Between October 2001 and February 2002, 324 healthcare workers were screened for methicillin-resistant Staphylococcus aureus (MRSA) by nose and throat swabs. A positive finding led to activation of a standardised control programme for the affected person who was immediately excluded from work. Family members of those who were MRSA-positive were offered screening free of charge. An eradication programme was carried out in the permanent carriers. MRSA was found in 17 (5.3%) healthcare workers, 11 of whom proved to be permanent carriers, and six temporarily colonised. Three children of a positive healthcare worker showed nasopharyngeal MRSA, the acquisition of which occurred within the hospital. The standardised eradication programme for carriers was successful in most cases but failed in two individuals, whereupon systemic antibiotics were used successfully. The decolonised carriers, observed for more than one year, remained MRSA negative.

Isolation precautions in hospitals do not always prevent hospital staff and their families from acquiring MRSA. The identification of affected employees is difficult because in most cases only asymptomatic colonisation occurs. Screening and eradication can be complicated and costly, and for the affected employees the occupational consequences can be far-reaching as they have no guaranteed legal protection.

Introduction: Infection following arthroplasty is a rare but significant and threatening complication. The incidence is about 2%. Treatment of an infected joint replacement may be demanding, time consuming and expensive. The aim was to evaluate the average cost of an infected arthroplastic in our own department under the given reimbursement system in Germany.

Material and Methods: During 3 month 20 consecutive cases of infected joint refered to our institution were monitored for treatment costs and final reimbursement by the health insurances.

Results: In 65% of the included cases the amount of reimbursement by the health insurance organisations did not cover the costs of the treatment in our department. The amount of financial loss in total was 48.142 € with more than 9.000 € in some cases.

Conclusions: For the treating institution there is a risk of substantial financial losses due to inadequate reimbursement. Calculated on the basis of ~ 150.000 implanted joint protheses / a, an infection rate of 2% and treatment costs of ~50.000 € / infected case the economic burden is an estimated 150 million € / a in Germany. This amount should justifie a sound evaluation of costs related to infection in arthroplasty, which should be the effort of the health insurance organisations. Additionally specific research in the field of infection prevention must be sponsored. The system of reimbursement should be adeaquately adopted and corrected.

Introduction: Septic glenohumeral destruction is one of the most feared complications after operative fracture care. Unlike for other joints resection arthroplasty is not a possible alternative form of treatment. Our aim in this study was to assess the long-term results of shoulder arthrodesis in 15 patients after septic joint destruction.

Patients and Methods: Between 1978 and 1998 septic arthrodesis of the shoulder was performed in 15 patients. There were four women and 11 men with a mean age of 51.9 years. All patients were asked to return for clinical evaluation in June 2002. Three had died from unrelated causes and one from abroad had been lost for follow up. The outcome was evaluated according to the modified functional score of Hawkins and Neer and David, Makowski and Muhr. We recorded the complications, further operations, alterations in working habits, pain and patient satisfaction.

Results: The mean follow up was 8.3 years (3 to 14y). 3.8 (1 to 14) previous procedures had been performed. The entire 11 pat. were limited using their arm behind their backs. None was able to perform toilet hygiene and only one patient was able to reach his back pocket. Function at the level of the head in order to shave or to comb hair was difficult for the most, whereas nine patients were able to work at waist level. Eight were able to put on shoes and socks. Four were able to climb a ladder. All had had pain before surgery. On visual analogue scale, the mean preoperative level of pain was 7.9 and 3.3 after fusion. Complications occurred in 5 patients. 3 had persistent infection and failure of bony fusion requiring further surgery, one patient with persisting infection denied surgical interventions, one sinus tract healed after hardware removal.

Conclusion: The outcome depends on the individual patient and the indication for arthrodesis. To our knowledge, this is the first study which has investigated the long term results after arthrodesis indicated by septic joint destruction. Heavy tobacco misuse and a high number of previous procedures could be identified as risk factors for persisting of infection, persisting pain and failure of bony fusion with statistical significance.

Introduction: Knee arthrodesis is a well-recognized salvage procedure in patients with septic destruction of the knee joint. If fusion can be achieved, it offers the opportunity for a stable lower limb and eradication of infection, but at the expense of knee motion. However, knee arthrodesis in this setting may be difficult to achieve because of poor bone stock, persistent infection and soft tissue compromise. In this study we present clinical and radiological results after knee fusion as well as an algorithm according to different surgical techniques (hybrid external fixator (HEF), antegrad compression nail (ACN) and modular cement less titanium rod (MCR)) and types of soft tissue damages and bone loss caused by infection

Patients and Methods: Between 10/2000 and 10/2002 in 37 patients knee arthrodesis was indicated after septic joint destruction. In 23 Pat. (67.0 y, 19.4–88,8 y) septic failure of total knee arthroplasty (TKA)caused severe bone loss and soft tissue damage. Because solid bony fusion was not to be expected weight bearing capability was restored by the use of MCR in a second stage procedure, using a PMMA Gentamycin spacer for eradication. In 14 Pat. (54.3 y, 23.l–87.7 y) remaining bone stock indicated direct fusion. In 10 of these cases HEF was used (6x primary joint infection, 3x septic failure of TKA, lx infected osteosynthesis). 2 pat. denied written consent for HEF, another 2 pat. had infected ipsilaterale midshaft femor-and/or tibia non unions. Because of these we used the ACN.

