Background: Inadequate proximal femoral pressures obtained during a cemented, primary hip replacement may lead to poor stem fixation. Proximal occlusion during stem insertion,may help in achieving a uniform and sustained rise in intra-medullary pressures, distally and proximally. High intra-medullary pressures correlate with better cement penetration and increased cement-bone interface push-out strength.

Methodology: An In-vitro analysis of femoral pressures was performed. A femoral medullary cavity was created in plaster of Paris constrained in an aluminium cylinder. Intramedullary pressures were measured via pressure transducers. High viscosity bone cement (Palacos-R) was gunned into the medullary cavity. No.3 Exeter stem was inserted with no proximal occlusion, with thumb occlusion over the calcar and with the Exeter Horse-collar. Experiments were repeated by delaying the timing of insertion and with lower viscosity cement (Simplex-P). A small series of experiments were done to ensure that that the stem insertion was performed at standard cement viscosity. The experiments were carried out with the same viscosity of Palacos-R at 4 minutes and Simplex-P at 6 minutes. Palacos-R at 4 minutes 30 seconds had a higher viscosity.

Results: A total of 54 experiments were performed. Of these 18 experiments were done with Palacos R cement, with the stem inserted early on in the curing phase and 18 with a delayed time of insertion. The last 18 experiments were performed with Simplex P cement with the stem inserted early on in its curing phase.

Intramedullary pressures were better in all zones, for all cement modes, with proximal occlusion. The highest pressures were seen with Palacos-R at 4 minutes 30 seconds with proximal thumb occlusion. Stem insertion into Palacos-R at 4 minutes or 4 minutes 30 seconds, gave higher pressures than Simplex-P, with or without any form of occlusion. With Simplex-P, intramedullary pressures were higher, with Collar rather than thumb occlusion.

Conclusion: Occluding the medial cal car area during stem insertion, is an effective way of achieving and sustaining high-pressures in the proximal and distal femur. The highest pressures are obtained with stem inserted into Palacos-R at 4 minutes 30 seconds, with proximal thumb occlusion. Collar occlusion may be better in achieving higher pressures, with lower viscosity, Simplex-P.

53 patients underwent closed reduction and longitudinal k-wiring of displaced Colles’ fractures and were reviewed after a mean of 26 months. Radiographs taken at the time of injury, after reduction and k-wiring, and at fracture union were compared for radial shortening and dorsal angulation. Manipulation significantly improved fracture position (p< 0.001). Dorsal angulation was successfully corrected by manipulation in 98%, and this position was maintained to fracture union in all cases. 73% of fractures manipulated for radial shortening > 2mm were adequately reduced, but 41% of these fractures subsequently lost position to malunite. The mean shortening between reduction and fracture union was 1.6mm. This did not correlate with Frykman Class or radial shortening at injury.

Closed Reduction and k-wire stabilisation is an attractive technique because it is relatively non-invasive compared with plating or external fixation. However, a degree of radial shortening between reduction and fracture union must be anticipated. Fractures reduced inadequately to allow for this loss of radial length, are more likely to malunite.

This may compromise functional outcome.

Arthroplasty is the most effective management of displaced intracapsular femoral neck fracture. Hemiarthroplasty (HEMI) is associated with acetabular erosion and loosening in mobile patients and total hip arthroplasty (THA) with instability.

We sought to establish whether HEMI or THA gave better results in independent mobile patients with displaced intracapsular femoral neck fracture.

Eighty-two patients were randomised into two groups. One arm received a modular HEMI, the second a THA using the same femoral stem. Patients were followed for a mean of three years after surgery.

After HEMI, eight patients died, two were revised to THA and there is intention to revise three. One patient had a periprosthetic fracture. Mean walking distance was 1.08 miles and Oxford Hip Score (OHS) 22.5. Twenty patients (64.5% of survivors) had radiological evidence of acetabular erosion.

After THA, four patients died, three dislocated, one required revision. Mean walking distance was 2.23 miles and OHS was 18.8.

HEMI is associated with a higher rate of revision than THA and potential revision because of acetabular erosion. THA after three years displayed superior walking distances (p=0.039) and lower OHS (p=0.033).

THA is a preferable option to HEMI in independent mobile elderly patients with displaced intracapsular femoral neck fracture.

Introduction: Between 1988 and 1993 we performed 154 primary hip arthroplasties with the Exeter Universal femoral stem and a variety of acetabular components and describe our experience after a minimum follow up of 10.5 years (mean 12.6 years).

65 hips were assessed clinically and radiologically.

Our aim was to establish whether results from the inventing centre for the Exeter Universal stem were reproducible and to identify the features of cementing technique associated with survival of this prosthesis.

