1
48
EDITORIAL
4
Standards for Trauma.
Authors: Matthew Dodd, Timothy Harrison, Alexandra Hazelrigg , David Llewelyn-Clark.
Worthing and Southlands
HIP:
MID-TERM RESULTS OF THE MODULAR ANCAFIT STEM IN TOTAL HIP REPLACEMENT.
Hamilton LC, Blakey CM, Eswaramoorthy V, Biant LC, Field RE Epsom
5
Introduction The first BOA “Standards for Trauma” detail clear management standards for hip
fracture patients aged over sixty including the goal that surgery should be within 48 hours of
admission.
With an expanding elderly population and the number of people suffering a hip fracture
increasing by 2% a year there will be an increasing burden on trauma services.
We have demonstrated that simple targeted changes can make a fracture.
Methods significant difference to wait till surgery after hip Comprehensive data was gathered
prospectively on all hip fracture admission over two 3 month periods one year apart. On the
basis of the poor results in the first 3 months and after discussions with the general surgeons
and anaesthetists, the following changes were implemented:
· 2pm to 5pm weekday trauma lists were extended from 2pm to 7pm two days a week.
· Priority for one hip fracture case first thing on the CEPOD emergency list each day.
· Fortnightly morning “day case” trauma list for minor cases.
Results
· Approximately 100 hip fracture admissions in both 3 month periods.
· Initially 72% of patients waited more than 48 hours, 75% of these were due to logistical
reasons (mainly lack of space on trauma lists).
· Percentage of patients operated on within 48 hours improved from 28% to 95%.
Discussion Auditing local practice against BOAST guidelines identified that logistical reasons
(mainly lack of capacity) were the major cause for delay in our trust.
Presenting and discussing these results with general surgical and anaesthetic colleagues
enabled simple changes that allowed us to meet the new BOA targets.
Conclusion.We suggest that trusts audit their compliance with the new BOA standards for
trauma. We have shown how this can be used to design simple improvements in service to
significantly reduce waiting times for patients.
THE DUROM ACETABULAR COMPONENT – SHORT TERM RESULTS
Matthew Dodd, Nikolai Briffa, Henry Bourke, David Ward. Kingston
6
CORRECTION OF SEVERE PISTOL GRIP DEFORMITY OF THE HIP.
S K Bajaj, S S Madan, R Maheshwari , J Fernandes, S Jones. Sheffield
7
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.
8
REVISION OF WELL FIXED BIRMINGHAM HIP ACETABULAR COMPONENT:
REVISION OF HIP RESURFACING TO TOTAL HIP ARTHROPLASTY - EARLY RESULTS
N.A. Sandiford, J.A. Skinner, S.K. Muirhead-Allwood, C. Kabir London .
10
KNEE
THE OXFORD UNICOMPARTMENTAL KNEE REPLACEMENT
Authors: A.Ujam, D.Neen, H.Oakes, W.Dunnet. Ashford
11
SHOULDER
HOW SAFE IS SHOULDER RESURFACING ARTHROPLASTY? Ravi Trehan
12
A THE SUPRASPINATUS BOTH IN ITS NORMAL CONFIGURATION AND WITH
FULL THICKNESS TEARS. Simon Thompson
13
ANALYSIS OF THE ACROMIO-CLAVICULAR JOINT EXCISION: IS JOINT MORPHOLOGY
AN AETIOLOGICAL FACTOR? Toby Colegate Stone
14
A PROSPECTIVE STUDY OF USING THE NOTTINGHAM SURGILIG AS A FIXATION
METHOD IN RECONSTRUCTION OF ACROMIO-CLAVICULAR JOINT DISLOCATIONS:
IS IT REALLY THE SOLUTION? E.Fawzy, Hastings
15
MUSCULOSKELETAL MANIFESTATIONS OF DIABETES IN THE SHOULDER JOINT
A PRELIMINARY REPORT. Prasad G, Kerr D, Kernohan J. Bournemouth
16
SPINE
HYDROXYAPATITE VERSUS NON-COATED PEDICLE SCREWS IN DYNAMIC POSTERIOR
STABILISATION. S Hoskinson, M Mueller, J Shepperd. Hastings
17
INCIDENTAL ABDOMINAL AORTIC ANEURYSM ON LUMBOSACRAL MRI
- A CASE SERIES. Alex J Trompeter , Guy P Paremain Guildford .
