Controversy surrounds the management of displaced three- and four-part fractures of the proximal humerus. The percutaneous Resch technique of stabilisation involves minimal soft-tissue dissection and a reduced risk of stiffness and avascular necrosis. However, it requires a second operation to remove Kirschner wires and the humeral block. We describe a modification of this technique that dispenses with the need for this second operation and relies on a sequential pattern of screw placement. We report the outcome of 32 three- or four-part fractures of the proximal humerus treated in this way at a mean follow-up of 3.8 years (2 to 8)). There were 14 men and 18 women with a mean age of 56 years (28 to 83). At final follow-up the mean Oxford shoulder scores were 38 (31 to 44) and 39 (31 to 42), and the mean Constant scores were 79 (65 to 92) and 72 (70 to 80) for three- and four-part fractures, respectively. We further analysed the results in patients aged < 60 years with high-energy fractures and those aged ≥ 60 years with osteoporotic fractures. There were no cases of nonunion or avascular necrosis.

The results were good and comparable to those previously reported for the Resch technique and other means of fixation for proximal humeral fractures. We would recommend this modification of the technique for the treatment of displaced three-part and four-part fractures in patients both younger and older than 60 years of age.

Introduction: Microfracture is found to be effective for isolated chondral defect of knee in young adults however controversy exists over the relevance of microfracture treatment in degenerative knee. The purpose of the study is to assess the outcome and patient satisfaction with the arthroscopic microfracture of osteoarthritic knee.

Materials: We collected the demographic details of the patient, weight, procedure and follow up details from June 2000 to Dec 2002. We reviewed the case notes retrospectively and assessed the patient satisfaction with Oxford knee score and Lysholm score.

Results: There were total of 194 patients but only 76 patients returned the questionnaire. The average patient age was 57 years (range: 27–87 years) with majority of the patients being male patients (43 patients). The average weight of the patient was 82 kg (44–119) and the mean duration of operation was 28 minutes. The patients were evaluated at an average follow-up of 51 months (range: 36–66 months). The average Lysholm score was 49 (4–100) with mean oxford score of 32.5(13–56).

21 patients required knee replacement at an average of 24 months (range: 6–48 months) from the initial microfracture. 17 out of 21 patients had kissing lesion and all showed grade 4 degenerative changes

Discussion: Age and weight does not appear to have any effect on microfracture treatment however more number of female patients seem to have more kissing lesion and poor result. With shorter duration of operation and proper explanation to patient give short term symptomatic relief before replacement surgery. It is worth considering this treatment for isolated grade 4 lesion or less than grade 4 degenerative chondral lesions in appropriately selected patients.

Background: Internal snapping often resolves with conservative treatment but persistent significant symptoms may require surgical treatment. Different approaches and treatments have been suggested in the literature with weakness of hip flexion, recurrence of symptoms and nerve injury following surgery. We describe a modified surgical approach for internal snapping of hip in adults with good results.

Methods: Patients who failed conservative treatment for internal snapping between September 02 to February 04 were included. All patients had x-rays of relevant hips; ultrasound and MRI were done when required to exclude other causes. Patients were operated in supine position. A skin crease incision was made just lateral to the ASIS. The psoas tendon was reached sub-periosteally along the internal iliac surface hooked into the wound and divided releasing its musculo-tendonous junction. The patients were allowed to mobilise as able in the postoperative period.

Results: There were 8 snapping hips (3 right, 3 left, 1 bilateral) in 7 patients (6 females, 1 male) with average age of 30 years (17–51 yrs). The mean follow was 11 months. The average duration of symptoms before operation was 4.5 years (range 2–10 years). Clicking was relieved in all patients. Two patients felt slight weakness of hip flexion. One patient had temporary neuropraxia of lateral cutaneous nerve of thigh.

Discussion: The diagnosis is made by ultrasound or examination for a palpable click. Surgical correction of snapping is considered after failure of conservative treatment. Different extra pelvic (medial and iliofemoral) and intrapelvic extraperitoneal approaches have been described with varying results. With our slightly modified intrapelvic and sub-periosteal approach through oblique inguinal incision in adults, psoas muscle release at musculo-tendonous junction seems safe and effective (all clicking resolved) method. This method could be used as an alternative surgical approach for treatment of internal snapping of hip in adults.

Background: Whether to cross match or simply group and save for a primary THR is still a matter of debate. The argument in favour of cross match being immediate availability of blood and against it being wastage of resources, underutilization of cross matched samples etc.

