Introduction

Lower limb immobilisation with full casts is commonly used to manage fractures. There may be the need to split casts in an emergency, such as compartment syndrome, with no current consensus as to which technique is most effective in reducing pressure quickly. Our study aims to compare the reduction in pressure across lower leg compartments using three different cast splitting techniques.

Aims

Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England.

Ankle arthrodesis is the gold standard for treatment of end stage ankle arthritis. We analysed the data of 124 Ankle Arthrodesis (Open Ankle Arthrodesis (OAA) −27; Arthroscopic Ankle Arthrodesis (AAA)- 97) performed between January 2005 and December 2015 by fellowship trained foot and ankle surgeons in a single institution. Based on preoperative deformity (AAA- 28 degree valgus to 26 degrees varus; OAA- 41 degree valgus to 28 degree varus), they were subdivided into 2 groups based upon deformity more than 15 degrees. Union rates, time to union, length of hospital stay and patient related factors like smoking, alcoholism, diabetes, BMI were assessed.

Mean age of patients was 60 years (Range 20 to 82 years)(Male:Female-87:32). Overall fusion rate was 93% in AAA and 89% in OAA (p=0.4). On sub group analysis of influence of preoperative deformity, there was no difference in union rates of AAA versus OAA. 7 patients in AAA and 3 in OAA required further procedures. Average time to union was 13.7 in AAA and 12.5 weeks in OAA (p=0.3). Average hospital stay was 2.6 days in AAA and 3.8 days in OAA (p=0.003). Smoking, alcoholism, Diabetes, BMI did not have any correlation with union rates. Although both AAA and OAA showed good union rates, hospital stay was significantly shorter in AAA. A larger deformity did not adversely affect union rates in AAA. Time to union was higher in AAA though it was statistically insignificant. Lifestyle risk factors did not have cumulative effect on union.

We conclude that AAA is a reproducible method of treating end stage tibiotalar arthritis irrespective of preoperative deformity and patient related factors.

Objectives

The Attune total knee arthroplasty (TKA) has been used in over 600 000 patients worldwide. Registry data show good clinical outcome; however, concerns over the cement-tibial interface have been reported. We used retrieval analysis to give further insight into this controversial topic.

Introduction

Anterior knee pain is a common presentation of patello-femoral dysfunction and patients with this disorder represent a significant proportion attending a specialist knee clinic. There is an on-going debate as to the cause and best treatment for such patients. Previous studies on patella-femoral morphology have suggested patella maltracking plays an important part in the aetiology but there had been no studies correlating maltracking with articular cartilage change.

Treatment of the rheumatoid forefoot involves resection arthroplasty of the MTP joints of the lesser toes. This can either involve resection of the metatarsal heads or, as described by Stainsby: resection of the proximal phalanx. The Stainsby procedure is a well accepted technique, however despite this there is very little information on the outcome of this procedure.

PURPOSES

Previous studies on patella-femoral morphology have suggested patella maltracking plays an important part in the aetiology but there had been no studies correlating maltracking with articular cartilage change.

We report the results of a modified Fulkerson technique of antero-medialisation of the tibial tubercle, combined with microfracture or abrasion arthroplasty in patients under 60 with patello-femoral osteoarthritis.

All patients operated on between September 1992 and October 2007 were reviewed by an independent observer in clinic or by postal questionnaire, using the Oxford Knee Score, Melbourne Patella Score and a Satisfaction Score. Only patients with Outerbridge Grade 3 – 4 osteoarthritis of the patello-femoral joint were included. They were assessed pre-operatively with plain x-rays, MRI scans (as well as tracking scans in the last 10 years) and arthroscopically. All patients with tracking scans showed lateral subluxation of the patella.

The surgical procedure was a modification of Fulkerson's tibial tubercle osteotomy, with an advancement of 1-1.5 cms and a medialisation of 1.5 cms. The exposed bone of the patella and trochlea was drilled in the early cases and in the later cases an arthroscopic microfracture or abrasion using a power burr was carried out.

Between September 1992 and October 2007, 103 procedures were carried out in 84 patients, 19 patients having staged bilateral procedures. The mean follow up was 84 months (range 24 – 204 months). The mean age was 45 (range 26 – 59) and the female to male ratio was 7.6:1. 70 patients were reviewed giving a follow up rate of 82%. The mean Oxford Knee Score was 18.5 pre-operatively (range 3- 32) and 34.3 post-operatively (range 11- 47). The Melbourne Patella Score was 9.6 pre-operatively (range 3- 30) and 20 post-operatively (range 11- 30). Patient Satisfaction Scores were excellent (54%), good (29%), fair (8.5%) and poor (8.5%). 4 knees in 3 patients were converted to a patello-femoral arthroplasty, giving a 10 year survival rate of 96.1%.

