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The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 5 | Pages 577 - 583
1 May 2012
Smith CD Guyver P Bunker TD

The outcome of an anatomical shoulder replacement depends on an intact rotator cuff. In 1981 Grammont designed a novel large-head reverse shoulder replacement for patients with cuff deficiency. Such has been the success of this replacement that it has led to a rapid expansion of the indications. We performed a systematic review of the literature to evaluate the functional outcome of each indication for the reverse shoulder replacement. Secondary outcome measures of range of movement, pain scores and complication rates are also presented.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XV | Pages 9 - 9
1 Apr 2012
Guyver P Cattell A Hall M Brinsden M
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Introduction

Patient-reported outcome measures (PROMs) are increasingly being used to assess the quality of healthcare delivery in the United Kingdom. It is important when using PROMs to know the score of the background population against which any clinical intervention maybe benchmarked. The purpose of this study was to measure an elbow-specific PROM for the population of the South West Peninsula.

Methods

We undertook a cross-sectional survey study of patients and healthcare professionals. Participants were asked to complete a simple demographic questionnaire and an Oxford Elbow Score for each elbow. Respondents with a history of elbow surgery, elbow injury, chronic elbow problems or an incomplete dataset were excluded from the study.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XV | Pages 3 - 3
1 Apr 2012
Guyver P Powell T Fern ED Norton M
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Introduction

Femoroacetabular impingement (FAI) is a relatively recent recognised condition and a potential cause of anterior hip pain in the young military adult population. Both Cam and Pincer type FAI may lead to inflammation, labral tears, and or damage to the smooth articular cartilage of the acetabulum leading potentially to early osteoarthritis of the hip. Open Surgical hip dislocation using the Ganz Trochanteric Flip approach is an accepted technique allowing osteoplasty of the femoral neck and acetabular rim combined with labral repair if required. We present our results of this technique used in military personnel.

Methods

All Military personnel who underwent FAI surgery in our unit since August 2006 were included in the study. Functional outcome was measured using the Oxford hip and McCarthy non-arthritic hip scores pre and post-operatively. Results: 13 hips in 11 patients with an average age of 36 years (21–45) underwent surgical hip dislocation for treatment of FAI. Average time of downgrading prior to surgery was 9.3(3-18) months. 6 out of the 11 patients have been upgraded to P2. Average time to upgrading was 6.8(3-17) months. There were no infections, dislocations, or neurovascular complications. Mean Oxford Hip Score improved from 22.8(range 8–38) to 39.5(11–48) and mean McCarthy hip score from 49.6(33.75–80) to 79.2(36.25–100) with an average follow up of 19.4 months (range 4– 42 months).


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 54 - 54
1 Jan 2011
Guyver P Norton M Cattell A Bartlett G Fern D
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Periprosthetic Hip Fractures (PHFs) and Complex Revision Hip Arthroplasty(CRHA) consistently present challenging management decisions. Extramedullary devices alone or in combination with strut graft or long stem prosthesis revisions (cemented and uncemented) have all been described as treatment options. A long distal locked femoral stem provides an alternative allowing immediate stability for weight bearing without impaction bone grafting or external plate fixation and strut grafting. It has a lower risk of subsidence.

24 patients underwent a Cannulok Stem procedure from 2003–2008. Each was reviewed regularly following surgery with clinical examination and Hip scores (Oxford and SF12). The indications for device use, Vancouver classification if a periprostheic fracture, radiological evidence of union and complications were all recorded from medical and radiological records. The results were then compared to similar studies.

The indications for Cannulok use were periprosthetic fracture (50%), infection with bone loss (12.5%), revision for aseptic loosening (33.3%) and subtrochanteric fracture post arthrodesis and metalwork removal (4.2%).

A 75% union rate was seen in periprosthetic fractures. There were 2 deaths, 2 deep infections and 1 superficial infection. The 40 mm offset stems resulted in 6 (25%) dislocations compared to 0% dislocations with the 45 mm offset stem. In addition there was 1 femoral stem revision for subsidence (no distal locking screws used) and 1 acetabular revision. There was an average follow up of 20 months.

This study suggests that the Cannulok Plus femoral reinforcement stem is a potential alternative treatment option in PHFs and CRHA with acceptable complication rates.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_II | Pages 299 - 299
1 May 2010
Guyver P Mccarthy M Neil J Keenan J
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Introduction: The PFNA device was developed to address problems of rotational instability in proximal femoral fractures whilst simultaneously employing a single femoral neck element. The PFNA makes use of a helical blade that compresses rather than destroys osteopaenic cancellous bone. It is hammered into place over the guide wire and then locked laterally to prevent rotation.

Study Design: Prospective cohort.

Methods: All subtrochanteric fractures (AO 31A3) admitted to the department were treated with the PFNA. Demographic and clinical data during admission was recorded and formal post-operative X-Rays performed.

Outcome Measures: 4 month follow-up appointment with clinical and radiological assessments, VAS, SF36, Jensen Social Function Score and Parker Mobility Score.