18
FEMALE SEXUAL DYSFUNCTION FOLLOWING ANTERIOR LUMBAR SPINE SURGERY
I Findlay, S Mahir, G Marsh . Mayday Hospital.Croydon
19
46
3
The Sheffield Telescopic Intramedullary Rod System in Management of
Osteogenesis Imperfecta – Outcome in Adulthood.
Nicolau N, Bowe JD, Wilkinson M, Fernandes JA, Bell MJ, Sheffield
Introduction: Telescopic intramedullary rods play an important role in
fracture prevention and deformity correction for patients with Osteogenesis
Imperfecta (OI). Many devices exist for this purpose, but very little long term
outcome data is available, particularly with regard to potential complications arising
from rod insertion techniques, and their effect on growing long bones. This
originator series assesses the functional outcome at 15-20 years after surgery.
Patients and Method: An early cohort of patients treated from 1986 with
Sheffield rods were contacted for review. Assessment was carried out by a
postal/e-mail questionnaire designed to assess all aspects of intervention with the
rods. SF-36 questionnaire was also used to assess functional outcome. Clinical
data was obtained from case notes for demographic information and details of
treatment.
Result: Of an original 35 patients, 22 were contacted successfully. All
responded. 2 further patients had died of factors unrelated to the rods; the
remaining 8 were lost to follow-up. Fractures became much less common with
increasing age. Mobility deteriorated with age, in most cases due to problems with
back pain as opposed to deformity or rodded bone complications. All patients were
satisfied with the procedure and would recommend it to others. Long term sequelae
due to rod insertion at the hip, knee and ankle were not significant. Most reoperations were due to migration of femoral rods at the trochanteric insertion point.
Where joint problems did occur, these were secondary to associated ligamentous
laxity. Re-fractures of rodded bones had occurred, although re-operation for this
reason was rare.
Discussion: The Sheffield Telescopic Intramedullary Rod system when used
in OI patients plays a key role in fracture prevention. Mobility does deteriorate with
age in these patients although this is often due to spinal pathology as opposed to
deformity and pain from the long bones. Patients are very satisfied with the
treatment and the benefits it provides.
ARTHROPLASTY:
MONITORING RADIOLOGICAL OUTCOME IN LOWER LIMB ARTHROPLASTY AS AN
INDEX FOR QUALITY CONTROL
Vasireddy A Ivory JP, Rigby MC, Brooks RA, Deo S, Satish V, Lowdon IMR. Swindon
34
INFECTION:
THE EFFECT OF STERILE VERSUS UNSTERILE TOURNIQUETS ON MICROBIOLOGICAL
COLONISATION IN LOWER LIMB SURGERY. Simon Thompson
35
HIP SUPPORTS AS A CAUSE OF CROSS INFECTION
Gautam Talewager
36
BASIC SCIENCE:
THE EFFECTS OF COCR WEAR DEBRIS FROM ORTHOPAEDIC METAL-ON-METAL
IMPLANTS ON HUMAN CELLS THROUGH A PLACENTAL CELL BARRIER. Gev Bhabra
37
A PROSPECTIVE STUDY OF THE NUTRITIONAL STATUS IN PATIENTS WITH FRACTURED
NECK OF FEMUR: ARE WE DOING ENOUGH?Jeannette Lahai-Taylor, Ernest Fawzy,
Guy Selmon, John Shepperd, Oliver Keast-Butler
38
ADMINISTRATION:
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.
39
PROSPECTIVE EVALUATION OF THE ACCURACY OF DATA COLLECTION FOR THE
TRAINEE SURGICAL LOGBOOK. HL Cottam, M Gee, A Khurwal, K Chettiar,
S Dawson-Bowling, C Southgate. Ashford.
40
PATIENT COMPLIANCE WITH XARELTO® (RIVAROXABAN). HL Cottam, A Ghosh, P
Housden,.Ashford.
41
STUDY OF TRAUMA CASE LOAD SUITABLE FOR A DAY SURGERY TRAUMA LIST
AND COST ANALYSIS.
42
REVIEW OF SUCCESSFUL LITIGATION AGAINST ENGLISH HEALH TRUSTS IN THE
TREATMENT OF ADULTS WITH ORTHOPAEDIC PATHOLOGY.
CLINICAL GOVERNANCE LESSONS LEARNED. Atrey A. Hastings.
43
RADIOLOGY:
THE USE OF ULTRASOUND GUIDED WIRE LOCALISATION IN ORTHOPAEDICS
Chettiar K, Sriskandan N, Thiagaraj S, Desai AU, Ross K, Howlett DC. Eastbourne
44
VISUAL ESTIMATION OF COMPUTERISED X-RAY ANGLES. SHOULD W47E BE USING
DIGITAL MEASURING TOOLS?C. McGarvey, S. Nicholson, L. Rajan, B. Singh.
