Infection remains a devastating complication of joint replacement surgery causing a significant burden to both patient and surgeon. However, despite exhaustive prophylactic measures, intraoperative contamination still occurs during cemented arthroplasty with current infection rates of 1-2%. A study was undertaken to determine the incidence of perioperative contamination in cemented arthroplasty patients, to identify contaminating organisms, to identify contaminated regions within the operative wound, to identify factors associated with increased contamination, and finally to assess the medium-term clinical outcome in patients with confirmed intraoperative wound contamination. Eighty consecutive patients undergoing hip and knee cemented arthroplasty were prospectively enrolled over a 6-month period. All scrubbed personnel wore total body exhaust isolation suits and procedures were carried out in ultra-clean air theatres. Of 441 samples, contamination was identified at 21 sites (4.8%) representing a cohort of 18 patients (22.5%). Longer duration of surgery predisposed to higher contamination rates while lower contamination rates were significantly related to fewer gowned personnel within the ultra-clean system, and fewer total personnel in theatre during the procedure. None of the patients developed clinical evidence of deep prosthetic infection at follow-up. We noted a high incidence of intraoperative contamination despite standard prophylaxis. However, this was not reflected by a similar rate of postoperative infection. This may be due to a small bacterial inoculum in each case or may be due to the therapeutic effect of perioperative intravenous antibiotic prophylaxis.

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The established treatment for severe rheumatoid arthritis in the ankle is arthrodesis. Numerous reports in the literature describe outcomes in patients with degenerative and posttraumatic arthrosis and rheumatoid disease. This has led to results that are difficult to interpret. In addition, in the few studies that have evaluated patients with rheumatoid disease many techniques of arthrodesis are reported, further confounding assessment of one fusion method. One technique of 20 ankle fusions in patients with rheumatoid disease was evaluated. A modified Wagner arthrodesis was used through a transfibular approach using parallel compression screws. The scoring systems of Mazur et al, Moran et al, and the Short-Form-36 were used to evaluate the outcome. The mean time to followup was 3 years 10 months. Eighteen of 20 fusions obtained a solid talocrural union (90%). No correlation was found between the scores of Mazur et al and Moran et al. Correlation was achieved between the scores for the Short Form-36 and Moran et al. The modified Wagner ankle arthrodesis is a simple, reliable, reproducible technique with a 90% union rate. The value of the technique has been confirmed in patients with rheumatoid arthritis by evaluating the outcome using a scoring system that is validated and relevant to this population.

Early results of revision acetabular surgery using impaction grafting and the Kerboull shell in patients with severe osteolysis have shown good functional outcome. However, 6 of 35 patients had radiographic evidence of aseptic loosening without progression for 4 years. Long-term follow-up is required to ensure that this loosening does not result in failure.