Introduction

Increasing numbers of elderly patients are being prescribed Clopidogrel, an anti-platelet agent for medical reasons. There are no international guidelines as to the management of patients with hip fractures on Clopidogrel in peri-operative period especially in relation to timing of the surgery. In Waterford Regional Hospital in Ireland, hip fracture surgery is deferred for 4 days and platelets are reserved for the operative/post-operative period, in case they have significant bleeding or an associated complication. We conducted a retrospective study on patients admitted over a period of 1 year.

Introduction

We propose that Total Hip Replacement with correction of fixed flexion deformity of the hip and exaggerated lumbar lordosis will result in relief of symptoms from spinal stenosis, possibly avoiding a spinal surgery. A sequence of patients with this dual pathology has been assessed to examine this and suggest a possible management algorithm.

Introduction

Elective Orthopaedics has been targeted by the UK Department of Health as a maximum six-month waiting time for operations could not be met. The National Orthopaedic Project was initiated as a consequence and Independent Sector Treatment Centres (ISTCs) and well established private hospitals were utilised to treat NHS long wait patients.

Fracture neck of femur with delayed presentation in young patients can be a surgical challenge. Such scenarios are rare in the developed world but not uncommon in developing countries.

To present the medium term results of open reduction and internal fixation accompanied by Quadratus Femoris muscle pedicle grafting in young patients who presented with a delay after sustaining a fracture neck of femur, 42 patients with fracture neck of femur with delayed presentation were treated with open reduction and internal fixation and supplemented with Quadratus Femoris muscle pedicle graft. A posterior approach was used in all cases. The patients were advised not to bear weight until there was clinical and radiological union. Functional recovery was assessed by gait and ability to squat on the floor.

The age of the patients, predominantly male, ranged from 24 yrs to 50 yrs. Radiological union occurred on average at 6 months. Thirty-six patients proceeded to union; six patients had non-union and needed revision surgery. Complications included varus union in 9 cases; shortening greater than 2 cms occurred in 6 cases.

Quadratus Femoris muscle pedicle grafting described by Meyer in the 1970s is useful in treating fracture neck of femur. Open reduction and internal fixation of the fracture neck of femur when supplemented with Quadratus Femoris muscle pedicle graft fixation promoted the union of fracture and preserved the head the femur.

To evaluate the effects of eccentric strengthening exercises (ESE) in athletic patients with Achilles tendinopathy. Forty five athletic patients (29 men, average age 26 years; 16 women, average age 28 years; average height: 173 ± 16.8, range 158 to 191; average weight 70.8 kg ± 15.3, range 51.4 to 100.5) with clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks.

The mean pre-management VISA-A scores of 36 (SD 23.8; 95% C.I.: 29 – 46) improved to 52 (SD 27.5; 95% C.I.: 41.3 – 59.8) at the latest follow up (p = 0.001). Twenty seven of the 45 patients responded to the eccentric exercises. Of the 18 patients who did not improve with eccentric exercises, 5 (mean age: 33 years) improved with two peritendinous aprotinin and local anaesthetic injections. 10 of the 18 patients (9 men, mean age 35 years; 1 woman aged 40 years) who did not improve with eccentric exercises and aprotinin injections proceeded to have surgery. The remaining three patients (3 women, mean age 59.6 years; 2 men, mean age 63 years) of the 18 non-responders to eccentric exercises and aprotinin injections declined surgical intervention.

ESE in athletic patients provide comparable clinical outcome compared to our previous results in non-athletic patients. ESE are a viable option for the management of AT in athletes, but, in our hands, only around 60% of our athletic patients benefited from an intensive, heavy load eccentric heel drop exercise regimen alone. If ESE fail to improve the symptoms, aprotinin and local anaesthetic injections should be considered. Surgery is indicated in recalcitrant cases after 3 to 6 months of non operative management.

Background: Unicondylar knee arthroplasty (UKA) are being expanded to include younger patients with more active lifestyles because of its minimally invasive nature. Prior to expanding this role, it is important to examine mode of failure and implication of conversion to TKA in the low demand elderly patients.

Aim: To ascertain the modes of early failure of unicondylar knee Arthroplasty and assess whether the conversion to TKA improved the functional scores, range of motion, pain, and patient satisfaction.

Method: A retrospective study to evaluate the results of 14 revision procedures after failed unicompartmental knee arthroplasty (UKA). Patients’ operative charts were reviewed. Details of modes of failure, technical difficulty of revision including exposure, component removal, and management of bone loss were noted. Post operative functional outcome was assessed using WOMAC osteoarthritis index and SF-36.

