Introduction

The most challenging aspect in rotational deformity correction is translating the pre-operative plan to an accurate intra-operative correction. Landmarks away from the osteotomy site are typically employed at pre-operative planning and this can render inadequate correction. Our proposed technique of pre-operative planning using CT scan and leg length radiographs can translate to accurate intra-operative correction.

Introduction

Circular frames in the lower limbs have been removed by Specialist nurses in our clinics for the past 20 years using Entonox. This standard of care has helped reduce the burden of health care cost by avoiding removal of frames in theatres. We have recently started using Penthrox and present our encouraging initial data suggestive of superior efficacy when compared to Entonox.

The use of tourniquet in lower limb orthopaedic surgery is well established, however, it does have associated risks and complications and its use has been previously questioned. The purpose of this study was to compare postoperative pain scores, analgesic requirements and time to discharge in patients undergoing tourniquet assisted and non-tourniquet assisted routine knee arthroscopy.

A total of 40 patients were randomised to tourniquet assisted and non-tourniquet assisted groups. Arthroscopy was performed using a standardised local anaesthetic infiltration in the non-tourniquet assisted group. All patients completed a postoperative pain score.

Findings demonstrated that the incidence and mean scores for postoperative pain were significantly lower in the non-tourniquet group. Additionally postoperative analgesic requirements of patients in the non-tourniquet group were also found to be significantly lower and time spent in recovery and on the ward postoperatively was also lower in the non-tourniquet group compared to the tourniquet group.

On the basis of the results in our study we recommend abolishing the use of tourniquet in routine knee arthroscopies in the virgin knee.

AIM: To investigate the relationship between patient variables and surgeons’ grade and experience on one hand and re-operation and mortality rates at six months on the other hand.

Method: Seven hundred and sixty-one patients with proximal femoral fractures (PFF) (463 intracapsular fractures, 286 extracapsular fractures, and 12 subtrochanteric fractures) were treated surgically between April 2005 to October 2007. The level of experience among trainees was quantified as the number of PFF they had fixed or replaced as the first surgeon, from the start of their training at Senior House Officer level to the beginning of the study period.

Logistic regression model was used to investigate the relationship between mortality and re-operation at six months and case mix variables (age, ASA grade, fracture types, pre-fracture residence, and mobility and activity level), and management variables (days to operation, the grade of the surgeon and supervision level). Mann-Whitney test was used to compare the level of experience among trainees in the group of patients who died or required re-operation at six months.

Results: At six months, the mortality rate was 24.2% (184) and the re-operation rate was 3.8% (29).

The logistic regression model used to predict six months mortality was highly significant (X2=166.6 [24df], p< 0.0001). It showed that age, ASA grade and pre-fracture activity level were strongly associated with mortality at six months. Patients operated on by a trainee without the consultant being scrubbed were 1.8 times (p< 0.05) more likely to die at 6 months. (Odds ratio of 1.8 with 95% confidence interval of 1.15 to 2.75). Re-operation at six months could not be predicted by these factors.

Regarding patients operated on by trainees, there was no significant difference in the level of experience among trainees who operated on patients who died or who required re-operation at six months compared to those who did not.

Aim: To compare the acute haemoglobin level drop following hip fracture fixation with IMHS and CHS at James Cook University Hospital and assess whether the surgeon’s seniority has any effect on the amount of blood loss in these two procedures.

Methods: Trauma data base was searched for all IMHS procedures performed from January 2002 till March 2007 both included and CHS procedures performed from January 2007 till March 2008 both included.

There were 159 CHS procedures and 146 IMHS procedures. 137 CHS and 123 IMHS procedures fulfilled the blood testing and transfusion criteria.

Haemoglobin levels were used as an indication for blood loss attributable to surgery. The difference between the last level of haemoglobin checked preoperatively and the first post operative level performed between 12–48 hours postoperatively is calculated. Cases where blood transfusion was carried out preoperatively without further preoperative haemoglobin check were excluded, so were cases receiving intra or post operative blood transfusion prior to the defined postoperative haemoglobin check was carried out.

Results: SPSS 13.0 statistical package was used to analyse the results. Levene’s test proved equality of variances of blood loss within the two groups of patients undergoing one of the two procedures, P=0.5. Hence, Independent Samples T test was applicable and showed that patients undergoing an IMHS procedure dropped their haemoglobin levels by 2.96 g/dl. While, those undergoing a CHS procedure dropped their haemoglobin levels by 2.32 g/dl. The 0.64 g/dl difference in haemoglobin drop was statistically significant at 5% significance level with 95% CI (0.27 to 1.01), P=0.001.

The surgeons’ grades were classified into three groups as: Consultants, Registrars and Senior House Officers. Levene’s test again proved the variances of haemoglobin drop within each group to be homogeneous. Hence a One-Way ANOVA test was carried out showing that the differences in haemoglobin drop were not statistically significant when comparing the three groups of surgeons to each other. This was true for both IMHS and CHS procedures.

Conclusion: Patients undergoing a CHS procedure drop their haemoglobin levels by 0.64 g/dl less than those undergoing an IMHS procedure. The surgeon’s seniority does not make difference to the amount of haemoglobin level drop following either of the two procedures.

We recommend the use of CHS for stable fractures and reserve the IMHS for the unstable ones due to the increased blood loss with IMHS procedures.

Introduction: Previous studies have demonstrated the value of the tip-apex distance (TAD) and the location of the screw in the femoral head in predicting cut-out. Similarly surgeons’ volume has been shown to affect mortality and morbidity in various surgical specialties, including in trauma and orthopaedics.

Aim: To determine whether re-operation due to cut out at six month can be predicted using TAD, location of the screw and fracture type; and whether the experience of the surgeon is important.

Methods: Logistic regression was used to analyse data collected retrospectively from 241 patients with extracapsular fractures (Jensen’s modification of Evans’ classification: Class I – 90, Class II – 93 and Class III – 58), treated with a dynamic hip screw, classic hip screw or intramedullary hip screw from April 2005 to October 2007.

Results: There were 7 cut outs (2.5%) requiring re-operation within 6 months – 1 in the consultant group and 6 in the trainee group,. The model used was statistically significant (X2=23.6 [13df], p< 0.05). The tip-apex distance was a strong predictor (p< 0.05) of cut-out requiring re-operation at six months. The odds of the patient requiring re-operation due to cut out increases by a factor of 1.2 for each millimetre increase in the TAD. Location of the hip screw and fracture type were however not significant predictors. The first surgeon was a consultant in 54 cases and trainee in 187 cases. There was no statistically significant difference in re-operation rate due to cut out between patients operated on by consultants compared to trainees.

Conclusion: The TAD is a strong predictor of cut out requiring re-operation at 6 months. No difference was found in our series in re-operation rate due to cut out among cases performed by consultants compared to trainees.

The proximal humerus internal locking system is an internal fixation device consisting of a low-profile plate and locking screws, which is used for the fixation of three- and four-part fractures of the proximal humerus. We describe a case in which the screws cut out of the humeral head causing injury to the axillary artery necessitating urgent removal of the implant.