Balancing training and outcomes in total knee replacement: A ten-year review.

INTRODUCTION: 10-year study examining differences in total knee arthroplasty (TKA) functional outcomes and survivorship in patients operated on by consultant and trainee orthopaedic surgeons. METHOD: Data was prospectively collected from all elective TKAs performed at our three linked institutions. Patient demographics, surgeon grade, and length of hospital stay were recorded. Outcomes pre-operatively and at 1, 3, 5, 7 and 10 years included mortality, need for revision surgery and function as documented by the patients' Knee Society Score. RESULTS: 686 patients were included in the study. 450 (65.5%) patients were operated by consultant surgeons and 236 (34.4%) by trainees. On multivariate analysis no significant differences were observed between groups in length of hospital stay (p = 0.695), implant survival (p = 0.422), and function (p = 0.507) at 10 years. On Cox regression analysis no significant difference was observed in mortality (p = 0.209) at 10 years. 4 patients over this time period were lost to formal follow up. CONCLUSION: No significant difference was observed in the TKA outcomes between consultants and trainees 10 years post-operatively.

Causative organisms in revision total hip & knee arthroplasty for infection: Increasing multi-antibiotic resistance in coagulase-negative Staphylococcus and the implications for antibiotic prophylaxis.

BACKGROUND AND PURPOSE: Increasing resistance among post-operative Coagulase-negative Staphylococci (CNS) infections have been reported. We present our experience changing resistance patterns. METHODS: We examined microbiological results from hip and knee revisions from 2001 to 2010 and compared resistance to all Staphylococcus aureus (SA) and CNS cultured from regional pan-speciality sources, in order to examine the patterns of antibiotic resistance. MAIN FINDINGS: 72 revisions in 67 patients were included. The most common organisms were SA (36%) and CNS (35%). Resistance to methicillin was 72% for CNS versus 20% for SA and resistance to gentamicin was 40% for CNS versus 4% for SA. Among all regional (background pan-speciality) cultures SA resistance to methicillin fell from 32% to 16% from 2006 to 10 with no change in gentamicin resistance at 3%. During the same period resistance of CNS to methicillin and gentamicin increased from 63% to 70% and 32%-47% respectively. CONCLUSIONS: Resistance of CNS to both methicillin and gentamicin is higher than with SA and appears to be increasing. At least 32% of CNS and 4% of SA from infected TKRs/THRs were resistant to our current prophylaxis regime. These changing patterns of resistance may have implications for future antibiotic prophylaxis regimes.

PPE fit of healthcare workers during the COVID-19 pandemic.

Historically, PPE (Personal Protective Equipment) has generally been designed around the size and shape of an average European or US white man's face and body. There is little academic evidence to support anecdotal reports that women are at a greater disadvantage than men from ill-fitting PPE. This is especially relevant in healthcare settings where women make up at least 75% of frontline workers. The COVID-19 pandemic has exacerbated problems associated with the fit of PPE that until now have been mainly anecdotal. This research presents results and analysis of a quantitative and qualitative survey concerning the fit of PPE worn by 248 healthcare workers, in a variety of healthcare roles and settings, during the COVID-19 pandemic. The analysis of the survey results showed that women were less likely than men to feel safe carrying out their roles, with only 30.5% of women and 53.3% of men stating that they felt safe all of the time. A statistically significant link is made between women suffering more with poor fit than men with certain categories of PPE (gowns, masks, visors, goggles). Over four times as many women (54.8%) as men (13.3%) reported their surgical gowns being large to some degree and women were nearly twice as likely (53.5%) to experience oversized surgical masks than men (28.6%). However, it was recognized that PPE fit problems are not exclusive to women as many men also do not conform to the underlying shape and size of PPE designs. Survey results indicated that both sexes felt equally hampered due to the fit of their PPE and around a third of both women and men had modified their PPE to address fit issues. Oversized and modified PPE presents its own set of unintended consequences. Following strict processes for doffing and removing PPE is key to virus control but doffing modified PPE can fall outside of these processes, risking cross infection. In addition, wearers of critical items of PPE (such as respirators) currently undergo a "fit test"; however, fit does not reconcile with comfort and over-tightened PPE can cause headaches, discomfort and distraction when worn for long periods. Requirements and fit tests are also not setting-specific; qualitative responses from the survey give an indication that this must be a future consideration.

Do trainee surgeons have an adverse effect on the outcome after total hip arthroplasty?: a ten-year review.