Results: In 5 pat. (21.7%) treated with MCR 1,4 revision procedures were indicated to eradicate infection before the implantation of MCR. Recurrence of infection after implantation occurred in 13% (n=3): 2 pat. were treated non surgically, lx amputation had to be done. No radiological signs for implant loosening were seen. HEF was removed after 15 weeks (12–18w) on average. 5 revision procedures were necessary in HEF cases (lx Pin-, lx ring exchange, lx sequestrectomy after pintractinfection,)- hi 2 cases the procedure was changed to MCR because of a non-union. Using the ACN we saw a 100% fusion rate, in one case the sinus tract persisted. The check up examinations were done 8,7 month (2,4–22,4mo) after arthrodesis procedure. 82,6% of pat. after MCR, 100% after HEF- and ACN-had full weight bearing capability. Eradication of infection was achieved in 86,9% (n=20) after MCR, in 70% (n=7) after HEF and in 75% (n=3) after ACN. In all 3 groups soft tissue reconstruction by flap surgery was indicated in 20%.

Conclusion: HEF is indicated when bone loss allows bony fusion. Failure occurred when bone defects were underestimated ort he fixator was removed before the 14th week. MCR can be used when eradication of infection is success and because of bone defects direct fusion is not possible. When eradication is not possible and bone stock makes the fusion reliable the ACN can be used under ongoing infection. ACN is also used when HEF is not recommended by the patient or because of mechanical reasons (floating knee).

Introduction: Although more than 30 different surgical procedures to achieve solid ankle fusion were described, after septic joint destruction or ongoing infection external fixation is preferred. In 1999 the referring institution reported on 45 cases with internal (screw) fixation and additional external fixation [1]. Later on we used hybrid external fixation including transfixation of the midfoot [2]. Since range of motion of the middle and forefoot is of great importance for limb function we designed a prospective study to compare fusion rate and limb function after ankle fusion without foot or midfoot transfixation.

Patients and Methods: Between 9/2000 and 2/2002 18 patients with septic ankle destruction were admitted for ankle fusion. 10 patients were treated with a fine wire ring fixator using 2 full rings in the tibia and one 5/8 shaped ring in the calcaneus and talus. Compression was applicated only between the distal tibia and the talus. Every 14 days the wires were retensioned. 8 patients were treated with a titanium compression nail in an antegrad technique. All operations were done by one surgeon. 14 patients had a posttraumatic osteitis complicated in 6 cases by polyneurophathy and in two cases previous fusion failed. 4 patients suffered from diabetic polyneuropathy, 2 of them with ongoing infection. In both techniques weight bearing was allowed after 3 weeks.

Results: External fixator was removed 16 weeks after operation on average (14w–18w). Solid fusion was achieved in 16 cases (88%). In 3 patients the fistula persisted in one of them fusion failed. Dynamic pedobarography showed better results in patients without fixation of the subtalar joint. (Compression nail)

Conclusion: The study showed similar fusion rates compared with surgical procedures including transfixation of the whole foot. Range of motion of the not fused joints of the foot was better because early physioptherapy was performed. The fixation of the fore and mid foot is not necessary to achieve solid fusion by increased stability.

We analysed the long-term results of arthrodesis of the shoulder after infection in 15 patients. At the time of operation, 14 cultures were positive for Staphylococcus aureus. The mean follow-up was 8.3 years (3 to 14) and 90% of the patients were satisfied with the outcome. There were complications in five patients (33%); in three there was nonunion with loosening of the implant. One patient had a sound bony union but with a persistent sinus six years after arthrodesis and another had a sinus which healed after the metal was removed. Four of these five patients (80%) were heavy smokers (> 20 cigarettes/day). Cancellous bone grafting did not affect the incidence of complications. The mean age of the patients with complications was 58.6 v 48.6 years for those without (p = 0.2808 ; not significant). Those with complications had had more previous operations (6.4 v 2.5, p < 0.05). Antibiotics, as determined by the bacteriological cultures, were administered for six weeks.

The complication rate was higher in patients with active sepsis but the younger the patient and the fewer number of previous operations (< 50 years, < four previous operations), the better was the outcome. Considering the rate of complications, we recommend early surgery in these patients.