Aims

Manual impaction, with a mallet and introducer, remains the standard method of installing cementless acetabular cups during total hip arthroplasty (THA). This study aims to quantify the accuracy and precision of manual impaction strikes during the seating of an acetabular component. This understanding aims to help improve impaction surgical techniques and inform the development of future technologies.

Anatomically specific fixation devices have become mainstream, yet there are anatomical regions and clinical conditions where no pre-contoured plates are available, such as for glenohumeral arthrodesis. In a case series of 4 glenohumeral arthrodesis patients, a consultant orthopaedic surgeon at GCUH implemented 3D printing technology to create reconstructions of each patient's shoulder girdle to pre-contour arthrodesis plates. Our aim was to quantify the cost-benefit & intra-operative time savings of this technique in glenohumeral arthrodesis. We hypothesized that the use of 3D printing for creating patient specific implants through pre-operative contouring of plates will lead to intra-operative time and cost savings by minimising time spent bending plates during surgery. This study analysed 4 patients who underwent shoulder arthrodesis by a single consultant orthopaedic surgeon at GCUH between 2017-2021. A CT-based life-size model of each patient's shoulder girdle was 3D printed using freely available computer software programs: 3D Slicer, Blender, Mesh Mixer & Cura. Once the patient's 3D model was created, plate benders were used to contour the plate pre-op, which was then sterilised prior to surgery. Arthrodesis was performed according to AO principles of fixation. The time spent pre-bending the plate using the 3D model was calculated to analyse the intra-op time and cost-saving benefits. For the 4 cases, the plate pre-bending times were 45, 40, 45 & 20 minutes (average 38.8 mins). The intra-op correction time to make small adjustments to the plate was 2 min/ case. 3 plates needed minor (3 degree) adjustment to fine-tune scapula spine contouring. 1 plate needed a 5 degree correction to fine-tune hand position. On average, the pre-bending of the plate saved approximately 38.8 mins intra-op/ case. These shorter anaesthetic and operating times equate to approximately $2586 saving/ case, given an estimate of $4000/hour of theatre costs. We conclude that pre-bending plates around 3D-printed life-size models of an individual's shoulder girdle prior to surgery results in approximately 38.8 mins time saving intra-op when used in shoulder arthrodesis. This is a viable and effective technique that will ultimately result in significant operative time and financial savings

Abstract. Objectives. Unicompartmental and total knee arthroplasty (UKA and TKA) are successful treatments for osteoarthritis, but monolithic implants disrupt the natural homeostasis of bone which leads to bone loss over time. This can cause problems if the implant needs to be revised. This study aimed to demonstrate that tibial implants made from titanium lattice could replace the tibial condyle surface while minimising disruption of the bone's natural mechanical loading environment. A secondary aim was to determine whether implants perform better if they replicate more closely bone's mechanical modulus, anisotropy and spatial heterogeneity. This study was conducted in a human cadaveric model. Methods. In a cadaveric model, UKA and TKA procedures were performed on 8 fresh-frozen knee specimens by a board-certified consultant orthopaedic surgeon, using tibial implants made from conventional monolithic material and titanium lattice structures. Stress at the bone-implant interfaces was measured with pressure film and compared to the native knee. Results. Titanium lattice implants were able to restore the mechanical environment seen in the native tibia for both UKA and TKA designs. Maximum stress at the bone-implant interface ranged from 1.2–3.3MPa compared to 1.3–2.7MPa for the native tibia. The conventional UKA and TKA implants reduced the maximum stress in the bone by a factor of 10 and 9.7 respectively. The conventional UKA and TKA implants caused 71% and 77% of bone surface area to be underloaded compared to the native tibia. Conclusions. Titanium lattice implants can maintain the natural mechanical loading in the proximal tibia after UKA and TKA. This may help maintain normal bone homeostasis throughout the life of the implant. These encouraging data indicate normal bone homeostasis can be maintained after arthroplasty using manufacturing methods already in widespread use. This would maintain bone quality throughout the life of the implant and alleviate complications at revision surgery

