Debridement, antibiotics and implant retention (DAIR) following hip and knee arthroplasty: results and findings of a multidisciplinary approach from a non-specialist prosthetic infection centre.

INTRODUCTION: Prosthetic joint infection (PJI) is a catastrophic complication following arthroplasty surgery. Recently a debridement, antibiotics and implant retention (DAIR) procedure has gained popularity for PJI where a thorough debridement, irrigation and modular component exchange is undertaken. METHOD: We present the outcome for DAIR, data collected prospectively, in a busy orthopaedic unit but not one specialising in PJI. All patients with PJI were included without loss of data or patients from 2012 to 2018 with a minimum follow-up of 5 years. RESULTS: Four total knee replacements, 17 total hip replacements, one revision total hip replacement and three hip hemiarthroplasties are included with an average duration from onset of symptoms to the DAIR procedure of 11 days (range 1-22 days). Staphylococcus aureus (24%) and Staphylococcus epidermidis (32%) were the most common causative organisms, and the most common antibiotic regimens included intravenous teicoplanin and flucloxacillin. Average follow-up was 67 months (range 9-104 months). Only four patients went on to require revision surgery. An analysis of midterm patient outcome measures for 6 of the total hip replacement (THR) DAIR patients were compared with a database of 792 THRs (with a minimum two-year follow-up) carried out by the same surgeon revealed no significant difference in Oxford hip scores at one-year post-surgery (OHS DAIR 36.2 vs 39 for control group). CONCLUSION: This study includes 25 consecutive patients treated with DAIR with only one reinfection, with a mean follow-up period of 5 years. Using a strict protocol, DAIR appears to offer a successful treatment strategy for the management of early PJI.

Transperitoneal removal of an intrapelvic acetabular component after total hip replacement and salvage of a destroyed acetabulum.

Intrapelvic migration of the acetabular component of a total hip replacement, with severe acetabular destruction making reconstruction impossible, is very rare. We present a patient in whom the component was removed using a laparotomy and a transperitoneal approach with subsequent salvage using a saddle prosthesis and a total femoral replacement.

Wedding rings are not a significant source of bacterial contamination following surgical scrubbing.

INTRODUCTION: Despite some evidence that the wearing of rings may increase the microbial load, there is currently nothing to suggest that viable bacteria remain following a standard surgical scrub. The aim of the study was to examine the distribution and type of microbial flora seen on the hands of doctors following a standard surgical scrub. MATERIALS AND METHODS: Ten surgeons and 10 anaesthetists, all of whom wore wedding rings on the fourth finger of their left hand, participated in the study. Each individual was asked to 'scrub-up' as for their normal first scrub of the day. Following completion of washing, the wedding ring was removed, its internal circumference swabbed and the swab placed in a culture medium. Volunteers placed each hand palm-down on separate agar plates. The plates were incubated and the number of colonies counted and classified. RESULTS: The culture plates of one of the anaesthetists were damaged in transit leaving a total of 19 subjects for analysis. In all the palm imprint plates, coagulase-negative staphylococci were grown. One surgeon grew coagulase-negative staphylococci from the ring swab. A Candida spp. from the right hand of one surgeon was grown. There was no statistically significant difference between the number of colony-forming units (CFUs) cultured from the right and left (ring-wearing) hands of the surgeons (P = 0.260) and anaesthetists ( P = 0.345). There was no statistical difference in CFUs when surgeons were compared with anaesthetists (P = 0.383 for right hand and P = 0.234 for left). CONCLUSIONS: This preliminary study would suggest that a traditional band wedding ring is not a source of a bacterial load following a standard surgical scrub procedure and, as such, there is no requirement for their removal pre-operatively.

Use of the Abbreviated Mental Test Score by junior doctors on patients with fractured neck of femur.

