Introduction:

Mayo 2A Olecranon fractures are traditionally managed with a tension band wire device (TBW) but locking plates may also be used to treat these injuries.

We present a novel use for an adult proximal humeral locking plate. In our case an 18-year-old female with cerebral palsy sustained a peri-prosthetic fracture of a blade plate previously inserted for a femoral osteotomy. Treatment was revision using a long proximal humeral locking plate. She had a successful outcome.

We present the history and operative management.

The female had a history of quadriplegic cerebral palsy, asthma, diabetes mellitus and congenital heart disease. She had a gastrostomy tube for enteral feeding. She was on nutritional supplements, baclofen, Omeprazole and movicol. She is looked after by her parents and requires a wheelchair for mobility. She is unable to communicate. Surgical History: Right adductor tenotomy, aged 11. Femoral Derotation Osteotomy & Dega Acetabular Osteotomy, aged 13. Right distal hamstring and knee capsule release, aged 14. Admitted to A&E (aged 18); unwitnessed fall. Painful, swollen, deformed thigh with crepitus. Xrays demonstrated peri- prosthetic fracture below blade plate.

No specific equipment available to revise. Decision made to use PHILOS (Synthes, UK). GA, antibiotics, supine on table. Lateral approach. Plate removed after excising overgrown bone. Reduced and held. 10hole PHILOS applied. Near anatomical reduction. Secure fixation with locking screws proximally away from blade plate defect. Blood loss 800ml. 5 days in hospital. Sequential fracture clinic review. Wound healed well. Fracture healed on Xray at 11 months and discharged.

To our knowledge this is the first reported use of a PHILOS plate for this specific fracture. The complexity of this case and underlying neurological disorder deemed long blade plate revision unsuitable. Fracture rates after femoral derotation osteotomies rare. 5/157 and 1/58 in the two largest studies to date. Conservative measures were the main recommendation. We have demonstrated a straightforward method for revision fixation with an excellent outcome. It would be recommended as an alternative to other surgeons in this position.

The Exeter Stem (Howmedica, UK) has been in use for over 35 years. Over the years it has undergone several modifications with the most recent being a highly polished, tapered stem in 1986. The manufacturers quote a rate of 0.0006%. In the current literature there are 16 (or less) instances of fractures of the Orthinox stem.

We present a case of fracture of an Orthinox Exeter Stem 9 years after insertion.

Our patient, BB, presented, aged 62, with symptoms & signs consistent with OA right hip. THR was performed through a lateral approach utilising a trochanteric osteotomy. A size 0 37.5 stem was inserted. Radiographs were very satisfactory. She suffered a post operative DVT/PTE from which she recovered uneventfully. She was independently mobile at 6 month review and was discharged at the 2 year stage pain free.

Aged 71, BB presented to outpatient clinic with a several month history of generalised groin pain. She had a Trendelenberg gait. Considerable pain was experienced on axial compression of the limb. Radiographs revealed a midstem fracture with cement loosening proximally. No trauma was reported. She underwent revision surgery through a posterior approach. Acetabular component was rigidly fixed. This was revised to a pressfit Trident (Zimmer, UK) cup with screws & polyethylene liner. An extended trochanteric osteotomy was used to remove the broken stem. An uncemented Restoration (Stryker, UK) stem was inserted with a 28mm head. Post-operative recovery was unremarkable and at 6 months osteotomy has healed. The stem was sent to Stryker UK Laboratories for analysis. They reported the stem broke in fatigue with the origin on the antero-lateral surface. No material or manufacturing defects seen. Dimensionally correct. Fracture may be due to abnormal bending stresses secondary to proximal loosening and firm distal fixation.

Our case demonstrates a set of circumstances that led to inevitable fatigue and stem fracture. The method of failure should reinforce the radiograph appearances that may cause concern or be acted upon.

Olecranon fractures account for 20% of elbow fractures. Displaced fractures can be treated by several methods – Tension Band Wiring (TBW), Open Reduction and Internal Fixation with a plate (ORIF) or conservative measures. Studies from UK specialist centres have demonstrated infection rates of up to 15% and metal ware removal rates of up to 80%. In addition studies have shown that conservative treatment provides a good function and pain relief in the elderly and infirm.