Results: At follow up the mean Oxford hip score was 24. Our stem revision rate was 1.7% and cup revision 13%. The majority of the cup failures occurred between 8 and 15 years and were the non flanged cemented metal backed Exeters which tended to both wear and migrate. We intend to revise 11 hips in 10 patients. 10 of these are for migration and or wear of the metal backed Exeter cup and one for distal stem-cement dissociation of the stem in a patient with thigh pain. Radiologically this stem showed migration and lucent lines at the cement-stem interface. 6% of stems had cement mantle defects, which were associated with endosteal lysis. Stem subsidence was related to Barrack’s grading for cementing technique. The worse the Barrack grade the more the prosthesis subsided within the cement mantle.

Conclusion: A complete cement mantle rather than 3rd generation cement compression is important for long term fixation of the femoral component. The Exeter universal stem is relatively forgiving of surgical technique. The cemented, collarless polished tapered device is suitable for general use and represents the reference standard for cemented femoral components.

Poor proximal femoral pressures obtained during a cemented, primary hip replacement may lead to poor fixation of the stem to the cement and cement to bone, contributing to early aseptic loosening of the prosthesis. Occlusion of the proximal femoral area during stem insertion, especially in the region of the calcar, may help in achieving a uniform and sustained rise distally and proximally.

An In-vitro analysis of femoral pressures was performed. Dental plaster was used to prepare femoral moulds in aluminium cylinders and the stem insertion phase of a cemented hip replacement was simulated with a number 3 Exeter stem, with no proximal occlusion, with thumb occlusion over the calcar and with the Exeter Horse collar. Pressure transducers were attached to the moulds. 54 experiments were performed. Of these 18 experiments were done with Palacos R cement, with the stem inserted at the recommended time of insertion and 18 with a delayed time of insertion. The last 18 experiments were performed with low viscosity Simplex P cement.

Good distal pressures were obtained in all cases. However, digital occlusion helped achieve sustained, high proximal pressures as well as early, high distal pressures. The Horse collar did achieve high pressures, but only towards the end of the stem insertion phase. This was much more appreciable with low viscosity cement, where peak pressures obtained with the collar were higher than with digital occlusion.

Our results show that occluding the medial cal car area is an effective way of achieving and sustaining high-pressures in the proximal and distal femur, during a hip replacement. The Exeter Horse collar is an effective means of increasing the pressure, towards the end of stem insertion, especially with low viscosity cement. Animal or cadaveric bone studies are required to show the actual penetration of cement in bone, achieved with these high pressures.

Background: Rates of around only 40% graft incorporation have been reported when irradiated bone allograft is used during revision hip arthroplasty. In this series we washed fat from irradiated allograft and added 40% by volume of autologous marrow from the iliac crest before impaction grafting. The aim of this study was to determine the rate of graft incorporation in a consecutive series of patients who underwent this modified technique of impaction bone grafting.

Methods: 85 consecutive patients, including 51 acetabular and 59 femoral revisions were reviewed. Evidence of graft cortication and or trabeculation was recorded by zone over the period of radiographic follow up.

Results: Using washed irradiated allograft with autologous marrow, 96% (49/51) of acetabular and 90% (53/59) of femoral grafts showed incorporation in the majority or all zones. Most of these changes were apparent within 6 months of surgery. The average subsidence of the stem at mean follow up of 45 months was 1.28 mm. Of the 8 patients whose graft failed to incorporate, 2 had grafts removed for post operative infection and 3 had early reoperation for intraoperative fractures. Only 3 out of 85 patients failed to demonstrate bone incorporation in the majority of zones with out an obvious reason why.

Conclusions: The addition of autologous marrow to irradiated bone allograft during impaction grafting is a cheap and effective way of increasing the rate of bone incorporation. This series demonstrates over 90% bone incorporation, usually occurring within 6 months after surgery.

Trochanteric bursitis is initially treated with local anaesthetic and corticosteroid injections but when this fails there are few interventions that relieve the symptoms.

We report a new surgical technique for refractory trochanteric bursitis in 43 patients. Fourteen patients had developed trochanteric bursitis after primary total hip arthroplasty (THA), 6 after revision THA, 17 for no definable reason (idiopathic) and 7 after trauma.

Follow up ranged from six months to 15 years (mean five years). Outcome was measured by pre and post operative Oxford Hip Scores. The mean post operative decreases were 23 points in traumatic cases, 13 in idiopathic and 13 for patients after primary THA. A mean increase of 3 was observed in patients after revision THA.

The operation relieved symptoms in 75%. The outcome depended on aetiology. 100% of traumatic, 88% of idiopathic and 64% after primary THA were successful. All operations after revision THA were unsuccessful.

This is the largest series of a single surgical technique for refractory trochanteric bursitis and the only one to subdivide the outcome by aetiology. Transposition of the gluteal fascia is indicated in patients with idiopathic, traumatic and post primary THA trochanteric bursitis, but not after revision THA.

