A RANDOMISED PROSPECTIVE STUDY OF POST OPERATIVE BLOOD
SALVAGE WITH AUTOLOGOUS RETRANSFUSION IN PRIMARY TOTAL
HIP REPLACEMENT
L. K. Smith, D. H. Williams, V. G. Langkamer
Weston General Hospital, Weston-super-Mare BS23 4TQ
Homologous blood transfusion (HBT) following primary total hip replacement (THR)
is not without risk. Postoperative blood salvage (POS) with autologous blood
transfusion may minimize the necessity for HBT but the clinical, haematological and
economic benefits have yet to be clearly demonstrated for primary THR.
The aim of this randomized prospective study was to determine if the use of POS
affects postoperative haemoglobin levels, haematocrit and HBT requirement.
Secondary outcomes included length of stay and patient satisfaction. A cost analysis
was conducted on the basis of the results. The patients were randomized at the point
of reduction of the primary THR to receive either two vacuum drains (82 patients) or
an autologous retransfusion system (76 patients).
Haemoglobin and haematocrit values were not significantly different between
groups but significantly fewer patients with the autologous system had a postoperative
haemoglobin value < 9.0 gdL-1 (8% vs. 20%, p = 0.035). Significantly fewer patients
with the autologous system required HBT (8% vs. 21%, p = 0.022). There was an
overall cost saving in this group.
This study has shown that use of an autologous retransfusion system for primary
THR reduces the necessity for HBT and is cost effective.
ASSESSING WRIST CARTILAGE: MRI OR EYEBALL
J. Mutimer, J. Field
Cheltenham General Hospital
The aim of this study was to compare arthroscopy and MRI as methods of assessing
cartilage quality in the wrist.
Patients and Methods - 15 patients were identified who had undergone both wrist
MRI and arthroscopy as part of their investigations for degenerative causes of wrist
pain. 5 patients had Keinbock's disease, 6 had scapholunate advanced collapse and 4
had scaphoid non union advanced collapse. A 3 point grading system for assessing
cartilage quality was devised for both arthroscopy and MRI assessing 5 articular
surfaces in the wrist joint.
Results - The scores for MRI and arthroscopy were compared statistically using
Kappa analysis to assess compatibility. (where 0 equates to no agreement and 1
indicates complete agreement).
The overall Kappa score was 0.43 which shows ‘moderate’ correlation between the
two methods. Individual Kappa scores for the articular surfaces were lunate fossa
0.21, proximal lunate 0.62, distal lunate 0.22, proximal capitate 0.42 and scaphoid
fossa 0.56.
Conclusion - Although MRI is a useful investigation, at present it cannot replace
arthroscopy in measuring cartilage quality. However it does remain an important
investigation in the management of such patients. As the quality of MRI scanners
improves it may be possible to avoid arthroscopy as a diagnostic procedure.
RATES OF MRSA SCREENING, CARRIER STATUS AND WOUND
INFECTION IN AUSTIN MOORE HEMI-ARTHROPLASTY PATIENTS : A 1
YEAR RETROSPECTIVE SURVEY
M. J. Kilshaw, C.H.M Curwen, N. Kalap
Department of Trauma and Orthopaedics, Gloucestershire Royal Hospital, Great
Western Rd, Gloucester, Gloucestershire GL1 3NN
Methicillin-resistant Staphylococcus aureus (MRSA) has increased in prevalence and
significance over the past ten years. Studies have shown rates of MRSA in Trauma
and Orthopaedic populations to be from 1.6% to 38%. Rates of MRSA are higher in
long term residential care.
It has been Department of Health policy to screen all Trauma and Orthopaedic
patients for MRSA since 2001. This study audited rates of MRSA screening in
patients who presented with fractured neck of femur treated with Austin Moore hemiarthroplasty over the course of one year. Rates of MRSA carriage and surgical site
infection (SSI) were derived from the computerised PAS system and review of case
notes.
9.8 % of patients were not screened for MRSA at any time during their admission.
The rate of MRSA carriage within the study population was 9.2%. The MRSA SSI
rate was 4.2%. MRSA infections are associated with considerable cost and qualitative
morbidity and mortality.
