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25
Continuous Infusion vs Single Bolus Popliteal Block Following Ankle and
Hindfoot Surgery: A Randomised, Prospective, Double Blinded, Placebo
Controlled Trial. Chris Pearce, Bob Elliot, Chris Seifert, James Calder
Introduction: Adequately managing post-operative pain following ankle and hindfoot
surgery can be difficult. Conventional analgesics have significant side effects
including nausea and gastric irritation. The results of a pilot study of continuous
infusion vs single bolus popliteal block encouraged us to perform the full PRCT.
Method:Inclusion criteria were all patients undergoing significant hind foot or ankle
procedures. Exclusion criteria included peripheral neuropathy and inability to fill in the
questionnaire.
The pilot study provided a standard deviation of pain scores which allowed us to
calculate the sample size required; 25 patients in each group would have 90% power
to detect a difference in means VAS scores of 3 which we considered clinically
significant. Sealed envelopes contained random allocations and were opened by the
anaesthetist. A bolus of 20ml 0.25% bupivacaine was injected and then the catheter
was inserted and connected to a pump. Patients were randomly assigned to receive
either an infusion of normal saline or bupivacaine over the next 72 hours.
Results: Both groups had very low median VAS pain scores on the day of operation
and there was no difference between the two; study 1.167, control 1.000 (p=0.893).
On the 3 post operative days studied there were significantly lower pain scores in the
study group; day 1: 1.67 vs 3.67 (p=0.003), day 2: 1.33 vs 2.83 (p=<0.001), day 3:
1.11 vs 2.56 (p=<0.001).
There was no difference in median morphine usage on the day of operation; study =
10, placebo = 10 (p = 0.942). The morphine usage was lower in the study group on
all post operative days and this was significant on days 2&3; day 1: 10 vs 15
(p=0.054), day 2: 10 vs 20 (p=<0.001), day 3: 7.5 vs 10 (p=0.02). Median total
morphine requirements over the 3 post operative days were 30mg for the study group
compared to 52.5mg for the control group and this was significant (p=0.012).
There were no major complications with the administration of the blocks or with the
catheters.
Conclusion:Despite the statistically significant difference in pain scores, we do not
feel that we can fully reject the null hypothesis. We started with the impression that a
difference of 3 points on the VAS would constitute a clinically significant difference.
The pain scores were surprisingly low in both groups throughout the follow up period
with the highest mean score being 3.6. The difference in the pain scores was only
between 1.5 and 2 points on the scale. Regional anesthesia via a popliteal catheter is
a safe and effective method of managing post operative pain patients undergoing
major ankle and hind foot surgery but it is debatable, from the results of this study,
whether the benefits of an infusion catheter over a single bolus warrant the extra time
and cost involved.
Outcome of First Metatarsalphalangeal Joint Arthrodesis using the Variax Plate
Arvind Mohan
We undertook a retrospective study to assess the results of Ist metatarsophalageal
joint arthrodesis using tricortical bone graft with dorsal locking plate (VariAx, Stryker).
We recruited 13 patients with 14 operations and this included 8 women (age range
49-67) and 5 men (age range 49-67). Senior author (AK) performed all the
operations in the period from Jan 2007 to Dec 2008. Indications for surgery were
failed Kellers osteotomy (7 patients), failed plate fusion (2 patients), primary OA (3
patients) and OA with severe hallux valgus (1 patient).
Tricortical graft was harvested from the ipsilateral iliac crest. A precontoured plate
with the locking screws was used to fix the prepared metatarsal and the phalanx with
the interpositional bone graft. The dorsal approach was used with the joint fixed in
15 degrees of dorsiflexion and 15 degrees of valgus.
Simulated weight bearing checked the gap between the first and second toe
intraoperatively. Outcome assessment was done using American Orthopaedic Foot
and Ankle society clinical rating scales.
Average preoperative score was 29 with a postoperative score of 74. Complications
included one non-union requiring revision and one infection requiring plate removal
and split skin grafting.
In conclusion, metatarsophalangeal joint arthrdesis with interpositional tricortical bone
graft is an effective procedure to restore the first ray length and potentially prevent
lateral transfer metatarsalgia.
22
27
The Scarf Osteotomy: Initial problems and pitfalls
N.A. Sandiford, Weitzel S, Tsitskaris K, Sidcup
.
Outcomes following the Stainsby procedure in the lesser toes: an alternative
procedure for the correction of rigid claw toe deformity.
Laurie Dodd
Investigation We reviewed 33 cases of hallux valgus treated using the scarf osteotomy.
Method The appearance, American Orthopaedic Foot and Ankle Society (AOFAS) score, Distal
Metatarsal Articular Angle (DMAA) and Hallux Valgus angle (HVA) were recorded pre and post
operatively. Patient satisfaction was recorded.
Results Twenty seven patients (33 feet) were included. Average follow up was 12.42 months
(2-29). Mean pre and post operative AOFAS scores were 53.5 (27-78) and 90.2 (67-100)
respectively. Satisfaction score improved from 3.0 to 8.5.