Maidstone and Medway
The Incidence and Outcome of Neural Injuries Following Pelvic and Acetabular
Fractures. BA Rogers, R Pearce, R Walker, M Bircher
STANDARDS FOR TRAUMA. Matthew Dodd, Timothy Harrison, Alexandra
Hazelrigg , David Llewelyn-Clark. Worthing and Southlands
45
47
48
44
5
The Use of Ultrasound Guided Wire Localisation in Orthopaedics
Chettiar K, Sriskandan N, Thiagaraj S, Desai AU, Ross K, Howlett DC.
Eastbourne District General
Ultrasound guided wire localisation is widely used in breast surgery, but has not
been described in orthopaedic practice. We present two cases to illustrate the potential
advantages of this technique in orthopaedics.
Case 1: A 54 year old female patient presented with non-specific thigh pain. MRI
demonstrated a 1 cm probable left femoral nerve neuroma.
Case 2: A 15 year old male presented with probable left sacroileitis. MRI
demonstrated a 2cm abscess near the lower end of the joint.
In both cases, the lesions were impalpable and UGWL was performed preoperatively to guide surgery. This technique comprised of the insertion of a hollow core
introducer needle under ultrasound guidance.
In case 1, surgical dissection along the wire revealed a mobile lump arising from
the femoral nerve. Resection and subsequent histology confirmed a benign
schwannoma. In case 2, wire localisation enabled incision and drainage of the abscess
with minimal surgical exploration. There were no complications and the patients had
complete symptom resolution.
UGWL has not been described in orthopaedic practice. In lesions that are small or
impalpable, diagnosis and surgical management may be challenging. UGWL is becoming
more available enabling safe, minimally invasive surgery, with reduced operative times
and tissue disruption.
Mid-term results of the modular ANCAfit stem in total hip
replacement.
Hamilton LC, Blakey CM, Eswaramoorthy V, Biant LC,
Field RE Epsom
Investigation:We report the mid-term follow-up of 352 THRs
using an uncemented, modular, femoral component.
Method: Prospective protocol of Oxford hip scores. XRays
evaluated by two independent observers. Stability of femoral
component graded, migration measured and evidence of spot
welding, pedestal formation and reactive lines documented in
each of the Gruen zones. Survivorship analysis performed and
survival rate calculated using Kaplan-Meier survivorship curves.
Results: Mean Oxford hip score improved significantly from 41
points preoperatively to 20 points at five years. Radiological
assessment showed good bony stability in 98% of implants.
Two cases of aseptic loosening. No complications relating to
modularity seen.
Discussion: This study demonstrates that the clinical outcome
of the AnCA Fit stem is comparable with other metaphyseal
loading femoral stems.
42
7
Study of Trauma Case Load Suitable for a Day Surgery Trauma List and Cost
Analysis
Investigation: A ‘Rapid Access’ list was set-up to book patients from an emergency
pathway who required surgery and fulfilled standard day case criteria but for whom it was
safe to wait for over 24 hours before surgery.
Methods: A prospective study of the cases (n=119) undertaken on the day surgery
trauma list over a 12-month period was performed assessing the spectrum of procedures,
complications and costs
Results: A cost benefit of £617 per case for day surgery over in-patient surgery was
noted with a total saving of £67,519. At our hospital at least 17% of our trauma patients
could be managed on such lists, with a potential cost benefit of £136,000 per-annum.
Discussion: We demonstrate day trauma surgery to be safe and cost effective in
optimising the management of the appropriate trauma case workload. Further it reduces
demand for in-patient beds, provides significant cost savings and improves patient
satisfaction.
CORRECTION OF SEVERE PISTOL GRIP DEFORMITY OF THE HIP BY
SURGICAL DISLOCATION. S K Bajaj, S S Madan, R Maheshwari , J
Fernandes, S Jones. Sheffield
Introduction: Our experience with Ganz’s technique of flip greater
trochanteric approach and surgical dislocation for correction of pistol grip
deformity resulting from severe SUFE is described.
Methods: 12 cases (mean age of 13.6 years) of severe SUFE were
treated by this method .Mean follow up of 3.1 years (2.1 to 4.6 years). Patient
based outcome tools and scoring system is used. (incl. Non Arthritic Hip
scoring questionnaire)
Results: Patients had good to excellent outcome. The average preoperative slip angle was 84 degrees.The average Pre-operative external
rotation deformity at the hip was 70 degrees. Post operatively the internal
and external rotation and all other movements were similar to the
contralateral uninvolved hip. None of these had infection or non union of the
greater trochanter osteotomy. One of the patients developed avascular
necrosis (AVN)
Discussion: This technique is demanding but gives good control for
open reduction and is least disruptive to the blood supply of the femoral
head.
