Performing Bilateral Knee replacements simultaneously is a controversial issue with proponents on both sides of the argument. The advantages of simultaneous arthroplasties include the administration of a single anaesthetic, reduced hospital stay and consequent reduced costs. Reuben et al (J. Arthroplasty, 1998) reported a 36% reduction in hospital costs. Patients also have a quicker return to function and Leonard et al (J Arthroplasty 2003) reported a high patient satisfaction rate of 95%.

The primary disadvantages noted in previous studies include an increase in peri operative complications–both cardiac and pulmonary. An increase in mortality figures is perhaps the most serious complication recorded in some studies. Ritter etal (Clin. Orthop. 1997) reported a 30 day mortality rate of 0.99% in bilateral simultaneous TKA as compared to 0.3% in patients who underwent a staged procedure.

Our study comprised a total of 202 patients who underwent bilateral simultaneous total knee replacements at a District General Hospital in Harlow. Harlow is one of the centres involved in the multi centric trials for the PFC Sigma Knee System and is perhaps the only centre in the UK where bilateral simultaneous procedures are carried out in significant numbers. There were 103 males and 99 females. 12 of the patients had Rheumatoid arthritis. 45% of the patients were in the 71–80 years age group, 26% in the 61–70 years age group. The average age across the entire group was 71.3 years. 35% of patients had a BMI of 25–30, 23% a BMI of 30–35, while less than 5% had a BMI of greater than 40. Most patients (44%) were ASA grade 2. The 3 most common co morbidities included hypertension(85%), coronary artery disease(25%) and diabetes mellitus (12%). 90% of the patients had the procedure performed under a General Anaesthetic and Epidural. Tourniquet time ranged from 55–159 minutes. (average 96 minutes). The patella was resurfaced in all patients. Post operatively the average drain collection was 1200 mls(range 7002600mls). Average pre op Hb was 13.8 g/dl, the post op average being 9.7 g/dl. 71% of patients required blood transfusion after surgery (average 2.8 units). Average hospital stay was 12.4 days (range 5–38 days). 6 patients required HDU admission.

Complications: None in 60%; there were 3 deaths in the first 30 days(1.5%), 2 cases of pulmonary embolism(1%); 6 cases of Myocardial Infarction (3%). There were 14 superficial wound infections and 10 patients required wound washouts. An MUA was performed on 8 knees. 2 patients had Revision Knee replacements for infection.

These figures are comparable to those in published literature. We have found Bilateral simultaneous Total Knee replacements to be a safe procedure with quick return to function.

Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal fractures. Most intramedullary nails are designed for proximal and distal locking with screws. We describe our experience with the Brooker Wills femoral nail. This nail is unique as distal fixation is achieved with as transverse fixator deployed through slots in the nail, a concept first enunciated by deCamargo in 1952. The fins of the fixator pierce the distal cortex when deployed thereby conferring rotational stability. The entire nail (including the proximal and distal fixation devices) can be inserted through a single proximal incision in the skin.

We treated 17 patients with femoral shaft fractures using this system. 93% of the patients were males. Motor vehicle accidents accounted for 80 % of the fractures. Most fractures involved the middle third of the femur (54%), followed by distal third (33%) and proximal third (13%). 67 % of the fractures showed Winquist and Hansen Grade 3 or 4 comminution.

All the nailings were performed in the supine position. Static locking was done in 16 cases. Post operative weight bearing was individualized with 86% of the patients bearing full weight before the end of 16 weeks. The average time to full weight bearing was 14 weeks.

The mean time to union was 17.1 weeks, with proximal, middle and distal third fractures showing average healing times of 19, 15.6 and 18.8 weeks respectively. All the fractures united. There was one case of delayed union. Intra-operative complications included–inability to deploy the distal fixator in one case and unwinding of the reamer in another case. There was one case of superficial infection where a patient developed a sinus over the metallic fin of the distal fixation device, which had penetrated the cortex. This healed after the distal fixation device was removed. There was one case of proximal nail migration, but the fracture went onto union with some limb shortening.

Results were evaluated using the scoring system devised by Sanders etal (1991). The functional criteria in their scoring system include- knee flexion, presence of pain, femur deformity, walking distance, stair climbing and pre injury functional status. We achieved excellent results in 53% of patients, good- 27%, fair–13 % and poor-7%.

We feel that the main advantage of the Brooker Wills Nail is the ease of distal locking. This saves time and also leads to lower level of radiation exposure, as the image intensifier is sparingly used for distal locking. In fact, this nail is an attractive option in centres which lack an image intensifier. We achieved good results with this nailing system and feel that it is an acceptable alternative to other nailing systems with conventional locking systems with screws.

Carpal Tunnel Syndrome is the most common entrapment neuropathy encountered in clinical practice. Previous studies have suggested that the disease has a higher prevalence in the elderly(Stevens JC etal, Neurology 1988;) and that this sub group also tends to have a higher prevalence of severe CTS.(Seror P, Ann Hand Surg 1991; Bland etal, J Neurol Neurosurg Psychiatry). Surgical decompression of the median nerve is the treatment of choice with a reported success rate of between 53 and 97 %.(Katz et al, J Hand Surg 1998).

There has been some controversy regarding the effectiveness of surgery in elderly patients. The aim of our study was to evaluate the results of carpal tunnel release in patients over the age of 75 years at the time of surgery. A literature search revealed few studies carried out in elderly patients–Weber etal-(mean age 75 years), Porter etal (mean age 59.8 years) and Leit et al (mean age 79 years). The average age of our patient group (80.4 years) is the highest reported in literature so far.