This procedure offers an alternative to patello-femoral arthroplasty for younger patients with isolated patello-femoral arthritis.

We report the early results of a patello-femoral prosthesis with a more anatomical trochlear component than previously reported designs, and with a patella component, geometry and instrumentation that allows optimum tracking and coverage of the patella, prior to final fixation of the patella component.

The first 115 patello-femoral prostheses were implanted between April 2000 and October 2005, and were followed up in a Special Clinic by one observer, who was not the operating surgeon, using the Bristol Knee Score (BKS), and the Oxford Knee Score (OKS). 115 patello-femoral arthroplasties were performed in 86 patients, 28 bilateral procedures (24.3%). 20 (71%) of which were performed as a single procedure. There were 100 females and 15 males, a ratio of 6.6:1, with a mean age of 70.05 years. (range 57 – 79). There were 9 patients lost to follow up, giving a follow up rate of 89%. The mean period follow up was 36 months (range 12 – 78 months). The median OKS (maximum 12/60) was 40/60 pre-operatively (range 22-46) and 22/60 Post-operatively (range 12 – 38), and the BKS was 45 pre-operatively (range 35 – 65) and 85 post-operatively (range 55 – 100). The mean range of movement was 110° pre-operatively (range 90 – 120°), and 125° (range 90 – 130°) post-operatively.

There was 1 superficial wound infection. 2 knees were revised to total knee replacement for progression of arthritis. Four other patients had re-operations, 1 for bilateral subluxing patellae, 2 for soft tissue problems, 1 patient had a locked knee with displacement of the patella prosthesis, which was revised successfully.

Early results of the FPV prosthesis demonstrate, like other more recent designs, that there are fewer problems with mal alignment and mal tracking than with earlier prosthesis, giving 90% good or excellent results.

The purpose of the study was to investigate the outcome of Oxford medial unicompartmental knee replacement (UKR) in patients over 70 years old and also to assess their ability to kneel.

We identified from our prospectively collected knee database 90 patients (98 knees) undergoing Oxford medial UKR who were 70 years or older on the day of surgery.

Oxford Knee Scores (OKS) were collected pre-operatively and also post-operatively at the following intervals: 3 months, 6 months, 1 year, 2 years, 5 years and then annually after this.

The mean patient age at surgery was 73.2 years (range 70.2 – 84.3 years). The OKS pre-operatively had a mean of 35.8/60 (range 22-55) and improved to 23.6/60 post-operatively (range 14-34). Patient follow-up was 44.3 months and ranged from 12-111 months. Two patients were lost to follow-up, 1 was converted to a total knee replacement and 3 died of causes unrelated to the knee surgery. 91.7% of patients still had their original prostheses at last follow-up.

Forty percent of patients stated they were able to kneel pre-operatively which improved to 50.2% postoperatively. This was consistent throughout all the follow up intervals that were assessed. Specific kneeling score from the OKS showed no statistically significant change with a mean of 3.94/5 pre-operatively and a mean of 3.54 averaged over all the post-operative follow up intervals.

We conclude that medial Oxford UKR is a reliable operation in patients over 70 years old. Previous studies include a younger age group which potentially encourages the less familiar surgeon to use a UKR for the young active patient but continue with a total knee arthroplasty for the older patient. Our study suggests age should not be a factor when considering performing Oxford UKR. Ability to kneel is not altered significantly by UKR in this age group.

Introduction

Pre-operative urine screening is accepted practice during pre-operative assessment in elective orthopaedic practice. There is no evidence surrounding the benefits, effects or clinical outcomes of such a practice.

Introduction: Non-union occurs at a rate of 5–10 % following ankle and hindfoot arthrodesis, but the effect of early weight bearing on union rate in these patients has not been studied.

Materials and Method: We have looked at the union rate following ankle and hindfoot arthrodesis with an early weight bearing protocol in a single surgeon series between 2003 and 2008. Data was collected retrospectively on 108 patients with a total of 198 ankle and hindfoot joint arthrodesis.

Results: The non-union rate was 3.4% (9 in 154 joints) in the early weight bearing group and 18% (8 in 44 joints) in the late weight-bearing group. Union rate following revision surgery with bone graft was 100% in both groups.

Discussion: Early weight bearing following ankle and hind-foot arthrodesis has no adverse effect on the union rate.