The number of total knee arthroplasties continues to increase annually with over 90,000 total knee replacements performed in the United Kingdom in 2018. Multiple national bodies including the British Association for Surgery of the Knee (BASK) and the British Orthopaedic Association collaborated in July 2019 to produce best practice guidance for knee arthroplasty surgery. This study aims to review practice in a regional healthcare trust against these guidelines. Fifty total knee replacement operation notes were reviewed between January and February 2020 from 11 different consultant orthopaedic surgeons. Documents were assessed against 17 criteria recommended by the BASK guidance. Personnel names and grades were generally well documented. Tourniquet time and pressure were documented in over 98% of operation notes however, protection from spirit burns was not documented at all. Trialling and soft tissue balancing was well recorded in 100% and 96% of operation notes respectively. Areas lacking in documentation included methods utilised to optimise cementation technique and removal of cement debris. Protection of key knee structures was documented in only 56% of operation notes clearly. Prior to closure, final assessment of mechanism integrity, collateral ligament was not documented at all and final ROM after implantation of components was recorded 34% of the time. Subsequently authors have created a universal operation note template, uploaded onto the patient electronic notes, which prompts surgeons to complete documentation of the relevant criteria advocated by BASK. In conclusion, detailed and systematic documentation is vital to prevent adverse events and reduce the risk of litigation. By producing detailed operative templates this risk can be mitigated

To determine the effect of Dexamethasone on post-operative pain management in patients undergoing Total Knee Arthroplasty in terms of numerical pain rating scale and total opoid consumption. This Randomized Controlled Trail (RCT) was conducted for 02 years (7th September 2015 to 6th September 2017). All patients undergoing primary Unilateral Total Knee Replacement (TKR) for Osteoarthritis knee were included in the study. Patients with poor glycemic control (HbA1c > 7.6), Hepatic/Renal failure, corticosteroids/ Immunosuppression drug usage in the last 06 months, known psychiatric illnesses were excluded from the study. All patients were operated by consultant Orthopaedic surgeon under Spinal Anaesthesia and tourniquet control using medial para-patellar approach. Patients were randomly divided into 02 groups, A and B. 79 patients were placed in each group. Group A given 0.1mg/kg body weight Dexamethasone Intravenously 15 minutes prior to surgery and another dose 24 hours post-operatively while in group B (control group) no Dexamethasone given. Post-operative pain using the numerical pain rating scale (NRS) and total narcotics consumed converted to morphine dose equivalent noted immediately post-op, 12-, 24- and 48-hours post-operatively. Data analysis done using SPSS version 23. A total of 158 patients were included in the study. Of the total, 98 (62.02%) were females and 60 (37.98%) males. Average BMI of patients 26.94 ±3.14 kg/m2. Patients in group A required less post-operative analgesics (p < 0 .01) and had a better numerical pain rating scale score (p < 0 .01) as compared to group B. Pain scores at 24- and 48-hours post-op were significantly less for Dexamethasone group (p < 0 .01). Use of Dexamethasone per- and post-operatively reduces the pain and amount of analgesics used in patients undergoing TKA. For any reader queries, please contact . drjunaidrmc@gmail.com