The average HV and IM angles improved from 37.8° (18-48) and 14.8° (10-28) to 9.6° (2-20)
and 7.7° (3-14) respectively. Average DMAA improved from 14.6° (4-30) to 6.9° (0-20)
Nine complications occurred.
Discussion Early results are encouraging. Complications occurred during the first 25 cases.
Clawing of the digits is a deformity seen both in patients with and without rheumatoid
arthritis, resulting in pain and deformity in the forefoot. Following failure of conservative
treatment, the Stainsby procedure is one surgical option for severe clawing and
metatarsalgia in both rheumatoid and non-rheumatoid feet. Results from the originating
authors (Stainsby G.D and Briggs P.J) are consistent and reliable; however there is little
material outside of the originating centre. This paper reviews our experience in the Western
Sussex Hospitals NHS Trust.
Sixteen consecutive patients who underwent Stainsby procedure between 2006 and
2009 were prospectively reviewed. All operations were performed by a single consultant
surgeon, the senior author (SP). All patients were scored using the Manchester Oxford
Foot and Ankle score pre and post operatively. Minimum follow up was six months with a
mean follow up of fourteen months.
Significant improvements in all scores were seen post operatively. Walking scores
dropped from a mean of 22 pre-operatively to 12.7 post-operatively (P = 0.007). Pain
scores dropped from a mean of 13.3 to 7.1 (P=0.001). Social scores dropped from a mean
11 to 6 (P=0.001). Overall patient satisfaction was high.
The Stainsby procedure has been shown to improve function and reduce pain in
patients from its originating centre in both rheumatoid and non-rheumatoid feet. This study
demonstrates this simple technique is reproducible and effective in reducing morbidity
20
29
Tibio-talo-calcaneo fusion using a locked intramedullary compressive nail
Chettiar K, Hader S, Bowman N, Cottam H, Armitage A, Skyrme A
Introduction: We report our clinical results of 31 feet (30 patients) who have undergone
tibiotalocalacaneal arthrodesis using an intramedullary nail by the senior author to achieve
bony union.
Method: This was a prospective study and all patients were operated on, in a single centre
over four years. Indications for surgery were pain predominantly and deformity. Aetiology
included rheumatoid arthritis, osteoarthritis, Charcot arthropathy, avascular necrosis of the talus
and post traumatic arthritis. Patients were assessed using the AOFAS ankle-hindfoot scoring
plus SF-36 and patient satisfaction.
Result: One patient died of unrelated causes 2 years post surgery. There were 20 females and
9 males with a mean age of 62 (31-86). 28 patients went onto radiological union with 1 fibrous
non-union in which the patient was asymptomatic with minimal pain. There were 4 wound
complications with 3 infections that required repeat operation in one patient. The mean preoperative AOFAS score was 22.9 (10-47) and the mean SF-36 was 35.7 (14.9-65.5). Post
operatively the mean AOFAS score was 65.8 (51-82) and p< 0.01 and the mean SF-36 was
56.9 (14.8 – 84.7) p< 0.01. 92% (27 out of 30) were either highly satisfied or satisfied whilst
one patient was dissatisfied. 92% of patients would have the other side operated on if required.
Discussion: The advantages of this device and technique are that there is less soft tissue injury,
patients can weightbear at an earlier time, union rates are reliably high as is patient
satisfaction. We conclude that this method of arthrodesis is reliable in producing excellent
patient outcomes.
The Effect of the Grade of Surgeon on Blood Loss in Fractured Neck of Femur
Surgery. Barry Rose, Margate
Investigation :Significant neck of femur (NOF) fracture surgery blood loss contributes
to high morbidity/mortality. We assessed NOF surgical blood loss in relation to
surgeon grade and experience.
Method: Blood loss was calculated as the difference between pre- and post-operative
haemoglobin levels for a prospective consecutive cohort of 105 acute NOF fracture
patients treated surgically.
Results: Mean haemoglobin drop was 2.8g/dL (intra-capsular 2.5g/dL, extra-capsular
3.1g/dL (p=0.019)). The difference in blood loss between different surgeon grades
was not significant: Consultants 2.4g/dL, senior Staff Grades 2.7g/dL, junior Staff
Grades 3.1g/dL and Registrars 2.9g/dL. Mean blood loss unaffected by anti-platelet
agents.
Discussion: Surgeon grade does not significantly impact peri-operative haemoglobin
drop. It is safe for Trainees to operate on NOF fracture patients without compromising
blood loss.
18
Incidental Abdominal Aortic Aneurysm On LumboSacral Magnetic
Resonance Imaging - A Case Series
Alex J Trompeter , Guy P Paremain Department of Spinal Surgery,
Trauma and Orthopaedics,Royal Surrey County Hospital.
