The purpose of this study is to evaluate the clinical outcomes between a bipolar prosthesis and a hemiprosthesis (unipolar) in the treatment of displaced intracapsular femoral neck fractures. The theoretical advantage of a bipolar prosthesis is a reduction of acetabular erosion. Movement within the prosthesis may also reduce the pain caused by movement in the acetabulum.

A prospective randomised study was conducted evaluating 40 patients over the age of 70 years, who presented with intracapsular hip fractures Garden 3 or 4, treated either with a bipolar prosthesis (medical international) or a Thompsons hemiarthroplasty. There were 20 patients in each group, and the operation was performed through a Hardinge approach by the same surgical team. All prostheses were uncemented. All patients were rehabilitated by the same Physiotherapist using the same routine. An out-patient assessment was performed at 6 weeks, checking the wound, the clinical result and doing an AP x-ray of the pelvis.

39 Patients were followed for a median period of 13 months. 1 Patient who received a Thompsons prosthesis died in hospital. The average hospital stay in patients receiving a bipolar prosthesis was 7 days, and 13 days for those who were treated with a Thompsons prosthesis. There were 2 deep infections and 1 peri prosthetic fracture in the hemiarthroplasty (Thompsons) group. 15 Of the 20 patients treated with a bipolar prosthesis returned to their pre-injury state with mild pain, and were satisfied with the procedure. Only 9 of the 19 patients in the Thompsons group returned to their pre-injury level, with 12 complaining of pain and only 4 satisfied with the procedure.

The early subjective outcome in elderly patients is difficult to assess, and the optimum realistic outcome should be a return to pre-injury function and the presence or absence of pain. This review was not blinded, and hence the assessment of results could be biased towards certain prostheses. The findings suggest that a bipolar prosthesis may give a better short term result in the elderly. The bipolar prosthesis used in this series is inexpensive, and we felt its use justified.

The increased prevalence of HIV has increased awareness and concern for the diagnosis and treatment of patients requiring total joint arthroplasty. Collective experience with HIV and arthroplasty at any institution is small and limited. This study evaluates the clinical outcome of arthroplasty in HIV infected patients.

Between July 2000 and August 2001, we treated 14 patients (4 female) and with uncemented total hip replacement. (Mean age of 42 years). Informed consent was obtained before HIV testing and counselling was provided for all patients. Patients were classified according to the WHO and CDC classification. All patients were operated on by a single surgeon using the Hardinge approach.

14 Patients were followed up with a mean follow up 62 months. The pre-lymphycyte subset analysis was TLC-2.24, CD4 425, CD8 873, CD4/CD8-0.52. All patients were fully ambulant. One patient sustained a periprosthetic fracture following a high energy car accident which was treated non operatively. Three patients have dropped their CD4 count to below 200 and are presently receiving antiretroviral treatment. There was no loosening, infection or dislocation.

The literature on complications associated with arthroplasty in HIV infected patients is inconsistent. A few authors have reported a 40% incidence of infection with total joint replacement. In this series there were no infections, and the outcome of total joint arthroplasty depends on the nutritional status of the patient, the stage of the under lying disease, as well as previous surgery and co-morbidities. Orthopaedic Surgeons should be aware of the increasing prevalence of HIV infection, and that arthroplasty in these patients can be safely performed with minimum complications.

The treatment of fractures has evolved from extensive open reduction and internal fixation to minimally invasive surgery and biological fixation. High energy bicondylar tibial plateau fractures pose a treatment challenge to most orthopaedic Surgeons. This study evaluates the results of biologic plating of bicondylar tibial plateau fractures.

Between January 2005 and January 2006 we treated 25 closed bicondylar tibial plateau fractures with minimally invasive surgery using locking plates and screws. Routine tomograms and CT scans were performed after a detailed history and physical examination were performed. Pre-operative planning and templating was performed in all cases. Surgery was carried out by the same surgical team using a tourniquet and an anterolateral or medial surgical approach. Bone grafting was also performed in some cases. The implants used were pre-contoured locking plates (Synthes, Smith & Nephew). The rehabilitative programme was commenced on day 2 by the same Physiotherapist and non weight bearing for 12 weeks.

Four patients refused to be part of the study and two were lost to follow up. Nineteen patients were available for follow up with a mean follow up of 10 months. There were 10 males with mean age of 35 years. Two patients were treated for early superficial wound sepsis which healed. Eight patients needed a bone graft at the time of surgery. The average range of movement was 5–110 degrees of flexion. There were no implant failures or non unions. At six months all patients walked unaided with no deformity and were satisfied with the operation.

As an alternative to external fixation of these difficult fractures we recommend a less invasive precontoured plate with locking screws. The advantages include sub-muscular, extraperiostal plate application through a relatively small incision, percutaneous screw placement through a guide, the fixed angle of the plate obviating the necessity of medial plate fixation, and plate lengths are available to span the metadiaphysis. The results suggest that biologic plating with a precontoured locking plate of bicondylar tibial plateau fractures may give better short term results with excellent function.

Compound fractures are a surgical emergency. The primary treatment is early operative debridement and stabilization of the bone. Debridement of a compound fracture includes exploration of the wound to define the injury, removal of devitalized tissue and the use of pulse lavage to achieve additional mechanical debridement of the wound. We could not find any study confirming the use of a pus swab in acute fractures. This study evaluates the significance of early pus swabs taken pre and post debridement of compound fractures in long bones.

Between January 2005 and March 2006, 50 patients with compound fractures of long bones were assessed. A detailed history, mechanism, time of injury, presentation to hospital and time taken for debridement were recorded. The fractures were classified according to Gustilo and Anderson. A pre-debridement washout and a pus swab was taken at presentation to the orthopaedic emergency room. All patients were given ATT and cephalosporin, and the limbs were splinted. All fractures were again irrigated and debrided and fracture stabilized in theatre. A second swab was taken and the time recorded.

