The 8-plate (Orthofix, SRL, Italy) is a titanium extraperiosteal plate with 2 screws which acts as a hinge at the outer limits of the physis. It has been used for correction of both angular and sagittal deformity around the knee. To our knowledge this is the first study describing the use of 8-plates in leg length discrepancy (LLD) correction.

We aimed to evaluate outcomes of temporary 8-plate epiphysiodesis in LLD, and to assess the complications associated with its usage.

This retrospective study included 30 patients between 2007 and 2010 whom underwent 8-plate epiphysiodesis to address LLD.

Leg length measurements were recorded using erect full leg length scanograms and comparison made between pre-operative, interval and final scanograms. Any deviations of the mechanical axis were also recorded.

During the study period 34 epiphysiodeses were performed on 30 patients. There were 17 males and 14 females. The average age at the time of procedure was 10.7 years (range 3–15). Average time to final follow-up was 24 months (range 52–10). The average pre-operative LLD was 2.5 cm (range 1.5–6 cm). The mean overall rate of correction was 1.0 cm per year. The mean residual LLD at end of treatment was 1.1 cm (range 0–4.5 cm). Two patients experienced genu recurvatum deformity. This was associated with placement of distal femoral plates anterior to the mid-lateral line.

Based on our experience 8-plate epiphysiodesis is a reversible, minimally invasive procedure with reliable results in length correction. However, careful device placement is required to prevent deformity.

Background

Distal radial fractures in the elderly population have been traditionally managed by closed techniques, primarily due to their poor bone quality and low functional demands. Since the introduction of the volar locking plate (VLP), which provides a good fixation in osteoporotic bones, there maybe an increased use of open reduction and internal fixation (ORIF) in the elderly population.

The administration of prophylactic antibiotics is essential in the prevention of surgical site infection, particularly when metalwork is implanted. Intravenous Cefuroxime has been the antibiotic of choice for prophylaxis in our unit over the last few years. Unfortunately this has been linked to an increased rate of Clostridium Difficile infection. Our departmental antibiotic prophylaxis guidelines, based on the Scottish Intercollegiate Guidelines Network (SIGN), were therefore revised, such that intravenous Flucloxacillin and Gentamicin became the first line agents.

We primarily aimed to assess whether prophylactic antibiotics were being administered according to our revised local guidelines. Steps were then taken to improve adherence to the guidelines, and the audit repeated.

Data was collected prospectively between 1^st November 2010 and 28^th November 2010 (cycle 1). Demographic data, type of surgery, details of choice, dose and timing of antibiotic administration were compiled. The quality of documentation was also reviewed. Interventions to improve adherence to the guidelines were commenced between 1^st January 2011 and 28^th February 2011. This included a departmental presentation, supplementary distribution of the guidelines and email communication to all orthopaedic surgeons and anaesthetists to increase awareness. A repeat audit cycle was performed between 1^st March 2011 and 28^th March 2011 (cycle 2). All data was stored and statistically analysed using SPSS for Windows 17.0.

A total of 130 patients were included, with 65 patients in each cycle. Demographic data and type of surgery were reasonably similar in both cycles. Intravenous antibiotics, when required, were administered within 30 minutes of the surgical incision in most cases in both cycles of the audit. In the first cycle of the audit only 9 out of 65 patients (14%) received the correct antibiotics as suggested by our updated guidelines. This improved significantly to 46 out of 57 patients (81%) in the second cycle. Documentation of antibiotic prescribing in the anaesthetic record, operation note and drug charts also improved in the second cycle.

We observed poor initial adherence to our updated guidelines as most patients received incorrect antibiotic prophylaxis. However, following our audit interventions to increase awareness of the new guidelines, we witnessed a significant improvement in compliance. Our next step will be to ensure that the new policy of using intravenous Flucloxacillin and Gentamicin does indeed reduce the rate of Clostridium Difficile infection while maintaining a low rate of deep and superficial wound infection.

Background: Back pain is a common presenting feature in patients with hip arthritis. Hip replacement surgery is performed primarily to relieve hip pain but is known to improve global function. The aim of this study was to quantify the effects of total hip arthroplasty on back pain.

Patients and Methods: A prospective study was conducted from 2001 to 2005 at the Victoria Hospital, Kirkcaldy, Fife. A novel body diagram was devised to collect and quantify back pain. Patients were asked to localize their pain on this diagram prior to their surgery and six months later. The patients were also asked to record their level of satisfaction on a visual analogue scale (VAS) and to complete validated functional and psychological assessments (SF-36; Harris Hip Score).

Results: Preoperative and postoperative data were complete for 872 patients. Preoperatively, 234 (27%) patients complained of pain in the lumbar region. A low score in the baseline SF-36 correlated with low back pain. At six-month post total hip arthroplasty, the low back pain had resolved in 50% (n=116) of these patients, and resolution of this pain correlated with improved post-operative SF-36 score. The mean postoperative satisfaction score was 8.8 out of a maximum 10 (VAS). Satisfaction correlated with reduced back pain.