Result: Total of 106 primary unicondylar knee arthroplasty procedures was performed between 2003 and 2007 in our institution. Oxford unicondylar implant was used in all patients. 13.21% of these were revised to total knee replacement. Revisions were performed 4 months to 36 months after the primary procedure; 86% of these were required within the first 12 months. The average time to failure was 15.6 months.

The modes of failure were aseptic loosening (4), progression of osteoarthritis (2), instability (3), infection (2), dislocated insert (1) and persistent pain after UKA (2). Tibia insert exchange was done in one patient and the rest were converted to primary Scorpio and PFC components. Three of the patients had significant defect in femoral condyle. Fourteen percent of cases required femoral stem extension or metal wedge augmentation.

Nine of the 14 knees (64%) were followed up for an average of 15 months. The mean WOMAC and SF-36 scores at latest follow up were 33.33 and 63.79 respectively.

Conclusion: Despite the advantage of minimally invasive UKA, early failure can occur in the face of good surgical technique. The higher long-term success rate claimed by implant manufacturer is challengeable and patient should be informed during consent.

Background: Infected total knee arthroplasty causes significant morbidity to patients and also challenges to surgeons to provide a functional mobile knee joint.

Aim: Present a 10-year review (1997 to 2006) of all the revision total knee replacements performed for infection in our centre.

Methods and Materials: Data including the demographics, ASA grade, blood loss, blood transfusions, length of stay, laboratory investigations including culture and sensitivity of the deep swabs. The sensitivity and specificity of pre-operative CRP and ESR were related to culture results. Post operative complication was recorded. The financial implication of the whole treatment was calculated by applying the prescribed cost by the Voluntary health insurance limited.

Results: Revisions for suspected infection constituted 14.8% (28 out of 189 cases) of the total revision knee procedures performed during the period. All the patients underwent 2 staged revision knee Arthroplasty. The mean age was 68.6 (46–83 yrs). The mode for ASA grade was 2. The average blood loss was 2 litres and the mean blood transfusion units per case were 3.8 units. The average length of stay was 42.25 days, a 24.32 days longer than aseptic revisions.

46.4% of the cases had positive cultures from the deep tissues. Staphylococcus species were responsible for 62% of cases, while enterococci, pseudomonas, streptococcus pneumonia, and MRSA have similar occurrences. The mean total cost per case was € 21,895 (13,597 for aseptic revision) a 61% increase in cost for cases revised for non septic reasons.

Conclusion: Revision Total knee replacement for infection remains significantly more expensive than revision for aseptic loosening or other causes and provides a significant financial burden on orthopaedic services. Every precaution should be taken to avoid infection in total knee arthroplasty.

Aim: To investigate and compare the effects of two types of LCS total knee arthroplasty on joint proprioception and range of motion.

Methods: 47 patients were randomised to receive either a LCS AP glide or Rotating platform prosthesis. Clinical scores (Oxford knee score, American knee society score, EuroQol), range of motion and proprioception were assessed prior to and at 3,6, and 12 months after the operation. Proprioception was assessed in terms of absolute error angle (mean difference between the target angle and the response angle). Knee angles were measured in degrees using an electromagnetic tracking device, Polhemus 3Space Fastrak that detected positions of sensors placed on the test limb. Student’s t-test was used to compare the mean of two groups (with a level of significance of p < 0.05).

Results: Both groups were comparable in terms of pre-operative range of motion, oxford knee score, American knee society score, EuroQol score and proprioception. There was statistically significant improvement in the Oxford knee score, AKSS and EuroQol score in both groups (p< 0.001), but there was no difference between the groups with respect to these parameters. There was improvement in the proprioception (reduction in absolute error angle) in both groups though this was not significant statistically (p> 0.05).

Conclusions: We did not find significant difference between AP glide and RP LCS knee arthroplasty in terms of improvement in proprioception and range of motion.

It is well appreciated that thigh pain following recent arthroplasty surgery is likely to be due to prosthetic loosening or infection. Both these sequelae can lead to periprosthetic fracture presenting complex challenges to even experienced surgeons.

Revision arthroplasty patients are prone to both fatigue and insufficiency fractures as they may have reduced bone stock after previous surgery and reduced bone density secondary to medical and immobility reasons. The post operative painfree condition will frequently permit early load bearing leading to a relatively rapid increase in activity and load bearing.

Fatigue fractures occur in bone of normal quality subject to abnormal cyclical overloading, leading to resorption and eventual failure, before adequate time has passed to permit adaptive remodelling. Insufficiency fractures occur when normal physiological loads are applied to bone of abnormal quality.

Surprisingly few periprosthetic stress fractures are reported in the literature but a series notes lateral tensile stress fractures associated with varus prosthetic alignment. These all occurred near the tip of the prosthesis.

