We aimed to investigate the treatment and outcome of patients over 65 years of age with tibial Pilon fracture. Patients were treated by primary open reduction and internal fixation or external fixation (EF) as determined by local soft tissue conditions. Patient course, incidence of radiological osteoarthritis and functional outcome using the SF-36 questionnaire were recorded. All patients were evaluated serially until discharge from final follow-up. The mean follow-up time was 28 months (12-45). Statistical analysis was performed using Analyse-it(tm) software for Excel.

In total 25 patients were studied. Two patients died before completion of treatment and were excluded from the final analysis. Therefore, 23 patients (10 male) were included with a mean age of 70.9 years (range 66-89) and a mean ISS of 10.25 (range 9-22). There were 4 grade IIIb open injuries.

Three patients suffered superficial tibial wound infection. Two patients underwent early secondary amputation due to deep bone sepsis within 8 weeks of injury. One patient in the ORIF group underwent primary arthrodesis, which was subsequently revised due to non-union. 3 patients underwent secondary bone grafting to enhance healing, performed at 2, 6 and 9 weeks. 2 patients with metal work failure underwent subsequent revision of ORIF and progressed to union; the mean time to union was 33.8 weeks. At final follow-up 7 (28%) patients had radiological features of osteoarthritis but none had symptoms severe enough to warrant ankle arthrodesis. There were significant differences from the USA norm in physical function score, role physical score, and physical component score, (p< 0.01).

We aimed to quantify the health related quality of life in a series of patients suffering a variety of different tibial injuries. Patients with previous tibial injury, randomly selected from our trauma database, who successfully completed their entire course of treatment at our institution, were recalled for final assessment. Mean time to final follow-up was 37.4 months. Statistical analysis was performed using SPSS computer software.

Overall, 130 patients were evaluated. There was no significant difference in the self-care dimension between the groups. Psychological problems were common in patients with IIIb and IIIc fractures, as well as amputees, with the highest incidence in those with IIIc fractures. Patients who had undergone amputation and those with IIIb open fractures reported problems with mobility significantly more frequently than those who had IIIc type injuries. However, this could be partially attributed to the significant difference in mean age between groups, with patients sustaining IIIc injuries being younger (31.9 vs 46.9). Patients with IIIb and IIIc type fractures reported significantly more problems with pain compared with those who had undergone amputation. Interestingly, patients who had undergone fasciotomy reported pain as frequently as amputees. Regarding the VAS, only patients with closed fractures reported significantly different scores from the mean of all the other groups.

These data represent the health related quality of life of patients having suffered the full spectrum of tibial injury and should be considered when determining the treatment options for these patients.

Introduction: A single hip screw is the recommended method of fixation for slipped upper femoral epiphysis (SUFE). Current practice favours the placement of the screw in the centre of the femoral head on both anteroposterior and lateral planes to avoid the risks of chondrolysis and avascular necrosis (AVN).

Aims: To investigate the correlation between different positions of the screw in the femoral head and the prevalence of AVN, chondrolysis, late slippage, and the time to epiphyseal closure.

Methods: The clinical notes and radiographs of 38 consecutive patients (61 hips), who underwent single screw fixation for SUFE, were evaluated retrospectively with a mean follow up of 36 months. Two way ANOVA and post hoc test was performed to analyse the correlation between the different variables and the outcome, at 5% significance level.

Results: There were 16 acute slips, 18 chronic slips and 10 acute on chronic slips. 17 slips were treated prophylactically. Mild slip was encountered in 39 hips, moderate in 4 and severe in 1 hip. Central-Central position was only achieved in 51% of cases. The most significant results of the study were as follows. I: No significant difference between the time to epiphyseal closure and the position of the screw. II. No late slippage or chondrolysis was observed in our series.

Conclusion: Our results showed that the position of the screw, other than in the centre of the femoral head, has the ability to provide physeal stability and has no correlation with the timing to closure of the epiphysis and the risk of avascular necrosis or chondrolysis. We therefore recommend that other positions be considered if the “optimal central-central position” is not initially achieved specifically for the treatment of mild SUFE as the potential hazards from several attempts to achieve the optimum position outweigh the benefits.

Purpose of study: A single dynamic hip screw is the recommended method of fixation for slipped upper femoral epiphysis (SUFE). Current practice favours placement of the screw in the centre of the femoral head on both anteroposterior and lateral planes. This study investigated screw placement in the femoral head for SUFE and the prevalence of AVN, chondrolysis, late slippage, and time to physeal closure.

Method: Clinical notes and radiographs of 38 consecutive patients (61 hips), who underwent single screw fixation for SUFE, were evaluated retrospectively with a minimum follow up of 24 months (24–56). Two way ANOVA and post hoc tests were performed to analyse the correlation between the different variables and the outcome, at a 5% significance level.

Results: There were 16 acute slips, 18 chronic slips and 10 acute on chronic slips. 17 slips were treated prophylactically. Mild slip was noted in 39 hips, moderate in 4 and severe in 1 hip. A central-central position was only achieved in 50% of cases. No significant difference between the time to physeal closure and the screw position was found. No late slippage, AVN or chondrolysis occurred in this series.

Conclusions: Our results demonstrate that positions of the screw, other than in the centre of the femoral head, provide adequate stability. There is no correlation between screw position and the time to physeal closure, the risk of avascular necrosis or chondrolysis. We recommend that positions other than the “optimal central-central position” be accepted if not initially achieved, especially for mild SUFE. The potential hazards from several attempts to achieve the optimum position outweigh the benefits.

