To study the outcome of complex proximal humeral fracture sequelae (Type 3 & 4) treated with the Delta III Total Shoulder Replacement (TSR) Prosthesis. This is a prospective outcome study involving 10 patients mean age (71.5 yrs). All patients failed conservative treatment of proximal humeral fractures. Mean time from injury to surgery was 10.5 (+/− 11.5) months. All patients underwent a Delta III TSR via McKenzie approach by a single surgeon. Patients were assessed clinically with Constant scores, asked whether they were satisfied, and radiologically with plain film radiographs. Since last review one patient has died. Mean time at follow up was 20.8 months post-operation (12 “32 months). Three patients had undergone early revision for dislocation. Since last review two patients have developed deep infection, one treated with washout and suction drain, one with removal of prosthesis. One patient has a clinical diagnosis of complex regional pain syndrome. Three patients are very happy with the outcome of surgery, one is happy, one unhappy and four very unhappy. The mean pre-operative Constant scores was 8.9 (2–15), at first review 44.4 (15–96) and now 35.8 (4–76). The mean pain score on a visual analogue scale (0–10) was 3.6 (0–10). Radiographs showed no progressive notching of the glenoid in any patient. Mean flexion was 93 degrees (10,170), mean abduction 61 degrees (10,100) and mean external rotation was “1 degrees (−20,20).

This is a new technique for treating proximal humeral fracture sequelae. Some individual results are excellent. There has been a high complication rate and a significant rate of poor results. At this time we cannot recommend the reverse geometry prosthesis for the treatment of proximal humeral fracture sequelae.

Aim: To describe a radiographic biomechanical classification of tibial plateau fractures which dictates treatment. To compare the intra- and interobserver reliability and reproducibility of this, the Chertsey (C1-3) classification, and the Schatzker (SK1-6) classification.

Method: This classification system has been used at this institution for 8 years by the orthopaedic trauma consultants and consists of C1 – valgus fractures, C2 – Varus fractures and C3 axial fractures. Our treatment regime is based on this classification and results presented in a sperate study. These consultants were excluded from the study on reliability and reproducibility. 2 Orthopaedic consultants, 2 orthopaedic registrars and 2 radiologists were selected randomly to classify 30 sets of AP and Lateral radiographs, of randomly selected patients treated in this institution with tibial plateau fractures, consisting of 9 SK1-3/C1, 8 SK4/C2 and 13 SK5,6/C3 fractures, and again with the same radiographs in a random order 1 month later. Radiographs of fractures treated conservatively were excluded. Statistical analysis included Kappa concordance according to Landis and Koch, and the Mann-Whitney U test.

Results: The Schatzker system was only moderately reliable (K=0.66), and the Chertsey classification system significantly more reliable (K=0.82) (p=0.03) with regards to interobserver reliability. Excellent reproducibility (intra-observer reliability) was seen amongst all observers. The consultant orthopaedic surgeons were significantly more reliable than the radiologists, but not the orthopaedic registrars. No particular fracture type in any classification proved to be significantly more difficult to classify.

Conclusion: We present a classification used in our institution based on plain radiographs, which depicts investigations and treatment. The Chertsey classification is significantly more reliable between observers than the Schatzker classification and is reproducible.

We wished to estimate the incidence of surgical-site infection (SSI) after total hip replacement (THR) and hemiarthroplasty and its strength of association with major risk factors. The SSI surveillance service prospectively gathered clinical, operative and infection data on inpatients from 102 hospitals in England during a four-year period.