Patients & Methods: We retrospectively analyzed the records of 136 patients who underwent primary THR at Manchester Royal Infirmary in 2004.

Result: Of the 136 patients, 104 had 220 units of blood cross matched. The average blood loss was 520 mls. The average pre op. Hb level was 12.8 g/dl while the average post op. Hb levels at 1, 3 & 5 days were 9.4, 9.9 & 10.1 gms/dl resply. Blood loss in patients on pre op. anticoagulant treatment (n = 44) was 596 mls while in the rest, it was 502 mls. The drop in Hb levels between the 2 groups was 3.6 gms/dl and 3.1 gms/dl resply. Patients with drain had an average drop in Hb level of 3.5 gms while it was 3.1 gms in others. The overall transfusion rate was 43.7 %. The most common reason for transfusion was asymptomatic low Hb (< 8 g/dl). Out of the 220 cross matched units, 99 (44.8 %) were transfused. Various probabilities like Cross-match to Transfusion ratio, Transfusion Probability & Transfusion Index were used to find out whether the cross matched units are used effectively.

Discussion: The only factor which influenced the transfusion rate was pre-op. Hb value. 79 %of patients required transfusion when pre op. Hb level was < 12 gm/dl.

Conclusion: 1. Group & Save is a safe policy for primary THR’s 2. Cross match only for patients with Hb of < 12gms/ dl. 3. Consider oral/IV iron therapy, autologous blood transfusion and retransfusion drain 4. Use of Aprotinin and transanamic acid reduces bleeding during surgery.

Introduction: Tantalum Monoblock Acetabular cup was designed to reduce backside wear and stimulate osseo-integration of cup with bone. The cup has peripheral fit to improve the initial stability and further stability and longevity depends on the osseointegration of cup with acetabulum. The revision cup was intended to give added stability with screws in case of defective rim or large acetabulum. The aim of this study is to assess the radiological outcome following tantalum monoblock revision cup in total hip replacement.

Methods: Between 1999 and 2000, 32 Tantalum mono-block revision acetabular cups was used in 31 patients. Standard hip radiographs were performed during post op, at three months, six months and then annually. X rays were assessed for loosening in De Lee and Charnley zones and for migration of cup.

Results: At a minimum follow-up of 2 years (range 2 to 5 years), 31 hips in 30 patients were assessed. The average age of the patient was 62.4 years (39–78 years). Three Brookers type 1 and one type 2 heterotrophic ossification was seen. There was a gap of 2–5mm in Zone 1(6 patients), 1–5mm in Zone 2 (8 Patients) and 5mm in Zone 3 of one patient. At final follow up, all the gaps were filled, except for one, where 5mm gap was persistent. There was no migration of cup or problems with screws. All the patients were satisfied with the operation.

Conclusion: Short term radiological result following uncemented revision tantalum monoblock acetabular cup in total hip replacement is highly encouraging. However, similar results from other centres and long term follow up studies are necessary to confirm the efficacy of the revision cups.

Objective: We report an unusual presentation of telangiectatic osteosarcoma of distal femur in a preadolescent boy.

Methods: A 9 year old boy fell down heavily while he was on holiday and fractured his distal femur. He was given above knee plaster locally and then transferred him to hospital where he lives normally. He developed increasing pain over next two weeks over fracture site (4 weeks after injury) and was reviewed in clinic. X ray of his femur showed permeative pattern of bone destruction with new bone formation. Subsequent biopsy of his lesion confirmed telangiectatic osteosarcoma. His subsequent MRI scan of thigh and CT scan of his chest showed pulmonary metastasis and dissemination of tumour to proximal femur. He never noticed any pain, discomfort or swelling before fracture and until four weeks after fracture apart from symptoms of fracture. Retrospective review of his x ray which was taken at the time of fracture demonstrated not very obvious osteolytic lesion in distal femur.

Conclusion: Telangiectatic osteosarcoma is a rare subtype of osteosarcoma and represents nearly 2% of all osteosarcomas. The incidence peaks in early to mid-adolescence and is not commonly encountered in very young and preadolescent patients.

Osteosarcoma usually presents with pain at night and precedes tumour by weeks or months. Some times there may be only a history of a tired feeling, a slight limp or a history of trauma.

Our case did not have any symptoms at all until two weeks before the presentation. The fracture made the tumour extra compartmental and led to metastasis and poor prognosis. We should always aware of this possibility of rare presentation when we see a preadolescent patient with increasing pain following fracture.