40
9
Prospective Evaluation of the Accuracy of Data Collection for the Trainee
Surgical Logbook. HL Cottam, M Gee, A Khurwal, K Chettiar, S Dawson-Bowling,
C Southgate. Ashford.
.
Introduction:It is a requirement of the RITA and ARCP [1] process that surgeons
in training keep a record of theatre activity. It is recommended that the online
eLogbook[2] be used for the collection of orthopaedic logbook data. The eLogbook
encourages contemporaneous recording, and aims to ensure an accurate record, both
for the individual trainee and the trainee body as a whole. Despite this many trainees
continue to collect data from the theatre record, and complete their logbook
retrospectively. Our study demonstrates that the accuracy with this retrospective
method is poor, compared to prospective collection with the eLogbook.
Methods: Five trainees in four different hospitals in the South East of England
collected contemporaneous surgical logbook data, using the eLogbook , for the period
of April to June 2009. The consolidation data was then compared to the theatre record,
collected contemporaneously by theatre staff.
Results:The theatre record collected 72% (range 43% - 81%) of the procedures
recorded prospectively. Of the procedures in the theatre record, 41% (range 33% 50%) noted the trainee as lead surgeon, compared to 61% in the prospective
eLogbook.
Discussion:It is clear that the retrospective method falls short, both with the
association of the trainee to a procedure, and with the status of the trainee (as
operating surgeon or assistant). This results in an incomplete and inaccurate record.
With concern regarding reduced training opportunities following implementation of the
EWTD[3], it is imperative that cases are actually recorded, and accurately. This study
raises further questions with regard to the validity of data collection within the theatre
environment, and the validity of audit performed based on this data.
[1] http://www.iscp.ac.uk/Documents/ACRP_Checklist.pdf[2] http://www.elogbook.org 3]
http://www.bota.org.uk/dl.php?id=95
Revision of the well fixed Birmingham Hip Resurfacing Acetabular
component: Results using a novel device
N.A. Sandiford, S.K. Muirhead-Allwood. The London Hip Unit.
Investigation:We present the results of using a novel adaptor designed to
facilitate removal of the well fixed BHR socket using the explant device.
Method:This prospective study evaluated the effectiveness of this device.
The explant cup extractor was used with its standard centering head and curved
blades. The size of the explanted cup, last reamer size and size of the implanted
component were recorded
Results:Average time to revision was 24.2 months (7-40). Average explanted
cup size was 51mm (46-58). Final reamer size 53.8mm (51-59). Mean final size
was54.8 (50-62). Overall a mean of 2.8.mm size difference between the
explanted cup and the final reamer was found.
Discussion:The device facilitates removal of the well fixed BHR sockets with
minimal acetabular bone loss.
38
11
A prospective study of the nutritional status in patients with fractured
neck of femur: are we doing enough?
Jeannette Lahai-Taylor, Ernest Fawzy, Guy Selmon, John Shepperd,
Oliver Keast-Butler
Introduction: We report a prospective study of the nutritional status in 32
elderly patients with proximal femoral fractures.
Aim of study: To establish association between malnutrition indices and
perioperative morbidity.
Patients and Methods: Thirty-two consecutive patients were prospectively
reviewed. Nutritional status was assessed using validated anthropometric
and biochemical tools.
Results: Strong correlation between albumin level and postoperative
infection (r = -0.517), moderate correlation with perioperative morbidity (r =
-0.403) (p = 0.052). Moderate correlation between anthropometric
parameters and perioperative morbidity (r = -0.308) (p = 0.376). No
correlation between lymphocytes and perioperative complications (r =
0.062) (p = 0.668)
.
Conclusion: Strong association between malnutrition and postoperative
infection. Albumin level is the best predictor for malnutrition and
perioperative morbidity.
The Oxford Unicompartmental Knee replacement
Authors: A.Ujam, D.Neen, H.Oakes, W.Dunnet. Ashford
Introduction: Oxford unicompartmental knee replacements have variable
survival rates. Their use for isolated unicompartmental osteoarthritis has
become more popular as an alternative to total knee replacement.
