Antibiotic-associated complications following lower limb arthroplasty: a comparison of two prophylactic regimes.

INTRODUCTION: As part of a wider drive to reduce Clostridium difficile rates (CDAD), our trust switched from cefuroxime to gentamicin and flucloxacillin prophylaxis for joint replacement surgery. Anecdotal evidence suggested that we were seeing an increased incidence of acute kidney injury (AKI) following elective total hip replacement (THR) and total knee replacement (TKR) since this change. The aim of this study was to compare rates of AKI and post-operative infection between the two antibiotic regimes. METHODS: We carried out a single-centre retrospective cohort study comparing 200 patients (100 THR and 100 TKR) who received cefuroxime with another age and procedure-matched group who received gentamicin and flucloxacillin (gentamicin 3 mg/kg and 5 g flucloxacillin in total). We compared rates of AKI, haemofiltration, CDAD, surgical site infection (SSI) and return to theatre for infection (RTT). RESULTS: Gentamicin was associated with a significant increase in AKI (1 vs. 8%, p < 0.01). More patients needed haemofiltration (0 vs. 1.5%) although this was not significant. Interestingly, when the groups were subdivided into THR and TKR, significantly more TKR patients receiving gentamicin developed AKI (0 vs. 11, p < 0.01). This difference was not significant following THR (2 vs. 5, p = 0.44). This may be related to tourniquet use in TKR. SSI and RTT were comparable. No patient developed CDAD. CONCLUSIONS: Gentamicin with flucloxacillin is comparable with cefuroxime in rates of SSI and RTT but is associated with a significant increase in AKI. AKI is associated with additional morbidity and mortality. This association should be considered when choosing a suitable prophylactic regime.

A prospective randomised comparison of the dynamic hip screw and the gamma locking nail.

We made a randomised prospective comparison of the Dynamic Hip Screw and the Gamma locking nail for the internal fixation of 200 petrochanteric femoral fractures in elderly patients. There was less intraoperative blood loss and a lower rate of wound complications in the patients treated by the Gamma nail. They had, however, a high incidence of femoral shaft fracture which we relate in part to implant design. We do not recommend the use of the Gamma nail for these fractures.

Arthroscopic lavage of osteoarthritic knees.

A strong clinical impression exists that joint lavage often provides symptomatic relief for painful osteoarthritis of the knee. A controlled trial was conducted to test this hypothesis. A group of 37 painful osteoarthritic knees were treated by arthroscopic lavage and physiotherapy, and a control group of 24 knees were treated by physiotherapy alone. There was better relief of pain in the lavage group, and the effect was still present at one year. An improvement in the signs of inflammation lasted for about three months. Pain was relieved more effectively in patients with slight radiographic changes than in those with advanced changes. Our results confirm the effectiveness of joint lavage in the management of painful osteoarthritis of the knee.

Like father, like son: a tale of two patellae.

A father and son travelling in their car were involved in a collision with another vehicle. Subsequently, both were found to have what were thought to be long-standing developmental bipartite patellae. However, subsequent investigations and the patients' progress cast doubt on this diagnosis and suggested that the lesions were fractures.

Surgical treatment of fixed flexion contractures in the hands of institutionalised patients.

Three severely demented elderly patients had fixed flexion contractures of all fingers of one or both hands. This caused an unpleasant problem of hygiene and of nail ingrowth into the palm. A surgical solution to this problem is described, with good results.

Pisotriquetral loose body. An unusual cause of wrist pain.

A loose body flicking in and out of the pisotriquetral joint was found to be the cause of intermittent wrist pain and locking in two patients. Appropriate X-rays gave the diagnosis and surgical removal provided a satisfactory cure.

Conservative management of wrist ganglia. Aspiration versus steroid infiltration.

Wrist ganglia were randomly allocated for conservative treatment by either aspiration or aspiration and injection of steroid. Both treatment methods had 33% success rates. Almost all ganglia which recurred after one aspiration did not resolve with further aspirations. After aspiration and explanation of the benign nature of ganglia, only a quarter of patients requested surgical treatment.

Local anesthesia for postoperative pain relief after foot surgery: a prospective clinical trial.

A prospective, randomized, controlled clinical trial was set up to test whether the addition of ankle block to general anesthesia was useful in providing postoperative pain relief following forefoot surgery. Forty feet (20 treatment, 20 control) were entered into the trial and all underwent bony operations on the first ray. Pain was assessed at fixed times following the operation using pain analog scales. Analgesic consumption and wound healing were also assessed. A significant difference was found between the pain scores in the two groups at the 6-hr stage, but there was no difference in any of the other assessments. It is concluded that ankle block is a useful addition to general anesthesia for this type of surgery.

Trochanteric exostoses following total hip arthroplasty. A complication of trochanteric osteotomy.

Trochanteric osteotomy has long been a fundamental part of the technique of the Charnley low-friction arthroplasty. It is, however, not without its complications, the principal one of which is nonunion regardless of the type of fixation used. A previously undescribed complication requiring reoperation is reported with regard to eight cases of primary hip arthroplasty.

Preoperative traction for hip fractures in the elderly: a clinical trial.

A consecutive series of 100 patients with femoral neck fractures were assessed by a mental test score on admission. The 67 scoring within the normal range were randomly assigned to skin traction or no traction between admission and operation. Using pain assessment scales and records of analgesic consumption, there was found to be little difference between the two groups. The conclusion was that skin traction offered no benefits in pain control for the patient and therefore should not be used routinely.

Use of a hydroxyapatite-coated hemiarthroplasty in the management of subcapital fractures of the femur.

A prospective clinical trial has been conducted comparing the use of a hydoxyapatite-coated bipolar hemiarthroplasty and an uncemented bipolar prosthesis in the treatment of displaced subcapital fractures of the femur. The trial was conducted over 1 year, 82 patients suffering displaced subcapital fractures of the femur were included. The patients were followed up for 1 year postoperatively. The functional result was significantly superior in the hydroxyapatite-coated group. Characteristic changes were found on radiographs both proximally and distally, indicating that distal stem fixation with proximal stress shielding had occurred.