We aimed to look at all displaced olecranon fractures within our unit over a 4 year period and analyse their case notes for patient features, age stratification, treatment methods, complications and outcomes. We also aimed to compare our results to outcomes in studies published by specialist centres.

All olecranon fractures admitted to our unit in calendar years 2007–2010 were identified from our trauma database. Case sheets were analysed for patient's age, co-morbidities, treatment, complications and outcome. X-rays were analysed to classify the fractures and assess outcome of treatment.

71 patients were identified, Male: Female = 33:38. Age range was 7–93, mean was 62.8 years. Treatment used – TBW 42 (59.1%), ORIF 9 (12.7%), and Conservative 20 (28.2%). In the surgical group of 51 patients there were 4 infections (7.8%). There were no incidences of nerve palsy. Metalware was removed in 15 patients (29.4%) – for TBW this was 11/42 (26.25%) and ORIF 4/9 (44.4%) – however the difference was not significant (p=0.06). The conservative group had no complications.

In our study group we have demonstrated a lower infection rate and a far lower rate of metal ware removal than published studies. We have a high rate of patients treated conservatively who do well. Further work is being performed into the functional outcome of the whole group.

Olecranon fractures account for 20% of elbow fractures. Displaced fractures can be treated by several methods – Tension Band Wiring (TBW), Open Reduction and Internal Fixation with a plate (ORIF) or conservative measures. Studies from UK specialist centres have demonstrated infection rates of up to 15% and metalware removal rates of up to 80%. In addition studies have shown that conservative treatment provides good function and pain relief in the elderly and infirm.

To look at all displaced olecranon fractures within our unit (the busiest district general hospital in Scotland) over a 4 year period and analyse for patient features, age stratification, identify treatment methods, complications and outcomes. To compare this to outcomes in studies published by specialist centres.

All olecranon fractures admitted to our unit in calendar years 2007–2010 were identified from our trauma database. Case sheets were analysed for patient's age, co-morbidities, treatment, complications & outcome. Xrays were analysed to classify the fractures and assess outcome of treatment.

71 patients were identified, Male: Female = 33:38. Age range was 7–93. Mean 62.8. Treatment used – TBW 42 (59.1%), ORIF 9 (12.7%), Conservative 20 (28.2%). In the surgical group of 51 patients there were 4 infections (7.8%). There were no incidences of nerve palsy. Metalware was removed in 15 patients (29.4%) – for TBW this was 11/42 (26.25) and ORIF 4/9 (44.4%) – however the difference was not significant (p=0.06). The conservative group had no complications.

In our study group we have demonstrated a lower infection rate and a far lower rate of metalware removal than published studies.?We have a high rate of patients treated conservatively who do well. Further work is being performed into the functional outcome of the whole group.

Displaced fractures of the neck of femur are routinely treated in the elderly by either cemented hemiarthoplasty, in the fit, or uncemented hemiarthroplasty, in the less fit. In Scotland the Scottish Intercollegiate Guidelines Network (SIGN) guidelines are followed to identify which patients should have a cemented prosthesis. This is based on cardiovascular status, and the age and fragility of the patient. An uncemented prosthesis should be a final operation. A peri-prosthetic fracture is considered a failure of treatment as the patient then has to undergo an operation with a far greater surgical insult.

We looked at all neck of femur fractures over a period of Jan 2007 to June 2010. The number of the peri-prosthetic fractures for uncemented hip hemiarthroplasties was established, and a case note review was carried out.

There was 1397 neck of femur fractures. 546 hemiarthroplasties were carried out, of which 183 were cemented, and 363 uncemented. 15 patients (4% of uncemented hemiarthoplasties) had peri-prosthetic fractures. There were no peri-prosthetic fractures in the cemented group, p = 0.004 using Fisher's exact test. The case notes of these patients were analysed. We found there was a common link of significant cardiovascular risk, lack of falls assessment (only 14% of the patients had a completed falls assessment and 21% sustained their fracture during an admission to hospital) and confusion (50% had a degree of dementia that caused significant confusion).

