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The Bone & Joint Journal
Vol. 96-B, Issue 6 | Pages 817 - 822
1 Jun 2014
Al-Nammari SS Dawson-Bowling S Amin A Nielsen D

Conventional methods of treating ankle fractures in the elderly are associated with high rates of complication. We describe the results of treating these injuries in 48 frail elderly patients with a long calcaneotalotibial nail.

The mean age of the group was 82 years (61 to 96) and 41 (85%) were women. All were frail, with multiple medical comorbidities and their mean American Society of Anaesthesiologists score was 3 (3 to 4). None could walk independently before their operation. All the fractures were displaced and unstable; the majority (94%, 45 of 48) were low-energy injuries and 40% (19 of 48) were open.

The overall mortality at six months was 35%. Of the surviving patients, 90% returned to their pre-injury level of function. The mean pre- and post-operative Olerud and Molander questionnaire scores were 62 and 57 respectively. Complications included superficial infection (4%, two of 48); deep infection (2%, one of 48); a broken or loose distal locking screw (6%, three of 48); valgus malunion (4%, two of 48); and one below-knee amputation following an unsuccessful vascular operation. There were no cases of nonunion, nail breakage or peri-prosthetic fracture.

A calcaneotalotibial nail is an excellent device for treating an unstable fracture of the ankle in the frail elderly patient. It allows the patient to mobilise immediately and minimises the risk of bone or wound problems. A long nail which crosses the isthmus of the tibia avoids the risk of peri-prosthetic fracture associated with shorter devices.

Cite this article: Bone Joint J 2014; 96-B:817–22.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_19 | Pages 24 - 24
1 Apr 2013
Jalgaonkar A Mohan A Dawson-Bowling S Muthukumar T Pollock R Skinner J Cannon S Briggs T Aston W
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Introduction

Local recurrence of tumours along the biopsy tract is a known complication of percutaneous closed needle biopsy. Correct surgical management requires preoperative identification and excision of the biopsy tract at time of surgery. These tracts become increasingly difficult to identify with time, leading to risk of inadequate excision of the biopsy tract and recurrence of the tumour at the biopsy site.

Materials/Methods

In a prospective study conducted at our institution, 22 of the 45 patients with musculoskeletal tumours (49%) had unidentifiable biopsy sites, with a mean duration between biopsy and definite surgery being 98 days (range 13–164 days). We concluded that identification of the biopsy site was more difficult after 50 days. Radiotherapy related scar formation and the longer time duration between biopsy and definite surgery in patients requiring neoadjuvant therapy made identification more unlikely. Consequently, all patients received India ink skin tattoo to mark the biopsy site at the time of the needle biopsy. 56 patients were then prospectively reviewed on the day of surgery to identify the biopsy site.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 30 - 30
1 Jan 2013
Dawson-Bowling S Jha S Chettiar K East D Miles K Gould G Apthorp H
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Introduction

Typical UK patients spend 5–7 days in hospital following total hip replacement (THR). Decreasing length of stay (LOS) increases throughput and reduces cost. We have developed a short stay THR programme (SSP), which has been used in all patients since May 2006; we present the first 100.

Methods

Every patient undergoing THR is included in the dataset. All attend ‘bone school’ before admission, with talks and individual assessments by the senior sister, physiotherapist and occupational therapist. Medical concerns are discussed with an anaesthetist. Patients receive training with crutches; crutches are provided for home practice.

All receive an uncemented Corail-Pinnacle THR via piriformis-sparing mini-posterior approach. ‘Low dose’ spinal plus light general anaesthesia provides sensory block whilst retaining motor function; painfree fully weightbearing mobilisation is predictably achieved within four hours. Following radiograph and haemoglobin check next morning, patients are discharged on meeting specific nursing/physiotherapy criteria. Those within 20 miles receive outreach follow-up. Follow-up assessment is undertaken using SF36, Visual Analogue, Merle d'Aubigné-Postel and Oxford Hip Scores.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 31 - 31
1 Jan 2013
Dhinsa B Gallagher K Dawson-Bowling S Mohan A Miles J Carrington R Skinner J Briggs T
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Introduction

The aim of this study was to see if the evaluation of the initial postoperative radiograph following primary knee and hip arthroplasty correlated with clinical outcome at five years postoperatively.

