Introduction: Compromised by pre-existing medical co-morbidities, weakened by the second hit of surgery, elderly patients with hip fractures are amongst the most challenging cases to manage appropriately in the acute hospital setting.

Aim: To document the frequency and outcome of post operative medical complications in elderly patients following surgery for hip and proximal femoral fractures.

Methods: Retrospective analysis of acute admissions to a University teaching hospital with hip and pertrochanteric fractures over an 18 month period. Medical records and radiographs were reviewed for details relating to location of fracture, in-patient morbidity, mortality and length of stay. In-patient fracture referrals and patients under 65 years of age were excluded.

Results: From a total of 438 fracture fixation procedures or prosthetic replacements, 368 patients were eligible for analysis. The mean age of patients was 83.6 years. The mean length of stay was 14.2 days.

142 patients experienced significant postoperative morbidity consisting of 24 myocardial infarctions, 46 respiratory tract infections, 33 urinary tract infections, 3 cerebral vascular accidents and 36 exacerbations of congestive cardiac failure. There was no correlation between morbidity and location or type of fracture. The mean age (86.1 yrs) and length of stay (26 days) was greater in the morbidity group (p< 0.05). The overall post operative in-patient mortality rate was 9%, rising to 50% in those who suffered a myocardial infarction and 33% in those with exacerbations of congestive cardiac failure.

Conclusion: This study reinforces the poor prognosis conferred by a hip fracture on the elderly patient both in terms of morbidity and mortality. As the population ages and life expectancy increases, health services will come under ever more pressure to cater for the expansion in numbers of hip fracture patients. Greater resources and dedicated professional medical staff are required in order that the best possible care and outcome may be achieved for these patients

Aim: An epidemiological analysis of spontaneous community acquired septic arthritis cases in an elderly population at a university teaching hospital

Method: We studied confirmed cases of spontaneous septic arthritis in the over 65 population. Patients with prosthetic joint infections were excluded from the study. We analysed data relating to initial presenting complaint and clinical examination, haematological and microbio-logical tests along with ultimate patient outcome.

Results: There were 7 confirmed cases of spontaneous septic arthritis in over 65 population in the last 6 months (2 hips, 5 knees). The mean age was 72.14 (range 65–82) with a mean length of stay of 49 days. Those with septic arthritis of the knee presented with swelling, pain and immobility. Hip cases presented with pain and immobility. All patients were systemically well at time of presentation, with no other foci of infection detected after septic screening. All patients had aspirate and arthroscopic/arthrotomy confirmed infection. Staphylococcus Aureus was isolated from 6 joint aspirations and Pseaudomonas Auruginosa from one patient. Complications of treatment included acute renal failure, cardio/respiratory failure, disseminated infection and death (1 case).

Conclusion: Septic arthritis must be considered as a differential diagnosis in all patients with joint pain, swelling and immobility. This diagnosis is not confined to the paediatric population. A backround of degenerative disease and the occult presentation in the elderly may delay diagnosis. Sepsis must be considered in the elderly with joint pathology, with treatment initiated in a prompt and aggressive manner to prevent the sequelae that ensues.

Introduction: C1-2 polyaxial screw-rod fixation is a relatively new technique. While recognising the potential for inadvertent vertebral artery injury there have been few reports in the literature outlining all the possible complications.

Aim:To review all cases of C1 lateral mass screw insertion with emphasis on the evaluation of the potential structures at risk during the procedure.

Methods: We retrospectively reviewed all patients in our unit who has C1 lateral mass screw insertion over a 2 year period. The C1 lateral mass screw was inserted as part of an atlantoaxial stabilisation or incorporated into a modular occiput/subaxial construct. Outcome measures included clinical and radiological parameters. Clinical indicators included age, gender, neurologic status, surgical indication and the number of levels stabilised. Intraoperative complications including blood loss, vertebral artery injury or dural tears were recorded. Radiological indicators included post-operative plain radiographs to assess sagittal alignment and to check for screw malposition or construct failure.

