Aim

To determine the effect of the use of radial extracorporeal shockwave therapy (rESWT) in the treatment of patellar tendinopathy.

There is currently wide variation in the management of patients who are anticoagulated with Warfarin and require urgent orthopaedic surgery. These form an important and significant group of patients, in terms of real numbers (at least 5,600 per annum in the UK).

A study was initiated with an audit of 34 patients presenting to the West Wales unit who were warfarinised at admission and required trauma surgery. Observations were recorded about their pre-operative management and the delay this caused in taking the patient to theatre. 6 months later, a similar group of patients were re-audited.

The mean delay to surgery in those patients in whom the INR was left to fall spontaneously was 5.5 days. Following administration of 1mg i.v. Vitamin K in those patients without cardiac valves, re-audit showed the mean delay reduced to 2.2 days.

Representations from at least 6 major specialties were considered and a consensus statement was derived. Standardised protocols, which hinge on whether or not the patient has or does not have a cardiac valve were devised. Vitamin K should not be given to those patients with a cardiac valve and early consultation with cardiology and anaesthetics is recommended, with consideration of referral to a specialist cardiothoracic unit. For those patients without a cardiac valve, 1mg of Vitamin K may be administered, repeated as necessary until the INR is less than 1.8. Intravenous Heparin should be provided in the interim whilst the patient is waiting for surgery. This is discontinued the morning of surgery and subcutaneous Heparin reinstated post-operatively. These recommendations have been trialled in the two units involved in the study and have been relatively safe and easy to implement.

We evaluated the use of bilobed acetabular components in the treatment of acetabular deficiency during revision and complex primary total hip replacements. 79 patients (83 hips) were operated upon between august 1990 and December 2005 64 patients were reviewed clinically and radiologically.7 patients had died from unrelated causes. 3 patients were followed up clinically and radiologically for one year and were doing well at their last appointments. 5 were lost in follow up. The mean follow up of patients was 5.5 year (range, 2–15 years). One patient was revised for aseptic loosening.

The average post operative Harris hip score was 94.9 (range 74–100) at the last follow up appointments of 68 patients. Two patients developed deep wound infection and one patient dislocated three months post operatively, treated with a constrained liner. At the latest follow up the cumulative survival rate for aseptic loosening with revision being the end point is 97% at 15 years.

These results support the use of bilobed of-the-shelf cups in the reconstruction of acetabular defects with intact anterior and posterior columns.

Aim: To review our practice of performing two-stage revision for infected total knee arthroplasty by using articulating interval prosthesis and short course parenteral antibiotic therapy

Patients and Methods: We included 70 patients treated by a single surgeon using a uniform protocol since 2001. All patients were planned to have two- stage revision for infected total knee arthroplasty with an articulating interval prosthesis made up of cruciate retaining femur and all poly tibia at stage one. All patients were given short course parenteral antibiotic therapy (5 days IV) followed by and 6 weeks dual oral therapy.

Results: The average age was 68 yrs at the time of first stage. Five patients required repeat of 1st stage procedure because of persistent infection. Twenty six (40%) patients opted not to have a 2nd stage procedure because of eradication of infection after 1st stage and good functional result with interval prosthesis. We had recurrence of infection in 6 patients after two-stage procedure at a mean follow up of 42 months. Four patients out of these six had multiple surgeries for infection before our two-stage protocol

Conclusion: Articulating interval prosthesis gives excellent function and also makes subsequent revision easier with well preserved soft tissue balance. It also takes pressure off on the time constraint for the 2nd stage and good number of them may not require a 2nd stage at all. Our results of recurrence are comparable with published literature evidence and we don’t think that prolonged parenteral antibiotics therapy is required provided adequate surgical debridement has been performed.

Introduction: Trochanteric bursitis is a common hip problem that can be refractory to treatment. The available modalities of treatment can be less effective. We evaluated the use of extra-corporeal shockwave therapy treatment for trochanteric bursitis.

Methodology: 22 patients with the clinical and radiological (in 6 patients) diagnosis of trochanteric bursitis were treated in a dedicated shockwave therapy clinic using Swiss dolocast radial shockwave therapy machine. 3 sessions of treatment were given one week apart, delivering 2000 impulses at 10 Hz at each session. Patients were evaluated prior to treatment, 3 months, 6 months and 12 months following their treatment. The visual analogue score (VAS) was used in all patients pre and post treatment. Hip disability and osteoarthritis score (HOOS) was performed post-treatment.