Introduction Magnetic Resonance Imaging (MRI) is commonly used as part
of the assessment of patients presenting with leg/back pain to the
orthopaedic spinal outpatient clinic. Abdominal Aortic Aneurysm (AAA) can
cause symptoms often similar to those of spinal stenosis.
We report a case series of 4 patients who had incidental AAA detected on
lumbosacral MRI. All patients were suffering from degenerative spinal
disease and had been referred to the orthopaedic spinal clinic. After history,
examination and review of the imaging, all patients were referred to a
vascular surgeon, and 3 were found to be completely asymptomatic from
their aneurysm. One patient required open repair with an aortic graft due to
the size of the aneurysm, although his symptoms were attributable to his
spinal disease. All patients still required management of their degenerative
spinal disease after their vascular review.
We can find no other case reports of AAA as an incidental finding on
lumbosacral MRI. This case series highlights the importance of looking at all
aspects of our imaging and to remember the non-spinal causes of back and
leg pains. Furthermore, in the presence of AAA when managing patients in
the orthopaedic outpatient setting, the authors recommend vascular review
before offering orthopaedic interventional management options to these
patients.
31
Do Precontoured Locking Clavicle Plates Fit?
Lydia K Milnes, David Boardman, Thomas D Tennent, Eyiyemi O
Pearse . St Georges
Background It has been suggested that the precontoured Acumed
clavicle plates often do not fit. In our clinical practice we have found that
they sometimes fit better when reversed (ie when the medial end of the
plate is applied laterally and the lateral end of the plate is applied
medially). The purpose of this study was to quantify this.
Methods: 50 human cadaveric clavicles and all the plates on the
Acumed set were photographed from a fixed distance. Using digital
imaging software the plates were superimposed over each clavicle to
determine the quality of fit. The fit was defined as good if there was no
overhang of the plate either anteriorly or posteriorly, fair if there was
overhang either anteriorly or posteriorly and poor if there was either
overhang both posteriorly and anteriorly or if any of the screw-holes
missed the bone
.
Results: We found that 94% of the plates had a good and 4% had a fair
fit when superimposed over the midshaft of the clavicles in the
orientation suggested by the manufacturer. If the plates were placed
more laterally in this orientation the fit was universally poor. The fit was
much better when the plates were reversed: 62% had a good fit and a
further 30% had a fair fit.
Conclusions: Our results show that the previous literature which
suggests a poor fit may be inaccurate. The option of reversing the
plates should be considered by the surgeon particularly when plating
more lateral fractures.
16
33
Musculoskeletal manifestations of Diabetes in the shoulder joint – a preliminary
report. Prasad G, Kerr D, Kernohan J. Bournemouth
Aims: To determine the prevalence of shoulder symptoms in patients with type I
compared to type 2 diabetes mellitus and to evaluate the clinical presentation of
patients diagnosed with adhesive capsulitis
Methods: Retrospective case note review of 164 diabetic patients treated for
shoulder symptoms from 1996 to 2007. Diabetes register (Diabeta 3)
Statistics – ANOVA, Tukey HSD, Chi-Square, Fisher’s Exact tests
Results: Male 86 (52%); Female 78 (48%) Average age 58 (range 22 – 83) years
Duration of DM : 10 (1-33) years HbA1c at presentation 8.3% Retinopathy 16%
Neuropathy 12% Type I 34, Type II 66
Impingement Syndrome 101, 62% Adhesive Capsulitis 35, 21% Rotator cuff tear
17, 10% Arthritis 11, 7%
Pre-treatment ROM: Impingement SyndAdhesive CapsulitisRotator Cuff
TearArthritisForward Flexion1189311470Abduction1077710459External
Rotation37125018
Treatments - Steroid 53 MUA + Injection 49 Arthroscopic Surgery: Subacromial
decompression 88 Adhesiolysis 5 Debridement 6 Open release 6 Excision lateral
end of clavicle 6 Decompression 4 Cuff Repair 23 Arthroplasty 17
RelapseDNARefer to Pain ClinicDiedOverall111638Adhesive Capsulitis8313
Average DischargeRefer to Pain ClinicRelapseDiedDiabetics8231116Non Diabetics95103
Conclusions: Adhesive Capsulitis group associated with: Type I diabetes,
p<0.003 Duration of diabetes, p<0.03 HbA1c p<0.001 Impingement Syndrome
associated with Type 2 diabetes, p<0.003
Future Direction: Close liaison with the Diabetology and Endocrine Department in
effective treatment of Diabetic Shoulder pathology. Compare patient related outcomes
(DASH) to the functional outcomes. Research Physiotherapy group to target Diabetics
who present to us with frozen shoulders. Age controlled study for type II Diabetics with
relation to impingement syndrome.
Femoral bending strength in independently ambulant young adults with spastic
cerebral palsy.
M Al-Sarawan, NR Fry, SF Keevil, AP Shortland, M Gough.
Guy’s and St Thomas
Introduction: It is not known whether bone strength is altered in independently ambulant
young adults with spastic cerebral palsy (SCP).
