Aims

Stiffness is a common complication after total knee arthroplasty (TKA). Pathogenesis is not understood, treatment options are limited, and diagnosis is challenging. The aim of this study was to investigate if MRI can be used to visualize intra-articular scarring in patients with stiff, painful knee arthroplasties.

The incidence of DDH Varies depending on genetic and ethnic varieties but in Ireland on an average in 3 per 1,000 live births. Current treatment is focused on early diagnosis and congruent reduction of the hip joint. With conservative measures, principally skilful use of the Pavlik harness, the majority of (85%) of dislocated or subluxated hips will be successfully treated. Late diagnosis impacts on the mode of treatment and on the subsequent outcome.

An audit of annual incidence of DDH in North Eastern health board, in Ireland showed a dramatic increase in late diagnosis (> 4 month). There were 4668 live births in 2004 with 17 cases of DDH presenting between the ages of 4 – 36 months during this period. The mean age of presentation was 10 months. Two cases were bilateral. The male: female ratio was 4.6:1. Risk factor analysis showed, only 50% fell in to the high risk group, majority of them had positive family history. Three fourth of them were frank dislocations and all of them required operative intervention. As opposed to early presenters, only 10% needed operative intervention. 30% of the late presenters needed major osteotomies.

We examined the reasons for this extreme high rate of late presenters and argue for the introduction of routine ultrasound screening in this region based on historical high incidence of DDH and the dramatic incidence of delayed diagnosis.

Purpose: The use of a bioabsorbable suture anchor across a joint as a means of internal stabilization has not previously been described. This study assesses the iatrogenic damage caused by such a procedure in the normal immature porcine hip.

Materials and Methods: Six twelve week old pigs underwent unilateral transarticular suture anchorage of the hip using a Panalok® RC Quick Anchor® Plus with Panacryl® suture. (Mitek® Products Johnson and Johnson). Anteroposterior pelvic radiographs were taken pre-operatively and six weeks post-operatively. Acetabular index, diameter of the femoral head ossific nucleus of both hips on both occasions were measured and compared. Pigs were sacrificed six weeks post-operatively. Specimens were analysed macroscopically for femoral head diameter, acetabular dimensions, and presence of gross chondrolysis. Histological analysis was performed to assess the presence of articular chondrolysis, and proximal femoral physeal arrest.

Results: In four out of six hips the rate of change of the acetabular index slowed as compared to the unoperated side though none worsened. The diameter of the femoral ossific nucleus on the operated side continued to increase in size at a similar rate as the unoperated side, despite the surgical procedure according to radiographic comparison. Similar findings were made in the macroscopic analysis of the hip geometry. Gross and histological analysis of the articular cartilage show only local areas of chondrolysis related to the drill holes, and in one hip where a second hole was drilled, cartilage regeneration was noted. Metaphyseal growth at the proximal femoral physis was unaffected by the procedure.

Conclusions: The use of a trans-articular suture anchor across the hip appears to cause marginal retardation of acetabular development in the normal hip. The procedure does not appear to affect proximal femoral physeal or epiphyseal growth and the presence of a bioabsorbable suture within the joint did not result in chondrolysis.

Introduction: The use of a trans-physeal, trans-articular suture anchor across a joint as a means of internal stabilisation has not previously been described. This study assesses the damage caused by the procedure to the immature porcine hip.

Methods: Six twelve week old pigs underwent unilateral hip surgery. Anteroposterior pelvic radiographs were taken preoperatively and six weeks post-operatively. The acetabular index and diameter of the femoral head ossific nucleus of both hips were measured and compared. Specimens were analysed macroscopically for femoral head diameter, acetabular dimensions and for evidence of gross chondrolysis. Histological analysis was performed to assess the presence of articular chondrolysis and proximal femoral physeal arrest.

Results: In four out of six specimens the rate of change of the acetabular index slowed as compared to the unoperated side, though none worsened. The diameter of the femoral ossific nucleus continued to increase in size at a similar rate to the unoperated side on radiological examination. Similar findings were seen with the macroscopic analysis. Gross and histological analysis of the articular cartilage showed only local areas of chondrolysis, related to the drilling. Metaphyseal growth at the proximal femoral physis was unaffected by the procedure.

Discussion: The use of a trans-articular suture-anchor across the hip appears to cause marginal retardation of acetabular development in the normal hip. The trans-physeal approach to the hip does not appear to affect proximal femoral physeal or epiphyseal growth in the short-term, and the presence of a bioabsorbable suture within the joint did not result in chondrolysis.

Aim To document an outbreak of Vancomycin Resistant Enterococci in an elective Orthopaedic Unit. To describe the clinical course of the affected patients and treatment options. To describe methods employed in eradicating endemicity following the outbreak and to evaluate the lessons learnt.

Background VRE first appeared in the Microbiological literature in 1988. Very little is known about its effect in the Orthopaedic Realm. To our knowledge, this is the first report of a serious outbreak in such a unit and only the second reporting of peri-prosthetic VRE infection.

Material and methods All patients in the unit over a 1/12 unit formed the cohort for the study. Following identification of the index case, samples were taken form all in-patients. Immediately a nurse specialist in infection control oversaw sampling of all patients. Microbiological data, Clinical Data and antimicrobial therapy data was collected on all positive patients. Rapid laboratory procedure were instituted, environmental screening was preformed and a dedicated cleaning team was formed. The assistance of a Clinical Microbiologist and an Environmental Microbiologist was sought.

Results Following identification of the index case, 11 patietns had microbiological proven VRE. 1 patient had a VRE confirmed peri-prosthetic infection. This necessitated removal and appropriate anti-microbial therapy. However, this patient died. 2 pateints were found to have superficial wound infection, which resolved with oral Linezolid, while 8 patients showed colonization with the organism. No treatment was required other than clinical follow up and staged screening in these patients.

The unit was closed for 9 weeks following the outbreak and deep cleaning resulted in eradication of endemicity.

Conclusion Tracing of the index case and typing allowed us to confirm the source of the outbreak and to take steps to prevent a recurrence. Appropriate microbiological advice is essential in an outbreak situation, management of peri-prosthetic infection and follow up of affected cases. All protocols have been re-evaluated and retraining of all staff in good clinical hygiene has been undertaken. The speed of the outbreak and its devastating effect on a Joint Replacement Facility is alarming and should serve to aid other units in establishing preventative protocols and in preplanning their treatment options and an outbreak team.