The overall incidence of SSI was 2.23% for 16 291 THRs, 4.97% for 5769 hemiarthroplasty procedures, 3.68% for 2550 revision THRs and 7.6% for 198 revision hemiarthroplasties. Staphylococcus aureus was identified in 50% of SSIs; 59% of these isolates were methicillin-resistant (MRSA). In the single variable analysis of THRs, age, female gender, American Society of Anesthesiologists (ASA) score, body mass index, trauma, duration of operation and pre-operative stay were significantly associated with the risk of SSI (p < 0.05). For hemiarthroplasty, the ASA score and age were significant factors. In revision THRs male gender, ASA score, trauma, wound class, duration of operation and pre-operative stay were significant risk factors. The median time to detection of SSI was eight days for superficial incisional, 11 days for deep incisional and 11 days for joint/bone infections. For each procedure the mean length of stay doubled for patients with SSI. The multivariate analysis identified age group, trauma, duration of operation and ASA score as significant, independent risk factors for SSI. There was significant interhospital variation in the rates of SSI. MRSA was the most common pathogen to cause SSI in hip arthroplasty, especially in patients undergoing hemiarthroplasty, but coagulase-negative Staph. aureus may be more important in deep infections involving the joint.

Aim: To show that the Delta III Total Shoulder Replacement (TSR) Prosthesis is an alternate treatment for complex proximal humeral fracture sequelae (Type 3 & 4)

Methods: This is a prospective outcome study involving 10 patients (mean age (71.5 yrs). All patients failed conservative treatment with a mean time to surgery of 10.5 (+/− 11.5) months and a mean follow up of 8.2 months (6–24mnths). All patients underwent a Delta III TSR via McKenzie approach by a single surgeon.

Patients were assessed with constant and age adjusted Constant scores, radiographs and subjective questionnaire and whether they were satisfied at 6 weeks, 3, 6, 12, 24 months.

Results: At 6 months, age adjusted Constant scores changed form a mean 8.9 (5.3) pre-op to 50.1 (20.9). Six patients were satisfied, 2 unsure and 2 unsatisfied; elevation improved the most, with external rotation the least affected. Age adjusted power increase by 40.4 %, with a subjective function (10 points) improving by 32.6 %. X-rays at 6 months showed two glenoid notches in contact with the inferior screws. Three patients underwent revision surgery (total 5 revisions) for acute post – operative dislocations – all had inserts changed. Intra-operative tension assessment (by means of anterior dislocation of the humerus) was found to be a useful test of stability. Revision surgery found to be a significant predictor of poorer function at 6 months. (p< 0.025). No stem failures noted. Significantly better constant scores achieved with shorter period of time from fracture to delta replacement (p< 0.045). A single wound infection was treated successfully with oral antibiotics.

Conclusion: The results of the Delta III TSR in this difficult group of patients, appear satisfactory in terms of patient satisfaction, subjective and objective functional assessment and 6 months prosthesis survival (100%), and appear to offer a better functional outcome than hemiarthroplasty.

Aims: To study the outcome of lumbar spinal fusions in patients with chronic lower back pain due to degenerative spinal disorders. Methods: 85 patients with DSD’s, a mean age of 46.4 years, back pain for at least 2 years (mean=7.7years) and failed conservative treatment for at least 1 year were admitted to the study. Questionnaires recorded socio-demographic characteristics; changes in pain, clinical findings, disability (Oswestry (ODI)), employment, radiographic fusion, patient satisfaction and complications. All patients had 3, 6, 12 and 24-month follow-ups. Results: There were 37 males (44.9years) and 48 females (47.6 years) with a mean BMI of 24.8; 49% were smokers. Pain improved significantly at 3months (p< 0.001); no deterioration at 2 years with 38.4% having no back pain. Motor (p< 0.01), sensory (p< 0.05) and Oswestry Disability (0.001) improved significantly at 3 months and continued throughout. Unemployment improved significantly 30.4% to 16.5% at 2 years (p< 0.04). Radiographic fusion occurred in 91.8%, instrument failure in 11.8% and 9.4% required re-operation. Patient satisfaction revealed a significant increase in excellent (p< 0.02) and poor (p< 0.03) results. Instrument failure correlated strongly with ODI (r=0.94, p< 0.04). No other significant correlations. Conclusions:With the correct patient selection, lumbar fusions for DSD’s lead to a significantly improved outcome at 2 years, with an acceptable complication rate. There is no correlation between radiographic fusion and outcome, but instrument failure leads to significantly worse outcome

