To determine the outcome of subtrochanteric fractures treated by intramedullary (IM) nailing and identify causes for implant failure.

We performed a retrospective analysis of all subtrochanteric fractures treated by intramedullary nailing in Belfast trauma units between February 2006 and 2009. This subgroup of patients was identified using the Fractures Outcome Research Database (FORD). Demographic data, implant type, operative details, duration of surgery and level of operator were collected and presented. Post-operative X-rays were assessed for accuracy of reduction.

One hundred and twenty two (122) patients were identified as having a subtrochanteric fracture treated by IM nailing. There were 79 females and 43 males. Age range was 16 to 93 (mean 78). 95 (78%) cases were performed by training grades and 27 (22%) by consultants. Duration of surgery ranged from 73–129mins (mean 87mins). 47 patients (38.5%) were found to have a suboptimal reduction and 75 patients (61.5%) had an anatomical reduction on immediate post-operative x-ray. One year from surgery 73/122 patients were available for follow up. Of those patients with suboptimal reduction, 13/47 (27.7%) required further surgery. 8 required complete revision with bone grafting, and 5 underwent dynamisation. A further 6 patients had incomplete union. In the anatomical group, 4 patients underwent further surgery (5%). 3 required dynamisation and one had exchange nailing for an infected non-union. 3 patients had incomplete union at last follow up. 5/47 (10.6%) had open reduction in the suboptimal group compared to 25/75 (33.3%) in the anatomical group. Of the 27 cases performed by consultants, 13 (48%) were open reduction, compared to 17/93 (18%) by training grades.

This study has shown that inadequate reduction of subtrochanteric fractures, leads to increased rates of non union and ultimately implant failure. We recommend a low threshold for performing open reduction to ensure anatomical reduction is achieved in all cases.

Aims: To quantify the complication rate in Ilizarov surgery at an experienced Limb reconstruction Unit. Study Design: A retrospective study of prospectively collected data on complications. Material: Complications in 304 patients, treated between January 1998 and April 2001 were reviewed. Complications relating to the pin site, bones, joints, neurovascular structures, pain, mental status and mechanical failure of the frame were documented. Results: There were 103 complications (34%) in total. Twenty patients (6.6%) required IV antibiotics or curettage of a ring sequestrum. Forty- three (14%) experienced problems with non or delayed union, mal union, incomplete osteotomy, premature consolidation of regenerate or fracture through a pin site. Twelve (4%) developed neural problems in the form of nerve pain or permanent nerve damage. Twenty-one (6.9%) developed loss of joint motion sufþcient to stop distraction or as a permanent sequelae. One (0.3%) suffered from depression during treatment. Three (1%) required referral to a pain team. Despite re-useable hardware mechanical failure was represented by only 3 episodes (1%) of þne wire breakage. Conclusions: Analysis revealed no signiþcant difference between the calendar years and so represents a true complication rate. There was a signiþcant difference in the complication rate for frames applied for acute trauma, late trauma and elective surgery. The difference did not relate to time spent in the frame and seems to represent a separate variable. There was a disproportionate increase in complications for frames applied for upper limb pathology.

Aims: To establish the results of elbow arthrolysis for the post-traumatic stiff elbow. Methods: A retrospective review of 20 patients undergoing open arthrolysis of the elbow under brachial plexus block followed by continuous passive motion between 1994 and 2002. Results: Eighteen patients were reviewed independently at an average follow up of 35 months (6–84 months). The range of motion improved in all patients from a mean preoperative arc of ßexion of 59.7û (5û–85û) to a mean postoperative arc of ßexion of 99.3û (55û–120û). However, the range of motion achieved intra-operatively was rarely maintained at review. The greatest improvement was seen in those with the most severe restriction in movement preoperatively. A functional range of movement (30û–130û) was achieved in 14 patients (77.7%). According to the Mayo Elbow Performance Score, measuring functional outcome, 17 patients (94%) had a good or excellent result. Arthrolysis had the added beneþt of relieving chronic post-traumatic elbow pain in 10 patients (56%). We recorded no signiþcant complications and no evidence of contracture recurrence. Conclusions: The results of conservative treatment for elbow stiffness are often disappointing. Although open elbow arthrolysis can be technically challenging a functional range of motion is readily achievable. It has been shown to be a safe procedure with a high level of patient satisfaction.

Aim: To assess the functional and radiological outcome of AO wrist Arthrodesis using the AO wrist fusion plate.

Method: An 8 year, independent, retrospective, radiological and functional review was performed using The DASH (Disabilities of the Arm, Shoulder and Hand questionnaire) and the Buck-Gramcko/Lohmann outcome scores.

Results: Twenty-eight patients were reviewed. The two scoring systems correlated consistently in regards to the functional outcome. However, patients with systemic disease experienced problems completing the DASH questionnaire. Mono-articular arthritis was associated with an excellent/good outcome in 95% of cases. Results for patients with systemic disease were markedly worse. There was one case of plate breakage associated with a delayed union of the second MCP joint. There was a 100% union rate, no significant post-operative infections and no tendon ruptures.

