Total shoulder arthroplasty (TSA) and Reverse Total shoulder arthroplasty (RSA) are two of the most performed shoulder operations today. Traditionally postoperative rehabilitation included a period of immobilisation, protecting the joint and allowing time for soft tissue healing. This immobilisation period may significantly impact a patient's quality of life (Qol)and ability to perform activities of daily living (ADL's). This period of immobilisation could be safely avoided, accelerating return to function and improving postoperative QoL.

This systematic review examines the safety of early mobilisation compared to immobilisation after shoulder arthroplasty focusing on outcomes at one year.

Background/Aim: A preliminary biomechanical study conducted on cadaver fibulae, was observed to have a significant (p< 0.001) difference between two different methods of interfragmentary screw fixation for oblique fractures.

A further study was undertaken to verify the results on composite material with biomechanical properties similar to human bone.

Material and Methods: Forty, custom designed composite fibular specimens were used for the biomechanical testing. The specimens were divided into two groups of 20 each. Group I comprised of specimens with biomechanical properties similar to young healthy bone and group II comprised of osteoporotic bone quality. The fibular specimens were osteotomised to resemble a short oblique fracture of the lateral malleolus. The fractures were fixed with interfragmentary cortical lag screws placed in antero-posterior and postero anterior directions, 10 samples in each group.

Results: In both groups, the mean force required to disrupt the fracture fixation was observed to be 0.45 kN higher in samples fixed with screws placed in postero anterior direction.

Conclusion: This study further confirms the screw placement in postero- anterior direction provides a stronger biomechanical construct for short oblique fracture of the lateral malleolus.

A study on cadaver ankles was performed; two methods of ‘Danis-Weber type B’ lateral malleolar fracture fixation were compared.

Materials and Method: Ten ankles from five female cadavers were used. The distal fibulae were osteotomised at the level of the syndesmosis with a saw and the fracture fixations were divided into two groups. In Group I, the fractures were fixed with traditional anteroposterior cortical screws and in Group II, the contra lateral fractures from the same cadaver were fixed with postero-anterior cortical screws. The distal fibulae in both groups were subjected to biomechanical compression and torsion forces and the force at which the fixation gave way was recorded.

Results: In the former group the breaking force was significantly lower than that required in the latter group by a mean of 0.4 kN.

In conclusion, the fixation done in Group II was found to be better.

Aims: Treatment options for proximal humeral fractures are not very clear, specially in osteoporotic bones. Non operative treatment if on one hand leads to unpredicted and poor outcomes, the operative treatment on the other hand leads to devascularization of fractured fragments and implant failure leading to unacceptable results. Newer interlocking plates, which are applied with minimum soft tissue stripping of fractured fragments and better fixation abilities seems a promising alternative. We present our experience with such plates.

Patients and Methods: Over a period of two years 2002 and 2003, we used 50 plates to treat Neer’s two and three parts and surgical neck of humerus fractures. We reviewed our clinical results with PHILOS plates, which is in interlocking plate. Average age was 34 (24–82). 21 Male and 29 Females. We followed them clinically and radiologically for healing. The shoulder function was assesses with DASH scoring system. The DASH system questionnaire was filled by patients before the fracture and after healing of the fractures. We used a regimen of progressive rehabilitation of shoulder from immediate post operative period. All the complications including union issues, shoulder function, wound problems, nerve injuries, infection and implant failure were noted. Two different techniques were used to fix the fracture with the plate.

Statistical analysis was performed on the data collected through DASH questionnaires along with multivariate and univariate analysis and t-tests.

Results: We were able to follow all the patients who filled the pre fracture and post healing DASH system questioner. X-rays and clinical findings were available for all the patients in the study. All the patients united with average length of 6 weeks (5–12 weeks). All the fractures united. There were no deep infections; however, two patients had to have a week of oral antibiotics for superficial wound infection. There were no permanent nerve injuries. Eight patients had transient axillary nerve paresis, which resolved after 10–15 days. Patient satisfaction with the procedure was high.

48 % of patients showed a rise in DASH scores after the fracture healing, indicating decrease shoulder function. This was statistically analysed and failed to reach any significance p=0.867. There was no difference between the two techniques in terms of complications and union rates.

Conclusions: PHILOS interlocking plates in our study showed 100% union rate with no or minimal complications and preservation of shoulder function. They are technically not difficult to apply and allow immediate post operative mobilization. Hence we recommend their use in primary fixation of proximal humerus fractures.

