Orthopaedic surgical site infection surveillance in NHS England: national audit of current practice.

AIMS: The importance of accurate identification and reporting of surgical site infection (SSI) is well recognised but poorly defined. Public Health England (PHE) mandated collection of orthopaedic SSI data in 2004. Data submission is required in one of four categories (hip prosthesis, knee prosthesis, repair of neck of femur, reduction of long bone fracture) for one quarter per year. Trusts are encouraged to carry out post-discharge surveillance but this is not mandatory. Recent papers in the orthopaedic literature have highlighted the importance of SSI surveillance and the heterogeneity of surveillance methods. However, details of current orthopaedic SSI surveillance practice has not been described or quantified. PATIENTS AND METHODS: All 147 NHS trusts in England were audited using a structured questionnaire. Data was collected in the following categories: data collection; data submission to PHE; definitions used; resource constraints; post-discharge surveillance and SSI rates in the four PHE categories. The response rate was 87.7%. RESULTS: Variation in practice was clear in all categories in terms of methods and timings of data collection and data submission. There was little agreement on SSI definitions. At least six different definitions were used, some trusts using more than one definition. Post-discharge surveillance was carried out by 62% of respondents but there was again variation in both the methods and staff used. More than half of the respondents felt that SSI surveillance in their unit was limited by resource constraints. SSI rates ranged from 0% to 10%. CONCLUSION: This paper quantifies the heterogeneity of SSI surveillance in England. It highlights the importance of adequate resourcing and the unreliability of relying on voluntary data collection and submission. Conformity of definitions and methods are recommended to enable meaningful SSI data to be collated. Cite this article: Bone Joint J 2017;99-B:171-4.

Serial magnetic resonance imaging of metal-on-metal total hip replacements. Follow-up of a cohort of 28 mm Ultima TPS THRs.

Metal artefact reduction (MAR) MRI is now widely considered to be the standard for imaging metal-on-metal (MoM) hip implants. The Medicines and Healthcare Products Regulatory Agency (MHRA) has recommended cross-sectional imaging for all patients with symptomatic MoM bearings. This paper describes the natural history of MoM disease in a 28 mm MoM total hip replacement (THR) using MAR MRI. Inclusion criteria were patients with MoM THRs who had not been revised and had at least two serial MAR MRI scans. All examinations were reported by an experienced observer and classified as A (normal), B (infection) or C1-C3 (mild, moderate, severe MoM-related abnormalities). Between 2002 and 2011 a total of 239 MRIs were performed on 80 patients (two to four scans per THR); 63 initial MRIs (61%) were normal. On subsequent MRIs, six initially normal scans (9.5%) showed progression to a disease state; 15 (15%) of 103 THRs with sequential scans demonstrated worsening disease on subsequent imaging. Most patients with a MoM THR who do not undergo early revision have normal MRI scans. Late progression (from normal to abnormal, or from mild to more severe MoM disease) is not common and takes place over several years.

Metal-on-metal bearings: the evidence so far.

Lately, concerns have arisen following the use of large metal-on-metal bearings in hip replacements owing to reports of catastrophic soft-tissue reactions resulting in implant failure and associated complications. This review examines the literature and contemporary presentations on current clinical dilemmas in metal-on-metal hip replacement.

Early failure of the Ultima metal-on-metal total hip replacement in the presence of normal plain radiographs.

Metal-on-metal total hip replacement has been targeted at younger patients with anticipated long-term survival, but the effect of the production of metal ions is a concern because of their possible toxicity to cells. We have reviewed the results of the use of the Ultima hybrid metal-on-metal total hip replacement, with a cemented polished tapered femoral component with a 28 mm diameter and a cobalt-chrome (CoCr) modular head, articulating with a 28 mm CoCr acetabular bearing surface secured in a titanium alloy uncemented shell. Between 1997 and 2004, 545 patients with 652 affected hips underwent replacement using this system. Up to 31 January 2008, 90 (13.8%) hips in 82 patients had been revised. Pain was the sole reason for revision in 44 hips (48.9%) of which 35 had normal plain radiographs. Peri-prosthetic fractures occurred in 17 hips (18.9%) with early dislocation in three (3.3%) and late dislocation in 16 (17.8%). Infection was found in nine hips (10.0%). At operation, a range of changes was noted including cavities containing cloudy fluid under pressure, necrotic soft tissues with avulsed tendons and denuded osteonecrotic upper femora. Corrosion was frequently observed on the retrieved cemented part of the femoral component. Typically, the peri-operative findings confirmed those found on pre-operative metal artefact reduction sequence MRI and histological examination showed severe necrosis. Metal artefact reduction sequence MRI proved to be useful when investigating these patients with pain in the absence of adverse plain radiological features.

Who gets priority? Waiting list assessment using a scoring system.

This study examines the relationship between clinical priority and duration on the waiting list. Patients' priority is also compared from three different perspectives: the consultant at out-patients (clinical urgency), the general practitioner who later sends a letter requesting expedition of admission (clinical urgency) and the 18-month waiters. Clinical priority in 222 patients awaiting primary hip or knee arthroplasty was assessed using a modification of the New Zealand priority criteria scoring system, administered by postal questionnaire. There was no correlation between time on waiting list and clinical score (r = 0.0). The hip and knee patient scores were not significantly different. The mean scores in the consultant and GP groups were higher (greater pain and disability) than in the 18-month waiters. The Kappa inter-rater agreement method demonstrated that both groups of clinician's assessment of clinical urgency had a 'fair' strength of agreement with scoring system, but the agreement of the 18-month waiter group was 'very poor'. Time on a waiting list should not be a decisive factor in establishing priority for primary hip or knee arthroplasty. Scoring systems can aid in assigning clinical priority for operation and indeed for the initial out-patient referral.

Transurethral surgery using intravesical bupivacaine and intravenous sedation.

We report our experience using intravesical 0.5% bupivacaine as a topical anesthetic along with intravenous fentanyl and midazolam sedation to perform a variety of transurethral procedures in 78 patients. We achieved adequate pain control in all patients and observed no anesthetic complications. Use of this combination of intravesical topical anesthesia and intravenous sedation provided safe, adequate anesthesia to our patients undergoing various transurethral procedures in an outpatient clinic setting.

Fracture of the femoral stem of the Ring TCH hip prosthesis.

We report the clinical and operative details of seven cases of fracture of the femoral stem of the Ring TiMESH cementless hip prosthesis (two were cemented and five uncemented). Six fractures occurred in the proximal one-third of the stem and one at mid-stem. The failures are attributed mainly to two defects in stem design, the narrowness of the anteroposterior dimensions and the depth of the recess for the titanium mesh pads. Great difficulty was experienced in removing the osseo-integrated distal fragments of the broken stems.

Urethrovaginal reconstruction using a perineal artery axial flap.

A 19-year-old woman was born with a cloacal malformation and a common urogenital sinus. We describe a method of urethral and vaginal reconstruction to correct these anomalous problems. A neourethra was constructed from tubularized anterior vaginal epithelium. A perineal artery based axial flap was used to cover the neourethra plus widen the vaginal orifice.

Acute management of the zipper-entrapped penis.

A zipper-entrapped penis is a painful predicament that can be made worse by overzealous intervention. Described is a simple, basic approach to release, that is the least traumatic to both patient and provider.