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Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_IV | Pages 96 - 96
1 Mar 2012
Edwards C Boulton C Counsell A Moran C
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The aim of this study was to investigate the risk factors, financial costs and outcomes associated with infection after hip fracture surgery.

Prospective hip fracture data from the University Hospital, Nottingham, was analysed, assessing patients with either deep or superficial wound infections admitted over a five year period.

3605 patients underwent hip fracture surgery. 2.3% of these patients developed a wound infection of which 1.2% were deep wound infections. 75% of infections were due to Staphylococcus aureus and 50% of all infections were caused by methicillin-resistant Staphylococcus aureus.

No statistically significant risk factors for the development of infection were identified in this study.

Length of stay, cost of treatment and pre-discharge mortality were all increased with deep infection. Deep wound infection increased the average length of stay from 28 days to 100 days. This quadrupled the ward costs. The mean overall hospital cost of treating a hip fracture complicated by deep wound infection was £34903 compared to £8979 fro those who did not develop infection. Pre-discharge mortality increased from 24.2% in the control group to 30% in the infected group (p<0.006).

MRSA significantly increased costs, LOS, and pre-discharge mortality compared with non-MRSA infection.

These results show the huge impact that infection after hip fracture surgery has both on mortality and hospital costs.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 67 - 67
1 Mar 2010
Heasley R Counsell A Paul A
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Introduction: Limb schwannomas are benign nerve sheath tumours. They typically present with a cystic swelling or palpable lump. They may also present with symptoms relating to the affected nerve. If the lesion is solitary there is no malignant potential. Clinically the lump will be freely mobile except in the plane of the longitudinal course of the nerve and may have a positive Tinnel’s test. Magnetic resonance imaging or ultrasound scanning are key adjuncts to diagnosis. Treatment is excision of the lump by incising the epineurium, “shelling out” the lesion and preserving unaffected nerve fascicles. We present a case series from a regional soft tissue tumour centre that shows the excellent outcome that can be achieved with these methods.

Methods: We retrospectively analysed the case notes of 16 cases of schwannoma who had surgical excision and preservation of the parent nerve. Our outcome measures were resolution of symptoms, post-operative neurological function and recurrence.

Results: Of 16 patients, 12 had no neurological deficit. 1 had motor weakness (foot drop) and 1 had residual par-aesthesia post-operatively. 2 patients declined surgery. In addition, 2 patients had persistent pain post-operatively, but at reduced levels to their pre-operative pain. There were no cases of recurrence.

Discussion: The diagnosis of schwannoma should be considered in patients with a lump associated with neurological symptoms. Following confirmation of diagnosis with appropriate radiology, surgical excision should be carried out as detailed above to minimise morbidity. This should be performed by a surgeon skilled in dealing with soft tissue tumours.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 69 - 69
1 Mar 2010
Arumilli B Heasley R Counsell A Conway A Khan T Paul A
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Introduction: PVNS is a benign proliferative disorder of the synovium presenting as local or diffuse variants. The condition commonly involves the knee with a slow and indolent progress.

Case series:

Presented with anterior knee pain. Examination revealed supra-patellar fullness and tenderness. MRI scan showed a suspicious soft tissue tumour. Histology confirmed PVNS after excision biopsy.

Presented with medial knee pain, most pronounced after exercise. McMurray test was positive for a meniscal tear. MRI confirmed meniscal tear and additional localised PVNS. The patient underwent repair of the meniscal injury but continued to complain of pain. Following excision of PVNS there was marked improvement in the patients’ symptoms.

Presented as massive soft tissue swelling of the right knee. Past medical history included a diagnosis of tuberculosis and fibrosarcoma on the knee. She was referred to our centre following two diagnoses, three surgeries and a supracondylar femoral fracture. The patient was previously advised an above knee amputation which she refused. A repeat biopsy with immunohistochemistry studies at our unit confirmed the diagnosis of a PVNS. Patient is awaiting a total knee replacement with subtotal synovectomy.

Presented with swollen right knee, pain and restriction of movement. MRI scan suggested a diagnosis of PVNS. The patient underwent subtotal synovectomy and histology confirmed this to be PVNS. Subsequently the patient had two recurrences, the first at 2 years and later at 4 years from initial surgery. Repeat MRI scan showed extensive third recurrence. The patient is awaiting a further open synovectomy, followed by low dose radiotherapy.

Conclusion: This case series aims to highlight the complexities in diagnosing PVNS. It should be a differential diagnosis of any kind of soft tissue problem especially around the knee. Immunohistochemistry may be useful. Multiple recurrences is a problem; adjuvant therapy may be indicated in resistant cases.


The Journal of Bone & Joint Surgery British Volume
Vol. 90-B, Issue 6 | Pages 770 - 777
1 Jun 2008
Edwards C Counsell A Boulton C Moran CG

Prospective data on hip fracture from 3686 patients at a United Kingdom teaching hospital were analysed to investigate the risk factors, financial costs and outcomes associated with deep or superficial wound infections after hip fracture surgery.

In 1.2% (41) of patients a deep wound infection developed, and 1.1% (39) had a superficial wound infection. A total of 57 of 80 infections (71.3%) were due to Staphylococcus aureus and 39 (48.8%) were due to MRSA.

No statistically significant pre-operative risk factors were detected. Length of stay, cost of treatment and pre-discharge mortality all significantly increased with deep wound infection. The one-year mortality was 30%, and this increased to 50% in those who developed an infection (p < 0.001). A deep infection resulted in doubled operative costs, tripled investigation costs and quadrupled ward costs.

MRSA infection increased costs, length of stay, and pre-discharge mortality compared with non-MRSA infection.