There were 50 patients, 30 males with a mean age of 32 years. 15 Of the fractures were grade 1 compound, 13 grade 2, 10 grade 3A and 12 grade 3B. Cultures revealed 12 patients with staphylococcus, 10 with multiple organisms, and 28 patients with no growth in the pre-debridement group. In the post-debridement group staphylococci were cultured in 18 patients, there were multiple organisms present in 20 and no organisms in 12. Only 3 patients had their debridement within 6 hours of injury.

The timing of the colonization of the wound, the virulence and number of organisms and the immunological response of the patient’s vary. A combination of these factors will determine whether a compound fracture will be infected. Early wound infection has been found to be a poorer predictor of wound sepsis, hence the significance of a bacteriological swab. There is a relatively higher rate of wound infection following formal debridement as evidenced by the bacteriological cultures and is not related to the time of debridement.

This study was undertaken to determine the most effective way of treating intracapsular femoral neck fractures in HIV-positive patients. Ten patients with a mean age of 36 years were treated. Excision Girdlestone was performed In three patients in whom previous internal fixation had failed: all had poor nutritional status and low CD4 counts (mean 162). Three patients with undis-placed fractures were treated with percutaneous AO screws and a dynamic hip screw. In the remaining four patients, total hip arthroplasty (THA) was performed. At a mean follow-up of 14 months, all patients were fully ambulant with no signs of infection.

The decision to proceed with THA in HIV-positive patients should be made only after weighing the ratio of risks and benefits. The ultimate outcome depends on a number of factors, including displacement of fractures, previous surgery, co-existent medical problems, nutritional status and the stage of the disease.

With the rising prevalence of HIV, the number of immunocompromised patients is increasing. Higher rates of wound sepsis following implant surgery in seropositive patients have been anecdotally reported in Central and East Africa, but at any single institution experience with HIV and implant surgery is limited.

This is a review of 21 patients, 18 of whom were seropositive, who had infected implants after undergoing elective operations for fractures that presented late (mean time 24 months). In 16 patients radiological union had occurred and the septic implants were removed. The organisms cultured in these patients were Staphylococcus aureus and Group-A Streptococcus. In 14 of the patients, implant removal and antibiotics produced excellent results. Two required a Girdlestone excision of the hip and gentamycin beads. Incision and drainage was performed in three patients who had superficial sepsis. The organism cultured was Group-A Streptococcus. All wounds healed. One patient died of AIDS: aspirate revealed Escherichia coli with mixed organisms. In one patient the organism was Pseudomonas aeruginosa and after the nail was removed the patient had a persistent draining sinus.

The results suggest that HIV-positive patients are at increased risk of postoperative infection, and that early removal of implants may avoid future septic complications.

Supracondylar femoral fractures challenge even the most experienced trauma surgeon. Fracture comminution often extends into the articular surface, increasing the risk of joint stiffness and post-traumatic arthritis. This is a preliminary prospective report of 42 supracondylar femoral nailing procedures performed on 41 patients between July 2000 and March 2001.

The mean age of the 21 women and 20 men was 62 years. Five fractures were compound. Classified according to AO classification, there were 28 type-AIII fractures, 10 type-AII, two type-CIII and two type-CII. In all cases a percutaneous surgical technique was used and a 13-mm x 250-mm supracondylar nail inserted. The mean operative time was 70 minutes. Mean follow-up was four months (2 to 10). There were no deep or superficial infections and no implant failures. Twenty fractures healed with no shortening within four months. The mean flexion arc was 105° (5° to 130°). Eight patients with osteoporosis had 1 cm to 2 cm of shortening, which did not affect functional outcome. Of the 20 patients whose fractures united, 17 had no pain and three had mild anterior knee pain. A single patient had 8° of valgus angulation at the fracture site.

This study shows that supracondylar femoral nailing provides improved fracture stabilisation both in elderly patients with osteoporotic metaphyseal bone and in younger patients with extensively comminuted fractures. Percutaneous techniques eliminate the need for extensive surgical dissection, shorten operation times and reduce blood loss.

Fractures of the distal humerus present a challenge. The fractures are often intra-articular and the bone osteoporotic. The elbow tolerates surgery and immobilisation poorly, and it is difficult to secure rigid fixation. Union must be achieved and elbow motion preserved. The results of fixation of fractures of the distal humerus are unpredictable. Fixation with two plates at 90° angles to one another has become the standard against which all other treatment is measured. Following up patients for a mean of 24 months, the author conducted a prospective study evaluating posterior plating of the two columns of the distal humerus with reconstruction plates and intercondylar fixation.

Between 1996 and 2000, 18 women and seven men with unilateral intra-articular fractures of the distal humerus were treated. Their mean age was 46 years (35 to 71). The fractures were classified according to the AO classification: there were 22 type-CII and three type-CIII. Four fractures were compound.

One of two posterior approaches was used, either through the triceps aponeurosis or using an olecranon osteotomy. Postoperative management included prophylactic intravenous antibiotics for 48 hours and a posterior splint for 7 to 10 days. Active movement commenced once sutures were removed, but patients avoided active or resisted extension for six weeks. The mean time to union was 16 weeks. Patients attained a mean range of elbow movement of 105° (35° to 135°). One patient developed superficial sepsis but recovered after treatment with antibiotics. One patient with a compound injury developed a deep infection, which required multiple debridements, gentamycin beads and bone grafting to achieve union. There were no implant failures or cases of nerve paralysis.

This study demonstrated no differences in functional outcome between triceps aponeurosis or olecranon osteotomy approach. Union and satisfactory functional results were achieved with posterior plating of the columns and intercondylar fixation.