Introduction: In 2005, 88 patients (19M/69 F, mean age 55) initially referred by their GP to a Consultant Orthopaedic Surgeon were seen by an Operative Podiatrist as a waiting list initiative. The mean delay between GP referral and clinic appointment was 632 days. The majority of patients were listed for a surgical procedure. The podiatrist left the Trust before any listed surgery was performed. The cohort was subsequently reviewed by a Consultant Orthopaedic Surgeon prior to surgical intervention, creating a unique opportunity to compare podiatric and orthopaedic input in one patient group. Materials & Methods: Casenotes and clinic correspondence were identified by merging clinic datasets & retrieved in 86/88 cases. Medical records and documentation of peripheral vascular status were examined as a standard of care. Correlation of surgical decision making was examined qualitatively. Results: Circulatory status was found to be documented in 0/58 (0%) records available for patients seen by the podiatrist and 70/74 (95%) seen by the orthopaedic surgeon respectively. Vascular investigation or referral was initiated by the orthopaedic surgeon in 8 patients listed for surgery by the podiatrist. The listed procedure was postponed or cancelled by the orthopaedic surgeon in a further 11 patients (5 medically unfit for listed surgery, 4 treated conservatively & 2 unable to obtain valid consent). No written or dictated contemporaneous records were made for 23/88 (26%) of index podiatric consultations. Clinically significant drug history was documented by the podiatrist in 1/13 (8%) cases recorded by the orthopaedic surgeon. Discussion: Reasonable correlation was observed between proposed surgical interventions for forefoot problems. Poor correlation was observed for mid- and/or hind foot problems. Avoidable adverse outcomes might have been anticipated in 19/88 (22%) patients listed for surgery by the Operative Podiatrist. Conclusion: The employment of unsupervised non-medical surgical practitioners in hospital based orthopaedic practice is not appropriate

Introduction: Thromboembolic complications are common in both elective and trauma orthopaedic practice. Despite the many studies reported in the literature, there remain a number of unanswered questions regarding the use of thrombophylaxis. The aim of this study was to establish the current practice amongst Irish consultant orthopaedic surgeons regarding thromboprophylaxis. Materials and Methods: A detailed confidential written questionaire was sent to all consultant orthopaedic surgeons in the republic of Ireland. Surgeons were asked to indicate the type of mechanical and chemothromboprophylaxis in the setting of total hip arthroplasty, knee arthroplasty and hip fracture. They were also questioned regarding 1) time of commencement of therapy 2) duration of therapy 3) method of diagnosis of DVT 4) Estimated incidence of mortality from pulmonary embolism in the last five years 5) Whether there was established protocol for DVT prophylaxis in their unit. 6) Reason for not using chemothromboprophylaxis if not used and 7) whether their method of treatment was influenced by anaesthetic concerns. Results: The response rate was seventy percent. Over ninetyfive percent of surgeons used a combination of physical and chemical modalities. There was a wide variation between type of therapy, commencement time and duration of prophylaxis. There was a higher rate of intervention and duration of therapy in elective practice. A unit policy regarding thromboprophylaxis existed in a majority of hospitals (54.7%). Forty-seven per cent of respondents felt that there had been no post-operative mortality in their practice in the previous five years from pulmonary embolism. Twenty-six percent of respondents felt that anaesthetists influenced the type of prophylaxis used. The results of this survey shows that venous thromboembolism is regarded as a significant complication of orthopaedic surgery and that most orthopaedic surgeons take active steps to try and prevent its occurrence. There was a higher rate of intervention in this groug of surgeons compared to previous surveys of British orthopaedic surgeons. This may reflect a higher standard of care or a concern regarding the high rate of litigation in the republic of Ireland. However there is no consensus as to the optimum therapy which reflects the conflicting evidence available in the many publications on this subject