Methodology

Using our institution database we identified forty-nine hip replacements and fifty-two knee replacements performed between 2000 and 2006. All the patients underwent postoperative radiographs one day after surgery and clinical evaluation up to at least five years postoperatively. A consultant radiologist evaluated the radiographs for alignment and component position. The hip arthroplasty patients were assessed clinically using the Harris hip score, Oxford hip score, and the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC). The knee arthroplasty patients were assessed using the Knee Society score, Oxford knee score, and the WOMAC score.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 116 - 116
1 Sep 2012
Dawson-Bowling S Berber O Jalgaonkar A Miles J Aston W Pollock R Skinner J Briggs T
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Bizarre parosteal osteochondromatous proliferation (BPOP), or Nora's lesion, is a rare condition characterised by the formation of surface-based osteocartilaginous lesions typically affecting the hands and feet. 22 cases were identified from the records of a regional bone tumour unit, dating from 1985 to 2009. Of 22 cases, 9 lesions involved the long bones of the hand, 7 the long bones of the feet, 1 case originated from a sesamoid bone of the foot and 5 from long bones (radius, ulna, femur [2] and tibia). Age ranged from 6 to 66 (mean: 31.8) and male to female ratio was 1.8:1. Diagnosis was based on combined radiological and histological features, and initial surgical treatment was excision in 21 cases, and 1 amputation. Follow-up ranged from 12–162 months (mean 32). Recurrence occurred in 6 patients (27%), with mean time to recurrence 49 months (range 10–120). 2 of 8 patients with complete resection margins developed recurrence (25%), versus 4 of 14 with marginal or incomplete resection (28%). Given the potential surgical morbidity inherent in resection, our data suggest that there may be a role for a relatively tissue-conserving approach to the excision of these lesions.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 27 - 27
1 Sep 2012
Dawson-Bowling S Yeoh D Edwards H East D Ellens N Miles K Butler-Manuel P Apthorp H
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Introduction

Debate continues regarding the relative advantages of ceramic-on-ceramic (CoC) and metal-on-polyethylene (MoP) articulations in total hip arthroplasty (THA). Perceived benefits of CoC include longevity, and low wear - in turn limiting the effects of particulate wear debris. However, CoC bearings cost significantly more, and concern remains over the risk of ceramic fracture; a complication not seen with MoP bearings, which are also cheaper.

Method

We electronically randomised 268 consecutive patients undergoing THA to receive either a CoC or MoP articulation. Patients aged over 72 were excluded. In all patients the prosthesis used was an uncemented ABG II (Stryker, USA), implanted by one of the two senior authors (HDA, ABM). Patients were scored preoperatively, and at annual follow-up clinics, using SF36, Visual Analogue (VAS), Merle d'Aubigné (MD) and Oxford Hip (OHS) Scores. Satisfaction levels were also documented.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 195 - 195
1 Sep 2012
Edwards H Yeoh D Dawson-Bowling S Ellens N East D Miles K Butler-Manuel A Apthorp H
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Introduction

Deep vein thrombosis(DVT) and pulmonary embolism(PE) are well-recognised complications following lower limb arthroplasty (Cohen et al, 2001). The National Institute for Clinical Excellence and British Orthopaedic Association recommend the use of both mechanical and chemical prophylaxis. At our institute regimens have changed reflecting new developments in the use of thombo-prophylaxis. Our aim was to assess the efficacy of these methods in preventing complications.

Methods

Since moving from Aspirin and compression stockings (TEDS) only, three different treatment methods were prospectively audited. Regimen 1 consisted of Aspirin (150 mg OD) and TEDS for 6 weeks (n=660). Regimen 2 used Clexane 40mg OD (n=448). Regimen 3 used Rivaroxaban (n=100) as licensed and Regimen 4 Dabigatran (n=185) as licensed.