Conclusion: The short to mid term clinical outcomes for the AO wrist fusion plate are encouraging and its use can be recommended in a variety of wrist pathologies.

Leg-length inequality is not uncommon following primary total hip arthroplasty and can be distressing to the patient. An excellent clinical result with respect to pain relief, function, component fixation, range of motion and radiographic appearance can be transformed into a surgical failure because of patient dissatisfaction due to leg-length inequality.

Postoperative leg-length discrepancy was determined radiographically for 200 patients who had had a primary custom total hip arthroplasty. In all cases the opposite hip was considered to have a normal joint center.

The femoral component was designed and manufactured individually for each patient using screened marker x-rays. A graduated calliper was used at the time of surgery to control depth of femoral component insertion. The transverse acetabular ligament was used to control placement of the acetabular component and therefore restore acetabular joint center.

Using this method 94% of subjects had a postoperative leg-length discrepancy that was 6mm or less when compared to the normal side (average, +0.38mm). The maximum value measured for leg-length discrepancy was +/−8mm.

We describe a simple technique for controlling leg length during primary total hip arthroplasty and propose an alternative radiographic method for measuring leg-length discrepancy.

Aim: To determine the clinical, functional and radiological results of triple pelvic osteotomy for DDH.

Method: An independent, retrospective review of 35 osteotomies, in 32 patients, with an average follow up of 48 months (4–48 months).

Results: 75% achieved excellent to good results in The Harris Hip Score. The centre edge angle improved significantly from 10° to 35°. 3 hips have required further surgery in the form of total hip arthroplasty. We had 3 cases of incomplete sciatic nerve palsy (8%).

Conclusion: On the basis of our results the Triple Pelvic osteotomy can be recommended for the treatment of acetabular dysplasia in adolescents and young adults.

Aim: To quantify the complication rate in Ilizarov surgery. This study establishes the complication rate for an experienced Limb Reconstruction Team composed of 3 surgeons, 2 specialist nurses and 2 physiotherapists involved with acute trauma, late trauma reconstruction and elective limb deformity cases.

Study Design: Retrospective analysis of prospectively collected data on complications.

Material: Complications in 304 patients, treated between January 1998 and April 2001 were reviewed. Complications relating to the pin site, bones, joints, neurovascular structures, pain, mental status of the patient and mechanical failure of the frame were documented.

Results: Of the 304 cases treated there were 103 complications (34%) in total. Twenty patients (6.6%) required re-admission for IV antibiotics or curettage of a ring sequestrum secondary to a pin site infection. Forty three patients (14%) experienced problems with non or delayed union, mal union, incomplete osteotomy, premature consolidation of the regenerate or fracture through a pin site. Twelve patients (4%( experienced neural problems in the form of nerve pain during distraction or permanent nerve damage. Twenty-one patients (6.9%) developed loss of joint motion sufficient to stop distraction or as a permanent sequelae of treatment. One patient (0.3%) suffered from depression during the period of treatment. Three patients (1%) required referral to the pain team. Mechanical failure of the frame was represented by three episodes (1%) of fine wire breakage despite re-useable hardware.

Analysis revealed no significant difference in complication rates between the calendar years. However, there was a significant difference between complication rates in frames applied for acute trauma, late presentation of trauma, and elective surgery. This difference did not appear to relate to time spent in the frame, and therefore seems to represent a separate variable. There was a disproportionate increase in complications in Ilizarov frames applied for upper limb problems.

Conclusion: This study provides a baseline for the commonly occurring problems associated with the practice of Ilizarov surgery in the United Kingdom and Ireland.

To maximise the long-term survivorship of any hip prosthesis it is important to recreate joint centre. Normal joint centre is determined by horizontal offset and vertical height of the acetabular and femoral components. In this study joint centre and horizontal offset were analysed in 200 consecutive patients operated on from October 1998 in whom the opposite hip was normal. Joint centre was defined relative to the acetabulum and femur both pre- and post-operatively. On the acetabular side a horizontal line was drawn across the pelvis immediately below each teardrop. A vertical line was drawn at right angles through the middle of each teardrop. Acetabular offset was defined as the horizontal distance from the vertical trans teardrop line to head centre. For femoral offset a screened x-ray was taken to show maximum offset. The anatomical axis was drawn and the offset was defined as the distance from the anatomical axis to head centre.

Our results show on the acetabular side there was an overall tendency to leave the joint centre medial and so decrease acetabular offset. However, we found that 90% of our sockets were placed within 6 mm of normal joint centre. We attribute this accuracy to the principle of visualising the transverse acetabular ligament intra-operatively and using this landmark to control depth of socket insertion. Conversely, on the femoral side there was a slight tendency to increase the offset. Nevertheless, 98% of the custom stems were within 10mm of normal joint centre. When we looked at total horizontal offset i.e. the combination of femoral and acetabular offset we found that joint centre had been restored to within 10mm in 93% of cases.

This study confirms the effectiveness of the custom femoral stem and Duraloc socket in restoring joint centre.