Results: Between December 2005 and November 2008 22 patients were treated for symptoms of trochanteric bursitis. There were 17 women and 5 men. The average age was 55.8 years (range 33–76 years). 6 patients had proven increase signal on MRI scan the rest were mainly clinical diagnosis and after a limited response to steroid injections. Their VAS improved from 10 to 5. Their post-treatment HOOS score averaged 255.

Of the 6 patients who had MRI proven increased signal 5 patients had significant improvement. The average improvement in the VAS was 10 to 2.3 and their HOOS scores were 349.2 (range 427–243).

Conclusion: Though the number of patients in this study is only 22 it seems that radial shockwave therapy treatment for trochanteric bursitis is promising, especially on those who have got high signal on MRI scans.

Purpose of study: This study assessed the current availability of “out of hours” MRI scans for patients who present with symptoms suggestive of cauda equina syndrome to trauma units across the United Kingdom (UK).

Methods: 98 trauma units in 212 hospitals across the UK were identified. Senior house officers and registrars were questioned about the availability of emergency MRI scans after 5pm and midnight and at weekends. All units responded to the survey.

Results: 88 of 98 units had an on-site MRI scanner. In 32 hospitals, an MRI scan could be obtained after 5pm. In only 27 hospitals was this possible after midnight. In 58 units (65%) of cases, consultant to consultant contact was required to arrange the scan. 67 units found it “very difficult” or “impossible” to obtain an MRI scan at the weekend producing a potential delay of 64 hours from presentation at 5pm on a Friday night to 9am on a Monday morning.

Conclusions: The availability of urgent MRI scans in cases of suspected cauda equina syndrome currently represents a “postcode lottery” across the UK. This may mean that patients requiring urgent surgical decompression face a significant delay in diagnosis. Delayed or missed cases of cauda equina syndrome have huge personal, social and economic impact. On-site MRI facilities, which are available 24 hours a day for such cases are recommended in all units receiving an acute trauma on call.

Introduction: Sacroiliac joint pathology can contribute to lowback pain and sciatica. Its frequency and significance is controversial.

Aims: The purpose of this study is to evaluate the incidence and clinical significance of positive SI joint pathology on MRI scans.

Methodology: 353 MRI reports and scans carried out over a one year period for backpain and sciatica were reviewed. Demographic data and clinical notes of patients who had positive SI joint pathology on MRI scans were analysed. Correlation between clinical suspicion of SI joint pathology and MRI findings was studied.

Results: 12 scans showed pathology in the SI joint, an overall incidence of 3.3%.8(66%) were males and 4(33%) females. Only 4(33%) of these patients had Plain Film abnormality. Average age of 41.2 years (33–54). One patient was known case of Ankylosing Spondylitis. Other positive pathology included oedema, sclerois and bridging osteophytes. Clinicians requested inclusion of SI joint in 43 patients. 8 of these were positive, an incidence of 18.6%. In 130 patients, the SI joints were imaged as routine. This yielded positive pathology in 4 patients (3%).

Conclusion: Our study concludes that 18.6% of patients who are suspected to have SI joint involvement clinically have positive pathology on MRI scans.

Routine inclusion of imaging of the SI joint as part of lumbosacral spine MRI for back pain and sciatica shows only 3% positive results.

SI joint should be imaged only if clinically suspected.

In a prospective study to evaluate the benefits of radial extracorporeal shockwave therapy (ESWT) in patients with longstanding chronic Achilles tendonitis. 34 cases of non-insertional Achilles tendonitis were treated in 32 patients, using radial shockwave treatment. Symptoms had been present for at least ten months and were resistant to conservative treatments. Patients received three shockwave sessions at weekly intervals. Evaluation was performed prior to treatment, at six weeks and three months after the final session. Patients completed a visual analogue score (VAS) for maximal pain (0–100), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot Scale and the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A).

At short-term review all patients reported an improvement in symptoms. The VAS fell from a pre-treatment value of 74 (+/−15) to 22 (+/−17). An improvement in the AOFAS from of 64 (+/−10) to a post-treatment value of 90(+/−7) was seen, and an average from 30 to 70 in the VISA-A score. No complications from the treatment were reported. Four patients previously listed for surgery have improved sufficiently to be removed from the waiting list.

Conclusion: Short-term results using ESWT for the treatment of longstanding non-insertional Achilles tendonitis are encouraging. Longer-term follow-up subsequent to this prospective pilot study is underway to assess if results are reproducible over a greater time period.