Aim: The purpose of this study is to explore the experience of a consultant orthopaedic surgeon, and to quantitatively describe the learning curve for hip arthroscopy. Introduction: Arthroscopic surgery in orthopaedics is a well established procedure for both diagnostic and therapeutic purposes. Unlike many other joint arthroscopies, hip arthroscopy has been delayed in its development. It was first pioneered by Burman in 1931, who under-took a study on cadavers, stating that ‘it is manifestly impossible to insert a needle between the head of the femur and the acetabulum’. Over several decades, this technique has developed considerably, but still remains a technically demanding and difficult procedure. The learning curve for hip arthroscopy has not previously been objectively quantified. Method: We prospectively reviewed the first 100 hip arthroscopies performed in the supine position between 1999 and 2004. Surgery was performed by a single experienced hip and knee consultant orthopaedic surgeon (FH). We assessed the operative time (traction time), surgeon comfort, patient satisfaction at 6 months and operative complications. This was analysed for consecutive blocks of 10 cases. Results of the first 10 and the remaining 90 cases, subsequently the first 20 and remaining 80 cases, and finally the first 30 and remaining 70 cases were compared for a difference. Results: The mean traction time was 55 minutes (range: 36–94 minutes). Mean surgeon comfort was 73% (range: 52–89%). 49% of patients reported an excellent outcome at 6 months follow – up. Only 8% of patients reported an unsatisfactory outcome. The main complications noted were chondral damage (6 cases) and perineal injuries (4 cases). There was a remarkable decrease in complications from the first 30 cases compared to the remaining 70 operations. 5 cases of chondral damage was noted in the first 30 cases, compared to 1 (1.4%) in the remaining 70 cases. The number of perineal injuries was noted to decrease from 3 cases in the first 30 operations to 1 (1.4%) in the subsequent 70 operations. There is an overall decrease in operative time over the 100 cases, representing a gradual learning process throughout. However, the fall from an average time of 75 minutes for the first 30 cases, to the average operative time of 30 minutes for the remaining 70 cases, is a significant learning process (40% fall in operative time). We thus, believe the learning curve to be 30 operations. Conclusion: We have demonstrated that there is a considerable fall in operative time when comparing the first 30 cases with the remaining 70 cases. This quantitative decrease is indicative of a rapid learning curve. This is further suggested by the remarkable fall in complications during this learning phase

Introduction. Training the next generation of surgeon's forms part of routine Consultant practice. Stress causes activation of the Autonomic Nervous System and this can be directly measured using heart rate (HR). Training time is limited with pressures from EWTD and management and efficiency targets. The aim of this study was to assess whether being an orthopaedic trainer is more stressful than performing the surgery. Methodology. This was a prospective multicentre study. Consultant orthopaedic surgeon HR was monitored intra-operatively using a ‘Wahoo Fitness’ chest strap and the data recorded by the proprietary Android app. Data was collected prior to surgery to obtain a resting heart rate, and at set points during total hip arthroplasty (THA) and total knee arthroplasty (TKA). The peak and mean HR for each stage of the operation were recorded and compared to cases where the consultant surgeon was performing the case or assisting a trainee. Data was compared with a 2-way ANOVA with repeated measures. Results. 23 cases (13 THA, trainer operating in 3 and 10 TKR, trainer operating in 2). The average baseline HR during the procedure was significantly higher when the consultant surgeon was performing the procedure when compared to training a trainee. There were spikes in consultant HR at insertion of both acetabulum and femur during THA, during component trailing and insertion during TKA. These spikes were lower when training than when performing. Discussion. The average HR is lower and the increase in HR at key stages of THA and TKA is less when training than when performing. Although difficult to disentangle the contribution of physical exertion from stress, the lower HR may indicate lower stress, and given stress can significantly shorten your life expectancy – having and training a trainee could seriously help prolong your life and career

