Introduction

Topical diclofenac has proven efficacy and safety in the management of osteoarthritic pain. Its therapeutic efficacy is dependent on its ability to deliver pharmacodynamically active concentrations to the underlying tissues in the affected joint. However, the disposition of topical diclofenac is not fully characterized, and no studies have been performed using diclofenac diethylamine 2.32% gel.

We report our early experience with distracting external fixation used to offload the hip after avascular necrosis (AVN) of the femoral head secondary to severe slipped upper femoral epiphysis (SUFE).

A case series of five patients treated in a tertiary centre is reported. Electronic case records and radiographs were reviewed. Data recorded included demographics, initial presentation, timing of head collapse, timing and duration of distraction and outcome including referral to adult arthoplasty services.

Mean age at presentation was 12 years (range 12–15). 4 were females. Initial treatment in 4 cases was a delayed cuneiform osteotomy and pinning, one patient underwent serendipitous reduction and percutaneous pinning. Mean duration to initial surgery was 10 days (range 5–16). All patients had femoral head collapse at a mean of 148 days from time of presentation. 2 patients required backing out of screws due to intra-articular protrusion. All patients underwent distraction at a mean 193 days from presentation. Average distraction achieved was 10 mm and duration of application was 125 days (range 91–139)

All patients experienced improvement or resolution of pain but persistence of poor function, characterised by fixed adduction and limb length discrepancy. 3 patients were referred to adult arthroplasty services.

This may be an effective treatment option for pain associated with AVN post SUFE. However, in our experience normal anatomy and function of the hip is not restored if performed after collapse of the femoral head. Consideration should be given to application of the distractor either at the time of initial fixation or prior to femoral head collapse. Authors believe that timing of the application of the distractor is critical for a successful outcome and recommend a prospective study with large numbers.

Blood loss following total hip replacement is a major contributor to increase morbidity and length of stay. Various techniques have been described to reduce its occurrence. We now follow a set protocol, combining rivaroxaban for thrombo-prophylaxis and tranexamic acid to reduce immediate postoperative bleeding.

Introduction:

Two-stage revision is a widely accepted and performed intervention for septic total knee arthroplasty (TKA), with an infection eradication rate exceeding 90% in most studies. The ‘2-in-1’ single stage revision has recently been reported to have favourable results.

The 8-plate (Orthofix, SRL, Italy) is a titanium extraperiosteal plate with 2 screws which acts as a hinge at the outer limits of the physis. It has been used for correction of both angular and sagittal deformity around the knee. To our knowledge this is the first study describing the use of 8-plates in leg length discrepancy (LLD) correction.

We aimed to evaluate outcomes of temporary 8-plate epiphysiodesis in LLD, and to assess the complications associated with its usage.

This retrospective study included 30 patients between 2007 and 2010 whom underwent 8-plate epiphysiodesis to address LLD.

Leg length measurements were recorded using erect full leg length scanograms and comparison made between pre-operative, interval and final scanograms. Any deviations of the mechanical axis were also recorded.

During the study period 34 epiphysiodeses were performed on 30 patients. There were 17 males and 14 females. The average age at the time of procedure was 10.7 years (range 3–15). Average time to final follow-up was 24 months (range 52–10). The average pre-operative LLD was 2.5 cm (range 1.5–6 cm). The mean overall rate of correction was 1.0 cm per year. The mean residual LLD at end of treatment was 1.1 cm (range 0–4.5 cm). Two patients experienced genu recurvatum deformity. This was associated with placement of distal femoral plates anterior to the mid-lateral line.

Based on our experience 8-plate epiphysiodesis is a reversible, minimally invasive procedure with reliable results in length correction. However, careful device placement is required to prevent deformity.

Introduction

Taylor Spatial Frame (TSF) has been designed to treat complex tibial, foot and ankle deformities using computer software. We have performed various osteotomies in combination with different soft tissue procedures, with the use of TSF.

Introduction

Revision knee arthroplasty is an increasingly common procedure and can be challenging in the presence of bone defects, ligament instability and soft-tissue deficiencies. Current treatment options in addressing tibial and femoral bone loss in the revision setting include cement, morselised or structural allograft, metal wedges and augments and custom or hinge prosthesis. The aim of this study is to describe our early experience using unique femoral and tibial metaphyseal sleeves as an alternate for dealing with significant tibial and femoral bone loss.