Aims: To investigate the functional outcome with different autologous bone graft weights in posterolateral lumbar spine instrumentation for DSD’s. Methods: A total of 79 patients (mean age of 47.2) with chronic lower back pain for at least 2 years, with at least 1 year of failed conservative treatment and who were undergoing pos-terolateral spinal instrumentation for DSD’s were admitted to the trial. Patients were randomised into three groups to receive bone graft weights of 25g (Group A=26 patients), 50g (Group B=30 patients) and 100g (Group C=23 patients) per segment. Pain, clinical characteristics, disability (Oswestry), radiographic fusion, patient satisfaction and complications were recorded at 3, 6, 12 and 24-month follow-ups. Results: At 2 years, Group B (50g) had a significantly improved Oswestry Index, pain intensity, motor and sensory changes, and overall patient satisfaction than Group C (100g), which was significantly better than Group A (25g). There was no correlation between bone graft weight and radiographic fusion, between fusion and outcome, nor smoking and fusion or bone graft weight. Complications were similar. Conclusions: Patients had significantly better functional and clinical outcomes with bone graft weights of 50g. Bone graft weights of 25g had the worse outcomes and 100g did not seem to have any beneficial affect over 50g. We recommend autologous bone graft weights of 50g per fused spinal segments in this group of surgical patients.

Aims: Data collected on knee replacements from 93 hospitals in England were analysed to identify risk factors for surgical site infection. Methods: Prospective surveillance data collected from hospitals in England to calculate surgical site infection rates and potential risk factors Results: There were 242 (1.6%) infections in 15427 primary TKR, with a 0.11% joint infection rate, and 36 (3.6%) infections in 988 revisions, with a signiþcantly higher joint infection rate of 0.35%. There was considerable variation between hospitals. Multivariable logistic regression found signiþcant association between risk of SSI and type of procedure (p< 0.01), the hospital where the procedure was performed, male sex (p< 0.001), age (p< 0.001) and wound class (p< 0.05). The mean length of stay in primary TKRñs increased from 9 days to 18 days with an infection; and in revision procedures from 12 to 24 days. The median time to diagnosis for SSI was 7.5 days. Staphylococcus aureus accounted for 33%, 66% of which were methicillin resistant (MRSA). Conclusions: There is signiþcant inter-hospital variation in the incidence of SSI following knee replacements in England. Signiþcant risk factors include revision procedures. Male sex, age and wound class. SSIñs doubled the length of post-operative stay and MRSA accounted for 21% of organisms.

Aims: To calculate SSI rates and potential risk factors for primary total hip replacements (THR), hip hemiarthroplasties (HH), revision THR’s, and revision HH’s in England. Methods: Demographic, operative, and infection data was collected prospectively from 104 hospitals in England over 4 years to calculate SSI rates and potential risk factors. Results: There were 353 (2.3%) infections in 15697 THR’s with a 0.2% joint infection rate; 248 (4.6%) infections in 5456 HH procedures (0.9% joint). For revision THRs there were 92 (3.6%) infections in 2563 procedures, and 11 (5.6%) infections in 197 revision HH’s. Staphylococcus Aureus was identified in 52%; 58% were MRSA. With multivariable analysis, only inter-hospital variation (p< 0.001) and ASA score (p< 0.001) remained significant. Mean time to detection of infection varied from 9.2 days (superficial) to 11.3 days (joint). Mean length of stay increased from 9 to 14 days in THR’s; from 14 to 30 days for revision THR’s; from 19 to 34 days for HH’s and from 20 to 28 days for revision HH’s with an infection.

Conclusions: Infection rates are within acceptable levels, however there is a significant inter-hospital variation in infections following hip prosthesis in England. ASA score remains a significant risk factor and MRSA accounted for 30% of organisms.

We studied the use of autologous pre-donated blood transfusion in surgery for scoliosis in 45 patients who were divided into two groups; 27 who pre-donated autologous blood (group 1) and 18 who were planned recipients of allogenic blood (group 2). Normovolaemic haemodilution and intra-operative blood salvage was used in six patients in group 1 and three patients in group 2.