Methods: 9 independently ambulant subjects with SCP, mean age 17.4y(SD 2.46), and a
control group of 9 age and gender matched adults had MRI scans of the femoral midshaft.
Femoral area was measured and the section modulus calculated. Variables were
normalised to body size (body mass.bone length).
Results: Femoral area (p=0.0035) was greater in the SCP group as was medullary area
(p=0.0003) and femoral radius (p<0.0001). The normalised femoral section modulus ratio
was however similar in both groups (p=0.5721).
Discussion: The increased area of the femoral midshaft in the SCP group may be a
compensatory mechanism to maintain torsional strength.
14
35
An analysis of the acromio-clavicular joint excision: Is joint morphology a
aetiological factor? Toby Colegate Stone
Investigation: Acromioclavicular (AC) joint pain secondary to joint degeneration often
necessitates surgical intervention. Previous studies have classified AC joint morphology
into three main three-dimensional groups: flat, oblique or curved. The aim was to perform
an analysis of AC joint morphology in a cohort of patients requiring joint excision.
Method: Pre-operative radiographs of the AC joint in patients who underwent joint excision
were used to assess its morphology as flat, oblique, curved or unclassifiable. Patients were
scored pre and post-operatively using subjective scoring tools.
Results: The majority of patients requiring excision of the AC joint had an oblique
morphology. The proportion of patients that had an oblique morphology was
Discussion: In conclusion patients with an oblique morphology to their AC joint potentially
have an elevated risk of developing localised pathology over the other joint morphologies.
The effect of sterile versus unsterile tourniquets on microbiological colonisation
in lower limb surgery
Simon Thompson
Introduction
Surgical tourniquets are common place in lower limb surgery. Several previous studies
have shown that tourniquets can be a potential source of microbial contamination, but
have not compared the use of sterile versus non-sterile tourniquets in the same
procedures.
Materials and Methods
Samples were taken from individual tourniquets from two hospitals in the same NHS
trust. Prior to use on orthopaedic elective lower limb surgery a sample of unsterile
tourniquet was taken from the ties around the tourniquet sitting around the operated
limb. Sterile tourniquet samples were taken at the end of the operation in a sterile
fashion. The samples were then sealed in universal containers and immediately
analysed by the microbiology department on agar plates, cultured and incubated.
Results
27 unsterile tourniquets were sampled prior to surgical application. 18 (67%) of which
were contaminated with several different organisms, including coagulase-negative
Staphylococcus sp., Staphylococcus aureus, Sphingomonas paucimobilis, Bacilius
species, and Coliforms. 13 sterile tourniquets were used, with no associated
contamination.
Conclusion
In a district general hospital setting, there is a significant contamination of 67% of
orthopaedic surgical tourniquets. These are regularly used in procedures involving the
placement of prosthesis and metalwork, and may act as a potential source of infection.
We would recommend the use of disposable tourniquets where possible.
37
12
How Safe Is Shoulder Resurfacing Arthroplasty? Ravi Trehan
Background: To date, there is no documented evidence pertaining
specifically to complications following shoulder resurfacing arthroplasty,
although Sperling and his colleagues have published several reports on
complications following shoulder arthroplasty in general.
Purpose of this study: To determine safety of procedure and the incidence of
the following complications following shoulder resurfacing - excessive intraoperative and/or post-operative blood loss requiring blood transfusion, wound
infection, thrombo-embolic events, septic arthritis involving the glenohumeral joint, gleno-humeral joint dislocation, persistent pain and/or loss of
function.
Methods: A retrospective study involving 25 patients, who underwent
shoulder resurfacing arthroplasty done by single surgeon at the South West
London Elective Orthopaedic Centre from August 2008 to August 2009, was
performed to identify the above-described possible post-operative
complications in all these patients.
Results: By and large, all patients who underwent HSR or TSR had
uneventful post-operative recoveries on discharge as well as during
outpatient follow-up. No patient developed wound infections, required a postoperative blood transfusion, nor presented with symptoms consistent with
thrombo-embolic conditions.
Conclusion: The data from this study demonstrates that shoulder resurfacing
arthroplasty is a safe and reliable surgical treatment option for patients with
GHJ pathologies.
The effects of CoCr wear debris from orthopaedic metal-on-metal implants on
human cells through a placental cell barrier. Gev Bhabra
Introduction: Metal-on-metal THRs generate particles of CoCr known to cause
DNA damage to human fibroblasts in-vitro. These implants have been used in women of
child-bearing age who have subsequently had children. The MHRA have stated that
there is a need to determine whether exposure to CoCr represents a health risk during
pregnancy.
Methods: We used an in vitro model of the placental barrier and exposed this
barrier to physiologically relevant concentrations of CoCr particles and ions. We then
measured DNA damage in human fibroblasts cultured beneath the barrier
Results: Indirect exposure to CoCr across a model placental barrier caused DNA
damage to human fibroblasts. The metal itself did not pass through the barrier but
initiated a signaling response within the barrier to cause damage to the fibroblasts on the
other side.