We posted questionnaires to all patients who were over 75 years at the time of their surgery. There were a total of 49 patients (65 hands) operated over the last 10 years who belonged to this age group. We used the Brigham And Women’s Hospital Questionnaire devised by Levine et al. (1993). In addition, we added some questions to assess patient satisfaction with the procedure. 65% of the patients were females. The average age was 80.4 years.

The completed questionnaires were used to calculate the Pre and Post operative scores. The mean pre operative score was found to be 3.18, which improved post operatively to 1.8. (Scale of 1 to 5, with 1 being the best and 5 the worst). Importantly, although all symptoms improved, some such as pain and numbness showed a much greater improvement than grasping power. On the Visual Analogue Scale, pain scores improved from 6.4 to 2.3 post surgery. 82 % of patients had no scar tenderness, 12 % had mild to moderate tenderness, while 6 % reported severe scar tenderness. Overall 79% of patients showed improvement, 15 % felt that the surgery had made no difference, while 6% reported worsening of their symptoms after surgery.

Our study showed that 8 out of 10 elderly patients will improve after carpal tunnel release, though all symptoms are unlikely to improve. The symptom least likely to improve is weakness of the hand. The results of this study are important to counsel this sub group of elderly patients, so that they may take an informed decision on whether to proceed with the surgery.

Introduction The purpose of this study was to compare the time to union following acute shortening and subsequent lengthening versus Bone Transport using the Ilizarov external fixator.

Methods Eighteen patients with tibial non-unions (age range 26 to 63 years) were recruited between March 1995 and September 2001. Three subgroups of six patients each, were formed. Group 1 underwent Acute Shortening and subsequent Lengthening, whereas Group 2 underwent Bone Transport. Group 3 patients had defects < 1 cms but were still high energy injuries, therefore underwent application of a frame. This group was used as a comparison group. A proximal corticotomy was used for distraction osteogenesis. Bone grafting at the fracture or regenerate site was used if required to aid healing. All patients were followed-up to union. All three groups were similar for age, pre-injury health status including cigarette smoking. Ten infected non-unions were present. Most patients had at least two conventional operative interventions prior to referral to us for Ilizarov surgery. The mean bone resection in the Acute Shortening group (Group 1) was 4.6 cms and in the Bone Transport group (Group 2) was 5.9 cms. Patients in Group 2 had more procedures done before union was achieved. This included adjustment of frame/ reinsertion of wires to align transport segment for optimal docking and bone grafting at the docking/regenerate site. Four patients in Group 2 required bone grafting at the docking site compared to none in Group 1.

Results Eradication of infection and union was achieved in all patients with average time in frame being 12.1 months in the Acute Shortening group, 17.2 months in the Bone Transport group and 8.0 months in the Frame stabilisation group. Using Paley’s bone result evaluation system, an excellent result was achieved in all patients of all groups. However, patients in the Acute Shortening group had a shorter time to union and needed fewer procedures.

Conclusions We recommended that where feasible, acute shortening and lengthening is preferable to bone transport due to shorter union time and fewer procedures undertaken to achieve union. If this is not possible due to large defects, then a combination of acute shortening with transport to bridge the gap should be considered.

Data is collected prospectively on all patients undergoing total knee replacement at the Princess Alexandra Hospital in Harlow, as part of an on-going research programme. The database commenced in April 1994 and we will be presenting the details of 1114 patients who underwent total knee replacement between April 1994 and December 2000. The early outcomes will be discussed, as well as a particular emphasis on some groups, like simultaneous bilateral total knee replacements& total knee replacements in the elderly population. We will also present the details of the radiological component positioning in total knee replacements and comparison between the radiological alignment achieved between consultant grade and trainee grade surgeons. The effect of surgeon grade on component positioning was tested using factorial analysis of variance. The statistical analysis was performed using StatView4.0 software The main coronal alignment angle was 6.02 degrees and the mean sagittal tibial angle was 87.11 degrees. Our revision rates will also be discussed.

This study was conducted to assess the results in two subgroups:a) the effect of the PFC Sigma as compared to the PFC total knee replacement in lowering patella lateral release rates and b) the results of severe fixed flexion deformity correction with emphasis on some technical operative details.

Data is collected prospectively on all patients undergoing total knee replacements for an ongoing research programmer. As part of this project, we assessed the patella lateral release rate in 954 knees performed between April 1994 and January 2000.

Lateral release was reached in 55 out of 592 PFC knees compared with 25 out of 362 Sigma knees. The overall lateral release rate was 8.3%.

Using the Chi squared test, there is a statistically significant lower lateral release rate using the Sigma system and the study also demonstrated a low overall lateral release rate in our entire series. The biomechanics of the PFC Sigma system and some operative technical points will be discussed in the talk.

As regards the fixed flexion deformity group data was once again collected prospectively on the Knee Society Scoring form. The results are as follows:

Preoperative flexion deformity > 20 degrees = 53 knees, (Range 20 to 60 degrees),

Preoperative Mean Knee Score = 17.2,

Postoperative flexion deformity < 5 degrees=91%

Postoperative Mean Knee Score = 90.04.

These numbers and results are comparable to other large series and some technical operative details will be discussed in the talk.