Introduction: Crossed K-wires provide a stable fixation for supracondylar fractures of the humerus in children but are associated with a risk of iatrogenic ulnar nerve injury (≈5%). There is reluctance by many surgeons to use the medial approach and crossed K-wires because of the liability of ulnar nerve injury.

Aim: To assess the risk of iatrogenic ulnar nerve injury using the mini medial incision to reduce and stabilise displaced supracondylar fractures of the humerus in children with crossed K-wires.

Methods: We performed a retrospective evaluation of 26 children with closed Wilkins type IIB and III supracondylar fractures of the humerus, without vascular deficit, between January 1999 and April 2007. Mean age was 5.5 years (2.5–11 years). All were treated with open reduction and crossed K-wire fixation using a mini medial incision (5cm). Our modification is that we do not expose the fracture site or the ulnar nerve. It is a ‘feel’ rather than ‘see’ approach. The medial K-wire is placed under direct vision. All patients had early and late (4 months) post-operative ulnar nerve assessment. Patient outcome was assessed clinically using Flynn’s classification and radiologically using the metaphyseal-diaphyseal and humerocapitellar angles. Mean length of follow-up was 5 months (4–8 months).

Results: There was no post-operative ulnar nerve injury. Clinically and radiologically there were 23 excellent and 3 good results.

Conclusions: The mini medial incision is simple. It provides an excellent view for correct medial pin entry; hence it reduces the risk of iatrogenic ulnar nerve injury. Crossed K-wires provide a stable and reliable fixation.

Introduction: Idiopathic Adhesive capsulitis [IAC] of the shoulder is a self limited condition that can cause significant morbidity. Most patients (90%) respond to conservative management and those who fails (10%) undergo manipulation under anaesthesia (MUA) Patients who are refractory to both treatments, benefits from arthroscopic capsular release.

Aim: To assess the efficacy of arthroscopic capsular release in patients with IAC refractory to physiotherapy and MUA. Also to compare the clinical outcome between arthroscopic capsular release and MUA.

Materials and methods: We studied 59 patients with IAC, divided into 2 groups. Group A [36patients] had MUA and Group B [23 patients] underwent arthroscopic capsular release. The mean age was (54years).

The mean follow up was 21 and 9 months for group A and B respectively.

Results: We assessed our results according to three parameters:

Final outcome using the Constant and Murley score. The improvement in the score averaged 42 and 47 points in group A and B respectively

Conclusion:

Patients with IAC who fails to respond physiotherapy and MUA do well after arthroscopic capsular release with little operative morbidity.

Introduction: Hip arthroplasty represents a large consumer of resources in orthopaedic surgery. Although the need for follow up is universally accepted, there is much debate on the duration and frequency of outpatient visits. To date there is no evidence regarding the cost effectiveness of follow up.

There are no NICE guidelines for hip arthroplasty follow up. 90% of hip arthroplasty failures do so after 5 years. Joint replacement review is performed by a variety of personnel including orthopaedic surgeons, surgical care practitioners (SCPs) and extended scope practitioners (ESPs). Patients are reviewed in an outpatient clinic or by questionnaire.

Methods: A questionnaire was sent out to orthopaedic surgeons working in the Sandwell and West Birmingham Hospitals Trust enquiring about their practice for following up patients who have had hip replacements. Information regarding the length of follow up, frequency of visits and the use of check radiographs was recorded.

Results: The mean length of follow up was 28.8 months. (12–60 months). The mean number of visits in the first year was 3.9. (3–4). The mean number of total visits was 6. (4–9). The mean number of check radiographs performed in the first year was 2. Mean total number of check radiographs performed was 4. The mean cost for each patient is 590 pounds. (224–896 pounds).

Discussion: There is considerable variation in hip arthroplasty follow up with ensuing cost implications.

Guidance is required for the appropriate review, which will allow early detection of complications in an efficient and cost effective manner.

In our trust a protocol has been suggested for the follow up of hip arthroplasty by ESPs and SCPs.

To compare outcome between the medial and posterior approaches for the surgical treatment of supracondy-lar fractures when performed by two experienced surgeons.

A retrospective analysis of 45 children, mean age of 5.5 years (2.5-11 years), treated for closed Wilkins IIB/III supracondylar fractures without vascular deficit between January 1999 and December 2004. Twenty-one and twenty-four children were treated using the medial and posterior approaches respectively. The medial approach is quicker but technically demanding. The posterior approach is easier but cuts through the intact posterior structures. In both groups the fracture was stabilised using crossed K-wires and the arm was immobilised in an above elbow backslab for 3 to 4 weeks. Follow-up was at 3 to 4 weeks, 3, 6, and 9 months, and at 1 year. The results were assessed clinically using Flynn’s classification and radiologically using the metaphyseal-diaphyseal and humerocapitellar angles.