Personal injury claims following whiplash injury currently cost the British economy more than £3 billion a year, yet only a minority of patients have radiologically demonstrable pathology. Patients sustaining fractures of the cervical spine have been subjected to greater force and might reasonably be expected to have worse symptoms than those with whiplash injuries.

Using the Neck Disability Index, we compared pain and functional disability in four groups of patients who had suffered cervical spine injuries. The four groups were: patients with stable cervical fractures treated conservatively, patients with unstable cervical fractures treated by internal fixation, patients with whiplash injuries seeking compensation, and patients with whiplash injuries not involved in litigation.

After a mean follow-up of 3½ years, patients who had sustained cervical spine fractures had significantly lower levels of pain and disability than those who suffered whiplash injuries and were pursuing compensation (p< 0.01), but had similar level to those whiplash sufferers who had settled litigation or had never sought compensation.

Functional recovery following neck injury is unrelated to the physical insult. The increased morbidity in whiplash patients is likely to be psychological and is associated with litigation.

The purpose of the study was to objectively compare the effects of the scaphoid and Colles’ type casts on hand function. Currently there is no such published study.

Both casts are commonly used to immobilise suspected and radiologically proven undisplaced scaphoid fractures. There is no difference in non-union rates. The scaphoid incorporates the thumb in palmar abduction, whereas the Colles’ type cast leaves the thumb free. Although necessary for bone healing, immobilisation disrupts function and may require intensive corrective physiotherapy. Unnecessary immobilisation of uninvolved joints should be avoided when use does not compromise fracture stability.

We compared the effect of the two casts on hand function in 20 healthy right hand dominant volunteers using the Jebsen-Taylor Hand Function Test, which uses seven subtests designed to test tasks representative of everyday functional activities. Data were obtained through a mixed between and within subject design.

Using the Jebsen-Taylor Hand Function Test, median overall scoring in the Colles’ type cast was 2.5 times that obtained in the scaphoid. In timing individual subtests, the analyses show significant differences (p< 0001) between the presence and absence of a cast. When comparing the two cast types, mean times for all subtests are less in the Colles’ than in the scaphoid, with the difference reaching statistical significance in five out of seven subtests.

Having either type of cast significantly impairs handling and finger dexterity, and so affects activities of daily living. A scaphoid, however, is much more limiting than a Colles’ type cast. This makes it clearly more inconvenient for the patient with socioeconomic implications and occasionally issues of compliance during a long period of immobilisation.

Introduction and Aims: Patients with proximal femoral fracture are frail with multiple comorbidities and the anaesthesia often proves a greater challenge than the surgery itself. The aim was firstly, to determine whether general, compared to regional anaesthesia, caused a decrease in the mental test score (MTS) of patients with proximal femoral fracture. Secondly, what effect does a reduced MTS have on the general outcome for such patients.

Method: A prospective observational study was conducted in a regional trauma centre. One hundred and seventy consecutive patients over 60 years of age (mean age 82.6 years) were included. Age under 60 years was the only exclusion criterion. Pre- and post-operative (day five) MTS values were recorded by the same clinician.

Results: The MTS decreased by 2.43 points when general anaesthesia was administered compared to 1.5 for regional anaesthesia (p< 0.01 Mann Whitney). Lower post-operative MTS values were associated with increased mortality (p< 0.001 Mann Whitney). The greater the decrease in MTS (between pre- and postoperative values) the more likely it is that the patient will be institutionalised (p< 0.01 Mann Whitney).

Conclusion: Reduced mental function as observed after general anaesthesia is associated with increased mortality and institutionalisation. Thus the increased use of regional anaesthesia is advocated.

In 90 patients undergoing primary THA, leg length discrepancy (LLD) and hip function were assessed pre-operatively and 3 and 12 months postoperatively. Hip function was measured by the Oxford hip score (OHS).

Postoperatively the mean OHS improved by 26 points out of a possible 48 at 3 months and by 30 points at 12 months. Postoperatively 62% of patients’ limbs were lengthened by a mean of 9 mm. The LLD was perceived by 43% of the affected patients at 3 months and by 33% at 12 months. The OHS in patients who perceived true lengthening was 27% worse than in the other patients at 3 months and 18% worse at 12 months. In 98%, lengthening occurred in the femoral component.

The problem of LLD after THA is lengthening. Appropriate placement of the femoral component could reduce patients’ perception of this.

