We report a retrospective review of outcome after shoulder hemiarthroplasty for proximal humerus fractures. All patients managed with shoulder hemiarthroplasty for proximal humerus fractures between 1997 and 2008 were included. Clinical notes were reviewed and surviving patients completed postal Oxford Shoulder Score (OSS) questionnaires. Results were analysed to assess whether there was a difference in outcome for those above the age of 70 years. A total of 96 patients were treated during this period. Female to male ratio was 3.36:1 with mean age 72 ± 9.6 (45–93) years at time of fracture. At time of review 30.2% of patients were dead. Two patients were lost to follow-up after discharge. Complete case notes were available in 68 patients. Response rate to the OSS was 67.2%. There were 20 patients below 70 years and 48 patients above 70 years of age. The ASA grade was II in 60% of patients. Mean follow-up was 52 months. There were 2 in hospital post-operative deaths due to medical complications. Mean OSS was 27 (3–47) of a maximum of 48, with no significant difference between groups. Overall complication rate was 27.9%, with no significant difference between groups. Ten year survival was 96.9% overall with no significant difference between groups. There appears to be no significant difference in functional outcome, complication rate, or implant survival between patients below or above the age of 70 years treated with primary hemiarthroplasty for fracture of the proximal humerus. This procedure however carries a high complication rate in this group of patients.

Spinal anaesthetic (SA) with intrathecal diamorphine and general anaesthetic (GA) with blocks and/or patient control analgesia (PCA) are commonly used in hip and knee replacement surgery. Drop in blood pressure, feeling light-headed and drowsiness, itching are known early complications respectively. This causes delay in patient mobilization post operatively. Our study examines the use of a local anaesthetic infuser device (LAID) (pain buster pump) for post operative pain relief after total hip or knee replacement surgery.

Forty six patients (25) THRs and (21) TKRs were included in this study. Each were given a LAID which consisted of 0.25% bupivicaine infused at 4ml/hr via an elastometric pump over 48 hours. 100mls of 0.1% bupivicaine with 0.5mg adrenaline was infiltrated locally into the wound at closure. All patients were prescribed regular analgesic as per the multimodal pain regime and an hourly pain score maintained. Rescue opioids were prescribed if pain score crossed 5. Patient satisfaction score was recorded as excellent, some or no pain relief. Eleven patients were given general anaesthetic and 25 patients were given spinal anaesthetic.

26% were able to sit out of bed within 6 hours of surgery and 65% (30 patients) were sitting out by the first post operative day. Average length of stay was 6.15 days, decreased to 4 days for patients mobilised on day zero and compared to eight days prior to this study. 21% had excellent result, 29% had some pain and 6% had poor result. 90% needed oral rescue analgesia within the first 48 hours.

LAID allowed some patients to be mobilised within 6 hours of surgery. The use of LAID helps avoids the need for PCA or diamorphine and hence its associated complications though some amount of oral rescue analgesia was necessary. Patient compliance was satisfactory. The early results are encouraging and further studies are been conducted at our hospital.

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.

Delay in operative fixation of neck of femur fracture is associated with increased morbidity and mortality, and has reduced chance of successful internal fixation and rehabilitation. Apart from medical reasons, inadequate facilities or poor organization has also shown to delay neck of femur fracture patients going to theatre.

In the year 2005, the Orthopaedic Directorate of University Hospitals of Leicester formed a #NOF project group to look at achieving a mean 24 hour wait (from clinical fitness to surgery) for this group to get to theatre. This group identified the areas of deficiencies and suggested organizational changes to overcome these.

The salient changes effected by the group are as follows.

Assigning a dedicated #NOF ward where patients can be fast tracked from A & E, promptly assessed and pre operative management instituted.

These measures were implemented in total from June 2006.

As a result of these measures the mean time to theatre of fit #NOF patients increased from 35% in 2005 to 75% in 2007 and 90% for the first 6 months of 2008. The mortality decreased from 18.5% in 2005 to 13.2% in 2007 and 11.3% for first 6 months of 2008. Relative risk of death decreased from 123 in 2005 to 107.9 in 2007 and 79.8 for Jan – June 2008. Also percentage of patients staying longer in hospital decreased from 30.5% in 2005 to 19.3% in 2007 and 13.4% in 2008.

In conclusion, identifying deficiencies and re organization to over come them has resulted in a better service provision and decreased mortality rate in #NOF patients. This is also a model for other hospitals to follow to improve on their care of #NOF patients.

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: Arthroscopic stabilisation of shoulder joint for instability following a traumatic dislocation is gaining popularity. It has various advantages like being minimally invasive, causes minimal damage to the shoulder muscles, quicker rehabilitation, minimal loss of external rotation, and addresses the pathology. This can be performed using non-absorbable suture anchors to repair the Bankart’s lesion, which involves arthroscopic knot tying. Recently, devices, which avoid tying knots, and are absorbable, have been developed for arthroscopic shoulder stabilisation.

Aim: To evaluate the clinical results of arthroscopic Bankart’s repair using knotless, bio-absorbable suture anchor device.

Methods: A total of 32 patients with recurrent anterior dislocation of shoulder of traumatic origin underwent arthroscopic stabilisation using absorbable knotless suture anchors (Mitek U.K.). Average follow up was 2.4 years. Oxford shoulder instability score were used to evaluate clinical outcomes.

Results: The average age of patients at surgery was 24 (18–28). The average number of dislocations per patient were three. The average hospital stay was 1.1 days. The mean operating time was 70 minutes. 90.6 % (29 out of 32) had no further instability or dislocation. The recurrence rate was 9.4% (3 out of 32). The two redislocations required open repair and one patient has a residual instability. The average Oxford instability score was 22. All the patients returned to their pre-operative occupation. Of the 7 keen sportsmen, 5 returned to their contact sports at pre-injury level and 2 returned to their contact sports at a slightly lower level. In two cases we had breakage of anchor loop intraoperatively. Two patients had initial stiffness, which eventually resolved. No other complication was noted.

Conclusion: The clinical outcome of arthroscopic stabilisation of shoulder using knotless bio-absorbable suture anchors are good and are comparable to other methods of arthroscopic Bankart’s repair. The advantages are that the anchors are absorbable and there is no knot tying involved.

Economic evaluation of surgical procedures is necessary in view of emerging, often more expensive newer techniques and the budget constraints in an increasingly cost conscious NHS. The purpose of the study was to compare the cost effectiveness of open cuff repair with arthroscopic repair for moderate size tears. This was a prospective study involving 20 patients. Ten had an arthroscopic repair and 10 had an open procedure. Effectiveness was measured by pre and post-operative Oxford scores. The patients also had Constant scores done. Costs were estimated from the departmental and hospital financial data. Rotator cuff repair was an effective operation in both the groups. At the last follow up there was no statistically significant difference in the patients Oxford and Constant scores between the two methods of repair. There was no significant difference in the time in theatre, inpatient time, post-operative analgesia, number of pre and post-operative outpatient visits, physiotherapy costs and time off work between the two groups. The arthroscopic cuff repair was significantly more expensive than open repair. The incremental cost of each arthroscopic repair was £610 higher than open procedure. This was mainly in the area of direct health-care costs (instrumentation in particular). Health care policy makers are increasingly demanding evidence of cost effectiveness of a procedure. Such data is infrequently available in orthopaedics. To our knowledge there no published cost-utility analysis for the above said two types of interventions for cuff repair. Both methods of repair are effective but in our study open cuff repair is more cost effective and is likely to have better (lower) cost-utility ratio.