Discussion: The evaluation of the safety of CoCr particles from orthopaedic
implants should not be restricted to tissues in direct contact with the particles, but also to
tissues located behind cellular barriers.
10
39
REVISION OF HIP RESURFACING TO TOTAL HIP ARTHROPLASTY EARLY RESULTS
N.A. Sandiford, J.A. Skinner, S.K. Muirhead-Allwood, C. Kabir
The London Hip Unit.
Investigation: We present the early results of patients undergoing revision
of hip resurfacing to total hip arthroplasty.
Method: This prospective study examined the age, gender, reason for
and time to revision. Pre and post operative function were assessed using
the Oxford, Harris and WOMAC hip scores.
Results: Twenty five patients were included. Average age was 60.4 years.
Mean follow up was12.7 months. Average time to revision was 30.2
months. Pre and post operative Harris, Oxford and WOMAC hip scores
were 36.4, 39.4, 52.2 and 89.8, 17.4 and 6.1 respectively.
Patients returned to normal activities within three months.
Discussion: Revision of painful hip resurfacing prostheses to total hip
arthroplasty provides excellent pain relief and return to function in the
short term.
The importance of getting coding right in foot and ankle surgery.
An audit of current practise in our unit. S Haleem, P Hamilton, J
Piper-Smith, S Singh, IT Jones, Guy’s Hospital.
Introduction:
Since the introduction of payment by results in
the NHS in 2004, the accurate recording of services performed has
played a crucial role in reimbursement to hospital trusts by primary care
trusts (PCT). Failure to accurately charge for these services would
cause a shortfall in funding received. Under the new reimbursement
system, similar treatments are grouped together under the same tariff
and referred to as a Healthcare Resource Group (HRG). Coding is the
assignment of procedures to HRGs. We aim to assess the accuracy of
coding performed at our institution and link this directly to the funds
received from the PCT. Foot and ankle surgery has a particular interest
in coding due to the multiple codes that are needed to code for one
procedure.
Method: We looked at 40 consecutive operations performed at our
institution. We compared the codes as assigned by the surgeon who
placed the patient of the waiting list and where therefore the codes seen
directly on the operating list with the final codes given to the PCT. We
compared the two and looked at the final difference in final costing.
Results: There were a total of 75 codes from the 40 operations
assigned by the surgeon compared with 103 codes from the coding
staff. Although most of the codes were different when comparing one
with the other the final costing data showed little difference.
Discussion: The importance of getting the coding right has
become paramount in the current NHS funding scheme. We have
shown large discrepancies between the codes the surgeon produces as
to the final code given to the PCT. Although in our unit this has not
shown to produce different final reimbursement figures this does have
the potential for large inaccuracies and failure to be paid for work
performed. From this we also present our data as to the correct coding
for common procedures in foot and ankle surgery so that accurate
reimbursement can be achieved.
8
41
Uncemented custom made (CAD-CAM) hydroxyapatite coated
femoral components in young, active patients: Survival at 10-16
years. Nemandra A. Sandiford MRCS, John A Skinner, P S Walker,
Sarah Muirhead-Allwood, The London Hip Unit
Investigation: We present the minimum 10 year results of custom
uncemented total hip arthroplasty
Method:A prospective study was peformed. Clinical and radiological
examinations were performed pre-operatively and at yearly intervals post
operatively. Oxford, harris and WOMAC hip scores were recorded.
Results:One hundred and thirteen patients (114 hips) were included.
Average age was 46.2 years. Mean follow up was 13.2 years (10 to 16
years). The worst case survival at minimum 10 year follow up was 98%.
There were no revisions for aseptic loosening.
Discussion:These results are comparable with the best medium to long
term results for femoral components used in primary total hip arthroplasty
with any means of fixation.
Patient Compliance with Xarelto® (Rivaroxaban). HL Cottam, A Ghosh,
P Housden,.Ashford.
Introduction:Xarelto® is the first oral, once-daily direct Factor Xa inhibitor
prescribed for the prevention of venous thromboembolism in adult patients
undergoing elective hip or knee replacement surgery. As an oral preparation
that offers convenient once daily dosing, there is an assumed compliance
benefit over traditional subcutaneous prophylactic anticoagulation. There is
no evidence to support this assumption. In the RECORD 1 study[i] (THR),
the proportion of non-compliant patients was the same for both regimens and
in RECORD 3[ii] (TKR) the proportion of non-compliant patients was the
same in each arm of the trial.
Methods:Xarelto was introduced to East Kent Hospitals University Trust, at
the beginning of June 2009. This study assesses the level of compliance
with this new medication. Data collection took place over a month, starting
some eight weeks following the introduction of Xarelto (August 2009).