Conclusion: We describe a novel method of pain assessment in total hip arthroplasty. These data from a large prospective cohort indicate that many patients may expect an improvement in their back pain following hip replacement. This data will be useful in the preoperative counselling of patients considering arthroplasty.

Objective: The quality of femoral cementation is related with the long-term survival of hip prosthesis. We set out to identify if the quality of femoral cementing as assessed on the first postoperative AP radiograph was significantly different when operations performed by trainees were compared with those done by consultant staff.

The Barrack scoring system was used as a tool to evaluating cementation quality in all cases.

Material and Method: The cohort included 70 patients undergoing primary Exeter hip replacement. 41 cases were performed by consultants and 29 by trainees. The mean age of the consultant patients was 80 while in the second group this was 78. The ratio of “Funnel shaped” to “stove-pipe” femurs was 1/2.3 in the consultant group and 1/2.1 in trainees group. Thus the two groups were similar. The 1^st postoperative AP hip x-rays were numbered randomly and digital images were then graded using the method of Barrack by one observer (I.R) who was blinded to the seniority of surgeon.

Results: Of the total cohort of 70 patients, 35 (50%) were grade A, 28 (40%) grade B and 7 (10%) grade C. In the consultant cases 18(44%) were grade A, 19(46%) grade B and 4(10%) were grade C. The results in for training grade surgeons were 17 (58%) grade A, 9 (31%) grade B and 3 (11%) grade C. There were no grade D cases in either group. The standard deviation in consultant group was 23.46 while in case junior grade surgeons it was 25.46.

Conclusion: The results in this series of operations suggest that in our institution, the quality of femoral cementing was not significantly different when the operations carried out by consultants were compared to those where a trainee was the primary surgeon (p=0.087). As Barrack scores have been shown to correlate with the long term survival of hip arthroplasties, these results would suggest that patients undergoing operation undertaken by an adequately experienced and supervised trainee are not at increased risk for implant failure compared to the individuals where the Consultant is the primary surgeon.

Patients are increasingly demanding more (and better quality) information regarding the likely outcomes of THA surgery. Hip joint pain may be referred variably and widely in anatomical location and it has been unclear how reliably these pains can be relieved by arthroplasty.

193 patients undergoing primary unilateral Charnley THA were studied. Each patient was asked to indicate on a diagram where they were experiencing pain both preoperatively and at six months postoperatively. A scoring grid was superimposed for assessment. These two scores were compared with the Harris Hip Score, SF36 and satisfaction scores obtained at the same intervals. Comparisons were made between pre-operative and postoperative pain location and severity.

Preoperative pain is most often experienced in the groin (74% of patients), thigh (64%), knee (56%) and buttock (62%). Over 80% of pain in all zones is relieved by THA. However, the accepted assumption that groin and anterior thigh pains are the most reliably relieved is not borne out: pain is relieved in the leg and posterior thigh more reliably (in 97%, 93% and 100% cases respectively) than that in the groin (88%) or thigh (91%). Pain in the lower back is relieved in 81% of cases. Postoperative pain correlates closely with the postoperative SF36 and Harris Hip Score pain scores.

Postoperative dissatisfaction was most closely correlated with postoperative pain in the groin and buttock (p< 0.0001) and the anterior thigh (p< 0.05). 84% of patients would have the procedure again in the same circumstances, although 91% would recommend it to a friend or relative in the same situation.

THA is effective in relieving most pain around the hip. This is the case not only in the groin and anterior thigh which are often regarded as being highly specific for hip pain, but also in the lower back and leg. Postoperative dissatisfaction is highly significantly correlated with persisting pain in the groin, thigh and buttock.

To investigate the use of the Ilizarov circular fixator in treating diaphyseal non-union following previous intra-medullary nailing. The stability of each non-union was augmented using an Ilizarov fixator with nail retention.

We retrospectively reviewed nine consecutive patients (mean age 31 years, range 24–53 years) who were treated in our institution between 1993 and 1997 (mean follow up 19.2 months, range 6–33 months). Two femoral, three tibial and four humeral non-unions were included in the study. All patients were referred from other centers after failure to achieve bone union with intramedullary nailing. Patients who had non-union with other fixation devices in situ, those with active infection and those who had their non-unions explored at the time of fixator application were excluded from the study. The patients had undergone an average of 2.4 operations (range 1–5 operations) prior to fixator augmentation.

The circular fixator was applied over the nail as a closed procedure (non-union not surgically explored) in all nine patients. The non-union was manipulated either by compression or oscillation during fixator treatment. The mean duration of fixator treatment was 6.2 months (range 3–11 months).

Outcome measures assessed were bone union, deformity, shortening and functional outcome. Bone union was achieved in all nine patients. The bone results were graded as six excellent, one good and two fair. All patients reported a reduction in pain and satisfaction with their final outcome.

We recommend the use of the Ilizarov fixator with nail retention in resistant long bone union in carefully selected patients. This technique is particularly useful in the humerus where it avoids the morbidity associated with nail removal and plating. The augmentation method can shorten the fixator time and has the advantage of a simpler frame construct.