Abstract: A study on cadaver ankles was performed; two methods of ‘Danis-Weber type B’ lateral malleolar fracture fixation were compared.

Materials and Method: Ten ankles from five female cadavers were used. The distal fibulae were osteotomised at the level of the syndesmosis with a saw and the fracture fixations were divided into two groups. In Group I, the fractures were fixed with traditional antero-posterior cortical screws and in Group II, the contra lateral fractures from the same cadaver were fixed with postero-anterior cortical screws. The distal fibulae in both groups were subjected to biomechanical compression and torsion forces and the force at which the fixation gave way was recorded.

Results: In the former group the breaking force was significantly lower than that required in the latter group by a mean of 0.4 kN.

In conclusion, the fixation done in Group II was found to be biomechanically more stable.

Introduction: Uncemented total hip arthroplasty has evolved significantly over the past two decades. During this period many implants with different shapes, designs and coatings have developed and are being used with variable results. We present a series of 100 uncemented hip arthroplasties using the Duraloc 100 series cup and Corail stems which have been in use at Merlin Park for the past 5 years and 1 year respectively. The CORAIL stem first introduced in 1986 has a triplanar wedge design for optimal metaphyseal fixation. The prosthesis is pointed in its distal part to allow centering in the medullary canal without cortical locking. The titanium stem is fully coated with a 150 micron thick layer of hydroyapatite. According to the Norwegian arthroplasty register the stem has 99.5% survival at 4.5 years (Havelin L1, Espheaug B, Vollset SE, Engesaeter LB).

The Duraloc 100 series acetabular cups are hemispherical, porous-coated implants that are press fitted to a cavity reamed 2mm smaller than the cup diameter.

Material and methods: Between January 2002 and September 2003 we carried out 100 uncemented THRs in 65 males and 35 female patients. Patients were deemed fit for uncemented hip replacement if they had good bone stock and had no co-morbid condition which might compromise bone quality. Preoperative work up was carried out to exclude any generalised diseases that might compromise bone quality, including bone density measurements where appropriate. Baseline WOMAC scores and Harris hip scores were performed pre-operatively and at latest follow up. Operative details were recorded along with post-operative complications. Patients were followed up clinically and radiologically for a period of 6 to 26 months.

Results: There were 65 male patients and 35 female patients. Average age in men was 62.5 years (range 40 to 85 years) and in women was 65 years (range 48 to 86 years). Four patients had rheumatoid arthritis, the rest had osteoarthritis. The average post-op hospital stay was 12 days. The mean WOMAC score increased from 45 pre-op to 87 at the latest follow up. The average Harris hip score also increased from 52 pre-op to 92 at latest follow up.

All procedures were either performed or directly supervised by the senior authors. Operations were performed through an antero-lateral approach, the femur was prepared first and a trial reamer was left in the femoral canal to minimise blood loss while the acetabulum was reamed. The average duration of surgery was 65 minutes (range 45 to 100 mins) and average intra-operative blood loss was 300mls (range 125 to 750mls). Intra-operative complications included 2 proximal femur stable split fractures, they were identified on table and fixed with circlage cables. Patients were allowed to mobilise partial weight bearing as tolerated. Complications included 4 deep venous thromboses, three superficial wound infections, one respiratory tract infection and one myocardial infarction. At the latest follow up there are no dislocations, no deep infections and no loosening of the cup or the stem.

Discussion: When considering new implants and techniques in arthroplasty long term outcome of studies are necessary before any firm conclusions can be drawn regarding ultimate efficacy. This study however confirms that uncemented THRs using Duraloc cups and Corail stems is safe, involves minimal blood loss and gives good short term results. As there is no cement used, the duration of surgery is at least 15 to 20 mins less than an average cemented THR, which may be important when access to theatre is limited. The procedure is easy to learn and has well designed instrumentation. While there is no substitute for long term studies we feel that these early results are encouraging and justify continued work with the procedure in the context of a well designed prospective randomised trial comparing cemented and uncemented femoral components.

Hip fracture in the elderly is associated with significant morbidity and mortality. Significant intra-operative blood loss and the subsequent need for transfusion significantly contribute to patient morbidity. Making a surgical incision with diathermy reduces wound related blood loss, by coagulating small vessels as tissue is incised, however no study to date has looked at the use of diathermy in making surgical incisions around the hip. In addition, the increasing prevalence of blood borne infections makes the exclusion of sharps from the operative field an attractive option. The aim of this study was to compare diathermy incision with traditional wound opening using a scalpel to incise all layers. 50 patient undergoing hemiarthroplasty for fractured neck of femur were recruited prospectively. Patients on warfarin were excluded from the study while those on aspirin were not. After informed consent was obtained patients were randomized to scalpel or diathermy incision by coin toss.