There is good evidence for the use of nasal muprocin and triclosan baths in
reducing MRSA. Single dose Teicoplanin has been shown to be as effective as
traditional cephalosporin regimes. There is new guidance for the use of prophylactic
Teicoplanin for prevention of SSI. We should consider introducing both topical and
anti-microbial MRSA prophylaxis.
CLINICAL RESULTS FOLLOWING MEDIAL PATELLOFEMORAL
LIGAMENT RECONSTRUCTION WITH HAMSTRING TENDON
ANCHORED TO THE MEDIAL SIDE OF PATELLA USING
BIOTENODESIS SCREWS.
I. Arunkumar, A. Bidaeye, A. Lee.
Royal Cornwall Hospital, Truro Cornwall
Recurrent patellar instability and anterior knee pain is a common problem after
patellar dislocation. The medial patellofemoral ligament (MPFL) which contributes
40-80% of the total restraining forces is either attenuated or ruptured in these patients.
Various techniques have been described in reconstructing this MPFL using
hamstrings tendons. We wish to share our experience in treating these patients using
ipsilateral semitendinosus tendon anchored to the medial femoral condyle and medial
side of the patella using biotenodesis screws.
Study design and methods - 15 patients were assessed with a mean follow up of 12
months. All patients had preoperative true lateral knee x-ray, MRI or CT scan to look
at trochlear dysplasia and the sulcus tuberosity distance. They all under went MPFL
reconstruction using ipsilateral semitendinosus tendon. Two patients had sulcus
tuberosity distance greater than 20 mm and they under went a tibial tubercle transfer
in addition. Two patients had trochlear dysplasia and hence a trochleaplasty was also
done. In skeletally mature patients the hamstrings tendon was anchored to the medial
side of the patella in a 5x15mm blind tunnel using biotenodesis screw. This
significantly reduces the risk of having patella fracture. In. children the graft was
sutures to the soft tissues along the medial side of the patella and the medial femoral
condyle. All patients were treated by the same surgeon and assessments were
performed by a different surgeon based on Kujala scores and Tegner scores.
Results - Symptom relief was noted in all patients with in 3 months. No patient had
patella dislocation or fracture after this procedure. They all had full range of
movements and their Kujala scores and Tegner scores were good to excellent.
Conclusion - MPFL reconstruction using hamstrings tendon anchored to the medial
side of the patella and femur using biotenodesis screw gave a good result clinically
and is associated with fewer complications including patellar fractures.
ACUTE REPAIR OF MPFL (MEDIAL PATELLO FEMORAL LIGAMENT)
IN FIRST LATERAL DISLOCATION OF PATELLA
B.Guhan, A.S.Lee
Royal Cornwall Hospital.Truro
Recent literature suggests MPFL is the primary medial restraint in lateral patellar
dislocation and supports acute repair in first lateral dislocations.
Objective - To evaluate the results of patients who underwent acute surgical repair
of MPFL in our unit.
Materials and Methods - Nine patients with mean age of 25(12-41) were evaluated
in a dedicated clinic. The mean follow-up was 15.7 months (6 -22). All patients had
MRI scan preoperatively and were operated within two weeks of injury. Patients were
evaluated clinically and Kujala and Lysholm scores were recorded.
Results - None of these patients had further dislocations of patella and patellar
apprehension test was negative on examination. The mean Kujala score was 78(74100) and mean Lysholm score was 92(85 -100).All patients had returned to sporting
activities at clinic review. All but one mentioned that they would choose surgical
repair if the injury occurred in the other knee.
Conclusion - Our results confirm in selective patients acute repair of MPFL is the
ideal treatment to prevent recurrent dislocations and early return to sports.
THE AXIAL PATELLAR TENDON ANGLE – A SIMPLE NEW MRI
MEASUREMENT IN PATELLAR INSTABILITY
B.J.A. Lankester, A.J. Barnett, J.D.J. Eldridge, C.J. Wakeley
Bristol Royal Infirmary, Bristol
Patello-femoral instability (PFI) and pain may be caused by anatomical abnormality.