Introduction. The case of Montgomery in 2015 considered standards of risk disclosure, whether alternative treatments had been discussed, standards of professional performance, and the importance of patient autonomy. Methods. A survey was devised to investigate orthopaedic surgeons' knowledge of the law of consent and risk disclosure and distributed by Survey Monkey. Results. 194 respondents from a total of 365 consultant orthopaedic surgeons contacted (53%). 85% of respondents were aware that Montgomery is primarily an obstetric case, 14.5% thought it was a spinal surgery case, and 1 respondent (0.5%) thought it was a paediatric surgery case. 99% correctly defined the Bolam test, but 57% erroneously believed that Bolam was still applicable in consent cases. 7% of respondents believed that it was not necessary to disclose a risk of surgery if the risk was less than 1%, and 4% of respondents if the risk was less than 10%. The legal test of materiality was correctly identified by 86% of respondents where a reasonable person in the patient's position would be likely to attach significance to the risk. 5% erroneously believed that provision of a standardised, printed information booklet provides sufficient risk disclosure for the individual patient to give their informed consent. 97% were aware that the surgeon must discuss reasonable alternative treatments including ‘no treatment’. Only 28% were aware that when a surgeon refers a patient for an interventional radiology procedure, it is the referring doctor who should formally hold and document the initial consent discussion. Discussion. General awareness of Montgomery was satisfactory, including the need to discuss alternative treatments including ‘no treatment’, and the qualitative concept of material risk. There was less understanding that material risk is independent of any quantitative rate of occurrence. Over half of consultants erroneously believed that the Bolam test was still applicable in consent cases. Small numbers of respondents erroneously thought that an information booklet constituted sufficient information disclosure. There was widespread misunderstanding that if a consultant surgeon refers an individual for an interventional radiology investigation it is in fact for the referring doctor to hold the initial consent discussion. Further training is required in respect of several issues raised by Montgomery

Background. Radiation exposure remains a significant occupational hazard for Orthopaedic surgeons. There are no references values for trauma procedures performed with Image Intensifier (II). We aimed to determine and compare reference values for patient radiation exposure for common trauma operations, and to analyse the effect of surgeon grade on II usage. Methods. Data collected prospectively from 849 cases between 01/05/2013 and 01/10/2014 were analysed. Statistical analysis was performed to calculate reference values for dose area product (DAP), screening time (ST), and number of II images taken for common trauma procedures where n>9 (n=808). Results. Dynamic hip screw (DHS) fixation required significantly less radiation than proximal femoral nail (PFN) for intertrochanteric hip fractures for median DAP (668mG/cm2 vs 1040mG/cm2, p<0.001), ST (00:36 vs 00:48, p<0.001), and number of II images (65 vs 110, p<0.001). Radiation exposure was statistically significantly less when Consultant Orthopaedic surgeons were first surgeon compared to Staff grade doctors and Orthopaedic trainees for DAP (90.55mGy/cm2 vs 175.5mGy/cm2 vs 366.5mGy/cm2), screening time (00:26 vs 00:32 vs 00:36), and number of II images (49 vs 59 vs 66). Conclusions. We reported reference values for common trauma operations that are essential to enable monitoring of patient radiation exposure. PFN required greater radiation exposure than DHS for intertrochanteric hip fracture. Increased surgical experience lead to lower radiation exposure in trauma operations, which could be developed to assess trauma competence within surgical training. Level of evidence. III

By the end of training, every registrar is expected to demonstrate proficiency in total knee replacement (TKR). It is unclear whether functional outcomes for knee arthroplasty performed by training grade doctors under supervision of a consultant have equivalent functional outcomes to those performed by consultants. This study investigated the functional outcomes following TKR in patients operated on by a supervised orthopaedic trainee compared to a consultant orthopaedic surgeon. Patients undergoing surgery by a consultant (n=491) or by a trainee under supervision (n=145) between 2003 and 2006 were included. There was a single implant, approach and postoperative rehabilitation regime. Patients were reviewed eighteen months, three years and five years postoperatively. There were no significant differences in preoperative patient characteristics between the groups. There was no difference in length of stay or transfusion or tourniquet time. Both consultant (p<0.001) and trainee (p<0.001) groups showed significant improvement in AKSK and AKSF scores between preoperative and 18 month review and there was no difference in the magnitude of observed improvement between groups (AKSK p=0.853; AKSF p=0.970). There were no significant differences in either score between the groups preoperatively or at any review point postoperatively. At five years postoperative, both groups had a median OKS of 34 (p=0.921). This is the largest reported series of outcomes following primary TKR examining functional outcome linked with grade of surgeon. It shows that a supervised trainee will achieve comparable functional outcomes at up to 5 years post operatively