Aims: To ascertain the efficacy of viscosupplementation with Supartz intra-articular knee injections when used in the absence of a specific protocol for its use.

Methods: Retrospective cohort study using data from a dedicated injection clinic, patient case notes and knee radiographs. Patients received the therapy in the absence of a protocol for its use. Patient’s age, gender, symptoms, walking ability, presence of deformity, medication history, previous injection or surgical intervention, physiotherapy, co-morbidity, date of presentation, delivery of course of supartz injections and indication were recorded. Knee radiographs were analysed using Kellgren and Lawrence grading system. Pain relief and avoidance of surgical intervention (when surgery was an option) were the outcome measures.

Results: 965 intra-articular injections in 193 courses of supartz therapy were given in 143 patients. 45.6% were male and 54.4% were female patients. At presentation, 33.2% patients were able to walk < 1/2 a mile, 35.2% patients 1/2-1 mile and 31.6% > 1 mile. Radiological assessment (using Kellgren and Lawrence grading) showed 2 cases with stage 1 disease, 83(43%) with stage 2, 102(52.3%) with stage 3, and 6 cases with stage 4 disease. The medial compartment was involved in 185 cases (95.9%), the lateral compartment in 44 (22.8 %) and patellofemoral joint (PFJ) was involved in 122 (63.2 %).

Pain relief was obtained in 84/193 cases (43.5%). In 122 cases where the aim was to avoid surgery, this was achieved in 52 cases (42.6%). Success rate decreased with increasing severity of disease (Fisher’s Exact test; p< 0.01). Only 25/122 cases with PFJ involvement had pain relief (21%), compared to 59/71 cases without PFJ involvement (83%), (Chi squared test; χ 2(1)=71.57, p< 0.01). Younger age (< 60 years) is a poor prognostic factor (Chi squared test; χ2(1)= 5.86, p=0.02).

Conclusions: Younger patients and those with PFJ involvement and advanced disease are unlikely to benefit from Supartz intra-articular injection. We consider it inappropriate to use this therapy in the absence of a protocol for its use.

Routine metalwork removal, in asymptomatic patients, remains a controversial issue in our daily practice. Current literature emphasized the potential hazards of implant removal and the financial implications encountered from these procedures. However, there is little literature guidance and no published research on current practice.

To estimate the current state of practice of orthopaedic surgeons in the United Kingdom regarding implant removal for limb trauma in asymptomatic patients, an analysis of the postal questionnaire replies of 36% (500 out of 1390) of randomly selected UK orthopaedic consultants was performed by two independent observers.

47.4% replies were received. A total of 205 (41%) were found to be suitable for analysis. The most significant results of our study I: 92% of orthopaedic surgeons stated that they do not routinely remove metalwork in asymptomatic skeletally mature patients. II: 60% of trauma surgeons stated that they do routinely remove metalwork in patients aged 16 years and under, while only 12% of trauma surgeons do routinely remove metalwork in the age group between 16–35 years. III: 87% of the practising surgeons indicated that they believe it is reasonable to leave metalwork in for 10 years or more. IV: Only 7% of practising trauma surgeons replied to this questionnaire have departmental or unit policy.

No policy is needed for metalwork removal, as most of the orthopaedic surgeons were complying with literature guidance supporting the potential risks associated with implant removal, in spite of the limited number of departmental or units’ policies on implant removal and the paucity of the literature documenting the current practice. However, there is a discrepancy among trauma surgeons in relation to metalwork removal between patient age groups. This indicates guidelines would be helpful to guide the surgeon for the best practice. This is important from a medico-legal standpoint because surgeons are being criticised for not achieving satisfactory results in negligence cases.

Introduction: The National Institute for Clinical Excellence (NICE), in its “Guidance on the Selection of Prostheses for Primary Total Hip Replacement”, states that a revision rate of 10% or less at ten years should be regarded as the “benchmark” in the selection of prostheses for primary Total Hip Replacement (THR). Furthermore, they state that evidence for this, in relation to a particular prosthesis, should relate to data from a number of centres, obtained via adequately sized, well conducted observational studies, preferably with consecutive patients from non selected populations. Aim: This paper presents the results of such a study for primary Charnley THR. Methods: All patients undergoing primary Charnley THR during 1990 where prospectively registered with the Trent Regional Arthroplasty Study (TRAS). During 1990, 1198 Charnley THRs were performed on 1152 patients, under the care of 56 consultants, in 18 national health service and 6 private hospitals. The cohort contains 39.0 % male and 61.0 % female patients, with an average age at operation of 69.1years (21–103 years). At 10 years all surviving patients at 5 years were registered with the ONS to ascertain living patients. These patients were contacted by letter to determine whether or not their THR had been revised. The status of the THR, for non-responding patients, was determined by contacting the patient’s GP through the Contractor Services Agency (CSA). Survival analysis was performed using life table analysis as described by Armitage and Berry and the endpoint was defined as revision surgery to replace an original implant component. Results: At 10 years, the recipients of 246 THRs had died. The recipients of 86 THRs did not respond to the questionnaire at ten years. There was no follow–up data on 42 implants at both 5 and 10 years intervals. Thus, implant status at five or ten years, in living patients was known for 910 of 952 (95.6%) THRs. The ten-year crude revision rate was 43 out of 1198 (3.59%) and cumulative survival rate was 95.4% (95% CI, 93.2% – 96.9%). Conclusion: This is the first study to assess the survivorship at 10 years for primary Charnley THRs performed in the “general setting“ of the NHS as opposed to specialist centres and shows a result well within the NICE benchmark.