Patients returning to the William Harvey Hospital outpatients following
primary hip and knee arthroplasty (at the 6-8 week post-op stage) were
asked two simple questions, using a questionnaire containing a picture of the
tablet and packaging. The first to establish that the patient was able to
identify the medication and secondly, did they take the medication?
Results:The data collected demonstrates that all patients who were aware
that they were prescribed Xarelto® were compliant with the medication.
Discussion:This suggests compliance remains high outside of a major
pharmaceutical trial, and supports the supposition that there is a compliance
benefit over traditional subcutaneous prophylactic anticoagulation.
[i] Eriksson BI, Borris LC, Friedman RJ, et al; RECORD1 Study Group. Rivaroxaban
versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med.
2008;358(26):2765-2775.
[ii] Lassen MR, Ageno W, Borris LC, et al; RECORD3 Investigators. Rivaroxaban versus
enoxaparin for thromboprophylaxis after total knee arthroplasty. N Engl J Med.
2008;358(26):2776-2786.
6
43
The Durom acetabular component – short term results
Matthew Dodd, Nikolai Briffa, Henry Bourke, David Ward. Kingston
Introduction: The Durom hip acetabular component is a large diameter
metal on metal (MoM) implant that has recently been the subject of much
controversy. Dr. Lawrence Dorr, reported in a letter in April 2008 to the
American Association of Hip and Knee Surgeons a worryingly high
number of early revisions, as many as 8%, within the first 2 years as a
result of a loose acetabular component. Following a Zimmer investigation
an early revision rate of 5.7% in the US, but not in Europe, was revealed
and this has resulted in the withdrawal of the implant from the market in
the US and justifiable concern with regards to its usage resulting in
decreased implantation within the UK. Surgical technique in the US has
been sited as the main reason for failure as a result of low volume centres
not performing crucial steps in the technique which include, but are not
limited to, line-to-line reaming, use of trials in every case, proper cup
position for this device, appropriate impaction techniques and no
repositioning. We present the short term results and our experience of the
Durom Acetabular component in our centre in the UK. Method: We
reviewed all patients that had a Durom Acetabular component implanted
since its usage began in our unit in 2003. No patients were excluded and
the end point being revision surgery of the Durom acetabular component.
In addition we analysed the plain radiographs of a random selection of 50
patients to assess component integration. Results: 249 patients had
undergone primary hip surgery with the implantation of the Durom
Acetabular component. 101 as part of a hip resurfacing and 148 as a large
bearing MoM THR. Their follow up ranged from 1 to 6 years. None had
undergone revision for isolated aseptic failure of the acetabular
component. 3 had undergone revison for infection and 1 for peri-prosthetic
fracture. Analysis of the radiographs revealed a number of acetabulae
with a lucent line visible around the implant. None of the implants had
migrated from their original position at implantation. Conclusions: At
present their appears to be no evidence in our unit that the Durom
Acetabular component has a higher than expected rate of early revision.
However, a "significant" number of patients do appear to have lucency
around the component on radiographs raising the possibility of
questionable bony integration and on growth. Reports from the United
States have suggested that the cup will "pop out" easily at revision
showing no signs of bony integration. This may result in an increased
revision rate in the future and we suggest that all patients that have a
Durom acetabular component in situ be followed up with yearly clinical
assesment and radiographs to assess the longevity of this component.
REVIEW OF SUCCESSFUL LITIGATION AGAINST ENGLISH HEALH TRUSTS IN THE
TREATMENT OF ADULTS WITH ORTHOPAEDIC PATHOLOGY. CLINICAL
GOVERNANCE LESSONS LEARNED.. Atrey A. Hastings
Background Reviewing litigation brought against health institutions is a clinical governance
issue and can help in preventing further cases. Large-scale databases are however rare to find.
The NHS Litigation Authority deals with claims brought against all public health trusts in
England.
Method We reviewed all 2,312 successful cases pertaining to adult orthopaedic claims between
2000 and 2006 in a bid to establish trends of litigation and highlight specific areas of concern
such that orthopaedic healthcare could be potentially improved.
All cases were reviewed under the Freedom of Information Act with 1,473 entries having
sufficient detail to be considered in our study.
Results There were 4,847,841 elective and trauma orthopedic procedures between 2000 and
2006 in the UK. Compared to the number of cases performed, the frequency of successful
litigation is relatively low but financially costly to the NHS. In 2000 to 2006 a total of over
$321,695,072 (US$) was paid by the NHSLA in adult orthopedic related settlements.
The most common reason for successful litigation was due to the presence and sequelae of
infection (123 cases).
In the remaining cases, there appeared to be two common themes in the reviewed litigation.
These related to the consent process and the mismanagement of orthopedic conditions.
There were 78 cases, in which poor consent was reported as the sole reason for a successful
claim. In addition there were other cases where common and well-recognised complications
occurred, but they had not been explained in the consent procedure. In hip arthroplasty, leg
length discrepancy, femoral fracture and nerve injury following the intervention, resulted in a
high number of successful claims due to failure of the consent process.