We undertook 37 reverse total shoulder replacements within a 2 yr period for chronic complex shoulder conditions. All cases were undertook by one of two upper limb consultant orthopaedic surgeons. At time of listing for operation, the decision as to whether to undertake a bony-increased offset reverse total shoulder was made. Retrospective data was collected on the need for analgesia at final follow up and range of movement. Of the 37 patients, 12 underwent BIO-RSA procedures. Indications for surgery was predominantly rotator cuff arthropathy (n=9) but two patients had severe OA and one had a complex proximal humeral fracture. The average age of the patient was 76.6 yrs (69–87 yrs) with a mean follow-up of 6.8 months (6 weeks to 1 yr). The remaining 25 patients were similar in terms of indication, with 18 patients with cuff tear arthropathies and 7 with severe OA. Average age was slightly lower at 74.9 years (50–85). In terms of range of movement, outcomes between the two groups were broadly similar; those receiving BIO-RSA having an active forward flexion of 90.5° (50–130°) and abduction 88.6° (40–160°). Both groups had excellent analgesic effect with 92% in each either being completely painfree (33.3% BIO-RSA and 44% RSA) or requiring only occasional analgesia. The vast majority of patients were either very satisfied or satisfied with the outcome of the surgery, with one patient in the BIO-RSA group being slightly dissatisfied and three in RSA group. If grafting is necessary, the use of BIO-RSA within this centre seems to have comparable results to those undergoing standard RSA

Background. Total ankle replacement (TAR) design has evolved greatly in recent years and offers a reasonable alternative to ankle arthrodesis in a select patient population with end-stage arthritis. Originator series’ report good longevity and excellent patient reported outcomes (PROMs). We report our outcomes in an independent, non-inventor cohort. Method. We collected prospective data on consecutive patients undergoing total ankle replacement between April 2008 and March 2012, under the care of one Consultant Orthopaedic surgeon. The primary outcome measure was time to revision. Secondary outcomes measures included American Orthopaedic Foot and Ankle Society (AOFAS) scores, Visual Analogue Score (VAS) for pain, and complications. Results. 70 patients underwent TAR with a mean follow-up of 64 months (39–86). Three patients underwent revision of TAR to ankle arthrodesis, two for aseptic loosening and one for infection, equating to survivorship of 96%. Three patients sustained intra-operative fractures, one of the lateral malleolus and two of the medial malleolus. The patient who sustained the lateral malleolus fracture later went on to develop aseptic loosening requiring revision. One patient developed a late stress fracture of the medial malleolus. Two patients underwent open exploration, grafting of bone cysts and fixation for ongoing pain at a mean time of 4.5 years following the primary TAR. At the most recent review all patients reported improved AOFAS scores from 39.55 (21–52) to 82.10 (57–100) and VAS from 9.11 (6–10) to 1.79 (0–6) respectively. Conclusions. Longevity of the Zenith TAR in our non-inventor series is comparable to that of originator outcomes. Fractures are a recognized complication of TAR and when affecting the medial malleolus, do not appear to have an adverse effect on outcome. We feel that TAR offers an effective alternative solution to ankle arthrodesis with satisfactory relief of pain whilst preserving movement at the ankle joint