Non-union is a potential complication following hindfoot arthrodesis and occurs at a rate of 5–10% as reported in the literature. Following the procedure, patients are usually kept non-weight bearing (NWB) for 6–8 weeks followed by protected full weight bearing (FWB) for further 6 weeks. Based on radiological and clinical evidence of bony union at 12 weeks patients are allowed to mobilise FWB without protection. The aim of this study is to evaluate the effect of early post operative weight bearing on the union rate, following hindfoot arthrodesis.

In this retrospective study data was collected on patients who had hindfoot arthrodesis from 2003 to 2008 by a single surgeon. Two post operative mobilisation protocols were used and the union rates were compared. Protocol 1: 6 weeks Non weight bearing (NWB), 3 weeks partial weight bearing (PWB), 3 weeks full weight bearing (FWB) in plaster. Protocol 2: 2 weeks NWB, 4 weeks PWB, 6 weeks FWB in plaster.

One hundred and twenty-nine hindfoot joint arthrodesis were performed in 73 patients. Non-union rate was 1% (1 in 95 joints) in early weight bearing group and 20% (7 in 34 joints) in late weight bearing group. Union rate following the revision surgery with bone graft was 100% in both groups.

Early weight bearing following hindfoot arthodesis is safe, provides a more comfortable mobilisation for the patient and has no adverse effect on the union rate.

Performing Bilateral Knee replacements simultaneously is a controversial issue with proponents on both sides of the argument. The advantages of simultaneous arthroplasties include the administration of a single anaesthetic, reduced hospital stay and consequent reduced costs. Reuben et al (J. Arthroplasty, 1998) reported a 36% reduction in hospital costs. Patients also have a quicker return to function and Leonard et al (J Arthroplasty 2003) reported a high patient satisfaction rate of 95%.

The primary disadvantages noted in previous studies include an increase in peri operative complications–both cardiac and pulmonary. An increase in mortality figures is perhaps the most serious complication recorded in some studies. Ritter etal (Clin. Orthop. 1997) reported a 30 day mortality rate of 0.99% in bilateral simultaneous TKA as compared to 0.3% in patients who underwent a staged procedure.

Our study comprised a total of 202 patients who underwent bilateral simultaneous total knee replacements at a District General Hospital in Harlow. Harlow is one of the centres involved in the multi centric trials for the PFC Sigma Knee System and is perhaps the only centre in the UK where bilateral simultaneous procedures are carried out in significant numbers. There were 103 males and 99 females. 12 of the patients had Rheumatoid arthritis. 45% of the patients were in the 71–80 years age group, 26% in the 61–70 years age group. The average age across the entire group was 71.3 years. 35% of patients had a BMI of 25–30, 23% a BMI of 30–35, while less than 5% had a BMI of greater than 40. Most patients (44%) were ASA grade 2. The 3 most common co morbidities included hypertension(85%), coronary artery disease(25%) and diabetes mellitus (12%). 90% of the patients had the procedure performed under a General Anaesthetic and Epidural. Tourniquet time ranged from 55–159 minutes. (average 96 minutes). The patella was resurfaced in all patients. Post operatively the average drain collection was 1200 mls(range 7002600mls). Average pre op Hb was 13.8 g/dl, the post op average being 9.7 g/dl. 71% of patients required blood transfusion after surgery (average 2.8 units). Average hospital stay was 12.4 days (range 5–38 days). 6 patients required HDU admission.

Complications: None in 60%; there were 3 deaths in the first 30 days(1.5%), 2 cases of pulmonary embolism(1%); 6 cases of Myocardial Infarction (3%). There were 14 superficial wound infections and 10 patients required wound washouts. An MUA was performed on 8 knees. 2 patients had Revision Knee replacements for infection.

These figures are comparable to those in published literature. We have found Bilateral simultaneous Total Knee replacements to be a safe procedure with quick return to function.

Introduction: Non-union is a potential complication following hindfoot arthrodesis and occurs at a rate of 5–10% as reported in the literature. Following the procedure, patients are usually kept non-weight bearing (NWB) for 6–8 weeks followed by protected full weight bearing (FWB) for further 6 weeks. Based on radiological and clinical evidence of bony union at 12 weeks patients are allowed to mobilise FWB without protection.

Aim: The aim of this study is to evaluate the effect of early post operative weight bearing on the union rate, following hindfoot arthrodesis.

Method: In this retrospective study data was collected on patients who had hindfoot arthrodesis from 2003 to 2008 by a single surgeon. Two post operative mobilisation protocols were used and the union rates were compared.

Protocol 1: 6 weeks NWB, 3 weeks partial weight bearing (PWB), 3 weeks FWB in plaster.

Results: 128 hindfoot joint arthrodesis were performed in 73 patients. Non-union rate was 2%(1 in 44) in early weight bearing group and 20% (4 in 16) in late weight bearing group. Union rate following the revision surgery with bone graft was 100% in both groups.

