Prophylactic antibiotics administered prior to joint arthroplasty have become standard practice. Due to concern over the risk that 2nd generation cephalosporins posed to the elderly, as regards clostridium difficile associated infections the antimicrobial management team in our unit changed the protocol for prophylactic antibiotics. As of 1st September 2009, flucloxacillin and gentamicin were preferred over cefuroxime as the first choice of prophylactic antibiotic. However, it was noted that postoperatively patients were experiencing a decrease in renal function.

One hundred patients who underwent a total hip replacement following the policy change were randomly selected from the departmental joint arthroplasty database. This group was age and sex matched to 100 patients undergoing their surgery prior to the change. Data was collected on renal function, length of stay, antibiotic and age. Any change in renal function was categorised using the RIFLE criteria.

Exclusion secondary to variations from protocol or treatment for femoral neck fractures resulted in a total number of 156 patients with 78 in each arm. The average age for both groups was 64 years. Non-parametric analysis of preoperative and postoperative serum creatinine concentrations and Glomerular Filtration Rate (GFR) demonstrated a significant difference between the two groups, showing that GFR decreased (p=0.041) and serum creatinine concentration increased (p=0.037) in the cohort receiving gentamicin. Classing the impaired renal function as: risk, injury or failure (RIFLE criteria) demonstrated a statistically significant difference for any criterion positive (p=0.016) but no significant difference for the specific RIFLE groups (p=0.068).

Acknowledging the small numbers and potential confounders for renal impairment, this study was able to show a difference in renal function for patients receiving gentamicin over cefuroxime as prophylaxis for joint arthroplasty.

Surgery for degenerative lumbar spondylolisthesis may entail both decompression and fusion. The knee-chest position facilitates the decompression, but fixation in this position risks fusion in kyphosis. This can be avoided by intra-operative re-positioning to the prone position. The aim of this study was to quantify the restoration of lordosis achieved by intra-operative repositioning and to assess the clinical and radiological outcome.

A total of forty consecutive patients with degenerative lumbar spondylolisthesis and stenosis were treated by posterior decompression and interbody fusion with pedicle screw fixation. The screw insertion, decompression and interbody grafting were performed with the patient in the knee-chest position. The patient was then re-positioned to the fully prone position for fusion. Sagittal plane angles were measured pre-, intra- and post-operatively. Clinical assessment was performed using SF-36 scores and visual analogue scores for back and leg pain.

The sagittal plane angle increased from median 16.0 degrees pre-operatively to 23.1 degrees post-operatively (p<0.01) and this was maintained at the last follow-up (mean 21 months). The SF-36 scores improved for 7 out of 8 domains and the physical score improved from 29% to 40% (p<0.05). The mean pain scores improved significantly from 7.5 to 3.8 for back pain and from 7.6 to 3.7 for leg pain (p<0.001).

Lumbar spondylolisthesis was found to be associated with a reduction of normal lumbar lordosis and the knee-chest position exacerbates this loss of lordosis. Intra-operative repositioning restored lordosis to greater than the pre-operative angle and was associated with a good clinical outcome.

Introduction

Radiographic parameters have been shown to have a poor correlation with clinical outcome after open scoliosis procedures. However this has not been previously addressed after endoscopic surgery. The purpose of our study was to examine prospectively the relationship between curve correction and clinical outcome for endoscopic scoliosis surgery.

Introduction Endoscopic scoliosis surgery can be complicated by rod breakage. The aim of this study was to examine the effect of rod breakage on clinical outcome and to determine any predisposing factors.

Methods We studied 83 consecutive patients that had undergone endoscopic correction for scoliosis. Patients were assessed pre-operatively and at regular intervals for up to three years post-operatively. Those patients sustaining rod breakages were compared with those that did not. Clinical outcome was assessed using the Scoliosis Research Society outcome instrument (SRS-24). Radiological assessment included coronal Cobb angles and the angle between adjacent screws.

Results There were 13 (15.7%) patients sustaining 16 rod breaks at a mean time from operation of 21.5 months. No significant change in Cobb angle occurred after rod breakage (mean 18.3 vs 19.7 degrees), p> 0.05. Comparing patients with and without rod breaks we found no difference in SRS-24 scores for pain (4.30 vs 4.39), self image (3.50 vs 3.70), function (3.56 vs 3.35) or patient satisfaction (4.22 vs 4.58). There was no significant difference in screw angle for those patients that developed rod breakages (mean 3.2 vs 2.7 degrees). Significantly more breakages occurred with rib (11/40) and iliac crest (2/7) autograft compared with femoral allograft (0/36), p< 0.01.