Results: A total of 18 C1 lateral mass screws were implanted in 9 patients. There were 3 male and 6 female patients who had C1 lateral mass screws inserted in this tertiary referral centre. Two patients had atlantoaxial stabilisation of a C2 odontoid fracture. There were 4 patients with rheumatoid arthritis whose C1 lateral mass screws were inserted as part of an occipitocervical or subaxial cervical stabilisation. The other pathologies included trauma and spinal tumours.

There was no vertebral artery injury and no cerebrospinal fluid leak. Three patients developed post operative occipital neuralgia. This neuralgia was transient in one of the patients having settled at 6-week follow up. In the other 2 patients the neuralgia was unresolved at the time of latest follow up but was adequately controlled with appropriate pain management. Post operatively no patient had radiographic evidence of construct failure and all demostrated excellent sagittal alignment.

Conclusion: It has been reported that the absence of threads on the upper portion of the long shank screw may protect against neural irritation. However insertion of the C1 lateral mass screw necessitates careful caudal retraction of the C2 dorsal root ganglion. The insertion point for the C1 lateral mass screw is at the junction of the C1 posterior arch and the midpoint of the posterior inferior part of the C1 lateral mass. Two patients in our series suffered occipital neuralgia post insertion of the C1 lateral mass screws. This highlights the potential for C2 nerve root irritation during and after the insertion of the C1 lateral mass screw.

Introduction: Carpal tunnel decompression is the most commonly performed procedure in hand surgery. This study was done to assess the effectiveness and acceptability by patients of open carpal tunnel release under local anaesthetic and compare our results with previous published work from our department following alterations to our operative techniques.

Methods: 92 carpal tunnel releases were performed on 80 patients over a four year period, 2001 to 2004. 55 were females and 25 were males. A patient satisfaction survey was done by a postal questionnaire which addressed opinion regarding preference for LA over GA, pain due to LA infiltration, effectiveness of LA, patient comfort during surgery, outcome of surgery and overall satisfaction with the procedure. In this cohort of patients we did not use a tourniquet which caused severe pain in 29% of cases in the previous study. We also administered LA with adrenaline using a dental syringe to reduce pain which was previously reported as severe in 20% of cases.

Results: 62 patients replied to the questionnaire, a response rate of 77.5%. Preference for LA over GA was 90% as compared to 70% in the previous study. Pain due to tourniquet use was previously reported as severe in 29% of cases but this did not apply in this subset of patients. Pain due to infiltration of LA with a dental syringe was severe in 9% of cases compared to 20% with a 25G needle. Effectiveness of LA, outcome of surgery and overall satisfaction with the procedure remained unchanged.

Conclusion: Carpal tunnel decompression is a quick, convenient, inexpensive and safe method of treatment. We have demonstrated that injecting LA with adrenaline using a dental syringe obviates the need for tourniquet and improves patients’ acceptability and tolerance of this procedure.

Background: Aseptic loosening remains the most common cause of failure of total hip arthroplasty. Its pathogenesis is based upon the generation of wear debris particles which trigger synovial macrophage activation.

Statins, inhibitors of 3-hydroxy-3 methylglutaryl coenzyme A (HMG-Co-A) reductase, have revolutionised the treatment of hypercholesterolaemia. More recently statins have been shown to have potent anti inflammatory effects. We investigated the effects of cerivastatin in attenuating the activation of human macrophages by polymethylmethacrylate (PMMA) particles.

Methods: Polymethylmethacrylate-particle-stimulated human macrophages were cultured in vitro with cerivastatin at 75 and 150... mols/litre. TNF-α (tumour necrosis factor alpha) and MCP-1 (monocyte chemotactic protein) expression were determined using ELISA. An ERK1/2 inhibitor, UO126 was utilised to identify the mitogen activated protein kinase (MAP-Kinase) pathway involved and western blotting was used to demonstrate the effect of Cerivastatin on this pathway.