Conclusion: The union rate following hindfoot surgery significantly improves (p=0.01) with early post-operative weight bearing.

Purpose of Study: To assess the safety of our practice of Bilateral Simultaneous Total Knee Replacements.

Methods: We retrospectively reviewed 202 patients (404 knees) who underwent bilateral simultaneous total knee replacements using the DePuy PFC Sigma Cruciate Sacrificing Endoprosthesis between January 2000 and January 2006. There were 103 males and 99 females with an average age of 71.3 years (range 41–90 years) included. Indication for surgery was Osteoarthritis in 190 patients and Rheumatoid Arthritis in 12 patients. All patients were reviewed at 6 weeks, 1 year and then yearly post surgery.

Results: The average hospital stay was 12.4 days (range 5–38 days) with 6 patients needing HDUadmission post surgery. The average observed blood loss in the drains post surgery was 1200ml (700–2600ml) with an average drop in Haemoglobin of 4.1%, 71% of patients needed a blood transfusion post surgery. Two patients (0.99%) developed a deep vein thrombosis and 2 patients (0.99%) developed a pulmonary embolus.3 (1.48%) deaths were encountered in the immediate post operative period (within 30 days of surgery) and 6 (2.9%) patients suffered a myocardial infarct post surgery.14 (6.9%) patients developed a superficial wound infection of which 10(4.9%) needed a formal washout. 8(3.96%)knees needed a manipulation under anaesthesia for a poor range of movement, and 2(.99%) needed revision total knee replacement for infection.

Conclusion: Bilateral simultaneous total knee replacement is a safe procedure in our experience Complication rates observed comparable to published literature on the subject

Purpose of study: The aim of this project was to ascertain whether tibio-femoral joint space width (JSW) measured both on Schuss and full extension radiographic views were predictive and accurate relative to the articular cartilage findings on arthroscopy.

Methods & Results: The study was a prospective trial. The criterion for recruitment was knee pain indicative of arthritis that required arthroscopic assessment with a view to possible surgical management. Joint space narrowing (JSN) was assessed in the affected knee, in both the standing full extension and Schuss views. Joint arthroscopy was performed and each compartment area of the knee was calibrated and graded corresponding to the arthritic changes identified. In the 60 patients recruited, 61.7% were found to have grade 4 arthritic changes on knee arthroscopy. JSN in those with associated grade 4 changes on arthroscopy on either full extension or Schuss views was 75.7% and 78.4% respectively. However in 24.3% of those with grade 4 changes on arthroscopy no JSN was demonstrated on either full extension or Schuss views. Arthroscopic assessment of severe arthritic changes of the knee was significantly superior compared to the radiographic method (p< 0.05).

Conclusions: The findings suggest that despite narrowed JSW measured on either radiographic view being indicative of severe articular cartilage loss, neither view accurately predicts articular cartilage loss in less advanced cases. In cases of grade 4 changes and no JSN the sites of articular cartilage loss corresponded to sites that are less likely to be accurately represented on either radiographic view. Our findings suggest that knee arthroscopy may be better suited to identifying smaller patches of cartilage loss whose surface area may not be sufficient to cause JSN but may still cause symptoms. We suggest knee arthroscopy is indicated in patients with knee pain suspicious of arthritis but who lack obvious JSN on either full extension or Schuss views. This enables micro-fracture techniques to be used with the aim of attenuating disease progression, and offers a thorough lavage that may also provide symptom relief.

Introduction: Infection remains the single most important complication in elective joint replacement. 1.1% of patients suffer early deep infection and 10–17% of patients superficial infection [1]. Antibiotic prophylaxis has been used extensively in elective orthopaedic practice, approximately halving the post-operative infection rate [2]. Cefuroxime is almost universally used in the UK. However there is an increased incidence of multiple drug resistant bacteria within the environment in addition cephalosporin use and resistance is widespread [3]. Many patients are treated pre-operatively for urinary tract infections with cephalosporins, and a further group of patients are already colonised with cephalosporin resistant staphylococcus. We have previously shown that 8.1% of patients fall into one or other of these categories.

Methods: We present a prospective series of 630 serial elective orthopaedic admissions from all orthopaedic disciplines. We have examined notes and reviewed lab records in order to determine outcomes. The centre for disease control [4] definition was used for suspected infections, and confirmed with wound swabs. 48 cases were confirmed infectious from a suspected 142 cases meeting this definition.