AIMS: The long-term functional outcome of total hip arthroplasty (THA) performed by trainees is not known. A multicentre retrospective study of 879 THAs was undertaken to investigate any differences in outcome between those performed by trainee surgeons and consultants. PATIENTS AND METHODS: A total of 879 patients with a mean age of 69.5 years (37 to 94) were included in the study; 584 THAs (66.4%) were undertaken by consultants, 138 (15.7%) by junior trainees and 148 (16.8%) by senior trainees. Patients were scored using the Harris Hip Score (HHS) pre-operatively and at one, three, five, seven and ten years post-operatively. Surgical outcome, complications and survival were compared between groups. The effect of supervision was determined by comparing supervised and unsupervised trainees. A primary univariate analysis was used to select variables for inclusion in multivariate analysis. RESULTS: There was no evidence that the grade of the surgeon had a significant effect on the survival of the patients or the rate of revision (p = 0.987 and 0.405, respectively) up to 12 years post-operatively. There was no significant difference in post-operative functional HHS or total HHS among consultants, junior and seniors up to ten years post-operatively (p = 0.401 and 0.331), respectively. There was no significant difference in hospital stay (p = 0.855) between different grades of surgeons. There was no evidence that the level of supervision had an effect on the survival of the patients or the rate of revision (p = 0.837 and 0.203, respectively) up to 12 years post-operatively. There was no significant difference between supervised and unsupervised trainee groups in post-operative functional HHS or total HHS up to ten years post-operatively (p = 0.213 and 0.322, respectively). There was no significant difference in the mean hospital stay between supervised and unsupervised trainees (p = 0.908). TAKE HOME MESSAGE: This study suggests that when trainees are appropriately supervised, they can obtain results comparable with those of their consultant colleagues when performing THA.

Diagnosis and management of osteomyelitis. Decision analytic and pharmacoeconomic considerations.

Osteomyelitis, or bone infection, is becoming more common, largely because of increases in the use of implanted prosthetic devices in the management of arthritis or fractures. The clinical management of osteomyelitis requires accurate microbiological diagnosis that will identify appropriate antibacterials to which the pathogenic organisms are sensitive. Therapy will largely depend on the type of bacteria, the route by which the bacteria reach the bone, the presence of any orthopaedic devices and the patient's ability to mount an immune response. Consequently, therapy often requires a combination of medical and surgical management. The aim of this review is primarily to assess the impact of different drug regimens on the total cost and to clarify the implications of various treatment options for patients with osteomyelitis. Thus, the review examines the link between the main categories of osteomyelitis and common pathogens, and provides additional comments on the aetiology and epidemiology of the condition. At present, there is a real shortage of high quality evidence to guide the decision-maker through the range of available options. One way to deal with the complexity and uncertainty surrounding the management of osteomyelitis is to develop treatment protocols leading to decision trees which will in turn systematically analyse the options available for treating patients with osteomyelitis. Consequently, we have developed a number of decision trees to show the range of options available and have applied these to the relatively simple problem of route of administration of antibacterials. However, even here the available data allow only relatively crude estimations of the costs and consequences of alternative regimens. Thus, the aim has been to provide structures that may help to set priorities for research based on the expected value of new information. In the absence of evidence, there are broadly 2 alternatives. One is based on selection of the least expensive regimen in the absence of evidence to prove that more expensive options are more effective; patients with multiply resistant staphylococci, for which no effective oral regimen is available, should be treated with intravenous therapy. This is consistent with the UK legal system, which is founded on the so-called Bolam test. The alternative is providing the maximum available treatment; in the US, it is more likely that a doctor will be held negligent for not providing the maximum available treatment, and most standard texts recommend routine use of intravenous therapy for osteomyelitis.

Acute compartment syndrome of the thigh after joint replacement with anticoagulation.

We describe three patients with a compartment syndrome of the thigh, two after total hip replacement and one after total knee replacement. Two of the patients were fully anticoagulated. A compartment syndrome of the thigh is a rare, but important complication of joint replacement surgery if patients are receiving anticoagulants. Close observation is needed and when indicated monitoring of the intracompartmental pressure should be done. Early recognition of the signs and symptoms of an acute compartment syndrome and knowledge of the anatomy of the compartments of the thigh will help in the diagnosis and treatment of this potentially devastating complication.

Hip replacement surgery.

This review describes the current status of hip arthroplasty, hip mechanics, the materials used and the designs of the implants. The aims of and indications for surgery are outlined. Various complications and their prophylaxis are discussed, with particular stress on infection and thromboembolic problems. Results from published series and likely future developments are outlined.

Sequence landscapes.

We describe a method for representing the structure of repeating sequences in nucleic-acids, proteins and other texts. A portion of the sequence is presented at the bottom of a CRT screen. Above the sequence is its landscape, which looks like a mountain range. Each mountain corresponds to a subsequence of the sequence. At the peak of every mountain is written the number of times that the subsequence appears. A data structure called a DAWG, which can be built in time proportional to the length of the sequence, is used to construct the landscape. For the 40 thousand bases of bacteriophage T7, the DAWG can be built in 30 seconds. The time to display any portion of the landscape is less than a second. Using sequence landscapes, one can quickly locate significant repeats.