There was no post-operative infection or redisplace-ment. Clinically, the medial approach gave 18 excellent, 2 good, and one fair result, and the posterior approach gave 21 excellent, 2 good, and one fair result (P> 0.50). Radiologically, the medial approach gave 18 excellent and 3 good results, and the posterior approach gave 20 excellent and 4 good results (P> 0.50).

We found no significant difference in outcome between the two approaches, both giving mostly excellent long term results. Each approach has its known merits and drawbacks. This type of fracture needs an experienced surgeon comfortable with his preferred approach.

Introduction: Tennis Elbow affects 2% of the general population. 90% respond well to conservative management. Different surgical options are available for the treatment of recalcitrant Tennis Elbow. One of the most simple is percutaneous lateral release.

Methods: Prospective analysis of 31 patients, who failed a trial of conservative treatment, and underwent a lateral release of the common extensor origin under local anaesthetic as a day case. The symptoms had been present for an average of 21 months. Patients were scored for pain, activity and satisfaction.

Results: Pain relief was achieved in 90.3%, patient satisfaction in 90.3% and a return to full activity in 93.5%. The results were good in 28, fair in 2 and poor in 1. Return to work was on average after 4 weeks.

Conclusion: It is a simple, safe and effective procedure. It should be offered at an earlier stage, in those who failed conservative treatment. If all other procedures are equally effective, it is logical to choose the simplest.

Introduction: Locked posterior dislocations of the shoulder, with humeral head defects are rare injuries. It constitutes less than 2% of all posterior dislocations of the shoulder and 60% are misdiagnosed. There have only been a few articles describing the treatment of such injuries either by bone graft or Mc Laughlin’s procedure.

Patients: The first patient is a 23 year-old who presented as a missed diagnosis three weeks after a seizure. The second is a 35 year-old male referred four weeks after a traumatic dislocation. The third is a 55 year-old, known epileptic, who was diagnosed on admission. CT scan revealed a locked humeral head against the posterior glenoid rim, with defects of 30%, 20% and 30% respectively.

Treatment: All underwent reconstruction of the defect. The first using freeze-dried allograft, the second and third using iliac autograft.

Results: Each patient was assessed using the Constant and Murley score. The first patient scored 76 points at 30 months, the second patient scored 95 at 12 months and the third scored 97 after 12 months post-operatively.

Conclusion: Early diagnosis is important in management and prognosis of such injuries. Using bone graft in the reconstruction of the humeral head defect restores the normal anatomy, rather than distorting it by using McLaughlin’s procedure.

Introduction: Diagnosis of rotator cuff tears by clinical examination and MRI is not always accurate. If the extent of the tear could be predicted pre-operatively, both the patient and the surgeon would be better equipped for the subsequent operation and rehabilitation.

Aim: To assess the accuracy of clinical examination and MRI in detecting the presence of rotator cuff tears.

Method and Results: Retrospective analysis of 86 patients with symptoms and signs of rotator cuff disease. All underwent clinical examination of the shoulder followed by an MRI scan. The diagnosis was confirmed intra-operatively.

Sensitivity of clinical examination for all tears was 69%, with a specificity of 64% and a positive predictive value of 80%. Individual sensitivities were as follows: grade I 50%, II 76%, III 100%. MRI had a sensitivity of 82.8% for all tears, specificity of 57% and a positive predictive value of 80%. Individual sensitivities: I 69%, II 90%, III 100%.

Conclusion: In some patients clinical examination remains uncertain, MRI is helpful but the diagnosis is not always reliable.

Introduction: The Royal College of anaesthetists in 2000 issued its recommendations about raising the standard in postoperative pain management.

It recommended that 100% patients should be satisfied with the management of their pain and any side effects of analgesic treatment.

We conducted this prospective study to compare effectiveness of combining local nerve blocks with PCA (patient controlled analgesia) morphine to PCA morphine only in controlling acute post operative pain among total knee arthroplasty patients.

Patients and Methods: Prospective study from January 2002 till November 2003.

It involves 50 Patients underwent total knee replacement.

Average patient age 71y (range 53–83y)

Patients divided into two groups: (A) – PCA (patient controlled analgesia) Morphine only and (B) – PCA

Morphine + local nerve Blocks

Data collected:

Pain score at 1,3,6,12,24 hrs after operation, Morphine used, Supplementary analgesia, Side effects (vomiting score), Patients satisfaction, Patients’ knee joint early range of movement and Patients average period of hospital stay.

Results: Optimum pain control was 94% in group B compared with 78% in group A

Side effects was seen in 30% in group B compared to 45% in group A

There was no difference in the knee joint early range of movement

There was no difference in the patients’ average period of hospital stay.

Conclusion: This study concludes that the pain relief, morphine usage, side effects and patient satisfaction are much better with PCA when combined with local nerve blocks than with PCA alone.

We recommend that more total knee arthroplasty patients should be offered local nerve blocks in addition to their standard anaesthesia.