Introduction

Low dose technology of an EOS scanner allows mechanical axis radiographs to be produced using a continuously moving x-ray emitting a thin beam to form a single image which includes all three joints, without the need for stitching. The aim of this study was to identify necessary improvements to enable effective interpretation of the radiographs, and to assess whether the quality of the radiographs varied by production method compared to a previous audit of CR and DR radiographs.

Fracture neck of femur (NOF) in elderly is a serious debilitating injury and has been presenting in increasing proportions. Some of these patients are unfortunate to come back with a contralateral injury. We attempted at looking into the incidence of these episodes in a cohort attending our trust and compared various parameters

We retrospectively assessed our hospital theatre data for fracture NOF in patients over 60 years in the last 3 years. We reviewed their demographics, mode of injury, time to contralateral injury, incidence of any other insufficiency fracture, operative procedure and any complications.

There were 1435 patients who underwent surgery for fracture NOF over the 3 years. Forty-three of these had bilateral fractures. Females had 3 times more incidence as compared to males; average age at first injury was 84 years and at contralateral side was 85 years. Time between the two injuries ranged from 20 to 855 days (Median 242 days). Almost equal incidence of intra / extracapsular fractures was noted. Contralateral fracture pattern (Intra vs Extracapsular) for the was similar in 34 patients. Twelve patients had an associated insufficiency fracture.

Fracture NOF in elderly is a rising epidemic. Only 3% of these patients suffer a contralateral fracture NOF which usually occurs within a year. The fracture pattern is frequently similar to the first fracture in and hence similar implants have been used. Only 21% patients were on bone protection medications. It is rather difficult to identify this small group and hence prevent a second contralateral incident.

Background of study

Total Knee Replacement (TKR) is one of the commonest elective arthroplasty operations. Crepe dressings are used following TKR by most surgeons as it may provide comfort and hemostasis through external pressure however, may reduce early range of motion (ROM). Avoiding crepe dressings after TKR saves operating time, avoids bulky dressings (which may reduce ROM) and allows interventions such as cryotherapy in the early post-operative period. There are no published studies comparing the use of crepe dressing after TKR with an impermeable dressing alone

Aim

To assess the influence of posterior slope on Knee flexion and function in Asian and Caucasian populations.

Introduction: Fracture of cortical long bone can be treated with open reduction and internal fixation. Although the lag-screw technique would provide a stronger compression across the fracture site, this may not translate directly into a significantly better mechanical stability of the construct. In narrow long bone such as the metacarpus, it may be technically difficult to over-drill the near cortex. In addition, the fracture configuration as well as the presence of soft tissue attachment and neurovascular bundle in such smaller bones may give rise to technical difficulty in fixation with all the screws from the same side.

Hypothesis: We therefore propose to test the hypothesis that there is no difference in the mechanical stability of the construct, in terms of three points bending and axial loading, between fixation with lag screw (L) and cortical screw (1C) in long bone oblique fracture.

Secondly, we proposed that fixation with alternate cortical screws from both sides of the cortices (2C) may confer a stronger mechanical stability than fixation with all screws from one side (1C).

Method: A 12 cm long oblique osteotomy was created along the shaft of tibial saw bone to produce an artificial long oblique fracture. The two fragments were held together and precompressed similarly with reduction clamp. Lag screw technique (L), unilateral (1C) and bilateral (2C) simple cortical screws techniques were used to fix the fracture with a total of four 4.5mm cortical screw in each construct. The test piece was placed into position and compressed under displacement control using a Bose ElectroForce^® 3300 Series test instrument (Bose Corporation ElectroForce Systems Group, Minnesota USA). The displacement was applied at a rate of 0.42mm/s. The displacement and load were measured every 0.0586 seconds and recorded using Win-Test Software (Bose Corporation ElectroForce Systems Group, Minnesota USA).