Results: We found a positive correlation between previous urine infection, MRSA status, revision surgery, and diabetes and wound infection. Nearly 35% of bacterium cultured were cephalosporin resistant, and 12% demonstrated multiple antibiotic resistance.

Discussion: It is good clinical practice to provide antibiotic prophylaxis in joint replacement, but the blind use of cephalosporins in all patients does not make sense because of increased incidence of antibiotic resistant bacteria. We present evidence based guidelines for the use of antibiotic prophylaxis in elective orthopaedic surgery and empirical antibiotic treatment in patients with wound infection before culture results are available.

Introduction: An accepted treatment of lateral compartment osteoarthritis with valgus deformity is to correct the malalignment, and unload the affected compartment. Previous techniques have used large fixation plates to secure complete osteotomy sites. We present a prospective study using a novel incomplete opening wedge osteotomy, in treating lateral compartment osteoarthritis in active patients younger than 65.

Methods: We assessed all patients (n=26) who underwent opening wedge femoral osteotomy with Puddu plate fixation over a 5 – year period by one surgeon (PRA). All patients had long leg X rays and arthroscopic evaluation; revealing either grade 3 and 4 osteoarthritis within the lateral compartment; 11 secondary to lateral menisectomy, 4 to complex trauma to the lateral tibial plateau, the others were diagnosed with primary osteoarthritis. Pre operative and post-operative Knee Society and Oxford Knee scores and long leg X rays were used to monitor subjective and functional improvement.

Results: Patients had a mean age of 48, (mode 56); ASA of 1 (range 1–2); and BMI of 24 (range 20–26). Mean follow up time was 46.8 months (6–62 months). Results in table 1 show early benefits in post-operative pain and improved function scores, which were maintained to 42 months. All patients had radiological union by 3 months (2–8months). Plates were removed as a minor procedure in some patients at 8 months (6–18 months), and did not lead to loss of correction or conversion to total knee replacement within the study.

Subjective and functional progress was observed by using the Oxford Knee Score and the Knee Society Score, early results showed an improvement from in the Oxford Knee score from 54.4 (+/−5.7) to 27.2 (+/−4.7)*, and the improvement was maintained at 12**, 30**, and 62** months (*P< 0.002; **P< 0.005). The same pattern was repeated with the knee society score where a pre opetrative score of 53.9 (+/−4.8) improved to 87.6 (+/−6.2) at 6 months and was 82.4(+/−8.7) at 62 months.

No infections were recorded, or differences in pre and post-operative flexion were observed at 36 months (P< 0.005) in all patients. However, 3 patients required further manipulation to overcome post-operative stiffness. Plates were removed only for local discomfort, and follow up showed there was no loss of corrective angulation.

Conclusion: These results suggest using the puddu plate is an alternative to unicompartmental or total knee arthroplasty in young active patients with lateral compartment osteoarthritis, without significant morbidity.

Introduction The purpose of this study was to compare the time to union following acute shortening and subsequent lengthening versus Bone Transport using the Ilizarov external fixator.

Methods Eighteen patients with tibial non-unions (age range 26 to 63 years) were recruited between March 1995 and September 2001. Three subgroups of six patients each, were formed. Group 1 underwent Acute Shortening and subsequent Lengthening, whereas Group 2 underwent Bone Transport. Group 3 patients had defects < 1 cms but were still high energy injuries, therefore underwent application of a frame. This group was used as a comparison group. A proximal corticotomy was used for distraction osteogenesis. Bone grafting at the fracture or regenerate site was used if required to aid healing. All patients were followed-up to union. All three groups were similar for age, pre-injury health status including cigarette smoking. Ten infected non-unions were present. Most patients had at least two conventional operative interventions prior to referral to us for Ilizarov surgery. The mean bone resection in the Acute Shortening group (Group 1) was 4.6 cms and in the Bone Transport group (Group 2) was 5.9 cms. Patients in Group 2 had more procedures done before union was achieved. This included adjustment of frame/ reinsertion of wires to align transport segment for optimal docking and bone grafting at the docking/regenerate site. Four patients in Group 2 required bone grafting at the docking site compared to none in Group 1.

Results Eradication of infection and union was achieved in all patients with average time in frame being 12.1 months in the Acute Shortening group, 17.2 months in the Bone Transport group and 8.0 months in the Frame stabilisation group. Using Paley’s bone result evaluation system, an excellent result was achieved in all patients of all groups. However, patients in the Acute Shortening group had a shorter time to union and needed fewer procedures.

Conclusions We recommended that where feasible, acute shortening and lengthening is preferable to bone transport due to shorter union time and fewer procedures undertaken to achieve union. If this is not possible due to large defects, then a combination of acute shortening with transport to bridge the gap should be considered.