Method: A review of 45 patients undergoing unicompartmental knee
replacement was undertaken and their associated outcomes were
examined. Forty four medial and 1 lateral compartment were replaced
Results: Patients were seen in follow-up clinic at a mean time of 1 year and
11 months. Three patients required revision to a total knee replacement.
Discussion: We present the results of a single surgeon series of Oxford
unicondylar replacements evaluated by an independent practitioner. Thus
far the results are encouraging and support this prosthesis for use in
unicompartmental osteoarthritis.
36
13
Hip supports as a cause Of cross infection
Gautam Talewager
Introduction:Repeated use of hip supports, that come in direct contact with groin and
buttock areas of patients, could cause cross-infection
Materials:We swabbed 12 supports & cultured them at 37 0 C in Columbia Blood Agar.
2 random supports cleaned using detergent non-alcoholic wipes & samples obtained, 5
min later.
Result: 71% samples contaminated with Coagulase -ve Staphylococcus (Staph
Epidermidis - most common) - average 5.3 CFU (0-38) / swab. 5 min post-cleaning,
there was no growth from 4 swabs.
Discussion:Trauma patients are not subjected to groin MRSA swabs pre-operatively in
contrast to elective patients. Interchangeable use of hip supports defeats the purpose
of this practice. We recommend strict cleaning of these supports. Preferably, separate
supports should be used for elective and trauma cases.
The Effect of Cyclic Loading on Antibiotic Elution from Articulating Cement Knee
Spacers. BA Rogers, F Middleton, N Shearwood-Porter, A Roques, A Taylor, N
Bradley, M Browne, Southampton
Introduction 2stage revision surgery for infected total knee replacement is considered
optimal treatment with articulating antibiotic cement spacers being widely employed
during the first stage to eradicate infection whilst maximizing soft tissue function.
Minimal evidence exists concerning the performance of these spacers in terms of the
effect of ambulation on cement wear debris, mechanical failure and antibiotic elution.
This study investigates the effect of cyclic loading of cement spacers on antibiotic
elution.
Methods: This in-vitro study used femoral and tibial cement spacers, manufactured
from Palacos bone cement using specific molds, containing vancomycin at constant
concentration, and tobramycin of varying concentration. The specimens were
immersed in phosphate buffered solution (PBS) and cyclical loaded over 35,000 cycles.
The purpose built rig enabled a cyclic load between 25 and 250N to be applied axially
to the femoral component while it was rotated on the tibial component with amplitude of
45 degrees flexion. Triplicate PBS aliquots were taken periodically for subsequent
antibiotic concentration evaluation by ELISA and elution calculated. Unloaded samples
were used as controls for statistical comparison.
Results: Tobramycin elution increased proportionately to its cement concentration and
was significantly higher (p<0.05, independent t-test) in loaded components compared
with the controls. A similar trend was observed with vancomycin elution, but not to
statistical significance.
However, cyclically loaded and control components exhibited increased
vancomycin elution with increasing tobramycin concentration in the specimen, despite
all components having the same vancomycin concentration.
Conclusion:Tobramycin concentration influences both tobramycin and vancomycin
elution from bone cement. Cyclical loading of the cement spacers, with the associated
wear product related elution, increases both vancomycin and tobramycin elution; the
latter to statistical significance.
A the supraspinatus both in its normal configuration and with full
thickness tears
Simon Thompson
Background Tears of the supraspinatus tendon cause variable
functional deficit. It is not known why this variation occurs. It is the
hypothesis of this study that the involvement of central tendon retraction
is related to this functional deficit and therefore the aim of this study is to
quantify the anterior and posterior pennation angles and the central
tendon angle, differences between these, and their interrelationship using
magnetic resonance imaging
Methods MRI scans of the supraspinatus were reviewed and two groups
identified: no tear (NT) and full thickness tear (FTT). The following
measures were taken: anterior muscle fibre pennation angle (APA),
posterior muscle fibre pennation angle (PPA) and central tendon angle
(CTA). For the NT group differences between these measures were
assessed using paired t-tests with Bonferroni correction. A correlation
analysis between variables was conducted using Pearson’s product
moment correlation.
Results 157 scans had NT and 156 scans had FTT after exclusion
and inclusion criteria were satisfied. All FTT involved the central tendon,
with varying retraction. For NT the average anterior and posterior
pennation angles, and central slip angle was 19.0° (SD 5.9), 4.0° (SD 3.2)
and 17.8° (SD 5.1), respectively. These differences in pennation angles
are all statistically significant (PPA<APA, p<0.001; PPA<CTA, p<0.001;
CTA<APA, p<0.001). For FTT these values were: 17.6° (SD 8.6), 16.7°
(SD 12.2), and 7.3° (SD 4.9). All of these values were statistically different
and all changes were correlated with the magnitude of the tear size
(correlation between increasing retraction and PPA, p<0.001; correlation
between increasing retraction and APA, p<0.002; correlation between
increasing retraction and CTA, p<0.001).