INTRODUCTION: The mental state of patients with fractured neck of femur is important as a predictor of post-operative outcome. The Hodgkinson Abbreviated Mental Test Score (AMTS) is a validated and simple method of assessing the pre-operative mental state of patients with fractured neck of femur. This survey investigated whether or not orthopaedic junior doctors (SHOs) appreciated the importance of mental state assessment in patients with fractured neck of femur and whether they were able to recall the questions used in the AMTS. METHOD: A total of 47 on-call orthopaedic and trauma SHOs from the UK were randomly contacted by telephone and agreed to answer questions from a standard questionnaire to assess awareness of the ten-question AMTS. RESULTS: A total of 96% of SHOs claimed awareness of the importance of mental state assessment; 89% used the AMTS in their practice, of which 26% were aided by a pro forma. A mean of five (out of the ten) standard questions on the AMTS were correctly identified (95% CI = 0.68); 11% correctly identified all 10 questions. There was no correlation between use of a pro forma and correct identification of questions. CONCLUSIONS: Patients with fractured neck of femur and low AMTS have higher morbidity and mortality. If the AMTS is to be used as an assessment tool in this setting, then SHOs need to be better informed and educated as to its use. Furthermore, the validity of data collection for research and audit purposes is potentially flawed; as data collected using such scoring systems may be inaccurate.

Can a urinary tract symptom score predict the development of postoperative urinary retention in patients undergoing lower limb arthroplasty under spinal anaesthesia? A prospective study.

INTRODUCTION: There is no general consensus amongst orthopaedic surgeons on how best to manage the urinary tract and its complications after lower limb arthroplasty. This prospective audit investigates whether postoperative urinary retention can be predicted pre-operatively using the validated International Prostate Symptom Severity score (IPSS). PATIENTS AND METHODS: A total of 182 patients undergoing lower limb arthroplasty under spinal anaesthetic were given the IPSS questionnaire to complete pre-operatively and an audit into numbers catheterised postoperatively was performed. RESULTS: Overall, 69% of males and 39% of females required catheterisation. Following logistic regression analysis there was 0.85 predicted probability that males over 70 years would require catheterisation. The IPSS score was not useful in predicting retention in either sex at any age. CONCLUSIONS: We propose that all males over 70 years undergoing this type of surgery should be catheterised pre-operatively and all other patients should be catheterised postoperatively with close monitoring of bladder volumes to prevent established urinary retention.

The European Working Time Directive: One for all and all for one?

BACKGROUND: The European Working Time Directive (EWTD) became law in Britain on October 1, 1998. As a result, the maximum period that may be spent as a resident in hospitals is 56 hours per week and after August 2009, 48 hours per week. The aim of this study was to determine the views of senior house officers (SHOs), specialist registrars (SpRs), and general consultant surgeons (CONs) in Wales on the influence of the EWTD on surgical training and clinical experience. METHODS: In this cohort study, a postal questionnaire was sent to 150 SHOs in surgical specialties, 50 general surgical SpRs, and all 84 CONs in the Welsh Deanery. RESULTS: The response rates were 81%, 78%, and 71% for SHOs, SpRs, and CONs, respectively. The vast majorities at all grades (88% SHOs, 100% SpRs, and 96% CONs) were unhappy with the introduction of EWTD legislation to clinical medicine. Most felt that EWTD legislation will have a negative effect on clinical experience (96% SHOs, 97% SpRs, 96% CONs); patient care (83% SHOs, 85% SpRs, 96% CONs); and training (94% SHOs, 100% SpRs, 93% CONs). Furthermore, a large proportion felt surgical training should be exempt from EWTD regulations (76% SHOs, 87% SpRs, 89% CONs). A significant proportion at each grade was opposed to the introduction of shifts in order to comply with regulations (78% SHOs, 87% SpRs, 89% CONs), and an alarming number have considered leaving the National Health Service when the regulations are enforced (29% SHOs, 41% SpRs, 33% CONs). CONCLUSION: This study shows that, in Wales at least, a vast majority of surgical trainees and consultants alike are opposed to the introduction of the EWTD and believe it will have a detrimental effect on training, patient care, and doctors' lives outside of medicine.