Introduction: Fractures of the neck of femur has a considaerable impact on the NHS and due to the elderly group of population it involves morbidity can be very costly. We assesed the outcome of trauma patients with these fractures after providing orthogeriatric care in our hospital.

Aim: 179 patients had been studied who had been managed in our hospital over a period of 18 months with hemiarthroplasty for displaced intracapsular fracture of the neck of femur. 104 patients had routine orthopaedic care and 75 patients had regular orthogeriatric care. All the complication were noted, analysed and compared with the national averages.

Methodology: This was a retrospective study-clincal notes of all patients who had hemiarthroplasty during the 18 month period were reviewed and a performa was completed.

Result: Total sample size was 179 patients(104 before and 75 after the introduction of orthogeriatric service) who had hemiartroplasty for the displaced intracapsular fracture of the neck of femur. The median length of stay being 16.5 days before and 20 days after. The medical complications before and after the introduction of this service were-Cardiac complication 4% before and 1% after, Chest infection 2% before and 1% after, DVT 2% before and 1% after. The Overall complication rate has been reduced from 41% to 18% and the one year mortality reduced from 16.34% to 12 with the introduction of orthogeriatric service.

Conclusion: We believe that the weekly ward round and a continued supervision by the orthogeriatric team is one of the factors in improving the outcome of geriatric trauma patients in terms of reduced morbidity and mortality.

Aims: Our objectives is to evaluate the functional outcome of tibial nailing in 29 patients operated at the South Birmingham Trauma unit in the period between 1992–1996. Methods: This is a retrospective study; all patients included had a tibial nail inserted for two or more years. Assessment was made by reviewing the notes, interviewing and examining the patients. A pro-forma was for each patient was collected covering various activities and outcomes. Results: The results showed that the majority of patients demonstrated a compromised activity level, both in their leisure activity and occupation. No statistical difference was observed between reamed and unreamed nails in their functional outcome measurements. Conclusions: Our conclusion that the functional outcome of tibial nailing is not as good as the anatomical restoration would predicts.

Aims: A prospective study to evaluate the beneþts of extracorporeal shockwave therapy (ESWT) in patients with chronic Achilles tendonitis. Methods: 34 cases of non-insertional Achilles tendonitis were treated in 32 patients, using radial shockwave treatment. Symptoms had been present for at least ten months and were resistant to conservative treatments. Patients received three shockwaves sessions at weekly intervals. Evaluation was performed prior to treatment, at six weeks and three months after the þnal session. Patients completed a visual analogue score (VAS) for maximal pain (0–100), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot Scale and the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A). Results: At short term review all patients reported an improvement in symptoms. The VAS fell from a pre-treatment value of 74 (±15) to 22(±17). An improvement in the AOFAS from of 64 (±10) to a post-treatment value of 90(±7) was seen, and an average from 30 to 70 in the VISA-A score. No complications from the treatment were reported. Four patients previously listed for surgery have improved sufþciently to be removed from the waiting list. Conclusion: Shortterm results using ESWT for the treatment of longstanding non-insertional Achilles tendonitis are encouraging. Longer Ðterm follow-up subsequent to this prospective pilot study is underway to assess if results are reproducible over a greater time period.

Aims: Thirty-three patients with condylar fractures of the middle and proximal phalanges were treated with internal fixation using self-tapping titanium lag screws. The results were studied prospectively and prognostic factors identified. Methods: The age range was 14–45 (mean 26 years). Five patients presented at more than five weeks post injury. Four patients had bicondylar fractures. The surgical technique, which utilises a lateral approach, is outlined. All surgery was performed by the senior author (DS), semi-electively, within five days of presentation. Patients were seen in the 4th postoperative day for mobilisation and protective splintage. Results: The results were satisfactory in the majority of cases. 21 patients had achieved a full range of movement when reviewed at six weeks and further eight at 12 weeks. The remainder were left with a flexion contracture of 10–35 degrees (mean 26). All patients achieved full flexion. All fractures healed and there was no loss of fixation. Conclusions: Internal fixation using a single lag screw through a lateral approach restores joint congruity, facilitates union and provides fixation stable enough to allow early mobilisation. Bicondylar and proximal phalangeal fractures had a poorer prognosis. Fractures presenting even at eight weeks can be taken down and reduced. Delay in fixation does not appear to influence the long-term outcome.