Discussion Rod breakage can occur following endoscopic scoliosis surgery. Our study shows that this is not associated with any significant loss of curve correction and has no effect on clinical outcome. Since changing to femoral allograft and by increasing the rod diameter no further rod breakages have occurred.

Introduction A tertiary referral centre for spinal injuries will receive referrals from many different centres. The format and quality of imaging that accompanies these patients varies considerably.

Methods Two cases are reported where initial imaging demonstrated unstable cervical spine injuries that were subsequently found to be normal. The cases and images are presented.

Results A 19-year old female was transferred to our unit having fallen off a wall and sustaining a neck injury. The accompanying CT scan showed a C6 vertebral body fracture with bilateral fracture-subluxations of the facet joints. As there was a discrepancy with the clinical findings, a repeat fine cut CT scan was performed which was completely normal. The previous appearances were entirely due to artifact throughout the scan.

A 46-year old male fell down stairs sustaining a neck injury and loss of consciousness. A CT scan of his cervical spine demonstrated an odontoid peg fracture (type II). Subsequent imaging showed the odontoid peg was completely normal. The initial CT appearances were entirely due to artifact caused by the patients’ tongue piercing!

Discussion CT scans are used with increasing frequency in the assessment of cervical spine injuries. In both these case the abnormalities present on the initial scans were entirely due to artifact that was reciprocated through the entire CT scans. Reporting these cases reinforces the importance of careful clinical examination and correlation with appropriate investigations. If there is a discrepancy between the clinical and radiological findings then it is essential that further imaging is performed.

Introduction Endoscopic instrumentation for scoliosis has several advantages compared with open procedures. The purpose of our study was to prospectively assess the clinical outcome of patients after endoscopic anterior instrumentation and to evaluate their responses over time.

Methods A total of 83 consecutive patients underwent endoscopic instrumentation performed at a single unit. Patients completed the SRS-24 Outcomes Instrument pre-operatively and at 3, 6, 12 and 24 months postoperatively. The seven domains of the SRS-24 score were compared between each of the follow-up intervals. The dataset contained 24 responses at 3 months, 65 responses at 6 months, 63 responses at 12 months and 49 responses at 24 months.

Results There were 74 females and nine males with a mean age of 16.4 years (range, 10 to 46 years). The mean Cobb angle improved from 52.8 degrees pre-operatively to 21.9 degrees post-operatively. Over the follow-up period there were significant improvements in the activity level (p< 0.05), function from back condition (p< 0.05) and post-operative function (p< 0.01) domains. Most of this improvement occurred during the first post-operative year and none of the domains improved further after this time interval. There was no significant change in the pain, self image and patient satisfaction domains.

Discussion Our results for endoscopic scoliosis correction are comparable with those reported for open procedures. The greatest improvement in SRS scores occurred between six and twelve months post-operatively. The SRS-24 scores at one year from surgery may provide a good indicator of patient outcome in the long-term.

Aims: Leg length discrepancy is a well-recognised complication after total hip arthroplasty. However, the effect of using a cemented or uncemented femoral component on leg length has not been previously investigated. The aim of our study was to assess leg length discrepancy following total hip arthroplasty using a cemented femoral component and to compare this with an uncemented femoral component.

Patients and method: We included 140 patients who had undergone a primary total hip arthroplasty in our study. All patients received an uncemented Duraloc acetabular cup (Depuy, Leeds, UK). Our uncemented group consisted of 70 consecutive patients who had received an uncemented Accolade femoral prosthesis (Depuy, Leeds, UK). Our cemented group included 70 patients who had received a cemented Ultima femoral prosthesis (Depuy, Leeds, UK). Leg lengths were measured from radiographs by two independent observers using a validated assessment method, pre-operatively and at six months post-operatively. Clinical outcome was assessed using Harris hip scores.

Results: The mean age of the patients was 68 years for the uncemented group and 56 years for the cemented group. The overall leg length discrepancy was mean 5.7mm (range 0 to 26mm). The uncemented group had an increase in leg length discrepancy post-operatively compared to the cemented group (6.4mm vs 4.2mm), p< 0.05. There was no significant difference in Harris hip scores between the uncemented and cemented groups either pre-operatively (37.4 vs 38.7) or at 6 months postoperatively (77.9 vs 78.7 respectively).