Many radiographic measurements have been used to describe the shape and position
of the patella and femoral trochlea.
This paper describes a simple new MRI measurement of the axial patellar tendon
angle (APTA), and compares this angle in patients with and without patello-femoral
instability.
Method - Axial MRI images of the knee of 20 patients with PFI and 20 normal
knees (isolated acute ACL rupture) were used for measurement. The angle between
the patellar tendon and the posterior femoral condylar line was assessed at three levels
from the proximal tendon to its insertion.
Results - In normal knees, the APTA is 11 degrees of lateral tilt at all levels from
the proximal tendon to its distal insertion. In PFI knees, the APTA is 33 degrees at
the proximal tendon, 28 degrees at the joint line and 22 degrees at the distal
insertion. The difference is significant (p< 0.001) at all levels.
Discussion - Measurement of the APTA is reproducible and is easier than many
other indices of patello-femoral anatomy. In PFI, the APTA is increased by 21
degrees at the proximal tendon and by 11 degrees at its distal insertion.
In PFI, the patella is commonly tilted laterally. This is matched by the orientation
of the patellar tendon. The increased tilt of the tendon is only partially normalized at
its distal insertion with an abnormal angle of tibial attachment. When performing
distal realignment procedures, angular correction as well as displacement may be
appropriate.
MODERNISING MEDICAL CAREERS (MMC):
HOW INFORMED ARE PATIENTS AND HEALTHCARE
PROFESSIONALS?
N.P.M. Jain, P.M. Guyver, M.J.H McCarthy, M.D. Brinsden
Department of Trauma and Orthopaedics, Derriford Hospital, Plymouth. Devon.
With the imminent introduction of the Modernising Medical Careers (MMC) postgraduate training programme, we undertook a study to assess how informed the
orthopaedic Multi Disciplinary Team (MDT) and patients were with regard to the
details, implementation and future implications of MMC.
Methods: A questionnaire was designed to record the level of awareness of MMC
using a visual analogue scale and to document individual preferences for surgical
training, either traditional or MMC. 143 questionnaires were completed - consultant
orthopaedic surgeons (n=12); orthopaedic nursing staff (n=54); musculoskeletal
physiotherapists (n=27); and trauma and orthopaedic patients (n=50).
Results: Consultants felt most informed about MMC compared to patients and
other members of the multi-disciplinary team (p < 0.01). Consultants preferred old
style training in terms of their juniors as well as future consultant colleagues. Nurses
showed no preference for either system. Patients and physiotherapists expressed a
preference for their surgeon to have been trained under the traditional, rather than the
new system.
Conclusions: Our study showed that there is a wide variation in the degree to
which patients and healthcare professionals are informed about MMC.
LENGTH OF STAY FOLLOWING PRIMARY TOTAL HIP REPLACEMENT
J. Foote, K. Panchoo, P. Blair, G. Bannister
Avon Orthopaedic Centre, Southmead Hospital, Bristol, BS10 5NB
We examined the effect of age, gender, body mass index (BMI), medical comorbidity as represented by the American Society of Anaesthesiologists (ASA) grade,
social deprivation, nursing practice, surgical approach, length of incision, type of
prosthesis and duration of surgery on length of stay after primary total hip
arthroplasty (THA).
Data was collected on 675 consecutive patients in a regional orthopaedic centre in
South West England. The length of stay varied from 2 to 196 days and was heavily
skewed. Data were therefore analysed by non parametric methods.
To permit comparison of short with protracted length of stay, data were arbitrarily
reduced to 2 groups comprising 2 to 14 days for short stays and 15 to 196 for long.
These data were analysed by Chi-squared and Fisher’s exact test in univarate and by
Logistic regression for multivariate analysis.
The mean length of stay was 11.4 days, an over-estimate compared to the median
length of stay of 8 days which more correctly reflects the skewed nature of the
distribution. 81.5% of patients left hospital within 2 weeks, 13.6% within 2 and 4 and
4.9% after 4.