Results PMMA-stimulated TNF-α and MCP-1 expression was consistently attenuated by cerivastatin therapy.

PMMA activation was attenuated by the ERK1/2 inhibitor, UO126.

Western blotting confirmed ERK downregulation by cerivastatin, establishing a mechanism for its anti-inflammatory effects.

Conclusion: We have demonstrated the beneficial effects of statins in suppressing particle mediated activation of macrophages and the potential to prevent or treat periprosthetic osteolysis.

Background: Periprosthetic osteolysis precipitates aseptic component loosening, increases periprosthetic fracture risk and through massive bone loss, complicates revision surgery.

Its pathogenesis is based upon the generation of wear debris particles which trigger synovial macrophage activation. Statins, inhibitors of 3-hydroxy-3 methylglutaryl coenzyme A (HMG-Co-A) reductase, have revolutionised the treatment of hypercholesterolaemia and cardiovascular disease. The antiinflammatory properties of HMG-CoA reductase inhihitors or the statin family are well recognised. We investigated the effects of ceriv-astatin in attenuating the activation of human macrophages by polymethylmethacrylate (PMMA) particles.

Methods: Polymethylmethacrylate-particle-stimulated human macrophages were cultured in vitro with cerivastatin at 75 and 150micromols/litre. TNF- alpha (tumour necrosis factor alpha) and MCP-1 (monocyte chemotactic protein) expression were determined using ELISA. UO126, a Raf/MEK/ERK intracellular transduction pathway inhibitor, was utilised to identify the mitogen activated protein kinase (MAP- Kinase) pathway involved and western blotting was used to demonstrate the effect of cerivastatin on this pathway.

Results Human monocyte/macrophage cultures were activated by PMMA particles evidenced by TNF- alpha and MCP-1 expression(p< 0.05). This activation was consistently attenuated by cerivastatin therapy. Similarily, PMMA activation was attenuated by the Raf/MEK/ERK inhibitor, UO126.

Western blotting confirmed Raf/MEK/ERK down-regulation by cerivastatin, establishing a mechanism for its anti-inflammatory effects.

Conclusion We have demonstrated in vitro, that statins can abrogate particle induced inflammatory responses in a dose dependent manner and this is mediated intra-cellularily through its effect on the Raf/MEK/ERK transduction pathway. We propose that by attenuating this inflammatory response, the associated subsequent osteoclast activation and osteolysis is attenuated. Statins therefore may have role in promoting implant longevity

Aims: Pharmacological modulation of skeletal muscle reperfusion injury after trauma associated ischaemia may improve limb salvage rates and prevent the associated systemic sequelae. Resuscitation with hypertonic saline restores the circulating volume and has favourable effects on tissue perfusion and blood pressure. The purpose of our study was to evaluate the effects of hypertonic saline on skeletal muscle ischaemia reperfusion (I/R) injury and the associated endorgan injury.

Methods: Adult male Sprague Dawley rats (n=24) were randomised into three groups: control group, I/R group treated with normal saline and I/R group treated with hypertonic saline. Bilateral hind-limb ischaemia was induced by rubber band application proximal to the level of the greater trochanters for 2.5 hours. Treatment groups received either normal saline or hypertonic saline prior to tourniquet release. Following twelve hours reperfusion, the tibialis anterior muscle was dissected and muscle function assessed electrophysiologically by electrical field stimulation. The animals were then sacrificed and skeletal muscle harvested for evaluation. Lung tissue was also harvested for measurement of wet-to-dry ratio, myeloperoxidase content and histological analysis.

Results: Hypertonic saline significantly attenuated skeletal muscle reperfusion injury as shown by reduced twitch and tetanic contractions of the skeletal muscle (Table). There was also a significant reduction in lung injury as demonstrated by differences in wet-to-dry ratio, myeloperoxidase content and histological analysis.