We looked at rates of venous thromboembolism (VTE), rates of post op bleeding/haematoma and wound complications. Patients were reviewed prior to discharge, and at a six-week follow-up. Any casualty attendances were also recorded up to 12 weeks post-operatively.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 530 - 530
1 Sep 2012
Mohan A Jalgaonkar A Park D Dawson-Bowling S Aston W Cannon S Briggs T
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Sacral tumours are rare and can present difficult diagnostic and therapeutic challenges even at an early diagnosis. Surgical resection margins have a reported prognostic role in local recurrence and improved survival. Successful management is achieved within a specialist multidisciplinary service and involves combination chemotherapy, radiotherapy and surgery. We present our experience of patients with sacral tumours referred to our unit, who underwent total and subtotal sacrectomy procedures.

Materials and Methods

Between 1995 and 2010, we identified twenty-six patients who underwent a total or subtotal sacrectomy operation. Patients were referred from around the United Kingdom to our services. We reviewed all case notes, operative records, radiological investigations and histopathology, resection margins, post operative complications, functional outcomes and we recorded long-term survival outcomes. Patients who were discharged to local services for continued follow up or further oncological treatment were identified and information was obtained from their general practitioner or oncologist. We reviewed the literature available on total sacrectomy case series, functional outcomes and soft tissue reconstruction.

Results

We reviewed 26 patients, 16 male and 10 female, with a mean age at presentation of 53.4 years (range 11–80 years). Duration of symptoms ranged from 2 weeks to 6 years; lower back pain and sciatica were amongst the most common presenting features. Histological diagnoses included chordoma, Ewing's, malignant peripheral nerve sheath tumour, chondromyxoid fibroma, spindle cell sarcoma, synovial sarcoma, chondrosarcoma. A combined approach was used in two-thirds of patients and most of these patients had a soft tissue reconstruction with pedicled vertical rectus myocutaneous flap. Complications were categorised into major and minor and subdivided into wound, bladder and bowel symptoms. Wound complications and need for further intervention were more common amongst the patient group who did not have simultaneous soft tissue reconstruction at operation. All patients had a degree of bladder dysfunction in the early postoperative period. We present survivorship curves including recurrence and development of metastases.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXV | Pages 103 - 103
1 Jun 2012
Jalgaonkar A Mohan A Park D Dawson-Bowling S Aston W Cannon S Skinner J Briggs T
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There is very limited literature available on the use of prosthetic replacement in the treatment of primary and secondary tumours of the radius. In the past these were treated with vascularised and non-vascularised autografts which had associated donor site morbidity, problems of non union, graft or junctional fractures and delayed return to function. Our study is a mid to long term follow-up of implant survivorship and the functional outcome of metal prosthetic replacement used for primary and metastatic lesions of radius. We had 15 patients (8 males:7 females) with a mean age of 53 years. 8 patients underwent proximal radial replacement, 2 with mid-shaft radial replacement and 6 patients had distal radial replacements with wrist arthrodesis. The indications for replacement included metastatic lesions from renal cell carcinoma, primary giant cell tumours, ewings' sarcoma, chondroblastoma, radio-ulnar synostosis and benign fibrous histiocytoma. The average follow up was 5 years and 6 months (range 3 months - 18 years). Four patients died as a result of dissemination of renal cell carcinoma and two patients were lost to follow-up. There were no complications with the prosthesis or infection. Clinically and radiographically there was no loosening demonstrated at 18 years with secure fixation of implants. Two patients developed interossoeus nerve palsies which partially recovered. Functional outcomes of the elbow were assessed using the Mayo performance score with patients achieving a mean score of 85 postoperatively (range 65-95). All but one patient had full range of motion of the elbow. The patient with radio-ulnar synostosis had a 25 degree fixed flexion pot-operatively. Although the distal radial replacements had decreased range of movements of the wrist due to arthrodesis, they had excellent functional outcomes. Only one patient required revision surgery due to post-traumatic loosening of the implant. Our results of the use of endoprosthetic replacement of radius in the treatment of tumours are encouraging with regards to survivorship of the implant and functional outcome. This type of treatment results in an early return to daily routine activties, good functional outcome and patient satisfaction.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_III | Pages 129 - 129
1 Feb 2012
Dawson-Bowling S Chettiar K Cottam H Fitzgerald-O'Connor I Forder J Worth R Apthorp H
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This study aims to assess prospectively whether measurement of perioperative Troponin T is a useful predictor of potential morbidity and mortality in patients undergoing surgery for fractured neck of femur.