On univarate analysis age above 80 years, age between 70 and 79 years, Body
Mass Index > 35, ASA grades 3 and 4, transgluteal approaches, long incisions,
cemented cups and prolonged operations were associated with longer stays.
On multivariate analysis, age above 80, age between 70 and 80, ASA grades
3 and 4, prolonged operations and long incisions were highly significantly associated
with hospital stay of over 2 weeks.
This is the first study to record all the published variables associated with length of
stay prospectively and to subject the data to multivariate analysis. Prolonged stay
after THA is pre-determined by case mix but slick surgery through limited incisions
may reduce the length of admission.
ACCURACY OF PREOPERATIVE TEMPLATING IN HIP REPLACEMENT
H. Davies, R.F. Spencer, J. Foote
Department of Orthopaedics, Weston General Hospital, Weston-Super-Mare.
Restoration of hip biomechanics is an important determinant of outcome in hip
replacement. Pre-operative templating is considered important in preoperative
planning, and this trend is likely to develop further to satisfy consumer demand and to
facilitate navigated surgery, particularly as digitisation of radiographs becomes
established.
We aimed to establish how closely natural femoral offset could be reproduced
using the manufacturers’ templates for 10 femoral stems in common use in the U.K.
The most frequently used femoral components from the U.K. national joint registry
(cemented and un-cemented) were identified, and the CPS-Plus stem was added, as
this is in use in our unit. A series of 24 consecutive pre-operative radiographs from
patients who had undergone unilateral total hip replacement for unilateral
osteoarthritis of the hip were reviewed.
The non-operated on side of the pelvic radiographs was templated as described by
Schmalzreid. 3 surgeons of variable experience (junior trainee, senior trainee,
consultant) performed the assessment. The standard deviation of change in offset
between the templated centre of rotation and the normal centre of rotation of the set of
radiographs for each prosthesis was then calculated allowing a ranking.
The most accurate template was the CPS with a mean standard deviation of
1.92mm followed in rank order by: CPT 2.21mm, C Stem 2.42mm, Stanmore 3.02
mm Exeter 3.06 mm, ABG II 3.54mm, Charnley 3.54 mm, Corail 3.63 mm, Furlong
HAC 4.2 mm and Furlong modular 4.86mm.
There is wide variation in the ability of the femoral templates to reproduce normal
femoral anatomy in a series of standard pre-operative hip radiographs. The more
modern cemented polished tapered stems with high modularity appear best able to
reproduce femoral offset. Nevertheless, some older monoblock stems, despite poor
templating characteristics, are known to be associated with acceptable clinical results.
The coming years are likely to be witness to changes in patient expectations and
radiograph storage. Implant design and digital templates will need to improve apace
with these changes, to ensure accurate preoperative planning.
ALPHA-1-ANTITRYPSIN AND ASEPTIC LOOSENING FOLLOWING
TOTAL HIP REPLACEMENT : A PILOT STUDY
S. M. Dixon
Royal Cornwall Hospital, Truro
Lungs exposed to particulate debris may be damaged by proteolytic enzymes during
phagocytosis. Damage is worse if patients are deficient in α1-antitrypsin (A1AT)
which helps neutralise these enzymes. We investigated the possibility that A1AT
deficiency contributes to aseptic loosening following total hip replacement (THR)
when wear particles are phagocytosed.
Method: A1AT level and phenotype were measured in patients attending for
revision THR within 15 years of implantation. Periprosthetic lysis was graded from
X-rays by 3 hip surgeons with an interest in revision, blinded to history and A1AT
results. Patients were grouped according to presence of high or low levels of lysis
radiologically. Mean A1AT levels were calculated for the two groups.
Results: 17 patients were recruited, mean age 69.5, mean interval between surgery
and onset of pain 8.3 years (2-12). 2 were heterozygotes for the less active S form of
A1AT and therefore mildly deficient. Time to onset of pain in both was 12 years. Xrays were available for 12 patients. For all reviewers, the mean A1AT level in the
high lysis group was raised and greater than that of the low lysis group. For 1
reviewer this reached statistical significance (P<0.01). Mean A1AT level in the high
lysis group was 2.5 (raised) and in the low lysis 1.6 (normal). Both A1AT deficient
patients were classified as high lysis by all reviewers despite normal A1AT levels.
