Aims

The anterior pelvic internal fixator is increasingly used for the treatment of unstable, or displaced, injuries of the anterior pelvic ring. The evidence for its use, however, is limited. The aim of this paper is to describe the indications for its use, how it is applied and its complications.

Introduction: The proximal femur is the most common long bone to be affected by metastatic disease. The prognosis of patients with bone metastases is variable and depends on a number of factors. Risk factors affecting survival in this subgroup of patients need to be clearly determined.

Patients and Methods: We studied the survival of 32 consecutive patients with metastatic disease of the proximal femur in order to identify any clinical, radiological or physiological parameters that predict survival.

Results: Mean age of patients was 71 years (range 41–91 SE 2.2) and mean survival 393 days (95 % CI 236 to 550), cumulative survival at three years was 0.12. Univariate analysis showed that sex, serum haemoglobin < 10gm/dl, white cell count > 12, serum urea and the presence of a postoperative complication were all significant predictors of survival. However, multivariate analysis revealed that only sex, serum haemoglobin < 10 gm/dl, white cell count > 12 and a postoperative complication were independent risk factors predicting survival (p < 0.05).

Discussion: Perioperative factors should be optimised for all patients. Identification of risk factors adversely affecting survival can be used in conjunction with clinical and radiological information as a tool to predict outcome and to aid consenting and counselling of patients. Simple measures such as preoperative transfusion of blood or the administration of blood products may improve survival. The presence of an elevated white cell count may indicate more advanced systemic disease. Aggressive postoperative rehabilitation and the prevention of complications may also improve survival.

Introduction: The functional outcome and survivorship of knee arthroplasty in young patients remains a concern. The aim of this study is to assess patient reported outcomes of knee arthroplasty surgery in osteoarthritic patients age 55 years old or younger in a generalist setting.

Patients and methods: All patients 55 years old or younger at the time of index arthroplasty were identified from the Trent arthroplasty register. Demographic data was available for all patients. A self-administered questionnaire was mailed to patients. This questionnaire included an Oxford Knee Score along with questions relating to employment, leisure activities and the patient expectations of their surgery.

Results: 242 patients 55 years old or younger had a knee arthroplasty in the study period (male:female 1:1). 208 patients had a total knee arthroplasty. The remaining had a unicompartmental knee replacement. Mean age of patients for the total knee arthroplasty group was 51 years (range 37–55) and that for the unicompartmental group was 50 years (range 37–55). The average length of follow up for the total knee arthroplasty group was 33.3 months (range 12–57) and that for the unicom-partmental group was 29.3 months (range 16–45). The average Oxford knee score at follow up was comparable between the two groups; 31.8 (range 12–57) for the total knee arthroplasty group and 32.0 (range 13–54) for the unicompartmental group. 77% of patients in the total knee arthroplasty group and 71% of patients in the uni-compartmental group reported that the pain relief was better or just as they expected following the operation.

Conclusion: Knee arthroplasty remains a satisfactory procedure in young patients under the age of 55 years. There is no significant difference in Oxford knee scores between patients that have total knee replacement or unicompart-mental knee replacement. Pain relief is better or just as expected in the majority of patients in both groups.

Background: Many patients with hip fractures have multiple medical problems that require attention. Pre-operative specialist interventions can often cause unnecessary delay. The aims of this study were to quantify the proportion of hip fracture patients that have an echocardiogram, to find out who and why the investigation was requested and to quantify the delay and its consequences.

Methods: Retrospective review of all patients over a 9 month period that were admitted to hospital with a diagnosed hip fracture and had an echocardiogram as part of their pre-operative assessment.

Results: 31 patients fulfilled the inclusion criteria. 23 sets of notes were reviewed. The majority of echocardiograms 17/23 were requested by orthopaedic SHOs without anaesthetic request. The reason for requesting the echocardiogram was the finding of a murmur on clinical examination.

The average delay from admission to having an operation for patients who had an echocardiogram was 6.7 days (mode 5days). Mean delay to patients having the echocardiogram was 3.2 days (mode 2 days) and the delay to theatre after the echocardiogram was 3.5 days (mode 1 day). 15/23 patients had adverse effects. All but one patient had a routine uncomplicated anaesthetic. Conclusion: 6–7% of hip fractures have an echocardiogram. Junior members of the orthopaedic team request the majority of echocardiograms without anaesthetic input. Requesting an echocardiogram causes a delay from admission to theatre of approximately 1 week. Delay is associated with adverse effects, which may have fatal consequences for the patient.

Background: The majority of extracapsular proximal femoral fractures are treated with a sliding hip screw. The barrel of the plate can slide over the shaft of the screw in two modes; keyed (locked) or unkeyed (unlocked). The purpose of the study was to determine whether there is a difference in outcome following fixation using a sliding hip screw in the locked and unlocked modes.

Methods: A prospective randomised controlled trial of patients requiring a sliding hip screw for a proximal femoral fracture. Patients were randomised to receive a sliding hip screw either in the locked or unlocked mode. 20 patients were randomised to each group. Patients were assessed clinically and radiologically post-operatively and at three months following discharge from hospital. Screw slide and fixation failure were used as primary outcomes. A Visual analogue scoring system (VAS) was used to assess pain.

Results: A total of 40 patients were recruited in this study. The mean age of patients in the locked group was 74.05 years (range 55–90) and 78.0 years (range 65–97) in the unlocked group. There was one case of fixation failure in the locked group compared to two in the unlocked group. The mean screw slide was 10.98mm (range 1.04–37.62) in the locked group and 12.94mm (range 1.91–20.82) in the unlocked group. The pain score according to the VAS improved over the three months. There was no significant difference in pain score between the two groups.

Conclusion: When comparing screw slide, fixation failure and pain, the results show there is no significant difference between using the sliding hip screw in the locked and unlocked mode.

Background: Cerebral micro emboli have been noted to occur during both total hip and knee arthroplasty. These micro emboli have been implicated in the causation of post-operative cognitive impairment. The aim of this study was to determine whether cerebral micro emboli occur during hip fracture surgery.

Method: 28 patients undergoing hip fracture surgery had transcranial doppler assessment of the middle cerebral artery to detect cerebral micro emboli. Micro embolic signals (MES’s) were recorded during the operative procedure.

Results: Successful monitoring was carried out in 26 patients. MES were recorded in 16 out of 26 patients. 12 out of 16 patients who had MES’s had undergone a cemented hemiarthroplasty the remainder had a sliding hip screw for an extracapsular hip fracture. 75% (9/12) of patients that had a cemented hemiarthroplasty, had the majority of MES’s after reaming and cementing. MES’s in the patients that had a sliding hip screw occurred throughout the operative procedure.

Conclusion: Cerebral micro emboli do occur during hip fracture surgery. These emboli may be responsible for the cognitive dysfunction that occurs in this susceptible group of patients.