All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post-surgery. According to local protocol, a level of >0.03ng/mL was considered to be raised. Outcome measures adverse were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay.

108 patients were recruited after application of the exclusion criteria. 42 (38.9%) showed a rise in Troponin T >0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least outcome complication, as opposed to 7 (10.6%) from the group with no Troponin T rise (p<0.001). The mean length of stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p<0.012). There were 9 deaths in the raised Troponin group (21.4%), and 5 (7.6%) in the group with no rise (p<0.05).

The principal causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 38.9% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many hip fracture patients appear to be having silent cardiorespiratory events, contributing significantly to perioperative morbidity.

We recommend measurement of Troponin levels in all such patients to identify this risk and initiate appropriate treatment.


The Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 8 | Pages 1118 - 1121
1 Aug 2011
Berber O Dawson-Bowling S Jalgaonkar A Miles J Pollock RC Skinner JA Aston WJS Briggs TWR

We describe 22 cases of bizarre parosteal osteochondromatous proliferation, or Nora’s lesion. These are surface-based osteocartilaginous lesions typically affecting the hands and feet. All patients were identified from the records of a regional bone tumour unit and were treated between 1985 and 2009. Nine lesions involved the metacarpals, seven the metatarsals, one originated from a sesamoid bone of the foot and five from long bones (radius, ulna, tibia, and femur in two). The mean age of the patients was 31.8 years (6 to 66), with 14 men and eight women. Diagnosis was based on the radiological and histological features. The initial surgical treatment was excision in 21 cases and amputation of a toe in one. The mean follow-up was for 32 months (12 to 162). Recurrence occurred in six patients (27.3%), with a mean time to recurrence of 49 months (10 to 120). Two of the eight patients with complete resection margins developed a recurrence (25.0%), compared with four of 14 with a marginal or incomplete resection (28.6%).

Given the potential surgical morbidity inherent in resection, our data suggest that there may be a role for a relatively tissue-conserving approach to the excision of these lesions.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 299 - 299
1 Jul 2011
Dawson-Bowling S Cohen A Ritchie J Fordyce M
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Introduction: Osteoarthritis of the first metatarsopha-langeal joint (MTPJ) is common. A range of surgical treatment options is described, including different designs of total arthroplasty. The MOJE is a ceramic-on-ceramic press fit arthroplasty. We present a maximum 8 year follow up of 32 procedures.

Methods: 32 MOJE arthroplasties were undertaken by the senior author (MF) in 30 patients (9 male, 21 female; mean age 61.9, range 37–76) over six years. Patients were followed up in special clinics where symptoms, levels of function and radiographs were subjectively and objectively scored using the SF-36, modified Kitaoka and AOFAS systems.

Results: 100% follow-up was achieved, with mean time since surgery 58 months (range 25–97). Mean scores were: Kitaoka 53.8 (15–75, maximum possible 75), AOFAS score was 61.3/100 (range 18–100, maximum 100), SF-36 physical score 48.6 (27.6–58.7) SF-36 mental score 52.2 (19.5–62.2). Eight implants had required revision; two for component fracture.

Radiologically, 15 showed component subsidence, 9 demonstrating radiolucency around one or both components. In one case where the patient had not undergone reoperation component fracture was seen on x-ray. Clinically, in patients who had not undergone subsequent fusion, 15 had less than 36 degrees of movement, 9 had between 36–45 degrees, 4 were in the 46–60 range and only one had more than 60 degrees. There were no cases of infection.

