Component malrotation in total knee arthroplasty (TKA) is a reason for early failure and revision. Assessment of possible component malrotation using computed tomography (CT) might be useful when other differentials have been excluded. The aims of our study were to determine the proportion of symptomatic patients with component malrotation on CT, and review the subsequent management of such patients.

A retrospective review of case notes was performed locally for all patients who had a CT scan for a painful TKA. Measurements of the femoral and tibial component rotations were done according to the standard Berger protocol, giving net degrees of either external rotation (ER) or internal rotation (IR). Any subsequent surgery was noted, and patients were followed up as per local practice.

Between 2007 and April 2012, 69 knees in 68 patients had CT scans. There were 25 males and 43 females, and mean age at primary surgery was 65.03 years. The mean femoral component rotation for all knees was 0.1° ER (range 7.0° ER – 6.7° IR), and the mean tibial component rotation for all knees was 19.1° IR (6.6° ER – 37.0° IR). No statistically significant difference was found comparing the mean femoral and tibial component rotations between patients with and without further surgery. Further surgery was performed on 39 (56.5%) knees.

Overall, there were ten cases (14.5%) of isolated femoral malrotation, 26 tibial malrotation (37.7%), and two cases (2.9%) had malrotation of both components. Out of these 38 cases, secondary surgery was performed in 22 knees (57.9%), of which a satisfactory outcome was achieved in fifteen cases (68.1%).

It is impossible to establish component malrotation as the only cause of pain following TKA, however, our study does show that the Berger protocol has its uses when other causes have been excluded.

Carpal tunnel syndrome is a common condition with a prevalence of 2.7% based on symptoms, clinical signs, and neurophysiology. The procedure to cure these patients, whether it is open or endoscopic, is usually successful in returning sensation, abolishing numbness and paraesthesiae, and improving manual dexterity. However, as many as 14%–32% of patients may have persistent symptoms

The general treatment of patients with recurrent carpal tunnel syndrome is re-exploration of the median nerve and neurolysis. Various procedures have been described to cover the median nerve with muscle or fat tissue. These include–external neurolysis, local muscle flaps, fat grafts and flaps, vein wrapping and synovial flaps. The outcome of secondary carpal tunnel surgery is only fair and many procedures are possible.

In 19 patients presenting with recurrent carpal tunnel syndrome over a period of five years, silicone sheath was used to cover the median nerve following neurolysis. All of these 19 cases were performed by the senior author (ASR).

We audited the results of this procedure using the carpal tunnel outcome instrument (Levine et al., 1993) for subjective assessment and grip strength, thumb key pinch force and two point discrimination sensation for Objective assessment. 17 patients were followed up for the purpose of this study. 2 were lost to follow up. Twelve patients were satisfied with their outcomes and were prepared to undergo the surgery again or recommend it to others (more than 70%). However, two were dissatisfied and three were uncertain of their feelings.

Background Hip fracture is a common clinical problem that leads to considerable morbidity and mortality in the United Kingdom. Recommendations in our hospital suggest that elderly patients suffering from these fractures should have surgery within two calendar days from admission.

Methods From August 2002 to July 2003, we studied 407 patients over the age of 65 who had a fracture of the hip. (Cases were recorded prospectively in our department trauma database). This was to determine the effect of operative delay and patients age on in-hospital mortality and on post operative length of stay. An operative delay was defined as an interval more than two calendar days between the time of admission to the hospital and the operation.

Results In 199 (47%) cases, operation was performed within two calendar days from admission. The in-hospital mortality rate was 11%. The mean length of stay was 17 days.

In the cases studied, neither the operative delay nor the age of the patient had a significant effect on the length of stay post operation.

There was an increase in the in-hospital mortality rate associated with the operative delay, although this was not significant statistically.

There was a statistically significant increase in the inhospital mortality rate with an increase in the patients age (5 % if less than 80 years old, 11% if between 80 and 89 years old, 19% if 90 years or older, p is less or equal to 0.05). In all three age groups the mortality rate did not statistically significantly decrease if the surgery was performed within two calendar days from admission.

Conclusion Early surgery is not associated with significantly improved in-hospital mortality rate. Early surgery is not associated with decreased length of stay. Age is a prime factor in predicting the in-hospital mortality rate. We recommend early medical input for patient optimisation to reduce the proven high mortality rate.