How close is the axillary nerve to the inferior glenoid? A magnetic resonance study of normal and arthritic shoulders.

INTRODUCTION: Axillary nerve injury is a major complication of shoulder surgery during glenoid exposure. The aim of this study was to measure the mean distance between the inferior glenoid and the axillary nerve in healthy shoulders and then to compare this distance between osteoarthritic and rotator cuff deficient glenohumeral joints. METHODS: The magnetic resonance images of 50 patients with normal glenohumeral joints were reviewed. The infra-glenoid tubercle was determined as a fixed point and the distance to the axillary nerve was measured. Two separate assessors measured on the same sagittal sections. With a study power of 80%, the sample needed in each comparison group was 28 patients. Measurements were then performed on scans in patients with osteoarthritis and cuff tear arthropathy. The mean distance was compared between groups. RESULTS: The mean distance between the infra-glenoid tubercle and axillary nerve was 12mm (standard deviation, SD, 5.6mm) in normal shoulders, 10.6mm (SD 5.4mm) in shoulders with osteoarthritis and 9.7mm (SD 3.7mm) in those with cuff tear arthropathy. For this sample size of 50 patients with a confidence interval of 95%, the mean range is 12mm (95% CI 10.4-13.6). A comparison between normal shoulder and osteoarthritis showed a p-value of 0.3, and between normal and cuff tear arthropathy a p-value of 0.06. This was not statistically significant. CONCLUSIONS: The axillary nerve lies on average 12mm from the infra-glenoid tubercle. The presence of inferior osteophytes in glenohumeral osteoarthritis and the proximal migration of humeral head in cuff tear arthropathy does not seem to alter the course of the nerve significantly in relation to the inferior glenoid tubercle.

Is it necessary to change instruments between sampling sites when taking multiple tissue specimens in musculoskeletal infections?

Introduction Surgical debridement of orthopaedic infections allows biopsy for microbiology and facilitates successful treatment. It is recommended that biopsy instruments are changed when taking multiple samples. This study compared assessed cross-contamination between biopsy sites when using same instruments to take tissue samples from multiple sites. Materials and methods During the surgical debridement, we defined five sampling sites and marked them with diathermy. Two sampling techniques were performed on same patient to minimise any potential bias arising from the type of host and the severity of infection. First, fresh instruments were used for each biopsy site. Titleond, the instruments used in the first sampling site were reused to take samples from the remaining sites. By comparing the microbiology results of the samples taken by each technique for each site we determined cross-contamination with microorganisms. Results Fifteen patients with foot and ankle infections (mean age 56 years) were included. Ten patients were diabetic and five had neuropathies. Cross-contamination between sampling sites occurred in eight cases when the same instruments were used to take biopsies (P = 0.002, Fisher's exact test). One or more microorganisms were involved in cross-contamination and the latter always occurred between two consecutive sites rather than sites that were further apart. Conclusion It is important to use fresh instruments for each biopsy site when taking multiple samples in musculoskeletal infection as cross-contamination might occur otherwise and affect microbiological studies.

The orthopaedic manifestation and outcomes of methicillin-sensitive Staphylococcus aureus septicaemia.

AIMS: The aim of this paper was to present the clinical features of patients with musculoskeletal sources of methicillin-sensitive Staphylococcus aureus (MSSA) septicaemia. PATIENTS AND METHODS: A total of 137 patients presented with MSSA septicaemia between 2012 and 2015. The primary source of infection was musculoskeletal in 48 patients (35%). Musculoskeletal infection was considered the primary source of septicaemia when endocarditis and other obvious sources were excluded. All patients with an arthroplasty at the time were evaluated for any prosthetic involvement. RESULTS: The most common site of infection was the spine, which occurred in 28 patients (58%), and was associated with abscess formation in 16. Back pain was the presenting symptom in these patients, with a positive predictive value of 100%. A total of 24 patients had a total of 42 arthroplasties of the hip or knee in situ. Prosthetic joint infection occurred in six of these patients (25%). In five patients, the infection originated outside the musculoskeletal system. Three patients (6%) with MSSA septicaemia from a musculoskeletal sources died. CONCLUSION: Amongst the musculoskeletal sources of MSSA septicaemia, the spine was the most commonly involved. We recommend an MRI scan of the whole spine and pelvis in patients with MSSA septicaemia with back pain, when the primary source of infection has not been identified or clinical examination is unreliable. Cite this article: Bone Joint J 2017;99-B:1545-51.

Lifting incise drapes off the skin during wound closure can cause contamination.

Incise drapes adhere well to skin and reduce bacterial migration into the wound. We took skin swabs before and after the application of incise drapes during 49 hip and knee arthroplasty procedures. Contamination was detected under incise drapes in four cases (8.1%) and consisted mainly of skin flora. We conclude that it is important to clean the skin again with antiseptics if the incise drape is removed by the surgeon.

A prospective study on the risk of glove fingertip contamination during draping in joint replacement surgery.

INTRODUCTION: The aim of this prospective study was to investigate the risk of contamination of surgical gloves during preparation and draping in joint replacement surgery. METHODS: During 46 hip and knee replacement procedures, the gloves of orthopaedic consultants (n=5) and registrars (n=3) were assessed for contamination immediately after draping by impression of gloved fingers on blood agar. Contamination was evaluated by the surgeon's grade, the type of procedure, the role of the assistant and the dominance of the hand. RESULTS: A total of 125 pairs of top gloves were examined (79 pairs from registrars and 46 pairs from consultants). Bacterial contamination was isolated on 19 pairs (15.2%) (16 pairs from registrars and 3 pairs from consultants, p=0.04). Coagulase negative staphylococci were the main isolates and contamination was considered low in all cases (1-5 colonies). Contamination was seen more on the dominant hand (16 gloves from dominant hands and 6 from non-dominant hands, p=0.04), on the index finger and thumb. More contaminated gloves were seen in hip arthroplasty procedures (16 pairs from total hip replacements vs 3 pairs from total knee replacements, p=0.02). CONCLUSIONS: Contamination of glove fingertips during draping in joint replacement procedures is more likely to occur among junior surgeons, in hip rather than knee arthroplasty procedures and on the dominant hand. It is therefore essential that surgeons of different grades replace gloves used in draping to avoid exposing patients to the risk of infection.

Osteosynthesis of displaced intra-articular fractures of the calcaneum: a long-term review of 47 cases.

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders' classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale. There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler's angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders' classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler's angle.