Around 1% of total hip replacements are follow by prosthetic joint infection (PJI). There is uncertainty about best treatment method for PJI, and the most recent high quality systematic reviews in unselected patients indicates that re-infection rates following one-stage and two-stage revision arthroplasty are relatively similar. In the absence of evidence randomised controlled trials will help to identify the most clinically and cost-effective treatment for PJI. Before such trials are conducted, there is a need to establish reasons for current practice and to identify whether trials are feasible. This study aimed to deliver research that would inform trial design. Specifically, we aimed to characterise consultant orthopaedic surgeons' decisions about performing either one-stage or two-stage exchange arthroplasty for patients with PJI after hip replacement and to identify whether a randomised trial comparing one-stage with two-stage revision would be possible. Semi-structured interviews were conducted with 12 consultant surgeons from 5 high-volume National Health Service (NHS) orthopaedic departments in the UK. Surgeons were sampled on the basis that they perform revision surgery for PJI after hip arthroplasty and final sample size was justified on the basis of thematic saturation. Surgeons were interviewed face-to-face (n=2) or via telephone (n=10). The interview study took place before design of a multicentre prospective randomised controlled trial comparing patient and clinical outcomes after one-stage or two-stage revision arthroplasty. Data were audio-recorded, transcribed, anonymised and analysed using a thematic approach, with 25% of transcripts independently double-coded. Results: There is no standard surgical response to the treatment of PJI and surgeons manage a complex balance of factors when choosing a surgical strategy. These include multiple patient-related factors, their own knowledge and expertise, available infrastructure and the infecting organism. Surgeons questioned whether evidence supports the emergence of two-stage revision as a method. They described the use of loosely cemented articulating spacers as a way of managing uncertainty about best treatment method. All surgeons were supportive of a randomised trial to compare one-stage and two-stage revision surgery for PJI after hip replacement. Surgeons reported that they would put patients forward for randomisation when there was uncertainty about best treatment. Surgeons highlighted the need for evidence to support their choice of revision. Some surgeons now use revision methods that can better address both clinical outcomes and patients' quality of life, such as loosely cemented articulating spacers. Surgeons thought that a randomised controlled trial comparing one-stage and two-stage exchange joint replacement is needed and that randomisation would be feasible. The next stage of the work was to design a multi-centre randomised controlled trial, this has been achieved and the trial is now ongoing in the UK

Introduction:. Antimicrobial resistance is an important patient safety issue. Antibiotic Stewardship is one of the key strategies in tackling this problem. We present our data over a two year period from October 2011 to December 2013. Method:. A multidisciplinary, consultant led antibiotic ward round was implemented in October 2011. This involved the consultant orthopaedic surgeon, microbiologist, pharmacist and antibiotic prescription nurse. Data from the meetings was collected prospectively over a 118 week period using a standard data form. The case notes, prescription kardex, laboratory results including microbiology data and clinical information of patients was available at the time of the Ward round. The indications for, choice of antibiotics, duration and further treatment plan were made and a note for the case notes was dictated immediately. Changes to prescriptions were also made at the time. Results:. Over the first 2 years 269 patients were reviewed. We noticed a 22% decrease in the volume of IV antibiotic prescriptions. 35% of antibiotic prescriptions were de-escalated (reducing the dose or narrowing the spectrum), however 9% required escalation. 2% of prescriptions were stopped for being clinically not required any more. There was 48% decrease in costs of IV antibiotics and 30% decrease in total cost of oral and IV antimicrobials. Discussion:. We find that this exercise leads to a clear, documented, more cohesive approach to patients' treatment which improves patient care. It makes the orthopaedic consultant and on call team aware of all patients on antibiotics and the plan for the following week. Conclusion:. Antibiotic Stewardship in our hospital has led to the decrease in the use of antibiotics and reduced costs along with several other soft benefits in patient treatment. Given the rising problem of antibiotic resistance, this key pillar strategy against it should be implemented in all hospitals

In cerebral palsy patients, while upper limb function is acknowledged as being important, it has traditionally taken a back seat to lower limb function. This is partly due to inexperience and partly due to difficulty deciding on the best way of improving upper limb function. In Swansea since June 2008 we have been offering a multi-disciplinary service for the assessment and treatment of upper limb problems in cerebral palsy. The core team consists of a consultant orthopaedic surgeon, a consultant plastic surgeon with a special interest in CP upper limb problems, a consultant paediatric neurologist, a community paediatric physiotherapist and a community paediatric occupational therapist. Upon referral, the physiotherapist and occupational therapist carry out initial functional assessment of the patient. This is followed by a joint assessment by the whole team in a special clinic held every 3 months. If required, the child is offered surgery, botox injections or both. Further follow-up is in the special clinic until the child is suitable for follow-up in a normal clinic. We present our initial experience with this multi-disciplinary approach, the problems encountered in setting up the service and our plans for the future