Discussion: Although several previous studies have suggested favourable initial outcomes with this implant, all focus only on early results. The longest follow-up we found was 29 months; these authors quote excellent early outcomes but acknowledge the need for longer-term follow-up. In our series, the reoperation rate of 25% up to 8 years is worryingly high. Whilst a cohort of patients clearly have satisfactory results with the MOJE, we would suggest that surgeons contemplating its use give due consideration to these outcomes before proceeding.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_I | Pages 165 - 165
1 Mar 2009
Dawson-Bowling S Chettiar K Cottam H Forder J Worth R Apthorp H
Full Access

This study aims to assess prospectively whether measurement of peripoperative Troponin T is a useful predictor of potential morbidity and mortality in patients undergoing surgery for fractured neck of femur.

All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post surgery. According to local protocol, a level of > 0.03ng/mL was considered to be raised. Outcome measures adverse were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay.

108 patients were recruited after application of the exclusion criteria. 42 (38.9%) showed a rise in Troponin T > 0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least outcome complication, as opposed to 7 (10.6%) from the group with no Troponin T rise (p< 0.001). The mean length of stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p< 0.012). There were 9 deaths in the raised Troponin group (21.4%), versus 5 (10.6%) in the group with no rise (p< 0.05).

The principle causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 38.9% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many hip fracture patients appear to be having silent cardiorespiratory events, contributing significantly to perioperative morbidity. We recommend measurement of Troponin levels in all such patients to identify this risk and initiate appropriate treatment.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 301 - 301
1 Jul 2008
Dawson-Bowling S Chettiar K Cottam H Worth R Forder J Fitzgerald-O’Connor I Apthorp H
Full Access

Introduction: The principle causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive and specific enzymatic marker of myocardial injury. This study aims to assess prospectively whether Troponin T may be used as a predictor of morbidity and mortality in admissions with fractured neck of femur.

Methods: All patients aged 65 years and over presenting with a fractured neck of femur over 4 months were included. Exclusion criteria of polymyositis, renal failure and conservative fracture management were applied. Troponin T levels were measured on admission, and days 1 and 2 post surgery. According to local protocol, a level of > 0.03ng/mL was considered to be raised. Outcome measures were defined as adverse cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay.

Results: 108 patients were recruited over the 4 months. 42 (38.9%) showed a rise in Troponin T > 0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least one of the outcome complications including death, as opposed to 7 (10.6%) from the group with no Troponin rise (p< 0.001). The mean inpatient stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p< 0.012). There were 9 deaths in the raised Troponin group (21.4%), and 5 (10.6%) in the group with no rise (p< 0.05).

Discussion: The association between raised Troponin and hip fractures has not previously been made. Many patients appear to be having silent cardiorespiratory or related events, which may be a significant cause of perioperative morbidity and mortality. We propose measurement of Troponin levels as part of the standard perioperative screening for hip fracture patients to identify this risk and initiate appropriate treatment measures.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 326 - 326
1 Jul 2008
Dawson-Bowling S Chettiar K Hussein R East D Miles K Apthorp H Butler-Manuel P
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Introduction: Debate continues regarding the optimal timing of surgery for patients requiring bilateral knee arthroplasty; we reviewed the costs, clinical and functional outcomes of 116 patients undergoing simultaneous or staged bilateral surgery using 3 different prostheses.

Method: Data were retrospectively collected from 116 consecutive patients undergoing 232 knee replacements over 10 years, either simultaneously or over 2 hospital admissions (staged). Post-operative complication rate, total cost of treatment (calculated from pros-theses, theatre time, days in hospital and number of clinic attendances) and functional (HSS) score at 1 year were the outcome measures.

Results: 54 patients underwent Oxford unicondylar knee replacements, 41 simultaneously, 13 staged; respective mean total costs were £9890 and £13,553 (p< 0.001). 42 patients were treated with AGC prostheses; 14 simultaneously, 28 staged, with respective total costs of £12,187 and £16,920 (p< 0.001). 10 TMK patients had simultaneous surgery (mean total cost £14,812), 10 were staged (£20,191); p< 0.001. For all 3 prostheses, there was no significant difference in complication rate or 1 year functional outcome between simultaneous and staged groups.

Discussion: Some authors advocate replacing both knees simultaneously as safe and cost-effective; others report significant increases in medical and surgical morbidity. Our series shows significant cost savings with no increase in complication rate.