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Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_II | Pages 25 - 25
1 Feb 2012
Cosker T Ghandour A Elsayed S Visvakumar K Butchart E Routledge P Chatterji S
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There is currently wide variation in the management of patients who are anticoagulated with Warfarin and require urgent orthopaedic surgery. These form an important and significant group of patients, in terms of real numbers (at least 5,600 per annum in the UK).

A study was initiated with an audit of 34 patients presenting to the West Wales unit who were warfarinised at admission and required trauma surgery. Observations were recorded about their pre-operative management and the delay this caused in taking the patient to theatre. 6 months later, a similar group of patients were re-audited.

The mean delay to surgery in those patients in whom the INR was left to fall spontaneously was 5.5 days. Following administration of 1mg i.v. Vitamin K in those patients without cardiac valves, re-audit showed the mean delay reduced to 2.2 days.

Representations from at least 6 major specialties were considered and a consensus statement was derived. Standardised protocols, which hinge on whether or not the patient has or does not have a cardiac valve were devised. Vitamin K should not be given to those patients with a cardiac valve and early consultation with cardiology and anaesthetics is recommended, with consideration of referral to a specialist cardiothoracic unit. For those patients without a cardiac valve, 1mg of Vitamin K may be administered, repeated as necessary until the INR is less than 1.8. Intravenous Heparin should be provided in the interim whilst the patient is waiting for surgery. This is discontinued the morning of surgery and subcutaneous Heparin reinstated post-operatively. These recommendations have been trialled in the two units involved in the study and have been relatively safe and easy to implement.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 458 - 458
1 Aug 2008
Cosker T Jacobs J Ghandour A Basu K James N Chatterji S
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Purpose of study: This study assessed the current availability of “out of hours” MRI scans for patients who present with symptoms suggestive of cauda equina syndrome to trauma units across the United Kingdom (UK).

Methods: 98 trauma units in 212 hospitals across the UK were identified. Senior house officers and registrars were questioned about the availability of emergency MRI scans after 5pm and midnight and at weekends. All units responded to the survey.

Results: 88 of 98 units had an on-site MRI scanner. In 32 hospitals, an MRI scan could be obtained after 5pm. In only 27 hospitals was this possible after midnight. In 58 units (65%) of cases, consultant to consultant contact was required to arrange the scan. 67 units found it “very difficult” or “impossible” to obtain an MRI scan at the weekend producing a potential delay of 64 hours from presentation at 5pm on a Friday night to 9am on a Monday morning.

Conclusions: The availability of urgent MRI scans in cases of suspected cauda equina syndrome currently represents a “postcode lottery” across the UK. This may mean that patients requiring urgent surgical decompression face a significant delay in diagnosis. Delayed or missed cases of cauda equina syndrome have huge personal, social and economic impact. On-site MRI facilities, which are available 24 hours a day for such cases are recommended in all units receiving an acute trauma on call.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_I | Pages 7 - 8
1 Mar 2008
Gupta S Tayton K Dent C Chatterji S
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To study the survival analysis of the Accord TKR and to analise the causes for its failure. 111 Accord knees were implanted in 106 patients between 1986 and 1996. All components were cemented. Eighty-seven patients were followed up and assessed according to the Knee Society Clinical Rating System.

Life table analysis of this implant using revision as the end point shows a survival of 25% at 11–12 years.

Of the 87 knees, only 31 were still in situ and of these 7 showed radiographic signs of severe loosening. However, the average knee score for these 31 was only 65/100 and average functional score was down to 42/100.

56 implants have been revised, 21 due to aseptic loosening, 11 due to gross valgus/varus instability, 9 due to deep infection, 8 due to loosening of the patella liner and 7 due to mobile bearing complications.

All 21 (24%) cases of aseptic loosening were found to have a loose femoral component; however, 56% of the total showed significant radiographic osteolysis around the stem of the tibial implants.

Retrieved implants in 5 patients showed significant delamination of the UHMWP at its margins and also revealed a track through the tibial baseplate into the medullary cavity of the tibia.

Conclusion: Early failure of this implant is due to increased debris formation from the UHMWP due to edge loading and early delamination probably as a consequence of the shape of its articulating surface. This situation was significantly aggravated by a design fault in the tibial baseplate, which encouraged unrestricted access of debris into the medullary cavity of the tibia and hence early and severe osteolysis.