Conclusions: The incidence of A1AT deficiency is only marginally higher in this
group than in the general population therefore A1AT deficiency is unlikely to be a
common cause of failure of hip replacements. Elevated levels of A1AT in the
presence of lysis suggests that A1AT may play a role in the aetiology of aseptic
loosening. Further work is needed to evaluate this and to assess vulnerability of A1AT
deficient patients to lysis.
CEMENTED POLISHED TAPERED HIP REPLACEMENTS FOR PATIENTS
LESS THAN 50 YEARS OF AGE. A MINIMUM 10 YEAR FOLLOW UP.
B.J. Burston, P.J. Yates, S. Hook, E. Moulder, E. Whitley, G.C. Bannister
Avon Orthopaedic Centre, Bristol.
The success of total hip replacement in the young has consistently been worse both
radiologically and clinically when compared to the standard hip replacement
population.
Methods - We describe the clinical and radiological outcome of 58 consecutive
polished tapered stems (PTS) in 47 patients with a minimum of 10 years follow up
(mean 12 years 6 months) and compared this to our cohort of standard patients. There
were 22 CPT stems and 36 Exeter stems.
Results - Three patients with 4 hips died before 10 years and one hip was removed
as part of a hindquarter amputation due to vascular disease. None of these stems had
been revised or shown any signs of failure at their last follow-up. No stems were lost
to follow up and the fate of all stems is known. Survivorship with revision of the
femoral component for aseptic loosening as the endpoint was zero and 4% (2 stems)
for potential revision. The Harris hip scores were good or excellent in 81% of the
patients (mean score 86).
All the stems subsided within the cement to a mean total of 1.8mm (0.2-8) at final
review. There was excellent preservation of proximal bone and an extremely low
incidence of loosening at the cement bone interface. Cup failure and cup wear with an
associated periarticular osteolysis was a serious problem. 19% of the cups (10) were
revised and 25% of the hips (13) had significant periarticular osteolysis associated
with excessive polyethylene wear.
Discussion - The outcome of polished tapered stems in this age group is as good as
in the standard age group and superior to other non PTS designs in young patients.
This is despite higher weight and frequent previous surgery. Cup wear and cup failure
were significantly worse in this group, with a higher incidence of periarticular
osteolysis.
THE CPS-PLUS - A POLISHED, TAPERED, CEMENTED FEMORAL STEM
WITH MINIMUM 5 YEARS FOLLOW UP
B.J.A Lankester, R.F. Spencer, C. Curwen, I.D. Learmonth
Cemented, polished, tapered stems have produced excellent results, but some early
failures occur in younger patients. The CPS-Plus stem (Plus Orthopedics AG,
Switzerland) is a polished double taper with rectangular cross section for improved
rotational stability. A unique proximal stem centraliser increases cement
pressurisation, assists alignment and creates an even cement mantle.
Radiostereometric analysis has demonstrated linear subsidence in a vertical plane,
without any rotation or tilt. These features should improve implant durability.
Midterm (5 years) results of a prospective international multicentre study are
presented.
Materials and Methods - 222 patients (230 hips) were recruited to this IRBapproved study at three centres in the UK and two in Norway. Clinical and
radiographic outcomes were assessed at regular intervals.
Results - 160 hips in 153 patients were available for full clinical and radiographic
evaluation. 27 patients have died, 30 patients were unable to attend (outcome known)
and 12 patients have not reached 5 years follow-up.
The mean Harris hip score improved from 42 preoperatively to 91. There have been
no revisions for aseptic loosening and none of the stems have radiographic evidence
of loosening. There has been one revision for deep sepsis. With revision for aseptic
loosening as an endpoint, stem survivorship is 100%.
Conclusion - The design of the CPS-Plus stem attempts to address the issues of
cement pressurization, rotational stability, and subsidence. Earlier laboratory studies
have now been supplemented by this clinical evaluation, performed in a number of
different centres by several surgeons, and the midterm results are very encouraging.
