Fractures of the proximal humerus can offer a difficult surgical challenge particularly if they occur in elderly patients and/or are a complex fracture configuration. Much of the morbidity of the surgery relates to the extensile delto-pectoral approach traditionally used for operative treatment of these fractures. A minimally invasive technique for approaching these fractures has was developed using a proximal deltoid split approach at the anterior edge of the deltoid and sliding a precontoured proximal humeral locking plate submuscularly after provisional fracture reduction. This technique was tested in a cadaver model to identify “safe” and “at risk” holes in the plate for percutaneous fixation in relation to the axillary nerve. A case series of eighteen patients who had surgery using this technique were reviewed. All patients achieved acceptable reductions and went on to unite without any signs of AVN or implant failure. One patient had a transient sensory disturbance in an axillary nerve distribution post op. One patient has asymptomatic fibrous union of the greater tuberosity. Minimally invasive plate fixation using a lateral deltoid split approach is technically possible with excellent results. The danger zone around the axillary nerve has been identified and should be avoided with percutaneous fixation utilising this procedure. A jig to allow accurate MIPO fixation has been developed.
To assess the efficacy of percutaneous K wiring in the treatment of distal radius fractures. A retrospective audit was performed of patients with distal radius fractures treated with the combination of manipulation under anaesthetic, K wiring and cast application at Auckland Hospital. Patients were identified by using the Orthopaedic Trauma Database. Charts were reviewed for patient demographics, preoperative delay and complications. X-rays were reviewed recording Frykman Grade and radial tilt, radial inclination and ulnar variance preoperatively, immediately postoperatively and at 6 weeks postoperatively. Seventy five consecutive cases were identified over an 18 month period between May 2002 and October 2003 with 4 excluded because of inadequate notes or x-rays. The majority of patients were female with an average age of 55 years. Most operations were performed by Advanced Trainees using 3 wires with at least one trans styloid wire. 55% of fractures were intra articular. Radial tilt was restored to within 10 degrees of normal in all but 3 patients immediately postoperatively but at 6 weeks 12 patients had more than 10 degrees dorsal tilt. All patients had less than 2mm positive ulnar variance immediately postoperatively but at 6 weeks postoperatively 11 patients had more than 2mm positive ulnar variance. 9 patients (13%) experienced local complications related to the wires. Manipulation under anaesthetic, K wiring and cast application offers a useful treatment option for distal radius fractures which are reducible but unstable. Care is required with patient selection and surgical technique to minimise complications.
The aim of this study was to improve data collection, audit and research data by integrating a comprehensive patient data collection database into the day to day running of an orthopaedic department. The day to day processes of the house surgeon and registrar junior staff were analysed and tasks identified that would allow accurate recording and recall of orthopaedic-specific patient data by automating and performing tasks that would improve junior staff efficiency. A database was then designed and implemented with a “front end” that performed such tasks as generating operating lists, tracking ward locations of patients, producing discharge summaries and auditing complications. This database was then introduced on the hospital intranet and the “back end” constructed to gather accurate patient and injury data to allow improved data collection and research. Information and data collected was a significant improvement on previous methods available to the department. Junior doctor compliance for data entry was high but the system needed monitoring and “cleaning” on a weekly basis to maintain its accuracy. This method of data collection was more accurate than anything available in the hospital and has been surprisingly useful in producing data to support concerns within the department regarding managerial changes in hospital systems. Use of a database collection system that gathers information by performing day to day tasks for junior staff has been an effective and reasonably accurate method of obtaining useful patient data. It requires regular monitoring to be most effective but has been easily integrated and accepted within the hospital system.
There has been a growing concern amongst the Orthopaedic Department at Auckland Hospital regarding the time Orthopaedic acute patients are waiting for surgery. To address this concern this study was undertaken to examine the extent of the problem and to establish recommended practice guidelines for waiting times. A literature search was undertaken to identify universally accepted delays for surgery for the six categories of fracture studied – compound fractures, femoral shaft fractures, tibial shaft fractures, ankle fractures, neck of femur fractures and distal radial fractures. Current practise guidelines were then compared with the literature to ensure they are an acceptable standard of care. Every patient operated on at Auckland Hospital in 2002 that had a fracture that fell within the six categories was included in the study. Data regarding the age and time to surgery for each patient was analysed. The study demonstrated major discrepancies between recommended practise guidelines and the present acute service. The general trend is that the more acute the fracture, the less likely it is to be operated on within the guidelines. Further investigation should be undertaken to look at reasons behind the delays and ways to improve access. This will assist in identifying responsibility for ensuring that an acceptable standard of care is maintained.
The aim of this study was to assess the benefit and durability of isolated lateral release for advanced osteoarthritis of the lateral facet of the patellofemoral joint. A retrospective study of 23 knees in 20 patients who had isolated lateral patellofemoral joint arthrosis treated with arthroscopic debridement and limited open lateral release was carried out. Patients completed a specific patellofemoral questionnaire (35 points) including questions for pain and functional improvement and pain and functional Fisual Analogue Scores (VAS). Eighteen knees in 15 patients were clinically and radiologically examined. Patients averaged 50 years of age and 2 years from surgical treatment. Visual analogue scores for pain improved 28% and function 40% with little radiological change. Similar improvements were seen in the patello femoral specific questionnaire. The results appeared to be durable over the 2 year follow up period. Lateral release for treatment of isolated arthrosis of the lateral compartment of the patellofemoral joint is an effective, reliable, durable procedure in carefully selected patients.