Conclusion This study has shown that the size of a supraspinatus
tear is directly correlated with tendon pennation angles as quantified by
MRI. This information can be used to provide a direct measurement from
MRI that can now be employed in further studies of functional deficit and
tendon tear size.
Level of Evidence Level 1 Diagnostic Study
34
15
Monitoring radiological outcome in lower limb arthroplasty as an index for quality
control
Vasireddy A Ivory JP, Rigby MC, Brooks RA, Deo S, Satish V, Lowdon IMR
Introduction: We describe an easy method for monitoring radiological outcome following
lower limb arthroplasty
Methods: We undertook a two-year prospective study of total hip and knee arthroplasty
operations (over 2,600 cases). The Specialist Consultants marked post-operative weightbearing radiographs on a weekly basis using our own simple scoring system.
Results: Individual surgeons were given their average scores at six-month intervals.
Where necessary, feedback was provided in the form of formal advice and supervised
surgical sessions. Proportional analysis of the radiological scores showed significant
improvements for all the individual surgeons (Pearson-Chi Square p value <0.05)
.
Discussion: This assessment tool highlights the role of clinical governance, and can also
be used to assess and appraise trainees during their progression.
A prospective study of using the Nottingham Surgilig
as a fixation method in reconstruction of
acromio-clavicular joint dislocations: is it really
the solution? E.Fawzy, Hastings
Introduction: We report a prospective study of 24
patients with acromio-clavicular joint dislocation
(Grade 3-5) treated with surgilig synthetic coracoclavicular ligament.
Patients and Methods: Twenty-four patients
(average age: 42) underwent ACJ reconstruction
using the Nottingham surgilig were prospectively
reviewed. Average follow-up was 19 months (range
4-27). Self-reported Oxford Shoulder score
(maximum score= 48) was recorded.
Results: The mean Oxford shoulder score improved
from 34 preoperatively to 45. Complication included:
one removal of screw due to pain, one residual lump
not warranting further surgery, no infection. All our
patients had Oxford score of above 40, only one
scored 36 due to associated neck injury.
Conclusion: Surgilig is a reliable option for
reconstruction of ACJ dislocations and provides
satisfactory patient reported outcome.
32
17
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.
Introduction: The optimal management strategy for patient with slipped capital femoral
epiphysis (SCFE) is controversial. Concerns have been raised with regard to the
implications of early epiphysiodesis in the skeletally immature. We use a fixation device
which allows growth of the proximal femur while preventing any further slip. We studied
the clinical and radiological outcomes of patients treated with cannulated de-threaded
titanium (DTT) screws and compared the results with a matched cohort of patients
treated with partially threaded cancellous screws.
Materials and Methods: A prospective review of the outcome of patients treated for
SCFE. A matched cohort of patients in terms of age, sex and degree of slip were
compared for any significant difference in growth (p <0.05) radiologically following
intervention. We considered a difference of greater than 5% in the pin–joint ratio or in
the pin–physis ratio between the initial and the follow-up radiograph as an indication of
persistent growth. Clinical outcomes were classified as excellent, good, fair, poor or as
failure. Functional assessment was done using the Activities Scales for Kids (ASK)
scores.
Results: A matched cohort of 12 patients (18 hips) treated with 2 DTT screws or single
cannulated screws were studied. Radiologically, we identified persistent growth of the
femoral neck in 89% of the hips treated with DTT screws and in 77.8% in those treated
with standard screws. 3 patients (5 hips) in DTT group underwent exchange of screws
due to growth of the femoral neck and 1 patient (2 hips) underwent a further
advancement. 83% patient had an excellent clinical outcome.
Discussion: Treatment in SCFE aims to prevent further slippage of the epiphysis.
Premature closure of the proximal femoral physis leads to relative greater trochanteric
overgrowth, coxa vara, and coxa breva. DTT screws avoid premature closure of the
proximal femoral physis allowing continued growth which is greater than with a
standard cannulated screw.
HYDROXYAPATITE VERSUS NON-COATED PEDICLE SCREWS IN DYNAMIC
POSTERIOR STABILISATION. S Hoskinson, M Mueller, J Shepperd. Hastings
Introduction: To evaluate fixation of pedicle screws with and without hydroxyapatite (HA)
coating in Dynesys flexible stabilisation.