Conclusion: We found a significant increase in leg length discrepancy after total hip arthroplasty using an uncemented femoral prosthesis compared with a cemented femoral prosthesis. This was detectable radiologically but did not affect clinical outcome. Patients should be informed about the risk of leg length discrepancy before total hip arthroplasty particularly if an uncemented femoral prosthesis is used.

Aims: Post-operative check radiographs after primary total hip replacement are routine practice in many orthopaedic units. However they can be uncomfortable for patients and are often of poor quality. We conducted a prospective study to assess the quality of post-operative check radiographs after total hip replacement and to establish whether they alter the management of the patient.

Patients and method: We included 50 consecutive patients that underwent a primary total hip replacement in our study. During the post-operative period A-P and lateral check radiographs of the hip were performed. For each patient, any change in management and the time to discharge were recorded. The quality of each set of radiographs was assessed using a standard proforma (0–10) and scored by two independent observers.

Results: The mean age of the patients was 68 years (range 39 to 83 years). The median time to x-ray was 4.0 days from operation and the median length of stay was 7.0 days. Overall 7 (14%) patients had their discharge delayed by a mean time of 2.0 (±0.89) days waiting for post-operative radiographs. The mean score for quality of radiographs was 8.12 (±1.32) with good inter-observer and intra-observer agreement. In total, 15 (30%) sets of radiographs were of inferior quality (a score of 7 or less). None of the patients had their management altered by the post-operative radiographs.

Conclusion: We conclude that initial post-operative radiographs are of inferior quality and do not alter the management of the patient. Consideration should be given to performing check radiographs at the first out-patient clinic follow-up as an alternative.

Aims: Resurfacing arthroplasty of the hip is increasing in popularity. Recently concerns have been raised about resorbtion of the femoral neck after hip resurfacing, which may increase the risk of femoral neck fracture. We conducted a study to assess the degree of femoral neck resorbtion after using a cemented femoral component at hip resurfacing arthroplasty and to compare this with an uncemented femoral component.

Patients and Methods: We included 130 patients who had undergone a hip resurfacing arthroplasty in our study. Our uncemented group included 70 consecutive patients who had received an uncemented Cormet hip resurfacing arthroplasty (Corin, Cirencester, UK). Our cemented group included 60 patients who had received a cemented Birmingham hip resurfacing arthroplasty (Smith and Nephew, Cambridge, UK). All patients were regularly followed up for a minimum of two years. Clinical outcome was assessed using Harris hip scores. Femoral neck resorbtion was assessed by measuring the cup-neck ratio on post-operative radiographs by two independent observers.

Results: The mean age of the patients was 50.7 years for the cemented resurfacing group and 51.5 years for the uncemented resurfacing group. No difference was found in Harris hip scores between the two groups at any of the follow-up periods. The overall survival rate at two years was 100% for the cemented group and 98.6% for the uncemented group. There was however, a significant increase in femoral neck resorbtion for the cemented resurfacing group compared to the uncemented resurfacing group (median cup-neck ratio 1.11 vs. 1.04), p< 0.0001

Conclusion: We found a significant increase in femoral neck resorbtion with the use of a cemented femoral component at hip resurfacing arthroplasty compared with an uncemented femoral component. This may increase the risk of femoral neck fracture and could affect the long-term outcome if a cemented femoral component is used.

Aims: Outpatient clinic follow-up of patients after knee arthroscopy is routine practice in many orthopaedic units. It can be inconvenient and expensive for patients and may be unnecessary.The aim of our study was to compare oupatient follow-up with telephone follow-up after knee arthroscopy in a prospective randomised trial

Patients and method: Over a four-month period, 50 patients (mean age 41 years) were included in our study. Each patient underwent a day-case knee arthroscopy as previously planned. After surgery, each patient was randomised to either attend for an outpatient clinic follow-up after two weeks or to receive a telephone follow-up after two weeks from operation. All patients were assessed after four weeks from surgery by an independent assessor who was blinded to the type of follow-up each patient had received. No patients in the study were lost to follow-up.

Results: No significant difference was found in patient satisfaction scores between the outpatient and telephone groups (mean 7.78 vs mean 7.92). However, 81% patients in the telephone group and 57% patients in the clinic group (p< 0.01) preferred telephone follow-up if they were to undergo another knee arthroscopy. There was a significant increase in patello-femoral problems in those preferring outpatient follow-up (64%) compared to telephone follow-up (24%), p< 0.05. No difference in complication rates between the two groups was found.