Current health economics forces the clinician to consider the cost of treatment. Currently in Fife Hospitals, all lower limb injuries likely to require operative treatment are admitted from the Accident and Emergency department on the day of injury. The aim of this investigation was to see if non-emergency trauma cases could be managed pre-operatively as outpatients to reduce costs.

We prospectively recorded all patients admitted with lower limb trauma excluding neck of femur fractures, requiring operative treatment over an eleven-week period. The senior author reviewed all patients and a clinical judgment was made as to whether the patient could have been safely managed as an outpatient pre-operatively.

61 patients met the inclusion criteria. Average age 41.8 (Range 8-66). The three most common fractures were 23(38%) ankle fractures, 15(25%) tibial fractures and 8(13%) femoral shaft fractures. 28(46%) fractures were deemed safe to have been managed preoperatively on an outpatient basis. 14/23(61%) ankle fractures were deemed safe to be discharged home. The average pre-operative stay was 1.38 nights (Range 1-4 nights).

By initiating a simple policy of allowing uncomplicated ankle fracture patients to wait at home and return on the morning of surgery it is possible to reduce inpatient occupancy by 64 nights per year in our department. At a cost of £518 per patient per night, this could result in a saving of around £33,000 in unnecessary overnight inpatient stays. In order to achieve this, clear clinical guidance for admitting doctors is necessary and further prospective research should be conducted into the risk/benefit of implementing this policy.

A single centre, prospective study of 196 closed tibial diaphyseal fractures treated by monolateral external fixation. Surgical management of all patients followed a protocol of the senior author (PBMT), with regard to technique and fracture reduction. Operations were performed by several different surgeons including the senior author. A definitive fixator was used as a reduction tool in 34 cases, and a separate fracture reduction device was used in 162 patients. Follow-up was in a dedicated external fixator clinic by the senior author until one year post-fracture healing. Fracture healing was determined by fracture stiffness measurements. 196 tibial fractures in 196 patients, average age 29 (range 12-80). 111 right sided and 85 left sided. 166 male and 30 female. 116 fractures due to low energy and 80 due to high energy.

Clopidogrel, an anti-platelet agent is used in the secondary prevention of ischaemic events in high risk patients. Recent studies suggest that there are no National guidelines on when to stop clopidogrel in patients with hip fracture. It is suggested that stopping clopidogrel and waiting up to 1 week or more before surgery may have adverse effects on the patient.

This study is aimed at identifying factors predicting outcome in these patients. All patients admitted to our unit in 2006 with proximal femoral fracture were included. Patients on clopidogrel were identified for further investigation. Demographic, perioperative and postoperative data including complications and death were documented.

Thirty one of 586 patients with proximal femoral fracture were on clopidogrel on admission. Mean delay to surgery was 8.4 days (range 2–16 days SD 2.5). The mean age was 81 years (64–97) with a male to female ratio of 1:2.4. Of the 31 patients, 8 (25.8%) had died at 1 year. The standardised mortality ratio was higher in patients less than 65 years old and lower in all patients over 65 years.

Significant predictors of death on univariate analysis at one year were spinal anaesthesia (p = 0.04), postoperative blood transfusion (p = 0.03), postoperative complication (p = 0.03) and delay to surgery (p = 0.03). There was a positive correlation between delay to surgery and developing a postoperative complication (Pearson’s correlation 0.33 p = 0.04). Multivariate analysis revealed that delay to surgery was the only independent factor predicting death at one year.

No evidence exists to suggest that clopidogrel should be stopped 1 week prior to surgery for proximal femoral fracture. Waiting for 1 week or more prior to surgery is directly correlated to developing postoperative complications and subsequent death at one year.

Background: Patients undergoing total knee arthroplasty (TKA) frequently require allogenic blood transfusion. The incidence of blood transfusion varies between 1.4 and 24.5% in the published literature.

Purpose of the study: In order to determine the incidence of allogenic blood transfusion in patients undergoing primary TKA at our centre, we performed retrospective analysis of prospectively collected data for all patients who underwent TKA between 1 April 2006 and 31 March 2008.