The two groups did not differ significantly with respect to age, American Society of Anaesthesiologists score, mean operative time, number of vertebral segments fused, total blood loss, length of stay in intensive care and length of stay in hospital. The risk of requiring allogenic blood transfusion was found to be significantly less in group 1 (7.4% ν 88.9%, p < 0.001). Only 5.21% of autologous units were wasted. Although intra-operative blood salvage reduced the total blood loss in both groups, it did not affect the need for subsequent allogenic transfusion or reduce the number of pre-donated autologous units which were given (p < 0.67). Autologous blood transfusion required extra time, personnel, resources and cost £28.88 per patient more than allogenic transfusion, however, the projected costs at May 2002 make this programme cost-effective by £51.54 per patient.

Pre-donated autologous blood transfusion is acceptable and safe in scoliosis surgery. It significantly reduces the subsequent requirement of allogenic transfusion. Although the cost is currently more than allogenic transfusion, with the increase in the costs of the latter and the decrease in potential donors which is anticipated, pre-donation of autologous blood will become comparatively cost-effective.

Background

Various clinical outcome studies have consistently reported high dissatisfaction rate (25–33%) among the patients after hallux valgus surgery. We believe that a patient’s pre-operative expectations may play a major role in post-operative satisfaction.

Patients & Methods

Questionnaires were sent to 104 patients anonymously who were given a list of reasons and asked which they hoped to improve by having the surgery. They were also asked to list, in the order of priority, goals that they hoped to achieve from surgery.

Results

Overall, improvement in the ability to walk was the most important reason. Most patients also wished to reduce pain over bunion and to regain the ability to wear daily shoes. However, the expectations of patients vary significantly according to age. Patients under 40 placed more importance on their ability to wear dress shoes and improvement in functional activities. Patients between the age of 40 and 60 were more interested to improve physical appearance. Pain on other toes, and the abilities to squat and climb stairs are the main concerns for patients above 60. For the male patients, to be able to continue work is the second most important reason after improvement in walking ability. This is in contrast to the female group where the ability to wear shoes of their choice is more important. Occupation did not make any significant difference.

Conclusions

This study shows that patients have different expectations that can influence the choice of operation. We believe that understanding patients preoperative expectation is crucial in achieving better patient satisfaction, and it should be an important consideration in planning appropriate operation for the patients.

Data collected on total knee replacements (TKR) from 77 hospitals in England were analysed to identify risk factors for surgical site infection (SSI).

Demographic, operative, and infection data were collected prospectively over a four-year period by the Nosocomial Infection National Surveillance Scheme.

There were 213 (1.8%) infections reported in 11552 primary TKR of which 82% were superficial, 10% deep incisional, and 8% joint/bone infections. The incidence of SSI in 687 revision of TKRs was 4.1% (71% superficial incisional, 18% deep incisional and 11% joint/bone). In the single variable analysis of primary TKRs, significant risk factors were male sex (p< 0.01), age (p< 0.001), ASA score (p< 0.001), wound class (p< 0.001) and NNIS risk index (p< 0.001). In revision of TKRs, only age (p< 0.01) and pre-operative hospital stay of more than one day (p< 0.02) were found to be significant. Significant risk factors with multi-variable logistic regression were type of procedure (TKR or revision TKR), hospital where the procedure was performed, male sex, and age. The mean length of stay in primary TKRs was 10 days (19 days with SSI) and 12 days in revision TKR (22 days with SSI). The median time to diagnosis for superficial SSI was 7 days for superficial SSIs, 9 days for deep incisional SSIs and 7.5 days for joint/bone infections. Staphylococcus aureus accounted for 35% of the infections and nearly one third of these were methicillin resistant (MRSA).

There is significant inter-hospital variation in the incidence of SSI following total knee replacement. Revision TKR procedures are associated with a significantly higher incidence of SSI than primary TKRs (p< 0.001). Male sex and age are also important risk factors. Patients with SSI had a length of post-operative stay approximately twice that of those without SSI.