Faculty Bibliography

BACKGROUND:MRSA is a major economic and health issue internationally and as such is of particular importance in the appropriate management of orthopaedic patients. Bone, joint and implant infection can lead to unfavourable outcomes with a long protracted in hospital stay inevitable. The cost for the patient, the hospital and society are substantial. MATERIALS AND METHODS/METHODS:This study was a review of a prospectively maintained database from our unit over three time points from 2005 to 2007. At each time point a new infection control measure was implemented in an effort to reduce MRSA infections. Total rates of MRSA infection and colonisation in all orthopaedic patients were recorded, before and after separation of trauma and elective services, and after the introduction of a screening pre assessment clinic. RESULTS:12259 orthopaedic patients were reviewed over the three years. The mean age of MRSA infected patients was 71. A higher proportion of female patients were infected than male patients. The mean length of stay for infected patients was 23.4 days. The rate of infection dropped from 0.49% in 2005 to 0.24%in 2007. After the introduction of these measures there was a substantial reduction in organ space and deep tissue infections. CONCLUSION/CONCLUSIONS:The separation of emergency and elective orthopaedic services coupled with effective pre-operative screening has resulted in a significant reduction in MRSA infection despite an ever increasing prevalance.

We reviewed the peri-operative and financial data of patients who underwent revision total knee arthroplasty in our institution between 1997 and 2006. The aims were to compare difference in cost between aseptic and septic cases and to identify the sources of preventable cost increase in revision knee procedure. The study group comprised 117 women (65%) and 62 men (35%). The median age of patients decreased from 73 years (37-83 years) in 1997-2001 to 70 years (15-91 years) in 2002-2006, a decline of 4% (P < 0.05). The mean ASA scores also dropped from 3 to 2 between the two periods. Despite this, the mean total cost of revision knee procedure continued to increase. Patients undergoing revision arthroplasty because of infection had much higher (P = 0.0001) cost compared to their aseptic counterpart. Increase in the costs of investigations (P < 0.05) and implant (P < 0.05) was the major contributing factors. The cost of implants increased by 32-35% (P < 0.05) depending on implant selection. Changing demographics will increase the requirement for this surgery and thus increase its overall cost to society. Cost increases associated with unnecessary investigations, prolonged hospital stay and use of expensive implants should be avoided.

BACKGROUND:Supervised preoperative muscle strengthening programmes (prehabilitation) can improve recovery after total joint arthroplasty but are considered resource intensive. Neuromuscular electrical stimulation (NMES) has been shown to improve quadriceps femoris muscle (QFM) strength and clinical function in subjects with knee osteoarthritis (OA) however it has not been previously investigated as a prehabilitation modality. METHODS:This pilot study assessed the compliance of a home-based, NMES prehabilitation programme in patients undergoing total knee arthroplasty (TKA). We evaluated its effect on preoperative and postoperative isometric quadriceps femoris muscle (QFM) strength, QFM cross-sectional area (CSA) and clinical function (subjective and objective). Seventeen subjects were recruited with 14 completing the study (NMES group n = 9; Control group n = 5). RESULTS:Overall compliance with the programme was excellent (99%). Preoperative QFM strength increased by 28% (p > 0.05) with associated gains in walk, stair-climb and chair-rise times (p < 0.05). Early postoperative strength loss (approximately 50%) was similar in both groups. Only the NMES group demonstrated significant strength (53.3%, p = 0.011) and functional recovery (p < 0.05) from 6 to 12 weeks post-TKA. QFM CSA decreased by 4% in the NMES group compared to a reduction of 12% in the control group (P > 0.05) at 12 weeks postoperatively compared to baseline. There were only limited associations found between objective and subjective functional outcome instruments. CONCLUSIONS:This pilot study has shown that preoperative NMES may improve recovery of quadriceps muscle strength and expedite a return to normal activities in patients undergoing TKA for OA. Recommendations for appropriate outcome instruments in future studies of prehabilitation in TKA have been provided.

BACKGROUND:Overuse ankle injuries have been described in elite athletes and professional ballet dancers however the spectrum of injuries experienced by professional Irish dancers has not been defined. METHODS:A troupe of actively performing dancers from an Irish-dance show were recruited (eight male, ten female; mean age, 26 years). The prevalence of overuse injuries in the right ankle was determined from magnetic resonance imaging. Foot and ankle self-report questionnaires were also completed (AOFAS and FAOS). RESULTS:Only three ankles were considered radiologically normal. Achilles tendinopathy, usually insertional, was the most frequent observation (n=14) followed by plantar fasciitis (n=7), bone oedema (n=2) and calcaneocuboid joint degeneration (n=2). There were limited correlations between MRI patterns and clinical scores indicating that many conditions are sub-clinical. Dancers with ankle pain had poor low (p=0.004) and high (p=0.013) level function. CONCLUSIONS:Overuse ankle injuries are common in Irish dancers. Incorporating eccentric exercises and plantar fascia stretching into a regular training program may benefit this population.

Sleeve fractures of the superior pole of the patella are rare. The importance of their diagnosis lies in the fact that the avulsed fragment contains a source of bone forming tissue which may lead to duplication or enlargement of the patella. We report a case in a 16 year old boy who underwent plication of the medial patellofemoral ligament, vastus medialis obliquus advancement and percutaneous lateral release, for recurrent instability. Interruption of the blood supply with subsequent avascular necrosis is one possible mechanism for this complication. Another more likely mechanism is that of failure of the repair and re-dislocation, which may have been contributed to by prolonged cast immobilization.

BACKGROUND AND PURPOSE/OBJECTIVE:Fomites are increasingly being recognised as a source of hospital-acquired infection. We have therefore assessed tourniquets and exsanguinators for the presence of bacterial pathogens in 1 elective and 2 trauma orthopedic hospitals. MATERIAL AND METHODS/METHODS:Swabs were taken prior to and after decontaminating these devices with 1 of 3 different cleaning modalities. These were then assessed for colony counts and organisms identified. RESULTS:Bacteria commonly implicated in surgical site infections such as coagulase-negative staphylococci, Staphylococcus aureus and Proteus spp. were prevalent. We also found a resistant strain of Acinetobacter and Candida. Exsanguinators were the most heavily contaminated devices, and colony counts in the trauma hospitals were up to 400% higher than in the elective hospital. Alcohol- and non-alcohol-based sterile wipes were both highly effective in decontaminating the devices. INTERPRETATION/CONCLUSIONS:Infectious organisms reside on the tourniquets and exsanguinators presently used in the orthopedic theater. These fomites may possibly be a source of surgical site infection. We have demonstrated a simple and effective means of decontaminating these devices between cases.

We have analysed the management and clinical outcome of a series of consecutive patients who had a total hip replacement and developed post-operative surgical site infection (SSI) with methicillin-resistant Staphylococcus aureus. The incidence of this infection was 1% over a period of five years. We studied SSI in 15 patients (16 infections) with a mean age of 72.7 years (53 to 81). In all, 12 of the infections occurred early and half of the infections involved the prosthesis, resulting in an increase of 11-fold in the cumulative hospital stay. Methicillin-resistant Staph. aureus was successfully eradicated in all the patients after a mean follow-up of 53.6 months (25 to 88). Superficial incisional infections resolved after antibiotic therapy alone while deep infections required multiple operative debridements. Attempted retention of the implant in early organ space infections was successful in only one of five patients. Only three patients with implant-level infections obtained a pain-free, functional prosthesis while a further three required excision arthroplasty. We have formulated a protocol of treatment which may serve as a guide in the management of these infections.