The case of an unusual Gruen Zone 2, Vancouver B1 stress fracture, 9 months following revision arthroplasty is reported. Initially loosening was suspected due to the development of load bearing thigh pain. Plain radiography revealed the development of a dreaded black line, consistent with a stress fracture. Bone scintigraphy revealed the typical appearance of a stress fracture in the absence of loosening or infection.

The unusual location of this stress fracture allowed consideration of conservative non weight bearing management which lead to the alleviation of symptoms rather than further revision surgery.

This report illustrates this unusual stress fracture and highlights the importance of careful loading practises to permit adequate remodelling following complex revision surgery.

Purpose To ascertain whether there are differences in the histopathological appearance of tendinopathic Achilles and patellar tendons.

Methods In males, we studied biopsies from tendinopathic Achilles (n = 28; average age 34.1 years) and patellar tendons (n = 28; average age 32.1), and Achilles tendons (n = 21; average age 61.8 years) from deceased patients with no known tendon pathology, and patellar tendons (n = 15; average age 28.3) from patients undergoing anterior cruciate ligament reconstruction. Haematoxylineosin stained slides were interpreted using a semi-quantitative grading scale (0: normal to 3: maximally abnormal) for fibre structure; fibre arrangement; rounding of the nuclei; regional variations in cellularity; increased vascularity; decreased collagen stainability; hyalinisation. All slides were assessed blindly twice, the agreement between two readings ranging from 0.170 to 0.750 (Kappa statistics).

Results The highest mean score of tendinopathic Achilles tendons was not significantly different from that of tendinopathic patellar tendons (11.6 ± 5 and 10.4 ± 3, respectively). The ability to differentiate between an Achilles tendon and a patellar tendon was low.

Conclusions Tendinopathic Achilles and patellar tendons show a similar histological picture. It was not possible to identify whether a specimen had been harvested from an Achilles or a patellar tendon on the basis of histological examination. The general pattern of degeneration was common to both tendinopathic Achilles and patellar tendons. A common, as yet unidentified, etio-pathological mechanism may have acted on both these tendon populations.

Proximal tibial epiphyseal injuries are rare. Reported incidence varies from 0.5 – 3% of epiphyseal injuries. Proximal tibial epiphysis is well protected unlike distal femoral epiphysis. Thus, the distal femoral injuries are 7 times more frequent than proximal tibial epiphyseal injuries.

Case Report: 12-year old boy, hit a pole at the bottom of a dry ski slope and presented to A& E within 20 minutes. He had a swollen, deformed knee and leg that was immobilised in a temporary splint. He had absent posterior tibial and dorsalis pedis pulses. Emergency manipulation under GA and further stabilised with K-wires, A/K Back Slab in 450 flexion. Distal pulses returned on table. K-wires were removed after 4 weeks and physiotherapy started. At 3 months, he was back to normal activities except sports. At 2 years, he was longer by 1 cm in left tibia, valgus of 120 at the knee, full ROM, no ligament laxity and reports occasional anterior knee pain.

Discussion: Posteriorly displaced proximal tibial Salter Harris II injuries are very rare. Emergency reduction and stabilisation, absence of popliteal artery tear had prevented the immediate complications. The late complications did not warrant a surgical intervention.

Background Achilles tendinopathy is prevalent in athletes and individuals with an active lifestyle. It causes significant morbidity, which at times leads to changes in exercise habits. Recently, the VISA-A questionnaire, based on a visual analogue score to assess pain and activity, has been devised as a clinical tool to assess the severity of Achilles tendinopathy (minimum score – 0, maximum possible score – 100).

Aim To assess the clinical progress in patients with Achilles tendinopathy using the VISA-A questionnaire.

Method Thirty-four patients (18 males, mean age 44 years, range 23–67; 16 females, mean age 51 years, range 20–76) were selected to complete the VISA-A questionnaire, after a diagnosis of Achilles tendinopathy had been made at first and subsequent visits to a specialised outpatient clinic.

Results The average pre-treatment VISA-A score was 39 (SD 22.8, range 3–82, 95% CI: 31–47). The patients received intensive physiotherapy, including graded progressive eccentric calf strengthening exercises, and were offered a peritendinous injection of Aprotonin and local anaesthetic if physiotherapy was ineffective. Surgery was performed in six patients when six months of conservative management failed to produce improvements. The average post-treatment VISA-A scores at the latest follow up was 50 (SD 26.5, range 1–97, 95% CI: 40.8–59.3), with a mean difference between pre and post-treatment scores of 11.5 (SD 18.8 range -28.5–67.5, 95% CI: 4.9–18). The mean VISA-A score in patients offered surgery was 36, and 20 in patients who received a peri-tendinous injection of Aprotonin and local anaesthetic

Conclusion The VISA-A score can identify patients who need more aggressive management, and can be used to monitor their progress.