Result: In three-points bending, fixation with unilateral cortical screws (1C) provided the highest mean stiffness values of the three techniques with an average of 27.72 N/mm (standard deviation STD 4.90 N/mm). The lag screw technique (L) had slightly lower mean stiffness values with an average of 26.29 N/mm (STD 3.46 N/ mm). Fixation with opposing screws (2C) had a lowest mean stiffness averaging 18.31 N/mm (STD 14.49 N/ mm). In axial compression, unilateral cortical screws (1C) provided the highest average stiffness at 290.33 N/mm (STD 89.84 N/mm) The opposing pre-compression technique had an average stiffness of 241.24 N/ mm (STD 121.30 N/mm) and the lag screw technique 198.94 N/mm (STD 58.33N/mm).

Conclusion: In conclusion, fixation with unilateral cortical screws (1C) provided a better mechanical stability than lag screw. Fixation with bilateral cortical screws (2C) did not provide a more stable construct than unilateral screw fixation.

Background: Total knee replacement remains one of the most common knee surgery practices worldwide. The operative procedure universally requires the use of cutting jigs to resect predetermined amounts of bone irrespective of the preoperative anatomy and morphology of the femur and tibia.

Aims: The aims of this study were to elucidate anatomical morphological differences between ethnicities pre-operatively and to assess whether any change elucidated was preserved post-operatively.

Method: This was a retrospective study comparing the pre and postoperative lateral view X-Rays of TKRs performed. Distances measured from most prominent anterior point to midline and the most prominent posterior point to midline and their ratio was compared between two ethnic groups. Each x-ray measurement was triple checked.

Results: The study groups comprised of 60 Caucasian knees and 40 Asian knees. Preoperatively the mean ratio was 0.55 in Caucasians and 0.44 in Asians, with this difference being statistically significant (p value < 0.005). Post operatively the mean ratio was 0.59 in Caucasians and 0.55 in Asians and this difference was not statistically significant (p value =0.166). These findings were also cross-checked with range of movement measurements post-operatively in the same group of patients. There was no comparable improvement in range of movements (ROM) post-operatively in the Asian group.

Conclusion: We infer that the present TKR cutting jigs are not taking into account the anatomical differences within the knee of Asians individuals. This is converting the post operative distal femurs of this group to become morphologically comparable to the Caucasian knee and this is possibly affecting the kinematics of those knees leading to no significant improvement in the post operative ROM and affecting satisfaction with surgery.

Infection following total knee arthroplasty is a serious complication. Recently there has been increasing incidence of isolation of multi-drug resistant bacteria from peri-prosthetic infections. The aim of our study is to identify the organisms causing delayed deep infections following primary total knee arthroplasty in the current situation. We also compared the differences in outcome based on the infecting organism. We undertook a retrospective study of all the patients who presented with delayed deep infection following primary total knee replacement during a six year period between April 1998 and March 2004. Organisms were isolated in 27 of the 31 patients who presented with delayed deep infection. Forty-four % of the organisms isolated were multi-drug resistant with increasing incidence of Methicillin resistant Staphylococcus aureus and multi-drug resistant Staphylococcus epidermidis infections. Successful outcome following an infected total knee arthroplasty was lower compared to the previous studies where there were fewer multi-drug resistant organisms. The average number of surgical procedures carried out was significantly higher when the organism isolated was multi-drug resistant. The number of patients with satisfactory outcome is significantly lower when the organism isolated is multi-drug resistant.

Aims: To compare the preoperative knee function in patients of Asian origin and Caucasians living in the same community.

Background: The prevalence of osteoarthritis is high in all ethnic and demographic groups. The timing of surgery is important as poor preoperative functional status is related to poor postoperative function.

Methods: Prospective study of 63 Asian patients age and sex matched with Caucasian patients undergoing total knee arthroplasty. Pre operative Knee Society Clinical Rating System scores were recorded as a separate Knee Score and Knee Function.

Results: The mean preoperative Knee Score in Asian patients was 37.6 in comparison to 41.5 in Caucasians (p< 0.10) this difference was not statistically significant. The mean preoperative Knee Function in Asian patients was 32.5 in comparison to 45.0 in Caucasians (p< 0.0001) this difference was highly statistically significant.

Conclusions:Patients of Asian origin undergoing total knee arthroplasty have lower preoperative knee function to Caucasians. Cultural beliefs and social support explain part of this discrepancy but health care providers must also attempt to educate patients and close family members about the importance of timing the surgery to obtain the optimum benefits of pain relief and function.