TEN YEAR LIFE EXPECTANCY AFTER PRIMARY TOTAL HIP
REPLACEMENT
R. D. Ramiah, A. M. Ashmore, E. Whitley G. C. Bannister
Avon Orthopaedic Centre, Southmead Hospital, Bristol UK
We have determined the 10 year life expectancy of 5,831 patients who had undergone
6,653 elective primary total hip replacements (THR) at a regional orthopaedic centre
between April 1993 and October 2004.
Methods: We ascertained dates of deaths for all those who had undergone surgery
during this period and constructed Kaplan Meier survivorship curves for these
patients. Standardized mortality ratios were calculated by comparing this data with
available UK mortality rates for the same age groups over the same time period.
Results: The mean age at operation was 73 with a male to female ratio of 2:3. Of
those with 10 year follow up 29.5% had died a mean of 5.6 years after surgery. 10year survivorship was 89% in patients under 65 years at surgery, 75% in patients aged
between 65 – 74 years and 51% in patients over 75.
The standard mortality rates were significantly higher than expected for patients
under 45 years, 20% higher for those between 45 and 64 years and progressively less
than expected for patients aged 65 and over.
Discussion: By comparing our mortality curves with prosthesis survivorship curves
from the most recent Swedish Arthroplasty Register results we were able to
demonstrate that the survivorship of cemented hip arthroplasties exceeds that of the
patients over the age of 60 in our area. As these prostheses are less expensive than
their uncemented equivalents this suggests these are the prosthesis of choice in this
age group.
TREATMENT OF THE YOUNG ACTIVE PATIENT WITH
OSTEOARTHRITIS OF THE HIP: A 5-7 YEAR COMPARISON OF HYBRID
TOTAL HIP REPLACEMENT AND METAL-ON-METAL RESURFACING
T.C.B. Pollard, R.P. Baker, S.J. Eastaugh-Waring, G.C. Bannister
Bristol
Metal-on-metal resurfacing offers an alternative strategy to hip replacement in the
young active patient with severe osteoarthritis of the hip. The functional outcomes,
failure rates and impending revisions in hybrid total hip arthroplasties (THAs) and
Birmingham hip resurfacings (BHRs) were compared after 5-7 years. We studied the
clinical and radiological results of the BHR with THA in two groups of 54 hips each,
matched for sex, age, BMI and activity.
Function was excellent in both groups as measured by the Oxford hip score
(median 13 in the BHRs and 14 in the THAs, p=0.14), but the resurfacings had higher
UCLA activity scores (median 9 v 7, p=0.001) and better EuroQol quality of life
scores (0.90 v 0.78, p=0.003).
The THAs had a revision or intention to revise rate of 8% and the BHRs 6%. Both
groups demonstrated impending failure on surrogate end-points. 12% of THAs had
polyethylene wear and osteolysis and there was femoral component migration in 8%
of resurfacings. Polyethylene wear was present in 48% of hybrid hips without
osteolysis. Of the femoral components in the resurfacing group which had not
migrated, 66% had radiological changes of unknown significance.
In conclusion, the early to mid-term results of resurfacing with the BHR appear at
least as good as those of hybrid THA.
THE TECHNIQUE OF MICRODRILLING: STIMULATION OF BONE
UNION IN PATIENTS TREATED WITH CIRCULAR FRAMES WITH
ESTABLISHED NON-UNION.
B.W. Morgan, M. J. Rogers, M. Jackson, J.A. Livingstone, F. Monsell, R.M. Atkins.
The Department of Orthopaedic Surgery, Bristol Royal Infirmary, Bristol, BS2 8HW
17 patients have undergone 20 microdrilling procedures to stimulate bone union in
cases of established non-union. This occurred at the docking site following
completion of bone transport using a stacked Taylor Spatial Frame, non-union
following arthrodesis or non-union in long bone fracture.
Additional bone grafting was performed in only one patient. Further stimulation of
union via injection of Bone Morphogenetic Protein was undertaken with 3
microdrilling procedures.
