Background

Predicting length of stay (LOS) is key to providing a cost effective and efficient arthroplasty service in an era of increasing financial constraint. Previous studies predicting LOS have not considered enhanced recovery protocols in elective hip and knee arthroplasty. Our study aims to identify patient variables in the pre and peri-operative period to predict increased LOS on patients enrolled into the standardised Chichester and Worthing Enhanced Recovery Programme (CWERP).

Knee dislocation is a rare injury in high energy trauma, but it is even rarer in low energy injuries. We present, to our knowledge, the only case in the world literature of knee dislocation following a cricketing injury. The patient was a 46 year old recreational fast bowler who, whilst bowling, slipped on the pitch on the follow through. He sustained an anteromedial knee dislocation which was reduced under intravenous sedation. He also sustained a neuropraxia of the common peroneal nerve with grade 2 weakness of ankle and toe dorsiflexion. Magnetic Resonance Imaging (MRI) confirmed a complete rupture of anterior cruciate ligament (ACL), lateral collateral ligament (LCL) and postero-lateral corner (PLC). Patient underwent surgical reconstruction and repair of his PLC along with repair of LCL with combination of anchor sutures and metal staple within 72 hours of the injury. He was treated in a cast brace. The ACL insufficiency was treated conservatively. Patient made an uneventful recovery and follow up at 3 months revealed a full range of knee movements with asymptomatic ACL laxity

Hip resurfacing with metal-on-metal in patients with osteonecrosis (ON) raises concerns of early failure. This study addresses the hypothesis that osteonecrosis as a pre-operative diagnosis significantly increases the risk of failure following hip resurfacing. We analyzed data of 202 hips that underwent metal-on-metal hip resurfacing. In group 1 were 101 hips with a pre-operative diagnosis of osteonecrosis. In group 2 were 101 hips with other pre-operative diagnosis of osteoarthritis. Survival analysis with Cox regression was used to compare the revision risks of both groups. The mean age at operation was 42 years in osteonecrotic and 43 years in osteoarthritic group. The preoperative and postoperative hip scores were 62 and 96 for osteonecrotic group and 58 and 95 for osteoarthritic group, respectively. Survival analysis with revision for any reason as the endpoint was performed on the two groups which had identical follow-up periods. Survival at 10 years was 97.7% for osteonecrosis and 95.0% for osteoarthritis. The revision risk for patients with osteonecrosis was lower (0.37, 95% CI 0.07 – 1.82, Cox regression) but the difference was not significant (p = 0.19). Our study found no difference in revision risk in patients with osteonecrosis as compared to those with osteoarthritis

To assess the outcome of knee “arthrodesis” using cemented Endo-Model knee fusion nail in failed Total Knee Replacement (TKR) with significant bone loss due to infection. This is a retrospective case study of seven patients with infected TKR and multiple surgeries with significant bone loss.

All patients had antibiotic loaded cement with a temporary K-nail as a first stage procedure to eradicate infection. All seven patients had “arthrodesis” performed using cemented modular Endo-Model Knee Fusion nail (Waldemar Link, Hamburg) by the senior author. Cement was used to hold the stems in the diaphyses and not used around the coupling mechanism. The “arthrodesis” relied entirely on the coupling mechanism which has been shown to have good axial and torsional rigidity by mechanical testing. Outcome was assessed using pre and post Visual Analogue Score (VAS).

Mean age was 72.3 years(62–86). Mean follow up was 39.6 months (7–68). The VAS pain score improved from pre-operative mean score of 7.9 to a postoperative score of 1.5. One patient suffered fracture of femoral cement mantle at 50 months who underwent a technically easy exchange revision. One patient had recurrent infection with distal femoral fracture at 36 months and was revised to distal femoral replacement.

The Endo-Model knee arthrodesis nail restores limb lengths, has good early results in terms of pain relief and provides a stable knee “arthrodesis” in cases where there is significant bone loss and extensor mechanism insufficiency following an infected TKR.

Introduction: Trochanteric osteotomy provides excellent exposure to perform hip replacement surgery. In the UK, 5.9% of primary hip replacements are performed using an osteotomy. Trochanteric non union is one of the complications of this approach. The aim of this study was to investigate the role of release of posterior trochanteric soft tissue release on the incidence of trochanteric non-union.

Method: We present the results of 100 patients who underwent primary cemented total hip replacement at our centre using the biplanar, intracapsular osteotomy. Group A (50 patients) had received a posterior trochanteric soft tissue release as part of the approach and Group B (50 patients) had not. Patients were followed up clinically and radiologically.

Results: In group A the trochanteric non union rate was 12% and in group B 2% (p< 0.05). According to the Hodgkinson’s classification of trochaneric non-union, all the non-unions in group A were grade 3 (> 1.5 cm migration) and group B was grade 2 (< 1.5cm migration).

Discussion: The two different techniques were examined on cadaveric specimens and it was noted that the obturator externus tendon was consistently cut as a part of the posterior soft tissue release. We conclude that this important structure should not be released as part of this approach to hip replacement. Obturator externus is an important adductor of the trochanter and preserving it decreases the incidence of trochanteric non-union.

Aim: To assess the outcome of knee arthrodesis using cemented Endo-Model knee fusion nail in failed total knee arthroplasty with significant bone loss due to infection.