Results: From April 2006 to June 2007, 62 patients were included in the study. 4 month follow up has been completed in 30 patients (77% of those available). 11 are awaiting follow up, 12 died and 9 were unable to attend follow up for various reasons. The mean age was 79.9 years. 13 short and 17 long nails were inserted. 6 patients required open reduction and internal fixation. There were no significant intra-operative or immediate postoperative complications. 1 patient with a short PFNA nail sustained a fracture of the femur through the site of the distal locking bolt during the follow up period and required revision. At follow up, 9 patients had tenderness over the greater trochanter and 1 had leg length discrepancy. None had malrotation. Only 7 patients regained their pre-operative mobility status. The mobility and social function scores were significantly reduced at follow up compared to preoperative status (p=0.001). All domains of SF36 were low compared to normative data. The mean VAS was 3/10. All 30 fractures united and there was no migration, lysis around or cut out of the helical blade. In total, 46 distal locking bolts were utilised. 4 of these had migrated or become loose.

Conclusions: Subtrochanteric fractures in the elderly are a devastating injury. Patients do not return to pre-fracture function at 4 months post injury. Early results suggest that the PFNA appears to work well as evident by the fact that all of the fractures united. We recommend adding 4 to 6mm to the measured length of the distal locking bolts to prevent migration.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 500 - 500
1 Sep 2009
Guyver P Jain N McCarthy M Keenan J
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Classification systems are used for communication, deciding/planning treatment options, predicting outcome and research purposes. The vast majority of subtrochanteric fractures are now treated with intramedullary nails, which questions the need for classification.

Our objective was to assess the intra- and inter-observer reliability of the Seinsheimer, AO and Russell-Taylor (RT) classification systems and assess a new simple system (KMG).

The KMG system was developed to alert the surgeon to potential hazards: Type 1 – subtrochanteric fracture (ST#) with intact trochanters. Type 2 ST# involving greater trochanter (entry point for nailing difficulty). Type 3 –ST# involving lesser trochanter (most unstable).

32 AP and lateral radiographs of subtrochanetric fractures were classified independently by 4 observers twice with a 6-week interval (2 Consultants and 2 Registrars). The observers were asked to rank the systems based on how descriptive they thought they were, whether they felt they influenced treatment plan and whether they would predict outcome.

The intra- and inter-observer variation was poor in all systems. KMG gave the best inter-observer reproducibility (Kappa 0.3 to 0.6) followed by AO and RT, and then Seinsheimer. The observers felt that Seinsheimer and KMG were the most descriptive and would influence the treatment plan, and Russell-Taylor would perform worst at predicting outcomes. All of the fractures in this series united

The classification systems analysed in this study have poor reproducibility and seem to be of little value in predicting outcome of intramedullary nailing. The KMG system may be of some use in alerting the surgeon to potential problems.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_II | Pages 209 - 209
1 May 2009
Guyver P McCarthy M Jain N Keenan J
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The PFNA device was developed to address problems of rotational instability in proximal femoral fractures whilst simultaneously employing a single femoral neck element. The PFNA makes use of a helical blade that compresses rather than destroys osteopaenic cancellous bone.

All subtrochanteric fractures admitted to the department were treated with the PFNA (AO 31A3). Demographic and clinical data during admission was recorded and formal post-operative X-Rays performed.

Outcome assessment consisted of a 4 month follow-up appointment with clinical and radiological assessments, VAS, SF36, Jensen Social Function Score and Parker Mobility Score.

From April to December 2006, 46 patients were included in the study. 4 month follow up has been completed in 17 of 23 patients. The average age was 78. 11 short and 7 long nails were inserted. Four patients required open reduction and internal fixation. There were no significant intra-operative or immediate postoperative complications. 1 short nail fractured through the site of the distal locking bolt during the follow up period and required revision.

At follow up, 5 patients had tenderness over the greater trochanter and 2 had leg length discrepancy. None had malrotation. Only 2 patients regained their pre-operative mobility status. The mobility and social function scores were significantly reduced at follow up compared to pre-operative status (p=0.003 and p=0.001 respectively). All domains of SF36 were low compared to normative data. The mean VAS was 3/10.

All fractures united and there was no migration, lysis around or cut out of the helical blade. In total, 25 distal locking bolts were utilised. Four of these had migrated or become loose.

Patients with subtrochanteric fractures do not return to pre-fracture function at 4 months post injury. The PFNA appears to work well although there may be concern about bone hold of the distal locking bolts.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 503 - 503
1 Aug 2008
Jain N Guyver P McCarthy M Brinsden M
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With the imminent introduction of the Modernising Medical Careers (MMC) post-graduate training programme, we undertook a study to assess how informed the orthopaedic Multi Disciplinary Team (MDT) and patients were with regard to the details, implementation and future implications of MMC.

Methods: A questionnaire was designed to record the level of awareness of MMC using a visual analogue scale and to document individual preferences for surgical training, either traditional or MMC. 143 questionnaires were completed – consultant orthopaedic surgeons (n=12); orthopaedic nursing staff (n=54); musculoskeletal physiotherapists (n=27); and trauma and orthopaedic patients (n=50).

Results: Consultants felt most informed about MMC compared to patients and other members of the multidisciplinary team (p < 0.01). Consultants preferred old style training in terms of their juniors as well as future consultant colleagues. Nurses showed no preference for either system. Patients and physiotherapists expressed a preference for their surgeon to have been trained under the traditional, rather than the new system.

Conclusions: Our study showed that there is a wide variation in the degree to which patients and healthcare professionals are informed about MMC.