Conclusion: Telephone follow-up provides a satisfactory and safe alternative to outpatient follow-up after knee arthroscopy. It is preferred by the majority of patients and could relieve pressure on outpatient resources.

Aims: Surgery for degenerative lumbar spondylolisthesis may entail both decompression and fusion. The knee-chest position facilitates decompression, but fixation in this position risks fusion in kyphosis. This can be avoided by intra-operative re-positioning to the prone position. The aim of our study was to quantify restoration of lordosis achieved by intra-operative repositioning and to assess clinical and radiological outcome.

Patients and method: Thirty-six patients with degenerative lumbar spondylolisthesis and stenosis were treated by posterior decompression and interbody fusion with pedicle screw fixation. The decompression, interbody grafting and screw insertion were performed with the patient in the knee-chest position. The patient was repositioned to the prone position for fusion. Sagittal plane angles were measured pre, intra and post-operatively. Clinical assessment was performed using SF-36 scores and visual analogue scores for back and leg pain.

Results: The median pre-operative sagittal angle between fused spinal segments was 16.0 degrees lordosis. Intra-operatively in the knee-chest position the sagittal angle was median 13.5 degrees and after changing to the prone position increased to median 27.1 degrees. On the initial post-operative lumbar radiographs the sagittal angle was 23.1 and this was maintained at 6 months post-operatively (22.5 degrees). Overall there was a mean increase in lordosis angle after repositioning of 7.1 degrees per operative level (p< 0.01). The SF-36 scores improved for 7 out of 8 domains and the physical score improved from 29% to 40% (p< 0.05). Mean pain scores improved from 7.5 to 3.8 for back pain and from 7.6 to 3.7 for leg pain (p< 0.001).

Conclusion: Lumbar spondylolisthesis was found to be associated with a reduction of normal lumbar lordosis. The knee-chest position exacerbates this loss of lordosis. Intra-operative repositioning restores lordosis to greater than the pre-operative angle and was associated with a good clinical outcome.

Introduction: Treatment for ruptured Achilles tendon can be classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing); post-operative splintage can be with a rigid cast or functional brace. The aim was to identify and summarise the evidence from randomised trials of the effectiveness of different interventions.

Methods: We searched the Cochrane specialised register, MEDLINE, reference lists of articles and contacted trialists directly for all randomised and quasiran-domised trials comparing different treatment regimes for acute Achilles tendon ruptures.

Results: Fourteen trials involving 891 patients were included.

Open operative treatment compared with non-operative treatment was associated with a lower risk of re-rupture (odds ratio (OR) = 0.25, 95% confidence interval (CI) = 0.1–0.6, p=0.003) but a higher risk of other complications including infection, adhesions and disturbed sensibility (OR = 14.1, 95%CI = 6.3–31.7, p< 0.00001).

Open versus percutaneous operative surgical repair was associated with a longer operation duration and higher risk of infection (OR = 12.9, 95%CI = 1.6–105.6, p=0.02).

Patients splinted with a functional brace rather than a cast post-operatively tended to have a shorter in-patient stay, less time off work, quicker return to sporting activities and fewer reported complications (p=0.0003).

Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques and different non-operative regimes.

Conclusions: Open operative treatment significantly reduces the risk of re-rupture but has the drawback of a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay and time off work and sports.

Introduction and Aims: Surgery for degenerative lumbar spondylolisthesis may entail both decompression and fusion. The knee-chest position facilitates decompression, but fixation in this position risks fusion in kyphosis. This can be avoided by intra-operative re-positioning to the fully prone position. We aim to quantify restoration of lordosis achieved by this manoeuvre.

Method: Thirty-six patients with degenerative lumbar spondylolisthesis and stenosis were treated by posterior decompression and interbody fusion with pedicle screw fixation (without interbody cages). There were 16 men and 20 women with a mean age of 58.2 years (32–80). The decompression, interbody grafting and screw insertion were performed with the patient in the knee-chest position. The patient was repositioned to the fully prone position for subsequent fusion. The sagittal plane angle was measured on the pre-operative, intra-operative and post-operative x-rays. Short-Form 36 (SF-36) scores and Visual Analogue Scales (VAS) for pain (0 to 10) were determined pre- and post-operatively.