Cemented implants should be considered in all patients, especially those who are cognitively impaired or have failed falls assessments; even if the cardiovascular risk is significant. This decision should be made in conjunction with a senior anaesthetist. This is being implemented in our unit and a prospective audit is being carried out over the same time period (July 2010 to Dec 2013) to assess the benefit.

Low back pain admission to orthopaedics, aged >55, routinely received a myeloma screen (protein electrophoresis and urinary Bence Jones proteins). Myeloma association guidelines outline the symptoms that should trigger investigation. Acute admissions for back pain alone do not form part of this.

We aimed to establish the number of emergency back pain admissions, >55, in our unit over two years. We wished to identify all patients who had protein electrophoresis and/or urinary Bence Jones proteins taken, the number of positive results and diagnoses of myeloma.

From our database all patients >55 admitted with back pain in 2009 and 2010 were identified. Using the electronic laboratory reporting system we recorded FBC/ESR/Electrophoresis/Urinary Bence-Jones Proteins.

There were 7682 admissions from January 2009–December 2010. 87 were for back pain (1.4%). 55 patients were aged >55 years. Within this group – 22 had protein electrophoresis and 23 had Bence-Jones Proteins. All were negative. 36 patients had an ESR taken, 9 were elevated. None were subsequently found to have haematological malignancy. 53 patients had an FBC taken (5 were anaemic, 8 had leucocytosis and 3 had thrombocytopenia). 20 patients had a vertebral fracture (36.4%). There were no documented cases of myeloma.

The Information & Statistics Division of NHS Scotland published figures that demonstrate in 2006–2010, in patients > 55, there were 716 new cases of myeloma in the West of Scotland. Extrapolating this to our unit, on average, we would expect 24 new cases / year in this age group from all presentations. Performing myeloma screens on all back pains does not fulfil recognised screening criteria. We propose myeloma screens are not performed routinely in patients >55 admitted with back pain. It would be reasonable to do so where there is evidence of bone marrow failure, or plasmocytoma on Xray, associated with non-mechanical back pain.

Background

Back pain is a common orthopaedic problem which results in hospital admissions in severe cases. The aim of our study was to identify the reasons for back pain admissions and role of further investigations in the treatment of severe back pain.

Background

Nerve Root compression can lead to severe back pain. Different risk factors like high BMI, smoking, alcohol and psychological history have been identified. The aim of our study was to identify if the incidence of these risk factors was higher in patients with nerve root compression.

Displaced fractures of the neck of femur are routinely treated in the elderly by either cemented hemiarthoplasty, in the fit, or uncemented hemiarthroplasty, in the less fit. In Scotland the Scottish Intercollegiate Guidelines Network (SIGN) guidelines are followed to identify which patients should have a cemented prosthesis. This is based on cardiovascular status, and the age and fragility of the patient. An uncemented prosthesis should be a final operation. A peri-prosthetic fracture is considered a failure of treatment as the patient then has to undergo an operation with a far greater surgical insult.

We looked at all neck of femur fractures over a period of Jan 2007 to June 2010. The number of the peri-prosthetic fractures for uncemented hip hemiarthroplasties was established and a case note review was carried out.

There was 1397 neck of femur fractures. 546 hemiarthroplasties were carried out, of which 183 were cemented, and 363 uncemented. 14 patients (4% of uncemented hemiarthoplasties) had peri-prosthetic fractures. The case notes of these patients were analysed.

We found there was a common link of significant cardiovascular risk, lack of falls assessment (only 14% of patients had a completed falls assessment and 35% sustained their fracture during an admission to hospital) and confusion (43% had a degree of dementia that caused significant confusion).

Cemented implants should be considered in those who have failed falls assessment, or are confused; even if the cardiovascular risk is significant. This decision should be made in conjunction with a senior anaesthetist. This is being implemented in our unit and a prospective audit is being carried out over the same time period (July 2010 to Dec 2013) to assess the benefit.