Aim. To review the infants in our district general hospital receiving delayed treatment for DDH i.e. those infants who had more than one ultrasound scan prior to diagnosis and treatment. In this group all scans were abnormal at the time of treatment but the scans at first presentation were normal for age when reviewed by our senior radiologist. Method. An audit was performed of all the children attending our institution from 2008–2011 for treatment of DDH following diagnosis with clinical examination and dynamic ultrasound. A senior radiologist and consultant orthopaedic surgeon independently assessed the scans. Two questions were asked (a) were the scans at the time of treatment normal or abnormal and (b) in those who were treated following a repeat scan, was the initial scan normal. Results. 33 infants were treated for DDH, 8 of whom received treatment after more than one scan. In 3 cases the child had evidence of instability at first examination, 1 had limited abduction and 1 had asymmetrical thigh creases. The remaining 3 had scans that were deemed normal for age by the radiologist but due to suspicion from the treating surgeon they had a repeat examination and scan. Conclusion. This study although small in numbers highlights the need for a completely normal examination in the presence of a normal ultrasound scan before the diagnosis of DDH can be dismissed

Objective. Delayed radiographs are routinely done to help in diagnosis of occult scaphoid fractures. Our aim was to determine the diagnostic value of these late x-rays. Methods. This is a radio-diagnostic study. We prospectively reviewed radiographs of 67 patients with injury to their wrists who presented with anatomical snuff box to the accident and emergency department.5 patients showed up a fracture of the scaphoid on trauma x-rays and they were excluded from the study. All patients had a radiograph on day of presentation as well as a delayed radiograph at a later date. The radiographs were standardized to include 4 scaphoid views. All the radiographs were reported independently by a consultant radiologist (JN) and a consultant orthopaedic surgeon (ML). Results. 62 radiographs of 42 males and 20 females with an average age of 25.91 were examined. The two sequential radiographs were taken at an average delay of 10.23 days. There was no difference of opinion between the radiologist and the orthopaedic surgeon with regards to reporting. Only one of the late radiographs showed up a fracture of the proximal pole. Rest of the x-rays failed to detect any bony injury. Conclusion. If a fracture is not visible on first day it is difficult to visualize the fracture in delayed x-rays and a strong clinical suspicion should be supplemented with a more specific investigation like a bone scan or MRI scan. We present our data with an up to date review of literature

Trauma ward rounds (TWR) are usually preceded by trauma meetings where previous day admissions are discussed and management decisions made. Therefore, one would expect TWR to be relatively quick and efficient. We measured the distance walked during TWR over a one week period and examined effects of number of patients and their location on distance walked. We used a pedometer (after calibration) to measure the distance walked by a single consultant orthopaedic surgeon during his trauma week. The consultant conducted a daily TWR after the trauma meeting where previous day admissions and postoperative patients were reviewed. We initially measured the distance required to visit five wards where trauma patients could be found (trial distance) and used that for comparison. We recorded number of patients reviewed and wards visited daily. The distance walked daily during TWR was 1.37–2.4 times longer than trial distance. There was no correlation between number of patients reviewed or number of wards visited and distance walked. Despite the larger number of patients towards the end of the week (33 patients on 3 wards on last TWR), the distance walked remained shorter than on the first TWR (11 patients on 3 wards). The distance walked during the whole week was 30.8 miles!. We found no correlation between number of patients reviewed or their location and distance walked during TWR. The relatively shorter distances walked towards the end of the week could be explained by more familiarity and therefore, better organisation by the team as the week progressed