Introduction

Patellar resurfacing is performed in more than 90% of primary total knee arthroplasties (TKAs) in the United States, yet far fewer patellae are resurfaced internationally. Multiple randomized controlled trials have shown decreased revision rates in patients with resurfaced patellas (RP) vs. non-resurfaced (NR). However, most of these studies showed no difference in patient satisfaction, anterior knee pain, or knee society scores. (Figure 1) Given uncertain benefits, the purpose of this study was to determine if the rates of patellar resurfacing have changed over the past 10 years worldwide.

Introduction

The original Charnley-type negative pressure body exhaust suit reduced infection rates in randomized trials of total joint arthroplasty decades ago. Modern positive pressure surgical helmet systems (SHS) have not shown similar benefit, and several recent studies have shown a trend towards increased wound contamination and infection with SHS use. The gown glove interface may be one source of particle contamination.

Introduction

Two randomised trials concluded cast type (above or below elbow) makes no significant difference in the re-displacement rate of paediatric forearm fractures involving the distal third of the radius. This has not, however, led to the universal use of below elbow casts. In particular we noted one trial reported significant re-displacement in 40% or more of cases, which was much higher than we would expect.

To review the radiological outcomes and need for re-manipulation of paediatric distal forearm fractures treated with closed manipulation under anaesthesia in our institution, in part for subsequent comparison with published results.

All forearm fractures treated at a specialist children's hospital in one year were reviewed retrospectively. Based on the methodology of one trial, we included all fractures involving the distal third of the radius, with or without an ulna fracture, which underwent closed manipulation. Outcomes were radiological alignment using existing radiographs and need for re-manipulation. Cast type was at the discretion of the treating surgeon. The radiological criteria for re-displacement were based on published methodology.

79 children underwent manipulation, 71 receiving above elbow casts and 8 below elbow casts. Radiologically 21% of injuries treated in an above elbow cast re-displaced (15/71) compared to 38% of those in below elbow plasters (3/8). In 2 cases the re-displacement was treated with re-manipulation.

The preference in our institution was clearly for above elbow casts in this injury pattern. The small number of below elbow casts in our series limits any comparisons. Our rate of re-displacement using above elbow casts was half that of one of the published studies, so the existing literature is not consistent with our experience.

Introduction

In 2011 the Scottish Government published national MRSA screening requirements. A comparison of Orthopaedic and ENT elective surgery intended to juxtapose a specialty known to take MRSA screening seriously with one that has little clinical concern with regards MRSA infection. ENT surgery parallels Orthopaedics in using implants and there potentially being MRSA colonisation at or close to the site of surgery. In Orthopaedics MRSA infection is infrequent, but implant infection with antibiotic resistant bacteria has a particularly poor prognosis. In ENT MRSA infection is rare and colonisation does not influence patient care.

Intra-operative fluoroscopy in thumb metacarpophalangeal joint arthrodesis has been recommended as a means of achieving optimal alignment more consistently. This is not our current practice. A patient attending dissatisfied with an arthrodesis in excessive flexion performed outwith our unit highlighted the potential for problems, and we therefore elected to review our own outcomes.

An evaluation of the alignment achieved in thumb metacarpophalangeal joint arthrodeses, to determine if current outcomes satisfactory or if fluoroscopic assistance should be considered.

Radiological review of alignment of thumb metacarpophalangeal joint arthodeses carried out by two Consultant Surgeons with specialist interests in upper limb surgery in a District General hospital. Cases were predominantly identified retrospectively from sequential review of operating lists. The radiological images were, or had been taken, as part of routine follow-up and were not standardised. The alignment was also assessed independently by a junior doctor with no involvement in the patient's surgical treatment and no knowledge of the intended alignment. Recommended positions for arthrodesis have covered a range from 0 to 30 degrees, so for the purposes of analysis that range was considered acceptable.

14 cases had an average fusion position of 18 degrees flexion (range 6 to 30 degrees). 6 underwent concurrent ipsilaterel trapeziectomy.

The series achieved satisfactory alignment radiologically without the routine use of intra-operative fluoroscopy.

Locking plate fixation in proximal humeral fractures has demonstrated good results tempered by a significant rate of loss of fixation. Reported rates of failure are typically around 10% of cases but can be 20% or higher. In addition large series are often made up of a diverse patient population, so we have chosen to focus solely on patients confirmed to have significantly reduced BMD who can be considered a subset at high risk of fixation failure.

Twenty-three patients (5 male, 18 female) with a proximal humeral fracture treated by locking plate fixation were confirmed on DEXA scanning to be osteopaenic (17), osteoporotic (4) or severely osteoporotic (2). Patients early in the series were reviewed retrospectively and recalled for an updated assessment where appropriate, and the remainder were followed prospectively. The average age was 66 years (range 49 to 82). Follow up was for an average of nine months following surgery (range 2 and a half to 28 months). 17 patients underwent surgery for acute injuries and 6 for established surgical neck non-unions.

Seven injuries were 2-part fractures, 12 3-part, 3 were 4-part and one a 2-part surgical neck non-union.1 plate failed due to complete loss of fixation within 2 months in a patient with severe osteoporosis and was treated with removal of metalwork. This was the only injury that failed to unite. Avascular necrosis occurred in three patients with two revised to a hemiarthroplasty. 1 patient had ongoing pain and underwent removal of the plate.

Our series demonstrated that locking plate fixation of proximal humeral fractures is associated with a low rate of fixation failure and satisfactory outcomes in patients with significantly reduced bone mineral density.

Surgical waiting lists have led to development of clinical priority access criteria (CPAC) for prioritisation of patients selected for surgery. Although introduced widely into clinical practice in New Zealand CPAC tools have not been validated. Reliability studies were therefore undertaken by the CPAC Evaluation Consortium.

Methodology Thirty eight orthopaedic surgeons practising in public hospitals were randomly selected to participate in a prioritisation exercise using computer administered clinical vignettes. Fifty vignettes were developed from the clinical histories of patients selected for total knee arthroplasty (15), carpal tunnel decompression (15) and miscellaneous orthopaedic procedures (20). These were prioritised using each of 3 priority tools producing scores between 0 and 100: visual analogue scale reflecting global clinical opinion (VAS), a generic point scoring system based on points assigned to 5 clinical domains (GOPC), and diagnosis-specific 5 point Likert scale of priority combined with a predetermined table of a range of scores for each diagnosis (ISS).

The extent of inter-surgeon variability was striking but significantly less for ISS than GOPC or VAS. This was entirely explained by the complication of a predetermined table. The other two tools were similar except that the inter centile gap was larger for the clinical opinion based tool (VAS).

As access to elective surgery is determined by a fixed financial threshold a reliable scoring system will ensure equity of access. This seems to be best achieved by using the Integrated Scoring System.