Methods: From our prospective series we studied 58 patients with HA coated screws
(minimum 1 year follow-up) and compared them to 69 patients with non-coated screws.
Outcome measures were screw loosening, breakage, implant removal or revision.
Results: 320 HA coated screws were inserted. 3 patients had implants removed. There
were 5 screw breakages in 4 patients. There was no evidence of screw loosening. 354
non-HA coated pedicle screws were inserted. 5 patients required revision or subsequent
surgery. 12 patients had screw loosening.
Discussion: HA coating was introduced because of loosening in plain screws. The
improvement has been significant.
Disclosure: The authors did not receive any outside funding in support of preparation of this
work.
30
19
Revision surgery following lower limb amputation
A worthwhile procedure? A review of 71 cases.
HE Bourke1, K Yelden2, KP Robinson2, S Sooriakumaran2, DA Ward
Kingston
Introduction: previously there has been controversy as to the value of revision
surgery on limb amputation stumps. Today modern amputees have highly advanced
prosthetic technology and fitting available, allowing them to achieve an extraordinarily high
level of function. Many amputations are carried out in an emergency scenario and thus
stump shape may not be optimal for good limb-fitting and longevity in these patients. The
demand for revision amputation surgery is therefore on the increase but does it achieve its
goals in improving mobility and relieving pain?
Methods: a retrospective review of the case notes of 71 consecutive patients
undergoing revision surgery on an existing amputation stump and
Results: revisions for bony and soft tissue pathology had good outcomes from a
surgical (85% & 82%) and a rehabilitation perspective. Revisions for infection had decent
results from a surgical perspective (73%) but less so from a rehabilitation perspective
(28%). The results of the revisions in the two pain groups were poor showing surgical
success of only 50% and 25% and little or no improvement in rehabilitation.
Conclusion: revision surgery for certain pathologies gives a good surgical outcome
and can improve pain and mobility status. Surgery for is likely to cure infection but may not
improve mobility. Surgery for pain may be successful when neuroma is confirmed first by
imaging. Generalised pain is unlikely to improve and very unlikely to improve rehabilitation.
Rehabilitation and surgical outcomes may not always correlate.
Female Sexual Dysfunction Following Anterior Lumbar Spine Surgery
I Findlay, S Mahir, G Marsh . Mayday Hospital.Croydon
.
Investigation: Male retrograde ejaculation is a well-documented but rare complication of
anterior approach lumbar spine surgery. Retraction of the soft tissues which encase the
superior hypogastric plexus leads to dysfunction of the sympathetic control of the bladder
neck sphincter. We postulated that similar nerve root dysfunction in females may lead to
bladder problems and sexual dysfunction.
Method: The Female Sexual Function Index Questionnaire was sent to 20 consecutive
women who had undergone anterior spinal surgery using the anterior retroperitoneal
approach by the senior author (GM). Questionnaires were returned by 11 subjects.
Results: 9 women (82%) described a degree of post-operative sexual dysfunction with 7
(64%) recording urinary frequency and urge incontinence.
Conclusions: Although some sexual dysfunction maybe expected from pre-existing
conditions, we highlight this complication following anterior lumbar spine surgery in
females. We plan to further investigate its incidence and possible resolution of symptoms
after a prolonged period in a larger case series.
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Management of fracture neck of femur in medically unfit ASA4 patients using direct
infiltration local anesthesia. KamalT, Garg S, Win,Z
Dartford,
Introduction: Patients who are considered too unwell for surgery are often being delayed
until optimized. Those patients have a high morbidity and mortality and present significant
nursing difficulties.
Materials and Methods: We describe a technique of fixation of fracture of the femoral
neck under direct infiltration local anaesthesia; that can be performed on the sick elderly
patient without the risks associated with general or regional anaesthesia.
Results: Twenty four DHS and four Hemiarthroplasty were performed. The patients were
all able to complete the surgery using this technique.
Discussion: This technique can be in patients with severe co-morbidity and fracture in
order to optimise their chance of survival and avoid the morbidity associated with bed rest
and delayed surgery.
The use of 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, H
Mohan. Guys Hospital.
Introduction: The advantage of using SPECT-CT over conventional bone scanning is
that it has the promise of linking the multiplanar reconstructional image of CT with the
functional analysis of bone scintigraphy. It is useful in gaining further information
regarding new pathology and is regarded as more sensitive and specific. We present our
experience of use the SPECT-CT in the analysis of continued or recurrent pain post foot
and ankle arthrodesis.