In the diathermy group the dermis was incised with the scalpel and all further layers with the diathermy, while in both groups diathermy as used for haemostasis. All patients received prophylactic antibiotics at induction and for 24 hours post-op. Wounds were closed in a standard fashion using absorbable sutures for closing fascia and fat layers and surgical staples for skin. Intra-operative parameters measured included: 1) Time to open wound – defined as time taken to open wound from skin incision to complete opening of the fascia lata and achieve haemostasis. 2) Wound length and depth. 3) Wound related blood loss – swabs used while creating and closing the wound were weighed separately. 4) Total operative blood loss. Post-operatively all wound related complications were recorded. Statistical analysis was performed using the un-paired Student t-test parametric data.

Both groups were similar in relation to age, sex and pre-operative aspirin use. Intra-operatively neither wound sizes nor time taken to create the wound were statistically significantly different. In the scalpel group wound related blood loss represented over 30% of the total operative blood loss as compared with only 18.5% in the diathermy group. Post-operatively there were no wound infections or dehiscences in either group, however 4 patients in the scalpel group developed significant wound ooze that responded to conservative treatment. There were no significant wound problems in the diathermy incision group.

This prospective study has shown that the use of diathermy incision for hip hemiarthroplasty significantly reduces wound related blood loss and the incidence of post-operative wound ooze. We conclude that the routine use of diathermy to make incisions around the hip is effective in reducing wound related bleeding without adverse effects on wound healing or infection rate.

Percutaneous wiring is a successful technique for the management of distal radial fractures. Practice differs according to surgeon preference as to whether the wires used are buried or protruding. To assess patient satisfaction with wither technique, we prospectively randomised 52 consecutive patients undergoing percutaneous wiring for distal radius fractures with regard to whether the wires were buried or not.

Patients with a distal radial fracture managed with percutaneous wire fixation and casting only were randomly allocated to have the wires buried or protruding. The fractures were classified according to Frykmn’s classification of fractures of the distal radius, and there were no differences between the groups (p=0.9).

The total number of patients studied was 52, with a mean age of 56.6 years (range 19–84). The female: male ratio was 38:13. Twenty-five (48%) patients had percutaneous wiring of their fracture with the Kirschner wires buried and 27 (52%) had the wires protruding. Cast and wire fixation were removed at a mean duration of 5.8 weeks in an outpatient setting. Patients recorded whether they experienced pain during the period of wire fixation or pain during the removal of wires on a visual analogue scale. Fifteen patients reported pain during the period of fixation (55.5%), the severity ranged between 2–8 (mean 3.8) with no significant difference between the groups (p=0.8). All patients with buried wires compared with 10% of those protruding wires required local anaesthesia in the operating theatre for removal (p=0.03). Superficial infection was diagnosed in 4 patients with no significant difference between groups (p=0.14).

Buried wires are typically advocated to prevent pin site infections and to improve patient comfort and satisfaction. However, we found no difference between the study groups with regard to patient satisfaction, pain during the period of fixation or pin-site infections. Furthermore, all patients in the buried wire group required local anaesthesia for removal with some of these necessitating a visit to the operating theatre. We therefore feel that burying these wires confers no advantage while adding to the complexity, time and cost of removal and recommend leaving wires protruding through the skin.

Injuries to the sciatic nerve are an occasional complication of surgery to the hip and acetabulum, and traction is frequently the causative mechanism. In vitro and animal experiments have shown that increased tensile strain on peripheral nerves, when applied for prolonged periods, impairs nerve function.

We have used video-extensometry to measure strain on the human sciatic nerve during total hip replacement (THR). Ten consecutive patients with a mean age of 72 years undergoing primary THR by the posterior approach were recruited, and strains in the sciatic nerve were measured in different combinations of flexion and extension of the hip and knee, before dislocation of the hip. Significant increases (p = 0.02) in strain in the sciatic nerve were observed in flexion of the hip and extension of the knee. The mean increase was 26% (19% to 30%). In animal studies increases of this magnitude have been shown to impair electrophysiological function in peripheral nerves. Our results suggest that excessive flexion of the hip and extension of the knee should be avoided during THR.