Material and Methods: 1488 eligible patients were categorized into two groups: those who underwent TKA in year 2006 (group I, n= 647) and in year 2007 (group II, n = 841), respectively. Patients with haematological diseases, coagulation disorders or with a known malignancy or infection were excluded.

Data were collected for haemoglobin levels (pre-operative, postoperative and predischarge), duration of operation, ASA grade, number of transfusions, use of tranexamic acid and suction drains with relevant clinical data including postoperative medical and surgical complications. Allogenic blood transfusions were administered according to hospital policy. The transfusion threshold was haemoglobin of 8g/dl or less or a symptomatic patient.

Results: The two groups were similar with respect to age, gender, ASA, BMI, duration of operation, pre and post-op haemoglobin and tranexamic acid usage. A significantly greater proportion of patients in group I required allogenic blood transfusion when compared to group II. (4.2% vs. 1.2%, group I vs. group II, p < 0.001; respectively).

In group I, the usage of suction drain was significantly greater when compared to group II (48% vs. 20%, group I vs. group II, p = 0.27 respectively). The medical complications in group I, included superficial wound infections (two patients), myocardial ischemia (one patient) and reversible acute renal failure (one patient), while in group II, one patient developed a superficial wound infection, which was treated with oral antibiotics.

Conclusion: A low rate of allogenic blood transfusion can be achieved by using tranexamic acid and minimising insertion of suction drains. To the best of our knowledge, we report the lowest rate of allogenic blood transfusion for primary TKA. Our data have important implications in the management of patients undergoing TKA.

Introduction: Intramedullary humeral nailing (IMHN) is appropriate for metastatic lesions and fractures as it stabilizes the whole bone and allows immediate mobilization. We report the results of a patient cohort with metastatic lesions/fractures treated by IMHN.

Methods: We included patients who were treated with IMHN between June 2001 and December 2007 for metastatic lesions/fractures. We noted the source of referrals, site of fracture/lesion, primary lesion, metastasis elsewhere, operative complications, post-operative patient satisfaction and pain control, fracture healing and post-operative survivorship.

Results: We identified 38 patients. The median age was 71 years (50–87). Four patients presented with lytic lesions involving more than 50% of cortical diameter while 34 patients had a fracture. 10 patients had pain in their arm for at least 2 weeks before presentation. Primary malignancies were breast (9), Non-Hodgkins B-cell Lymphoma (4), prostate (4), kidney (5), myeloma and lung (2 each), bladder, leiomyosarcoma and oesophagus (1 each) and unknown (9). There were 22 proximal, 13 midshaft and 3 distal humeral lesions. All had metastasis elsewhere in addition to the humerus except six. 12 patients were without co-morbidities. Senior grade surgeons operated on all the patients. There were no intra-operative complications. Post-operative complications included sepsis (2), frozen shoulder(1), elbow stiff-ness(1), pneumonia(2), and transient radial nerve palsy (2). Three patients developed a second fracture distal to the first one and had revision surgery. Post-operative pain control was satisfactory in 34 and unsatisfactory in 3 patients. Difficulty in pain assessment occurred in 1 patient with brain metastasis. 36 patients died, with median survival from date of surgery of 12 weeks (range 1 – 62 weeks). Two patients are alive 2.5 and 1.7 years after surgery. The median follow-up period by the orthopaedic outpatient department was 2 months (1–26.5) for 33 patients as 5 patients died with in two weeks of operation. At follow up; 9 fractures had healed, 17 were healing, 2 had not united, and 5 patients did not have x-ray at follow up.

5 Out of 8 patients, who died with in 4 weeks of surgery, had a combination of at least one co morbidity, one area of metastasis other than the humerus and were in - patients. There was no co relation between mortality and sex, age, type of tumour, or presence of metastasis.

Conclusion: IMHN for metastatic lesions and fractures is effective for pain relief and fracture healing. However a long IM nail should be used and the whole arm should be radiated. Deviations from these principles lead to 3 surgical revisions in our cohort of patients. Also one group of patient had a high mortality rate and in this specific group non-operative treatment should be thought about.