Methods and Materials: A retrospective analysis of all post-arthrodesis patients with
continued pain who underwent SPECT-CT was carried out. The scans and notes from
clinical examination were evaluated. The request for the scan was at the clinician’s
discretion and was reserved for presentations where the diagnosis was unclear on
clinical and radiological grounds.
Results: A total of 30 patients underwent SPECT-CT of the foot and ankle for the
investigation of continued pain post arthrodesis. The scan proved helpful in 27/30 (90%)
cases in determining the cause of continued pain. Non-union with increased uptake at
the site of the fusion was identified in 8 cases. All the other cases showed successful
arthrodesis. Other abnormalities identified were metalwork impingement (13%),
degeneration at other surroundings joints (40%) and pathology distinct from the
arthrodesis site such as a stress fracture (10%).
Discussion: Determining the exact cause of continued pain in patients with previous foot
and ankle surgery can be difficult. Conventional methods include injection studies along
with CT, MRI and bone scanning as addition adjuncts. SPECT-CT has the potential
advantage of combining multiplanar CT to identify the anatomy with bone scintigraphy to
identify areas of active inflammation or degenerate changes. In our group of patients
who have undergone previous arthrodesis we have found this modality to be useful in the
majority of presentations in determining the site of pain and in mapping degenerate
changes.
Conclusion: SPECT-CT is a useful adjunct to clinical and plain radiological assessment in
the management of patients presenting with continued pain post arthrodesis procedure in
the foot and ankle.
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RESULTS OF PROXIMAL MEDIAL GASTROCNEMIUS RELEASE IN
PATIENTS WITH ACHILLES TENDINOPATHY.
S. Gurdezi, J A Kohls-Gatzoulis and M Solan. Guildford
Introduction: Most patients with Achilles tendinopathy (AT) are treated
successfully with physiotherapy ie eccentric calf training. In some patients
gastrocnemius contracture persists. There is one case-report of MRI proven
resolution of AT following proximal medial gastrocnemius release (PMGR). This
is the first series of patients to have PMGR for AT. The purpose of this study
was to review patients with refractory non-insertional and insertional Achilles
tendinopathy treated by PMGR with a minimum follow-up of 18mths.
Method: 12 patients (16 PMGRs) were performed between October 2005 and
July 2007. 9 patients (10 PMGRs) were available for follow-up. The mean age
of patients was 45.1yrs, with 5 female and 4 male subjects. The average followup period was 2.5yrs. The sample was divided into non-insertional and
insertional tendinopathy, with 5 PMGRs per group. Outcome measures were
VAS scores, VISA-A scores, AOFAS ankle-hindfoot score and overall
satisfaction. The Wilcoxon rank sum test was used to test for statistical
significance (p< 0.05). Complications and further procedures were recorded.
Results: At an average of 2.5yr follow-up, two-thirds of patients were highly
satisfied. The non-insertional tendinopathy group enjoyed better results than
the insertional group: mean improvement in VISA-A scores of 59% (noninsertional) vs 22% (insertional); mean AOFAS scores improved by 29% (noninsertional) vs 15% (insertional). The improvement in the non-insertional group
was statistically significant in all three outcome measures.
Discussion: In contrast to open or percutaneous debridement of the Achilles
tendon, PMGR is a day surgical procedure that is well tolerated with excellent
wound healing. Patients with non-insertional tendinopathy who have failed
conservative treatment can expect significant improvement, with VISA-A scores
normalising after the procedure. We recommend PMGR for patients suffering
recalcitrant non-insertional AT in whom gastrocnemius contracture persists
despite an eccentric stretching program.
Early results of posterior ankle arthroscopy for hindfoot impingment
Experience from a general hospital.
NA Sandiford, SH Weitzel, Queen Mary’s Hospital, Sidcup
Investigation: We present the early results of our patients treated arthroscopically for hindfoot
impingement syndrome.
Patients and Method: Twenty procedures were performed on 19 patients. Average follow up
was 7.9 months. Return to sport, patient satisfaction and the American Orthopaedic Foot and
Ankle Society (AOFAS) hindfoot score were assessed.
Results: Excision of os trigonum, flexor hallucis longus decompression and microfracture of
talus were performed. Return to sports occurred at 4 weeks. Four patients were unsatisfied, 1
was unsure and all others were satisfied. Average pre and post operative AOFAS scores
were 73.8 and 84.5 respectively. No neurovascular injuries occurred.
Conclusion:
A variety of conditions can be treated using this technique. There was a significant incidence
of dissatisfied patients in the absence of major complications.