Displaced fractures of the neck of femur are routinely treated in the elderly by either cemented hemiarthoplasty, in the fit, or uncemented hemiarthroplasty, in the less fit. In Scotland the Scottish Intercollegiate Guidelines Network (SIGN) guidelines are followed to identify which patients should have a cemented prosthesis. This is based on cardiovascular status, and the age and fragility of the patient. An uncemeted prosthesis should be a final operation. A peri-prosthetic fracture is considered a failure of treatment as the patient then has to undergo an operation with a far greater surgical insult.

We looked at all neck of femur fractures over a period of Jan 2007 to June 2010. The number of the peri-prosthetic fractures for uncemented hip hemiarthroplasties was established and a case note review carried out.

There were 397 neck of femur fractures. 546 hemiarthroplasties were carried out, of which 183 were cemented, and 363 uncemented. 14 patients (4% of uncemented arthoplasties) had peri-prosthetic fractures. The case notes of these patients were analysed. There was a common link of significant cardiovascular risk, lack of falls assessment, and confusion.

Cemented implants should be considered in those who have failed falls assessment, or are confused; even if the cardiovascular risk is significant. This decision should be made in conjunction with a senior anaethetist. This is being implemented in our unit and a prospective audit is being carried out over the same time period (July 2010 to Dec 2013) to assess the benefit.

Aims: Evaluate the outcome of orthopaedic intervention in children who sustained peripheral ischaemia resulting from meningococcal septicaemia and to assess the benefit of fasciotomies within this group.

Introduction: There have been only two published series on the orthopaedic management of meningococcal septicaemia in children. We carried out a retrospective review of all patients who had undergone this intervention in RHSC.

Methods: Between 1994 and 2004 there were 190 admissions to paediatric intensive care unit (PICU) with meningococcal septicaemia. 12 had significant Orthopaedic/Plastic Surgical input. Case notes were examined to establish admission patterns, limb progress, subsequent operative intervention and eventual outcomes.

All presented with vague viral symptoms and developed rapidly spreading purpuric rashes within 24hours. 8 children were admitted from A& E and 4 were transferred from other hospitals. All received antibiotics, fluid resuscitation, ventilation and inotropic support. One child died within 14 hours of PICU admission. Haemofiltration was used in 11 children (mean 14.8 days, range 2–60 days).

We were able to follow up 8 of the survivors clinically.

Results: All children had some form of surgical treatment. 9 children had one or more amputations. Two children did not require amputations. Seven of the 12 children had fasciotomies performed (mean 34 hours after admission, range 2–96 hours). The child who died from overwhelming sepsis had multiple fasciotomies at 9 hours post admission. The remaining children had varying amputations. The other five children did not have fasciotomies. Of these one child did not require any amputations, three children had partial amputation of a single limb and one child had partial amputations of two limbs. All five within this group required additional split-skin grafts.

8 children were followed clinically. 7 were mobile with walking aids with a mean of 1.3 prosthetic lower limbs (range 0–2).

Conclusion: There is no evidence from our study that early fasciotomies are detrimental to survival, limb function or subsequent wound healing after definitive amputation. In other published series fasciotomy has been advocated within 24hours.

In our study 2 of our 7 patients who underwent fasciotomy the demarcation level receded distally post decompression leading to more distal amputation levels.

Aims: To evaluate the outcome of open excision of the Acromio-Clavicular Joint (ACJ) in isolated Acromio-Clavicular Joint osteoarthritis and compare it with the published rates for arthroscopic intervention.

Introduction: Anectdotally this operation has been reported as very successful. There are no reviews of this particular operation in the literature. Arthroscopic excision has been advocated as being successful in > 90% of patients in repeated studies.

Methods: A two year period of theatre records produced a group of patients who had undergone this procedure. Case-notes were obtained and the patients with isolated ACJ were identified. Information on patient demographics, duration of symptoms, length of operation, operative complications and follow up were obtained. The patients were contacted and asked to fill out a DASH form. They were invited to a research clinic for clinical review.