Of the 20 microdrilling procedures, 8 were considered fully successful in terms of
stimulation of union, 7 were partially successful and 5 were not felt to have been
successful.
The mean time to fully successful union following microdrilling was 11.4 weeks,
ranging from 6 to 19 weeks.
There were 2 complications, both acute infections at the microdrilling site. Both of
these were in patients with previous significant pin site infections.
We present the use of a microdrilling technique as a safe and effective minimally
invasive technique that promotes union in cases of refractory non-union, whilst
avoiding the donor site morbidity associated with open bone grafting.
We present, as a pilot study, our experience in the use of this technique in patients
treated with circular frames for acute fractures, at the docking site in cases of bone
transport and in cases of non-union following arthrodesis.
A COMPLETED AUDIT OF MEDICAL CARE OF PATIENTS WITH A
FRACTURE OF THE NECK OF FEMUR
L.C.Wesson, M.Regan, N.Pollard and M.O.Battle.
Royal Cornwall Hospital, Truro, Cornwall, TR1 3LJ, UK.
Literature suggests that joint orthopaedic and geriatric care, and geriatric orthopaedic
rehabilitation units, would provide best care for fractured neck of femur (NOF)
patients. These are often elderly frail patients with concurrent illnesses and comorbidities who also have a fracture. There is to date no quantitative data. This
completed audit quantifies the care provided on the orthopaedic wards in the first
phase solely by orthopaedic team, and in the repeat phase with additional regular
geriatric input from an orthogeriatric senior house officer (SHO) and consultant
geriatrician ward rounds.
A retrospective audit of fractured NOF patients admitted to acute orthopaedic
wards under orthopaedics and treated operatively. The first phase analysed 72 patients
with sole orthopaedic care. The repeat phase analysed 25 patients after the
introduction of an orthogeriatric SHO and geriatric ward rounds.
The first audit phase of orthopaedic care alone found that 50% of patients were
reviewed each day of the first post op seven-day week. The mean number of reviews
in the post-op week was three. A total of 58% patients were operated on the next day.
A minority never had post-op bloods or x-rays prior to discharge from the acute bed.
Ad hoc medical input by referral occurred in 50% of patients.
The repeat audit of combined orthogeriatric care found that 75% of patients were
reviewed each day in the post-op week. The mean number of reviews in the post-op
week rose to five. Similar to the first phase, 59% proceeded to next day surgery with
combined care. All patients had timely bloods and x-rays before discharge from the
acute bed. Medical input rose to 80% due to regular ward rounds, and ad hoc referrals
decreased in quantity whilst increased in quality. Length of stay and mortality were
reduced.
The clinical risk of fractured NOF patients was reduced on the appointment of
an orthogeriatric SHO in combination with formal reviews by consultant geriatrician.
Further models of care are being evaluated. This audit adds evidence that joint care is
better for these usually elderly and co-morbid patients.
'CLOSED' CORECTIVE OSTEOTOMIES FOR MALUNITED FRACTURES
OF THE PHALANGES
G. Giddins, R. Patil
Royal United Hospital, Bath
Malunion of digital fractures can be difficult to correct especially for rotational
phalangeal malunion. We describe the simple closed corrective technique.
Materials/Methods - Patients whose phalangeal fractures were treated closed
(mobilised or POP +/- K wires) and malunited, typically with mal-rotation.
The technique is performed under LA. The bone is cut by percutaneous passage of a
1.1 mm K wire multiple times until the bone is fractured. The malunion is corrected
and held with one longitudinal 1.1 mm K wire. The osteotomies are supported for 6
weeks in POP/splint and the wire(s) removed.
Results - 11 patients with 12 post fracture malunion - All metaphyseal osteotomies
healed within 6 weeks with correction of malrotation and no significant angular
deformity. The one diaphyseal osteotomy united late healing only partially
(inadequately) corrected and requires revision. Apart from the malunion there were no
major complications albeit short-term PIP joint stiffness.
Conclusion - This is a safe and reliable technique that avoids most of the
complications of more challenging open techniques in the phalanges or the
compromises of distant techniques e.g. metacarpal correction of phalangeal
malrotation. It does however require immobilisation precluding any major
simultaneous soft tissue releases. It appears unsuited to diaphyseal correction.