The aim of our study is to identify the organisms causing delayed deep infections following primary total knee arthroplasty in the current situation. We also compared the differences in outcome based on the infecting organism.

We undertook a retrospective study of all the patients who presented with delayed deep infection following primary total knee replacement during a six year period between April 1998 and March 2004. We analysed the infecting organism, sensitivity of the organism to antibiotics, number of surgical procedure carried out and the outcome of the infected arthroplasty based on the infecting organism. Statistical analysis was done using Fisher’s Exact test for categorical data and Mann-Whitney U test for the non-parametric numeric data.

The mean age at the time of primary arthroplasty was 69.9 years (range 46 to 92 years, SD=10.8). The mean follow-up (time since the initial knee replacement) was 77.3 months (range 27–170 months,). The mean follow-up since the last surgical procedure to treat infection was 31 months (range 14–47 months). Organisms were isolated in 27 of the 31 patients who presented with delayed deep infection. Forty-four % of the organisms isolated were multi-drug resistant with increasing incidence of Methicillin resistant Staphylococcus aureus and multi-drug resistant Staphylococcus epidermidis infections. Successful outcome following an infected total knee arthroplasty was lower compared to the previous studies where there were fewer multi-drug resistant organisms. The number of patients with satisfactory outcome is significantly lower when the organism isolated is multi-drug resistant. Patients infected by multi-drug resistant organisms undergo higher number of surgical procedures compared to patients where the organism is not multi-drug resistant. We conclude that deep infection with MRSA and Methicillin resistant Staphylococcus epidermidis are on the rise. Outcome is significantly better when the organism isolated is non resistant Staphylococcus aureus.

Background: Aseptic loosening of the tibial component is the one of the commonest cause of failure following a TKR. Good cement penetration into bone can reduce this and this has led to the development of new devices and techniques to improve the pressurisation during the cementing process.

We have conducted a case controlled study on a novel cementing technique and compared the results with published optimum levels.

Methods: 104 patients that underwent TKR at our institution were studied. Half of these were cemented using a double mix of cement inserted under pressure via an inexpensive alternative to the cement gun. The data was collected prospectively and included patient information, knee outcome scores and radiological assessment and there was a minimum 4 years follow-up.

Results: We found a significant difference in the number of early lucent lines as well as the size of the cement mantle particularly in the most important Zones. Despite pressurisation 1 of the 14 zones did not improve and we have examined the reasons for this.

In order to achieve optimum cement penetration we recommend that attention is paid to good pressurization and cement penetration and describe our technique for doing this.

Purpose of Study: To assess the efficacy of two-stage correction (skeletal traction followed by Partial Fasciec-tomy) in treating severe Dupuytren’s contractures.

Material, Methods and Results: We retrospectively reviewed sixteen fingers in fifteen patients with severe Dupuytren’s contracture (Tubiana Grade III/IV), operated between April 2000 and July 2005. The mean age was 58 years (27 – 82 years).

All patients underwent an initial application of Orthofix external fixator with pins in the proximal and middle phalanx. The patients were advised to gradually distract the device 3-4 times a day, for two weeks. They were then brought back for removal of fixator and partial fasciectomy with closure of skin by V-Y plasty.

The results were assessed in thirteen patients, as two were lost to follow-up. The mean follow-up period was 30 months (6 – 64 months). The total mean preopera-tive extension deficit improved from 130 degrees to 38 degrees postop.; PIP joint deformity improved from a mean of 77 degrees to 33 degrees postop. and the mean TRAM (Total range of active movements) improved from 108 degrees to 165 degrees.

Functional assessment was done using Michigan Hand Outcome Questionnaire. Overall improvement in hand function was from a preoperative 34% to a postoperative 89%.; aesthetic improvement from a preop. of 46% to a postop of 81% and pain improvement from a preop of 66% to a postop of 96%.

One patient had recurrence, one had features of RSD (Reflex Sympathetic Dystrophy) and one had to undergo amputation due to poor tolerance and persistent infection.

Conclusion: Severe Dupuytren’s contracture is a challenging deformity to deal. The two-stage correction may be considered as an alternative method of treatment in cooperative patients. Our study has shown promising results with good patient satisfaction