The mortality following surgery in patients with a recent MI is high. Standard advice is to wait for a minimum of 6 months. In urgent situations, this may not be possible. From Jan 2003 to Aug 2004, 10 patients were admitted with fracture neck of femur and a recent MI proven by ECG changes or raised troponin. There were 7 females. The mean age was 79.5 yrs (59–95yrs). The premorbid mobility and co-morbidities were noted. Echocardiography was done in all patients preoperatively to assess the cardiac function. All patients were seen by physicians and anaesthetist pre-operatively. The mean time from infarction to operation was 11.5 days (3–23 days). The patients underwent either Thompsons hemiarthroplasty or DHS. The anaesthetic was performed by a consultant. Most patients received spinal anaesthesia (7/9). The anaesthetic records could not be found for 1 patient. 6 patients died within a month and 1 patient died within 6 month of operation. Despite thorough preoperative work-up and consultant anaesthesia, the mortality following surgery for proximal femur fractures in patients with recent myocardial infarction is 70% at 6 months. To our knowledge, there are no published mortality figures for this situation. This is much higher than the reported mortality following proximal femur fracture.

Purpose: To investigate the outcome of tibiotalocalcaneal (TCC) fusion using the retrograde intramedullary nail (IMN).

Methods and results: We reviewed clinical and radiological outcome of 42 patients who underwent TTC fusion with a retrograde IMN in a single health region from 1996 to 2003. Out of 42 patients, four patients died of unrelated causes and two patients were lost to follow up. Finally, 36 patients (20 males, 16 females) were followed up. Mean age was 63 years and the follow up averaged 10 months. Degenerative arthritis (primary and post traumatic) and rheumatoid arthritis made up the majority of the preoperative diagnoses. Clinical outcome was assessed using the AOFAS hindfoot score and three independent observers reviewing radiographs.

Radiologically 22 ankles fused, three probably fused whilst 11 (30%) had evidence of non-union. The majority of subtalar joints failed to unite, reflected by the high rate of distal screw breakage. Primary bone grafting appeared to aid union however smoking, age and the use of an open approach did not seem to be significant factors. Other than non-union complications included two nail fatigue fractures, two deep infections, seven screw breakages, six wound problems and one fractured tibia. Post operatively the mean AOFAS score was 51, 25 patients were satisfied (of these 20% had radiological non-union) and 19 would undergo the same procedure again.

Conclusion: Despite a high rate of ankle and subtalar non-union most of the patients were satisfied with the procedure and would undergo the same operation again. Technical errors apart, the high rate of complications and non-union probably reflected the advanced nature of the disease process and deformity in this group of patients. Although IMN TTC fusion remains a viable option in the management of concurrent ankle and sub-talar joint arthritis, patients should be warned of the potential for non-union and high complication rates.

Purpose To investigate the outcome of tibiotalocalcaneal (TCC) fusion using the retrograde intramedullary nail (IMN).

Method We reviewed clinical and radiological outcome of 42 patients who underwent TTC fusion with a retrograde IMN in a single health region from 1996 to 2003. Out of 42 patients, two patients died of unrelated causes and four patients were lost to follow up. Finally, 36 patients (20 males, 16 females) were followed up. Mean age was 63 years and the follow up averaged 10 months. Degenerative arthritis (primary and post-traumatic) and rheumatoid arthritis made up the majority of the preoperative diagnoses. Clinical outcome was assessed using the American Orthopaedic Foot and Ankle (AOFAS) hindfoot score and with three independent observers reviewing radiographs.

Results Radiologically 17 ankles fused, three probably fused whilst 16 (33%) had evidence of non-union. The majority of subtalar joints failed to unite, reflected by the high rate of distal screw breakage. Primary bone grafting appeared to aid union however smoking, age and the use of an open approach did not seem to be significant factors. Other than non-union complications included two nail fatigue fractures, two deep infections, seven screw breakages, six wound problems and one fractured tibia. Postoperatively the mean AOFAS score was 51, 25 patients were satisfied (of these 50% had radiological non-union) and 19 would undergo the same procedure again.

Conclusion Despite a high rate of ankle and subtalar non-union, most of the patients were satisfied with the procedure and would undergo the same operation again. Technical errors apart, the high rate of complications and non-union probably reflected the advanced nature of the disease process and deformity in this group of patients. Although IMN TTC fusion remains a viable option in the management of concurrent ankle and subtalar joint arthritis, patients should be warned of the potential for non-union and high complication rates.