Results: 31 patients with 32 isolated osteoarthritic ACJs were identified. Ratio of men to women was 22:9. Mean age at surgery was 48 years. Duration of symptoms before surgery was 105 weeks (mean). Mean time of surgery was 17 minutes. 80% were discharged from follow up by 4 months, mean follow up being 12 weeks. Complications were limited to 2 superficial wound infections. One patient did not have resolution of symptoms.

DASH score results were excellent in all bar one of those returned.

Conclusion: This simple operation has been shown to be effective in 96.9% of patients. The complication rate was 6.2%. Patient satisfaction is high.

These results are comparable to the best results of arthroscopic ACJ Excision.

Introduction: The aim was to evaluate the outcome of orthopaedic intervention in children who sustained peripheral ischaemia from meningococcal septicaemia and assess the benefit of fasciotomies within this group.

Methods: From 1994–2004 there were 190 admissions to paediatric intensive care unit (PICU) with meningococcal septicaemia. 12 had significant Orthopaedic/Plastic Surgical input. Case notes were examined to establish admission patterns, limb progress, operative intervention and outcomes.

All presented with viral symptoms and developed rapidly spreading purpuric rashes within 24hours. 8 were admitted from A& E, 4 transferred from other hospitals. All received antibiotics, fluid resuscitation, ventilation and inotropic support. One child died within 14 hours of PICU admission. Haemofiltration was used in 11 children (mean 14.8 days, range 2–60 days).

We were able to follow up 8 of the survivors clinically.

Results: All children had surgical treatment. 9 children had one or more amputations. Two children did not require amputations. Seven of the 12 children had fasciotomies performed (mean 34 hours after admission, range 2–96 hours). The child who died had multiple fasciotomies at 9 hours post admission. The remaining children had varying amputations. The other five children did not have fasciotomies. Of these one child did not require any amputations, three children had partial amputation of a single limb and one child had partial amputations of two limbs.. All five within this group required additional split-skin grafts.

8 children were followed clinically. 7 were mobile with walking aids with a mean of 1.3 prosthetic lower limbs (range 0–2).

Conclusion: There is no evidence from our study that early fasciotomies are detrimental to survival, limb function or subsequent wound healing after definitive amputation. In other published series fasciotomy has been advocated within 24hours.

In 2 of 7 patient, after fasciotomy the demarcation level receded distally leading to more distal amputation levels.

Aims: To evaluate the short to medium term outcome of the Souter-Strathclyde prosthesis when used as a primary elbow arthroplasty in rheumatoid arthritis.

Introduction: The Souter-Strathclyde prosthesis has been evaluated in several studies. In our hospital the operation is carried out using the same strict precautions as for lower limb arthroplasty. At the onset of surgery the ulnar nerve is handled minimally. This study looked at infection and complication rates, and also at outcome.

Methods: The operations were carried out in laminar flow theatres and scrubbed staff wore exhaust suits. At the start of the procedure the ulnar nerve was decompressed, but not mobilised from its bed, and held loosely with tape while being kept moist.

Cases were identified from theatre and implant records. 61 implants in 53 patients were identified. Complication and revision rates were established from case sheets. Of this group 19 patients had died, leaving 40 implants in 34 patients suitable for review. Case notes were analysed. Patients were contacted by post and were requested to fill out a DASH form. 30 patients (34 implants) responded; 2 declined to be involved leaving 31 implants in 28 patients to analyse, 78% of those available.

Results: From the 61 implants there were 4 complications within the first year; one ulnar nerve palsy – transient, one dislocated prosthesis – open reduction, two wound infections. The infection rate is thus 3.3%. Overall to date 4 implants from 61 required revision, a rate of 6.6% (range 13–92 months, mean 37 months). Reasons – one loose, two periprosthetic fractures and one infection. Mean follow up at clinic was 74 months (range 36–120). Mean DASH score at follow up was 48.7 (range 4.5–81.8)

Conclusion: The lower incidence of ulnar nerve palsy, compared to published studies, may be attributable to the surgical technique. The use of laminar flow theatres and exhaust suits may account for the lower infection rates. The complication rate and revision rate is favourable compared to previous studies.