Methods: A Retrospective case study of seven patients with infected TKR and multiple surgeries and significant bone loss (Type III AORI classification). All patients had antibiotic loaded cement with a temporary K-nail as a first stage procedure to eradicate infection. All seven patients had arthrodesis performed using cemented modular Endo-Model Knee Fusion nail (Waldemar Link, Hamburg) by senior author (RSJ). The arthrodesis relied on the strong coupling mechanism of the nail and not on bony union, providing pain relief while mainting leg length. Outcomes assessed using pre–and post Visual Analogue Score (VAS) and Oxford knee scores.

Results: Mean age 76.8 years (62–85). Mean follow up 23.7 months (3–42). The mean VAS pain score improved from 7.6 (6.5–8.5) pre-operatively to 1.1 (0–3.2) post-operatively. The mean post-operative Oxford score was 30.3 (27–36). One patient required revision for asceptic loosening. All but one of the patients thought that arthrodesis was preferable to amputation post-operatively.

Conclusion: The Endo-Model knee fusion nail has good early results in terms of pain relief and knee arthrodesis where there is significant bone loss and extensor mechanism insufficiency following an infected total knee replacement.

Purpose: To find if there is any difference in gapping of tendon repair on cylcic loading and energy to failure of tendon repair when the circumferential suture knot is placed on the same side of the core suture knot or to the opposite side of the core suture knot.

Methods: Ten pig flexor tendons were repaired using 3 0 braided Polyester (Ethibond) as core suture (modified Kessler) and 6 0 Nylon as circumferential stitch (Hal-stead). Five tendons were repaired with the circumferential suture knot placed on the same side as the core suture (Group I) and the other five placed on the opposite side (Group II). Allocation to either of the groups was random. Using a testing machine the tendons were cyclically loaded and the energy to failure was calculated. Gapping during cylical loading was recorded using digital images.

Results: Mean gapping in Group I was 0.01 mm and in Group II was 0.03mm. This was not statistically signifi-cant (2x3 ANOVA, p > 0.3). The mean load to failure in group I was 58.7 N (55 to 65) and in group II was 59.5 N (54 to 67). This was also not statistically significant (p > 0.3 one way ANOVA).

Conclusion: There is no difference in gapping and energy to failure of tendon repair when the circumferential suture knot is placed on the same side of the core suture knot or to the opposite side of the core suture knot.

Purpose: The management of comminuted inter trochanteric fracture are a serious and difficult problem. The proper selection of fixation device is must to avoid significant complication in the management of this common fracture.

The use of contoured side plate screw attached to the sliding screw plate anchors the comminuted fragments thus gives better stability, compression, early mobility and bony union to this fracture where other implant fails.

Material and method: Since 1997 to 2000, 60 comminuted inter trochanteric fracture- age of 67yrs (46–91year) were treated by close/open reduction and internal fixation with 135 dynamic hip screw plate +side screw plate.

The side plate is a narrow D.C.P. (4/5 hole) which is contoured to the fl are of greater trochanter proximally and is attached to the sliding screw plate. The proximal holes of side plate hold the comminuted fragment of greater trochanter with cancellous screw above the sliding hip screw The patient were encouraged to walk on 2nd post operative day with support to start with partial weight bearing followed by weight bearing at 4 wk.

Result: On an average 12-week (8–16 wk) all the Tranzo grade II/ III fracture went into union . There was lengthening of 2.5cm (2–5 cm) in 15 cases due to valgus reduction which reduced to 1.5 cm (2–3cm) at end of 6 months. Backing up of the side plate screw and sliding hip screw was seen in 40% of case (24) (mainly in poor bone stock and valgus reduction case).

Conclusion: The side plate/ screw with sliding hip screw stables buttress for comminuted trochanter fragments gives compression, prevent rotation and better bony union the piece. This implant is an extended arm for holding fragment. The major trochanteric fracture fragment are held by side plate to sliding screw plate thus gives stability to the device, better bony contact thus early mobility and union. The sliding screw device with side plate is “forgiving” it allows subsequent displacement to achieve stability in comminuted fracture. The success of the implant assembly rest on the ability of slide and hold the fragment to give stability and bony union. This method gives an option of open reduction and bone grafting.

The lateral condylar fractures of the humerus are the second most common injury around the elbow in children. Treatment of patients presenting late is controversial. We report our experience of treatment of these fracture over last thirteen years in 78 children seen between 1987 and 2000. Average age- 5.2 years ; 53 patients presented early and 25 patients presented more than 3 weeks after injury . In latter, 11 patients were treated conservatively and rest by internal fixation. Pseudovarus was observed in 30% cases on long term followup. Of 25 patients presenting late, open reduction, internal fixation with bone grafting was carried out in eight cases (those who presented between 3–6 weeks) and rest of the 17 cases were kept under observation on regular follow up. At final follow up, the cases operated late (n= 8) had preservation of 70–80 % of Flexion Extension Arc. Of the 17 cases kept under observation, 8 (showing non union) developed cubitus valgus. 9 cases (showing malunion) continue to have stiff elbow . The elbow function was better in the former group. We suggest that every effort should be made to fix the lateral condylar fragment in patients presenting even more than 3 weeks especially if the metaphyseal chunk is large, the fragment is not widely displaced and rotated and the fracture is type II Milch in a very young child (as those patients rapidly develop very severe cubitus valgus deformity with translocation of ulna).