It appears inadequate informed consent is still being practiced by some health institutions.
A large number of settlements were made for the mismanagement or misdiagnosis of common
injuries including fractures of the distal radius (48 cases), cervical spine (18 cases) and
scaphoid (15 cases). Mismanagement of other less common but serious injuries or
emergencies, including cauda equina (20 cases) and compartment syndrome (33 cases) also
occurred.
Surgical operative errors also resulted in high settlement payments including 51 instances of
wrong site surgery despite the preventative attention.
ConclusionThese findings highlight that education and vigilance remain important components
of orthopedic training and reflect issues around the globe.
Level of evidence: Level 3
4
45
Welcome to STOP number 8.
My friends complain that I am always talking. Perhaps misguidedly, I take this
as a compliment. There is always something to talk about, and I congratulate
both accepted, and rejected, contributors to these proceedings, and thank them
for their interest and efforts.
There are more submissions this year than ever, which is a clear affirmation of
both the Fred Heatley day initiative, and especially Fred’s inspiration. It could
also indicate rising interest in original thinking and research. Or again,it could be
a sign of rising panic amongst the rank and file of trainees, uncomfortably aware
of the mounting competitiveness of the world in which we live.
The Nation’s finances are overdrawn, and there will be a reduction in DOH
funding soon, regardless of the outcome of May 6th. This is likely to arrest the
massive expansion of consultant posts we have become accustomed to since
the end of the Thatcher years. There are about 50 retirement vacancies per
year, and hopefully most will be replaced, but at present we are producing over
150 CCT orthopaedic surgeons annually, to which must be added successful
article 14 applicants. Any adjustment now will take 6 years to have effect.
Culling 10% of training posts will mainly be compensated by more article 14
people, because EWTD requires a fixed number of middle grades, numbered or
not.
Big problem! In stark terms, there may only be posts for 1 in 3 fully trained
orthopods. Only those with the WOW factor need apply!
Research is often seen mainly as a discriminating tool for job selection, with
little legitimacy in the real world of service delivery. This perception could not be
more wrong. The funding issue runs far deeper than contemporary global
banking cock ups. The ever increasing elderly population guarantees financial
squeeze is here to stay. At the same time ambitious but uninformed politicians
make extravagant claims, and public expectation rises. The only chance of
accommodating the divergence is innovation, and research at all levels.
I believe that cell regulation and tissue regeneration will be important new
developments, and a few of us are launching a new Musculoskeletal
Regenerative Research Society later in the year, as a vehicle to encourage this
area. Delaying ageing is receiving considerable scientific attention, together with
recent publicity. It does of course contain inherent problems.
Other current developments include the evolution of the Brighton M Sc. We
hope to be able to offer an option to switch to an MD, and also offer two
additional diplomas, in”Medical Education”, and “Medical Business and
Management”. These are intended to help generate enlightened orthopaedic
surgeons.
But the other area in which adaptation is unfortunately required is on the
technical front. Increasingly, job descriptions are seeking technically competent
hyper-specialised appointees. Last year, of 186 consultant T & O appointments,
only 43 were advertising for a generalist, and several of these in fact wanted a
pure specialist.
I suppose it will keep us on our toes!.
Visual estimation of computerised x-ray angles. Should we be
using digital measuring tools? C. McGarvey, S. Nicholson, L.
Rajan, B. Singh. Maidstone and Medway .
Investigation: This study compares the accuracy of visual estimation to
measurement of angulation in distal radius fractures seen on digital
viewing software
Method: Fifty-nine subjects evaluated 13 distal radius fractures.
Subjects comprised Orthopaedic and Emergency Department (ED) staff
and F2 doctors from various specialties. Visual estimations were
compared to digital measurement of angulation by a single Orthopaedic
Consultant.
Results: Mean error between estimation and measurement was 11.8o
(5.0o-26.1o). Mean error for Orthopaedic doctors, ED staff and Medical
F2’s was 8.7o, 12.3 o and 19.3o respectively. There was weak
correlation between time taken and accuracy of estimation. Eighteen
subjects routinely used digital measurement. They performed better in
visual estimation (9.4o v 11.2o).
Discussion: Although F2 doctors without Orthopaedic or ED experience
performed particularly badly, neither experience nor time taken
eliminated the error between estimation and digital measurement.
Furthermore, routine use of digital measurement improved estimation.
2
47
FOOT AND ANKLE
TIBIO-TALO-CALCANEO FUSION USING A LOCKED INTRAMEDULLARY COMPRESSIVE
NAIL.Chettiar K, Hader S, Bowman N, Cottam H, Armitage A, Skyrme A
20
SPECT-CT IN THE EVALUATION OF THE CONTINUING PAIN FOLLOWING FOOT AND ANKLE
ARTHRODESIS. S Haleem, PD Hamilton, H Zaw, M Klinke, IT Jones, S Singh S,.Guys
21
THE SCARF OSTEOTOMY: INITIAL PROBLEMS AND PITFALLS
N.A. Sandiford, Weitzel S, Tsitskaris K, Sidcup
22
EARLY RESULTS OF POSTERIOR ANKLE ARTHROSCOPY FOR HINDFOOT
IMPINGMENT.EXPERIENCE FROM A GENERAL HOSPITAL.
