Open tibial fractures have traditionally been treated as surgical emergencies. However, the “golden eight hour rule” for emergent treatment of these injuries is based more on historic principles and in-vitro data.

A substantial number of open tibial fractures referred to our hospital from the peripheral referral units have transport times in excess of eight hours. These circumstances provide the source for the present study of the effect of delay in initial treatment on the final outcome in terms of infection, delayed union, non-union, malalignment and failure of fixation.

Between January 1998 and June 2001, 53 open tibial fractures were treated at our institution. The fractures were classified using the Gustilo classification. All patient had a minimum of one year’s follow-up. Patients were categorized into 4 groups based on the time delay from injury to surgery, namely those treated within 6 hours of injury, 6 to 12 hours, 12 to 18 hours and > 18 hours following injury. Following recognized methods of surgical toilet and wound debridement, treatment modalities included intramedullar nailing, external fixation and cast application.

There were 22 Grade 1, 22 Grade II and 9 Grade 3 open fractures. Twenty-three received treatment within 6 hours of injury, 10 between 6 to 12 hours, 6 between 12 to 18 hours and 14 at more than 18 hours following injury.

Forty three percent of cases with complications were in the group of patients treated within 6 hours of injury, 29% were in those treated between 6 to 12 hours, 7% were in those treated between 12 to 18 hours and 21% were in those treated at > 18 hours following injury.

27% of Grade I open fractures, 14% of Grade II fractures and 55% of Grade III fractures developed complications.

Our experience indicates that the incidence of complications correlates more with the severity of the injury rather than with time from injury to treatment. In spite of early treatment, fractures treated within 6 hours of injury developed more complications in our series. Delays of 6 to 18 hours did not reflect a proportional increase in incidence of complications.

We present the mid term results of 267, 3M Capital hip replacement performed in a single institution from 1991 to 1994. Patients were recalled back to clinic in April 1998 after the reported high failure rate of 3M hips. Fifty- nine hips were excluded from this study for various reasons.

Average follow-up was 68.8 months. Nine (4.2%) have been revised for aseptic loosening at the time of review and further 10(4.8%) of the stems are radiologically loose. There was no statistical significant difference between hips that failed, regarding grade of the operating surgeon, surgical approach: trochanteric osteotomy or Hardinge, or type of prosthesis used: monoblock (stainless steel) or modular (titanium). Acetabular wear rate, width of medial cement mantle or cancellous bone at level of neck at Gruen zone7, or stems with canal fill index less than 50%, 7 cm below the level of the collar also showed no statistical difference. Male patients had higher incidence of loosening (p=0.001) which was statistically significant. Both varus and valgus alignment of the stem had higher failure rate which was significant. We could no find any obvious reason for failure in 10 of the 18 patients. The stem was either in varus or there was an inadequate cement mantle in 8 of the failed hips on the initial postoperative radiograph. A feature of this study was high incidence of endosteolysis and debonding of prosthesis from cement in the failed cases.

The present series showed considerably lower revision and loosening rate of 3M stems compared to the published series, the reason for which is not clear. Only Palacos cement was used in this series, which may partly account for the lower failure rate. Surface finish of the stem leading to debonding of the prosthesis from cement along with different modulus of elasticity probably accounts for the higher rate. Technical failure is partly to blame for the higher failure rate.