Results: Twenty-eight patients underwent single-level fusion, two patients had two levels, two patients had three levels and four patients had four levels fused. The mean pre-operative sagittal angle between the operated vertebrae was 15.7 degrees lordosis, and the intra-operative angle before re-positioning was 14.9 degrees. The mean immediate post-operative angle was 23.7, and at six-month follow-up the angle was 23.1. Overall there was a mean increase in lordosis angle after repositioning of 8.0 degrees per operative level (p< 0.01). The mean scores of the SF-36 improved in all eight domains and this was significant (p< 0.05) for social functioning (44.4 to 68.9), energy and vitality (36.0 to 49.5), pain (23.8 to 58.3) and general health perception (51.4 to 65.6). Mean VAS pain scores for back pain improved from 7.47 pre-operatively to 3.84 post-operatively (p< 0.001); and for leg pain improved from 7.56 to 3.78 (p< 0.001). No complications attributable to the manoeuvre occurred.

Conclusion: Lumbar spondylolisthesis was found to be associated with reduction of normal lumbar lordosis. The knee-chest position for surgery exacerbates this loss of lordosis. Intra-operative repositioning restores lordosis to greater than the pre-operative angle, which may improve clinical outcome.

Introduction: Despite its common occurrence there is still controversy regarding the choice of treatment for the displaced intracapsular hip fracture in the elderly patient. Aim: To compare internal þxation and hemiar-throplasty in a prospective randomised controlled trial. Method: 455 patients aged over 70 years with a displaced intracapsular hip fracture were randomised to either hemiarthroplasty or internal þxation. Results: Internal þxation has shorter length of anaesthesia (p< 0.0001), lower operative blood loss (p< 0.0001) and lower transfusion requirements (p< 0.0001). Additional surgical procedures were required in 90 patients (39.8%) treated by internal þxation and 12 patients (5.2%) in the arthroplasty group. There was no statistical difference in mortality at one year (p=0.91), however there was a trend to improved survival for the older less mobile patients treated by internal þxation. There was no statistical difference in pain and mobility. Limb shortening was more common after internal þxation (p=0.004). Conclusion: We recommend that displaced intracapsular fractures in the elderly should generally be treated by hemiarthro-plasty, but internal þxation may be appropriate for the frail less mobile patient.

Integrated care pathways (ICPs) have been shown to have many benefits in clinical practice and are being widely adopted in orthopaedic surgery. A high standard of medical record keeping is important for safe patient care and provides information for research, audit and medico-legal purposes. This study compares the quality of medical notation in an ICP with traditional record keeping.

During a 3 month period 53 total hip replacements (ICP notation) and 30 total knee replacements (traditional notation) were performed in our unit. The records of each patient were scrutinised using a standardised scoring system, based on The Royal College of Surgeons’ guidelines on medical record keeping. Each set of records (83) were scored for admission clerking, subsequent entries, consent form, operation note and discharge letters. The time taken to retrieve this information was also recorded.

The overall score for traditional records (mean 70%) was significantly higher than for the ICP records (mean 62%), p=0.001. The mean scores for initial clerking, subsequent entries and consent form were higher in the traditional record group. It took 35% longer to retrieve information from the ICP group (p < 0.001).

In this study the quality of record keeping was higher when using the traditional notation than an established Integrated Care Pathway. In both groups the standard of clinical documentation was disappointing and must be improved if the potential clinical advantages of ICPs are to be realised. Better education of junior staff and regular auditing of medical records could improve this.

A total of 455 patients aged over 70 years with a displaced intracapsular fracture of the proximal femur was randomised to be treated either by hemiarthroplasty or internal fixation. The preoperative characteristics of the patients in both groups were similar.

Internal fixation has a shorter length of anaesthesia (36 minutes versus 57 minutes, p < 0.0001), lower operative blood loss (28 ml versus 177 ml, p < 0.0001) and lower transfusion requirements (0.04 units versus 0.39 units, p < 0.0001). In the internal fixation group 90 patients required 111 additional surgical procedures while only 15 additional operations on the hip were needed in 12 patients in the arthroplasty group. There was no statistically significant difference in mortality between the groups at one year (61/226 versus 63/229, p = 0.91), but there was a tendency for an improved survival in the older less mobile patients treated by internal fixation. For the survivors assessed at one, two and three years from injury there were no differences with regard to the outcome for pain and mobility. Limb shortening was more common after internal fixation (7.0 mm versus 3.6 mm, p = 0.004).

We recommend that displaced intracapsular fractures in the elderly should generally be treated by arthroplasty but that internal fixation may be appropriate for those who are very frail.