reports of a spinal subdural haematoma occurring as a complication of spinal surgery. We highlight the pitfalls in the diagnosis and management of a subacute subdural haematoma resulting from a dural tear which occurred as a surgical complication of microdiscectomy

1. Two patients with recurrent dislocation of the head of the fibula are described. 2. The difficulties in diagnosis are discussed

A case of chordoma affecting the first lumbar vertebra is reported, with comments on its situation, diagnosis and treatment

Six patients with longitudinal stress fractures of the tibia and femur are described. The difficulties of diagnosis and its confirmation are emphasised

Aims

Recurrent infection following two-stage revision total hip arthroplasty (THA) for prosthetic joint infection (PJI) is a devastating complication. The purpose of this study was to report the survival of repeat two-stage revision hip arthroplasty, describe complications, and identify risk factors for failure.

We report an unusual presentation of a solitary plasma-cell myeloma of the spine in an adolescent patient. Our case indicates the need to consider plasma-cell myeloma as a differential diagnosis even in younger patients

Fractures of the clavicle in the neonate are usually diagnosed by clinical examination and confirmed by plain radiography. Exposure of newborn infants to irradiation should be avoided if possible. Following the clinical examination of 2978 neonates, 15 had suspected fractures of the clavicle. All were confirmed by ultrasound. In combination with clinical examination, ultrasound is a satisfactory alternative to radiological assessment for the diagnosis of fractures of the clavicle in newborn children

1. A case of posterior dislocation of both shoulders, in a patient believed to be epileptic, is described. 2. The difficulties of early diagnosis are discussed

We present a case of septic arthritis of the hip caused by Candida albicans in a 24-year-old woman. This is the first report of a Candida infection of the hip in a patient without any predisposing factors. She underwent a two-stage total hip arthroplasty three years after the onset of the infection. An elevated plasma level of β-D-glucan suggested Candida as the infecting organism and the diagnosis might have been made earlier if this test had been undertaken at presentation

1. Two cases of pseudogout are described with an onset acute enough to be mistaken for septic arthritis. 2. The radiological and laboratory investigations for diagnosis are described

1. A case of traumatic aneurysm of the anterior tibial artery complicating fracture of the tibia and fibula is reported. 2. The diagnosis and management of such lesions are discussed

Amyloidoma of soft tissue is rare and there have been no previously published reports of limb involvement. We describe a case in which the tumour was present in the popliteal fossa. There was no evidence of systemic amyloid disease or of malignant neoplasm one year after the diagnosis