Background: The advent of locking plates used in the treatment of fractures of the surgical neck of the humerus has led to an increased use of internal fixation for these injuries. At present there are few large studies which have evaluated their success and potential factors which may contribute to any negative result.

Materials and Methods: We retrospectively reviewed 57 consecutive patients who were treated with internal fixation of 2,3 and 4-part fractures of the proximal humerus over a 3 year period with a minimum follow-up of 6 months. The MacKenzie (antero-superior) approach was used in all cases and fixation was achieved using either the PHILOS or Arthrex locking plates. Patients were assessed by a thorough chart review and at regular post-operative clinics for pain, range of motion, return to work/activity, smoking and alcohol intake and overall compliance with rehabilitation regime. X-rays were graded on the quality of initial reduction and maintenance of position. Primary end-points included union of fracture and need for additional operative procedures.

Results: The average age of patients was 63 years (range 19–91) with a preponderance of women (29:18 female: male). Average follow-up was 8 months. Ten (18%) patients were classified as problem drinkers, and 13 (22%) were smokers. Four patients were initially treated by a trial of conservative management which later failed, necessitating surgical intervention. Fifty three fractures (93%) went on to achieve union within 6 months of injury. Nine patients (15%) required an additional operation: 5 conversions to hemiarthroplasty for pain relief and 4 removals of metal for loss of screw fixation or impingement. There was no increased need for re-operation in alcoholics, but there was a 50% increase in the need for additional operations in smokers.

Discussion: To our knowledge, this study represents the largest cohort of patients treated with a fixed-angle locking plate for a fracture of the surgical neck of humerus. The use of the locking plate has led to improved union rates and good functional outcomes in the treatment of these often problematic fractures. Although these fractures tend to occur more often in alcoholics, union rates and need for re-operation are not affected. Smoking is a significant a risk factor for the need for re-operation and non-union.

Background and objectives: Total knee replacement (TKR) produces severe postoperative pain. Peripheral nerve blocks can be used as analgesic adjuncts after TKR. The use of peripheral nerve block has certainly reduced the use of opiates by 50%; however adding the sciatic nerve block to the femoral nerve block is controversial. The aim of this study was to compare femoral and femoral plus sciatic nerve blocks in postoperative pain management of patients undergoing TKR.

Materials and Methods: Total of 42 patients were studied. Twenty patients with an average of 75yrs (51–86yrs) received femoral nerve block alone. Twenty-two patients with an average age of 69yrs (53–83yrs) received femoral plus sciatic nerve block. 0.5% Chirocaine was used for nerve blocks. There was no significant difference between two groups in terms of pre-operative pain, pre-operative deformity, ROM and patella replaced. The primary outcome measures used were visual analogue scale (VAS) pain scores at 24 hours, 48 hours and 72 hours after the surgery. The amount of opiate consumption and PCA (patient controlled analgesia) used were also recorded. The secondary outcomes were postoperative nausea and vomiting, straight leg raise, neurological deficit, knee flexion, independent mobility and discharge from the hospital.

Results: The results showed significant decrease in the amount of pain in the femoral nerve block group than the combined nerve block patients. Patients who had combined nerve block complained of heaviness in the legs and were slow to mobilise. There was no significant difference in consumption of opiates, use of PCA, nausea and vomiting, independent mobility and the time of discharge from the hospital between the two groups.

Conclusion: The addition of sciatic nerve block to the femoral nerve block does not provide any additional benefits in TKR.

The aim of this study was to evaluate whether using a predetermined entry point and standard value for valgus cut could restore normal mechanical axis of the TKA.

The study included 125 consecutive patients, who underwent TKA under care of the senior author (NJD). Details of height, weight, BMI were noted. All the radiographs were taken with the patient standing, with the knees in maximum extension, with the patella facing forward. The long leg radiographs were evaluated and the mechanical axis and anatomical axis were marked. The entry point (EP) and the angle between the anatomical and the mechanical axis of the femur ware measured, which is valgus angle of distal femoral cut (VA). Statistical analysis was done using SPSS (Table 1). Proportion of the cases with VA less than 6 degrees or more than 7 degrees were identified. Similarly cases with EP distance less than 0 and more than 5mms were also identified. Cases with VA of 6–7 degrees and EP 0–5mms were identified as one group. Correlation was performed using nonparametric tests.

The results revealed the angle between the anatomical and the mechanical axis ranges from 4 to 9.5 degrees (mean 6.8 degree and standard deviation 1.11 degree). Only 53% had an angle of between 6 and 7 degrees, with 7% of knees having an angle of less than 5 degree or greater than 8 degrees.

The site of entry of the jig showed variation from 30mms medial to the centre to 18mms lateral to the centre with the mean entry point of 5.04mms medial to centre of the notch, with a standard deviation of 8.5mms.

Overall only 33% of the knees templated would have an optimal femoral jig placement and distal femoral angle cut with an entry point in the centre of the notch or up to 5mms medial to centre and a distal valgus cut of between 6 and 7 degrees. The author feel this study gives evidence that if the mechanical axis is to be restored then long leg pre-operative radiographs should be performed and used as a key component to the pre-operative plan.

Table 1. Spearman’s rho correlations, between the valgus angle and entry point to the height, weight and BMI of the patients.