NA Sandiford, SH Weitzel, Queen Mary’s Hospital, Sidcup
23
CONTINUOUS INFUSION VS SINGLE BOLUS POPLITEAL BLOCK FOLLOWING ANKLE AND
HINDFOOT SURGERY: A RANDOMISED, PROSPECTIVE, DOUBLE
24
OUTCOME OF FIRST METATARSALPHALANGEAL JOINT ARTHRODESIS
USING THE VARIAX PLATE. Arvind Mohan
25
RESULTS OF PROXIMAL MEDIAL GASTROCNEMIUS RELEASE IN PATIENTS WITH
ACHILLES TENDINOPATHY
S. Gurdezi, J A Kohls-Gatzoulis and M Solan Royal County Surrey Hospital
26
THE STAINSBY PROCEDURE IN THE LESSER TOES: AN ALTERNATIVE PROCEDURE FOR
CORRECTION OF RIGID CLAW TOE DEFORMITY. Laurie Dodd
27
TRAUMA
MANAGEMENT OF FRACTURE NECK OF FEMUR IN MEDICALLY UNFIT ASA4 PATIENTS
USING DIRECT INFILTRATION LOCAL ANESTHESIA. KamalT, Garg S, Win,Z Dartford.
28
THE EFFECT OF THE GRADE OF SURGEON ON BLOOD LOSS IN FRACTURED
NECK OF FEMUR SURGERY. Barry Rose, Margate
29
REVISION SURGERY FOLLOWING LOWER LIMB AMPUTATION: WORTHWHILE?
71 CASES. HE Bourke1, K Yelden2, KP Robinson, S Sooriakumaran, DA Ward. Kingston
30
DO PRECONTOURED LOCKING CLAVICLE PLATES FIT?
Lydia K Milnes, David Boardman, Thomas D Tennent, Eyiyemi O Pearse . St Georges
31
PAEDIATRICS:
DE-THREADED SCREW FIXATION OF SLIPPED CAPITAL FEMORAL EPIPHYSES.
AN ALTERNATIVE FOR ONGOING PHYSEAL GROWTH
Agrawal Y, Nicolaou N, Flowers M, Sheffield Children’s Hospital, Sheffield
32
FEMORAL BENDING STRENGTH IN INDEPENDENTLY AMBULANT YOUNG ADULTS
WITH SPASTIC CEREBRAL PALSY.
M Al-Sarawan, NR Fry, SF Keevil, AP Shortland, M Gough. Guy’s and St Thomas
33
Introduction:The incidence, outcome and recovery of operatively managed pelvic ring and
acetabular fractures were studied from a three-year cohort of patients. No previous
published studies have reviewed the factors influencing the outcome of operative
stabilization on neural recovery.
Methods:This study reviewed 945 referrals to a tertiary referral unit from 1st Jan 2004 to
31st Dec 2006. There were 489 pelvic injuries and 456 acetabular fractures, with an
associated incidence of neural injury being 8.6% and 6.3% respectively. Neural injuries
were graded clinically as complete or incomplete. Pelvic fractures were associated with
lumbosacral plexus injury and acetabular fractures with sciatic and obturator nerve palsy.
The degree of post-operative skeletal displacement was quantified using digital
radiographs. The mean clinical and radiographic follow up was 3.5 years
Results:Of the 489 pelvic fractures, 42 (8.6%) had clinically detectable lumbosacral nerve
injuries. Complete recovery was seen in 16 (38%) of these patients, incomplete recovery
in 11 (26%) and 15 (36%) has a permanent complete palsy. In this cohort, 88% of the
fractures were unstable Tile type C. Patients with full resolution of neural symptoms had
a mean reduction of the sacro-iliac joint or symphysis pubis of 5.8mm compared to
8.8mm in patients with ongoing neural symptoms
Of the 456 acetabular fractures, 29 (6.3%) had clinically detectable neural injuries.
Complete recovery was seen in 9 (31%) of these patients, incomplete recovery in 15
(52%) and 5 (17%) has a permanent complete palsy. Patients with full resolution of
neural symptoms had a mean fracture reduction of 1.2mm compared to 2.5mm in
patients with ongoing neural symptoms.In both groups, a superior fracture reduction was
associated with a beneficial neural outcome. However, ongoing complete nerve palsies
were associated with a significantly longer delay to surgery.
Discussion:Unstable pelvic ring and acetabular fractures are associated with a high
incidence of neural injury. Accurate fracture reduction and stabilization, achieved without
a prolonged delay, creates a better environment to achieve a good neural outcome.
Injuries with complete nerve palsy, delayed and sub-optimal surgical reduction predict a
poor prognosis.