RADIOGRAPHIC EVIDENCE OF HEALING OF TIBIAL DIAPHYSEAL
FRACTURES
V.A. Currall, G.C. Bannister
Avon Orthopaedic Centre
Aim - To determine the time at which callus is visible on plain radiographs of tibial
fractures and hence the appropriate time to order x-rays to assess union.
Method - The radiographs of patients with tibial diaphyseal fractures were graded
for amount of callus on a scale of 1 (no callus) to 5 (no visible fracture line) and the
time from injury recorded.
Results - 68 patients were identified, with 45 managed non-operatively by cast, 16
with intramedullary nails and 7 with other methods of fixation. Mean time to grade 3
callus (at least 2 cortices) in adults with non-operatively treated fractures was 8.4
weeks and 4.6 weeks for children. Mean time to union (four cortex bridging callus)
was 17.6 weeks for adults and 8.1 weeks for children. In the nailed fractures, mean
time to radiographic union was 20 weeks.
Conclusions - To assess union in adult tibial diaphyseal fractures, we recommend
an x-ray at eight weeks and 16 weeks after injury, providing there are no clinical
concerns. For children, the times should be reduced to 4 and 8 weeks after injury,
respectively. Nailed tibial shaft fractures should have radiographs at 12 weeks and 18
weeks to assess union.
SUPRACONDYLAR NAIL COMPATIBILITY FOR PERIPROSTHETIC
FRACTURES AROUND TOTAL KNEE ARTHROPLASTY
V.A. Currall, M. Kulkarni and W.J. Harries
Avon Orthopaedic Centre
The current incidence of periprosthetic supracondylar femoral fractures around total
knee arthroplasties (TKAs) is 0.3% to 2.5%, but may well be increasing. An
acceptable treatment is to insert a supracondylar nail, but not all TKAs will permit the
passage of a supracondylar nail.
Method - We ascertained the ten most common TKA prostheses currently used in
the United Kingdom from the National Joint Registry (NJR) Report published in
September 2005. We used samples of each prosthesis with a saw bone model and
checked their compatibility for accepting a supracondylar nail.
Results - We present the dimensions of the intercondylar notches of the top ten
TKA prostheses, which account for over 90% of TKAs performed over the last year
nationally. Our reference chart demonstrates which of these are suitable for use with
supracondylar nails.
Discussion - Most of the TKAs commonly used in the UK will allow
supracondylar nailing for fixation of periprosthetic fractures. There are, however,
notable exceptions and our chart provides a quick and easy reference for knee
surgeons involved in these cases.
PERCUTANEOUS PLATING OF DISTAL TIBIAL FRACTURES – A
REVIEW OF OUTCOMES AND COMPLICATIONS
R. Poulter, O. Adenugba, J. Davis, S. Davies
Trauma and Orthopaedic Department, Torbay Hospital, Lawes Bridge, Torquay,
Devon, TQ2 7AA
Objective: To evaluate the outcomes following percutaneous insertion of angle stable
plate for operative management of distal Tibial fractures and the incidence of
complications associated with this procedure.
Method: A retrospective analysis of all patients who underwent percutaneous
plating of distal tibia was performed. Of 51 cases 3 were holiday makers who returned
to their local hospitals, leaving 48 who were followed up until union. These were all
the cases treated in our units using this technique from January 2002 – September
2005.
Results: The mean time to callus formation was 9 weeks (7-12), full weight
bearing was 4 weeks (0-20) and solid union was 23 weeks (18-29). The mean hospital
stay was 9 days (2-31). The overall complication rate was 18%. Significant
complications included problems with union (6%) and deep infection (4%).
However 2 surgeons operated on 40 of the patients with a complication rate of 10% (1
non union, 1 superficial infection and 2 delayed removal of plate).
Conclusions: We found the use of percutaneous angle stable plates in operative
treatment of distal Tibial fractures very effective with acceptable complication rates.
Our data suggests that with greater experience of this fixation method complication
rates can be reduced.