Aim: To compare extracapsular and intracapsular proximal femoral fractures in terms of pain scores, morbidity, mortality and total stay in hospital. Method: A prospective study over a 8 month period at a regional trauma centre. 170 patients over 60 years of age were included and their mean age was 82.6 years. Pain scores were recorded daily using a visual analogue scale. Results: Extracapsular fractures are more painful (p< 0.01 Mann-Whitney), associated with greater morbidity (p< 0.05 Chi-square, Fishers Exact) and are slower to recover (p< 0.01 Mann-Whitney) compared to intracapsular proximal femoral fractures. There was less mortality associated with undisplaced intracapsular fractures compared to all others (p< 0.01 Mann-Whitney). Conclusions: trochanteric proximal femoral fractures are more problematic medically and as such require more medical, nursing and resource input compared to intracapsular fractures. This knowledge can be used by the clinician to anticipate greater morbidity and as such treat more promptly.

Patients with proximal femoral fracture are frail with multiple comorbidities and the anaesthesia often proves a greater challenge than the surgery itself. The aim was firstly, to determine whether general, compared to regional anaesthesia, caused a decrease in the mental test score (MTS) of patients with proximal femoral fracture. Secondly, what effect does a reduced MTS have on the general outcome for such patients?

A prospective observational study was conducted in a regional trauma centre. 170 consecutive patients over 60 years of age (mean age 82.6 years) were included. Age under 60 years was the only exclusion criterion. Pre- and postoperative (day 5) MTS values were recorded by the same clinician.

The MTS decreased by 2.43 points when general anaesthesia was administered compared to 1.5 for regional anaesthesia (p< 0.01 Mann Whitney). Lower postoperative MTS values were associated with increased mortality (p< 0.001 Mann Whitney). The greater the decrease in MTS (between pre- and postoperative values) the more likely it is that the patient will be institutionalised (p< 0.01 Mann Whitney).

Reduced mental function as observed after general anaesthesia is associated with increased mortality and institutionalisation. Thus the increased use of regional anaesthesia is advocated.

Proximal femoral fracture (PFF) is already epidemic and projected to increase. 50% of patients fail to recover their preaccident mobility, resulting in protracted hospitalisation and exposure to nosocomial (hospital acquired) infections which impairs recovery further.

The aim of this study was to establish the rate at which patients with PFF regain mobility, the point at which they cease to recover and the incidence, time of onset and effect of nosocomial infections.

Recovery of mobility and nosocomial infection was prospectively recorded in 170 consecutive patients with PFF. 53% regained their best level of mobility within 6 days of admission, 81% within 8 and 91% within 14. The mean hospital stay was 21 days and delay to discharge was 14 days. During the delay, mobility deteriorated in 22% of patients and 58% developed nosocomial infection of which 18 were methicillin resistant staphylococcus aureus. The risk of infection doubled after a delay of 6 days.

Protracted hospitalisation after PFF is unhelpful and dangerous to patients and wasteful of healthcare resource. There is a small window of opportunity to discharge patients after PFF that is often missed. Thus there are often no beds for patients with acute fractures because they are occupied by patients who do not benefit from hospital admission or remain because they have acquired iatrogenic disease.

General Practitioner (GP) attendances for non-specific disease increase after life events. Whiplash injury has the effect of a life event in some people.

The aim of this study was to compare GP attendance rates in the year before and after whiplash injury to establish their rate and cause.

Ninety-eight subjects (62 women and 36 men) with whiplash injuries examined for medicolegal reports, with complete GP records for a year before and after injury.

The number of attendances and the reason for attendance. Consultations after the accident were subdivided into those for neck pain and for other reasons.

Subjects were reviewed more than one year after injury. All described neck pain 11% mild, 62% moderate and 27% severe. GP attendance rates before the accident were within the normal range but increased after (p=0.0001) because of neck pain symptoms. There was no association between attendance rates before and after injury but consultations for neck pain rose in proportion to severity of symptoms (p = 0.0015). Attendances unrelated to neck symptoms fell after injury (p = 0.002).

GP attendances for non-specific disorders increase after life events, but not after whiplash injury as patients focus on their neck symptoms.

Of 586 employed patients with a whiplash injury 40 (7%) did not return to work. The risk was increased by three times in heavy manual workers, two and a half times in patients with prior psychological symptoms and doubled for each increase of grade of disability. The length of time off work doubled in patients with a psychological history and trebled for each increase in grade of disability. The self-employed were half as likely to take time off work, but recovered significantly more slowly than employees.

We studied 50 consecutive patients presenting at an accident department after rear-end vehicle collisions and recorded symptoms and psychological test scores within one week of injury, at three months and at two years. The range of neck movement was noted at three months.

Within one week of injury, psychological test scores were normal in 82% of the group but became abnormal in 81% of the patients with intrusive or disabling symptoms at over three months (p < 0.001) and remained abnormal in 69% at two years. The clinical outcome after two years could be predicted at three months with 76% accuracy by neck stiffness, 74% by psychological score and 82% by a combination of these variables.

The severity of symptoms after a whiplash injury is related both to the physical restriction of neck movement and to psychological disorder. The latter becomes established within three months of the injury.