Introduction: Percutaneous in situ pinning of severe SUFE can lead to problems. We describe our technique and results for surgical dislocation to reduce severe SUFE.

Method: Ganz’s approach of greater trochanteric flip, safe dissection and surgical dislocation to preserve the femoral head blood supply was followed to anatomically reduce the femoral head. We have treated 16 cases in this way, but describe nine with a minimum follow up of 2 years. Their mean age was 13.6 years (9 to 16 years). All had severe SUFE with four acute on chronic and two unstable slips. Two were previously pinned and another had a partially fused growth plate. The mean follow up was 3.1 years (2.1 to 4.6 years).

Results: All patients had a good to excellent outcome. Their pre-operative deformity was 84 degrees (65 to 110) measured by AP and cross table lateral x-rays, CT or MRI scans. The average hip external rotation deformity was 70 degrees. Post operatively internal and external rotation and all other movements were similar to the contra-lateral uninvolved hip. None developed avascular necrosis (AVN) or chondrolysis

Conclusions: This technique is demanding but can give good results for severe SUFE.

Purpose: In order to determine the incidence of allogenic blood transfusion in patients undergoing primary total knee arthroplasty (TKA) at our centre, we performed a retrospective analysis of prospectively collected data for all patients who underwent TKA between 1 April 2006 and 31 March 2008.

Methods and Results: In 2006/2007 there were 650 primary TKA patients (group 1) and in 2007/2008 this increased to 841 (group 2). Allogenic blood transfusions were administered according to hospital policy. The transfusion threshold was haemoglobin of 8g/dl or less or a symptomatic patient. For transfused patients data were collected for haemoglobin levels (pre-operative, post-operative and pre-discharge), duration of operation, ASA grade, number of transfusions, use of tranexamic acid and suction drains, and relevant clinical data including post-operative medical and surgical complications.

In group 1 27 patients were transfused (group 1T) and in group 2 10 patients were transfused (group 2T). This was a significant reduction in allogenic blood transfusions (4.5% vs. 1.2%, p < 0.001). The two transfused groups were similar with respect to age, gender, ASA, BMI, duration of operation, pre- and post-operative haemoglobin and tranexamic acid usage. In group 1T, the usage of suction drains was greater than in group 2T (48% vs. 20%) although this was not statistically significant (p = 0.27).

Conclusion: This study indicates that a low rate of allogenic blood transfusion can be achieved by using tranexamic acid and minimising insertion of suction drains. To the best of our knowledge, we report the lowest rate of allogenic blood transfusion for primary TKA. Our data have important implications in the management of patients undergoing TKA, particularly with respect to the need to cross-match all patients.

The long term results of Total Ankle Arthroplasty still remain largely unsatisfactory and Ankle Arthrodesis remains the gold standard treatment for severe degenerative ankle joint disease resulting from trauma and other causes. We describe the method and results of ankle fusion performed with a single anterior midline incision using the standard AO T-Plate.

18 patients underwent fusion of the tibio-talar joint with this technique over the past 5 years with a follow up range of 10 months to 5 years (mean-19 months). Though the commonest indication was post-traumatic degenerative joint disease (this included 6 patients who had previous internal fixation), other causes included primary osteoarthritis, rheumatoid arthritis, neuro-pathic joint (Charcot’s) and failed arthrodesis with other

Methods: The mean age was 65.5 yrs (range 37–91). The patients were assessed clinically and radiologically. Mazur’s criteria was used to assess function and serial radiographs were reviewed to assess union.

There was radiological union in all 18 patients. Excellent clinical results were finally achieved in 16 (89%). Complications included persistent pain(1), delayed union(2), infection(2, including one deep) and 2 under-went removal of plate with good final result.

This technique is a modification of that described previously by Rowan and Davey. In our practice the plate is contoured to the surface of talus and the distal screws are directed more vertically towards the sustenaculum talus. We found it helpful to obtain more compression of adjacent surfaces.

With the use of an anterior T-plate not only a better stability in biomechanical terms is achieved, less dissection and better soft tissue cover of the metalwork help in overall patient satisfaction. Though we have performed ankle arthrodesis with different

Methods: with satisfactory results, with this particular technique we have achieved excellent results and radiological union in all our patients.

Dysplasia of the hip in children, characterised by a shallow acetabulum and a deficient coverage of the femoral head, generally causes altered biomechanics of the hip joint. A kinematic analysis on the individual and comparative spatial movement of the acetabulum with some of the pelvic osteotomy techniques is performed. The osteotomy providing greater correction in most of the parameters potentially leading to greater reduction in loading is the choice of the surgeon.

Adult saw bone hip models have been used. Points of reference have been carefully chosen and data has been obtained using the Polhemus Electromagnetic measuring system before and after the osteotomy. Five techniques (Chiari, Salter, Steel, Tonnis and Ganz) have been performed, parameters like the Centre-edge angle, Sharp’s angle, Acetabular Head index (Femoral head cover), translation and rotation in 3 planes have been analysed.

Results show an improvement in most of the parameters when the above pelvic osteotomies are performed. Centre-Edge angle improved by a mean (in degrees) of 7.4 (Chiari), 9.6(Salter), 16.9(steel), 28.4(Tonnis) and 31.0(Ganz). There has been marked increase in Femoral head cover with mean 24% with Tonnis and Ganz. Significant changes in rotational parameters in all 3 planes were achieved, particularly with Ganz and Tonnis techniques.

Traditionally acetabular dysplasia correction has been assessed in one or two dimensions by plain radiographs and true three dimensional movement of the acetabulum is difficult to assess with simple techniques. This study describes a simple and reproducible method to compare the various pelvic osteotomies and comparative effects these can produce on the kinematics of the hip joint. It is intended to extend this study to include kinetics to compare the forces and stress distribution changes caused by performing the above techniques and a larger study is recommended, based on this technique and the initial trend of results shown.

Introduction: The long term results of Total Ankle Arthroplasty still remain largely unsatisfactory and Ankle Arthrodesis remains the gold standard treatment for severe degenerative ankle joint disease resulting from trauma and other causes. We describe the method and results of ankle fusion performed with a single anterior midline incision using the standard AO T-Plate.

Material and Methods: 18 patients underwent fusion of the tibiotalar joint with this technique over the past 6 years with a follow up range of 10 months to 5 years (mean-19 months). Though the commonest indication was post-traumatic degenerative joint disease (this included 6 patients who had previous internal fixation), other causes included primary osteoarthritis, rheumatoid arthritis, neuropathic joint (Charcot’s) and failed arthrodesis with other methods. The mean age was 65.5 yrs (range 37–91). The patients were assessed clinically and radiologically.

Results: There was radiological union in all 18 patients. Excellent clinical results were finally achieved in 16 (89%). Complications included persistent pain(1), delayed union(2), infection(2, including one deep) and 2 underwent removal of plate with good final result.

Discussion: This technique is a modification of that described previously by Rowan and Davey. In our practice the plate is contoured to the surface of talus and distal screws are directed more vertically towards the sustenaculum talus. We found it helpful to obtain more compression of adjacent surfaces.

Conclusion: With the use of an anterior T-plate not only a better stability in biomechanical terms is achieved, better soft tissue cover of the metalwork help in overall patient satisfaction. Though we have performed ankle arthrodesis with different methods with satisfactory results, with this particular technique we have achieved excellent results and radiological union in all patients.

A prospective study of 196 closed tibial diaphyseal fractures treated by a monolateral external fixator is presented.

The patients were managed by a group of Surgeons including the senior author (PBMT), a definitive fixator being used in 34 patients, and a fracture reduction device in 162 patients. All the patients were followed up in an external fixator clinic by the senior author, and follow up continued for 1 year after the fractures had healed. Fracture healing was determined clinically.

There were 196 tibial fractures, with an average age of 29 years (range 12–80 years). 111 Fractures involved the right tibia, and 85 the left. There were 166 males and 30 females. 116 Fractures were deemed due to a low energy accident, and 80 due to a high energy injury. The most common mechanism of injury was football (75), a fall (52), a road vehicle accident (49), direct trauma (7), assault (4), and rugby (3). According to the AO classification system 33 were A1 fractures, 47 A2, 42 A3, 15 B1, 46 B2, and 7 B3. Time to fracture healing was 19 weeks on average (with a range from 9–87 weeks).

15 Fractures united with a deformity of more than 5⁰ in the coronal plane. One patient required a corrective osteotomy for a mal-united fracture. There were 279 pin track infections that required antibiotic treatment in 85 patients. 33 Pins had to be removed due to persistent infection. Of these patients 15 developed 32 ring sequestrae, but infection was settled by debridement under GA. 7 External fixators had to be removed early because of pin site infection. One patient developed a full blown osteomyelitis, which was treated with the Lautenbach irrigation and settled. There were 7 re-fractures, but all healed after further treatment. 5 Were treated in a POP cast and 2 were re-treated with another external fixator. There were 7 non-unions, but all eventually healed with further treatment with an external fixator.

The authors conclude that treating a closed tibial fracture with an external fixator is a viable alternative method of treatment.

Introduction: The purpose of this study was to evaluate the effect of preoperative oral ferrous sulphate supplementation on the haemoglobin status of a group of patients undergoing primary THA and the incidence of homologous blood transfusion in them.

Methods: The authors prospectively studied 107 consecutive patients scheduled to undergo primary THA. All the patients were given ferrous sulphate, 200mg twice a day for a minimum of 21 days, six weeks prior to their proposed operation. We excluded patients on medications that can interfere with iron metabolism.89 patients managed to complete the course. To aid compliance the investigators collected tablet bottles after completion of the course. Haemoglobin (Hb), Mean Corpuscular Haemoglobin and Mean Cell Volume was conducted at the start, on the day before surgery and the second postoperative day. The details for blood transfusion were also recorded. We compared these patients to control group of demographically similar 90 patients, who did not have iron supplementation.

Results: 19 patients (21%) were anaemic at the start of the therapy.72 patients had rise in their haemoglobin by a mean of 0.61 g. In the study group16 patients (18%) had a blood transfusion as compared to 23 patients (26%) in the control group. Patients with preoperative Hb above 13.5g did not require transfusion in both study and control group.15 patients in the study group increased their Hb above 13.5 gdl, and were likely saved from requiring a transfusion. The relationship between the iron status and blood transfusion requirement was not statistically significant.

Discussion: The incidence of preoperative anaemia is significant in patients undergoing THA. Ferrous sulphate therapy on its own did not reduce the blood transfusion requirement. Non-anaemic patients seem to benefit most with iron supplementation, in terms of avoiding blood transfusion. Combination of early screening, appropriate treatment pre-operatively and strict guidelines may help reduce the incidence of blood transfusion.

Introduction: The thumb metacarpophalangeal (MCP) joint dislocations in children are relatively uncommon and scarcely described in the English literature. The aim of this study was to report the clinical course and outcome of traumatic dislocations of the thumb metacarpophalangeal joints in children.

Materials and methods: We retrospectively reviewed a cohort of 37 traumatic dislocations of the thumb metacarpophalangeal joints in 37 children between 1990 and 2005. All patients were treated by five orthopaedic surgeons at a tertiary referral children’s hospital. The outcome measures included patient demographics, method of reduction and short-term outcome. The mean follow-up was 6 weeks.

Results: The mean age at injury was 7.3 years. These occurred predominantly in boys (78.3%) and were dorsal dislocations in 97.2%. Thirty-three presented acutely on the day of injury, while 3 within 1–2 weeks. Four patients needed open reduction with or without temporary stabilisation. Thirty-three had a closed reduction (under general anaesthesia-12, under ring block-5, under sedation-9 and without anaesthesia-7). All patients undergoing closed or open reduction under anaesthesia had 1–4 unsuccessful relocation attempts. Two of four open reductions revealed soft tissue interposition of volar plate and flexor pollicis longus. Post-reduction, the thumb was immobilised in a thumb spica or plaster for 2 to 3 weeks period. All gained good result. There were no infections, recurrent dislocation or gross stiffness.

Conclusion: Thumb metacarpophalangeal (MCP) joint dislocations in children are mostly dorsal and managed non-operatively in majority with satisfactory outcome. Irreducible dislocations may need open reduction due to volar plate and flexor pollicis longus tendon interposition.