Conclusion: Resuscitation with hypertonic saline may have a protective role in attenuating skeletal muscle ischaemia reperfusion injury and its associated systemic sequelae.

Aim: To study the effect of traction on the compartment pressures during intramedullary nailing of closed tibial shaft fractures. Methods:Thirty consecutive patients with Tscherne C1 fractures were randomised into two groups. Sixteen patients underwent intramedullary nailing of the tibia with traction and fourteen patients without traction. Compartment pressures were measured before the application of traction or commencement of the procedure and at the end of the procedure with a Stryker¨intracompartmental pressure monitor system. Results:The data collected was analysed using paired student t-test. There was no statistically signiþcant difference (p> 0.05) in the preoperative mean compartment pressures for both groups. The mean postoperative measurements were higher in all the four compartments in the traction group (p< 0.05). None of the pressures reached the critical level Conclusions:These results show that traction increases compartment pressures signiþcantly. The group considered did not have compartment syndrome possibly due to lower pressures. With greater pre operative compartment pressures, it can reach a critical level on traction necessitating decompression. We advocate the procedure be done without traction.

Aims: Circulating endothelial precursor cells (CEPs) are thought to play a role in angiogenesis. We investigated the angiogenic stress of musculoskeletal trauma on CEP kinetics in trauma patients and their bone marrow progenitor populations in a murine model. Methods: Peripheral blood mononuclear cells (PB-MNCs) were isolated from patients (n=12) on consecutive days following closed lower-limb diaphyseal fractures. CEP levels, deþned by the surface expression patterns of VEGFR2, CD34 and AC133 were determined and cytokine analysis of collected serum was performed. Bonemarrow precursors deþned byLy-6A/E and c-Kit expression were harvested following the traumatic insult from the murine model and quantiþed on ßow cytometry. Human and murine progenitor populations were cultured on þbronectin and examined for markers of endothelial cell lineage (Ulexeuropaeus- agglutinin-1 binding and acetylated-LDL uptake) and cell morphology. Statistical analysis was performed using variance analysis. Results: A consistent increase in human CEPs levels was noted within 72 hours of the initial insult, the percentage increase over day 1 reaching 300% (p=0.008) and returning to normal levels by day 10. Murine bone marrow precursors were mobilisd within 24 hrs peaking at 48hrs (900% p=0.035). On culture, morphologically characteristic endotheliallike cells binding UEA-1 and incorporating LDL were identiþed. Serum VEGF levels increased signiþcantly within 24 hrs of the insult, (p=0.018) preceeding the peak in CEP mobilisation. Conclusion: We propose that musculoskeletal trauma through the release of chemokines such as VEGF, promotes rapid mobilisation of CEPs from born marrow, which have the potential to contribute to reparative neovascularisation. Strategies to enhance CEPs kinetics may accelerate this process and offer a therapeutic role in aberrant fracture healing.

Background: Circulating endothelial precursor cells (CEPS) are thought to play a role in postnatal angiogenesis. We investigated the angiogenic stress of musculoskeletal trauma on CEP kinetics in trauma patients and their bone marrow progenitor populations in a murine model.

Methods: Peripheral blood mononuclear cells (PB-MNCs) were isolated from patients (n=12) on consecutive days following closed lower-limb diaphyseal fractures. CEP levels, defined by the surface expression patterns of VEGFR2, CD34 and AC133 were determined and cytokine analysis of collected serum was performed. Bone marrow precursors defined by Ly-6A/E and c-Kit expression were harvested following traumatic insult from the murine model and quantified on flow cytometry. Human and murine progenitor populations were cultured on fibronectin and examined for markers of endothelial cell linage (Ulexeuropaeus- agglutinin- 1 binding and acetylated-LDL uptake) and cell morphology. Statistical analysis was performed using variance analysis.

Results: A consistent increase in human CEPs levels was noted within 72 hours of the initial insult, the percentage increase over day 1 reaching 300%.

Conclusion: We propose that musculoskeletal trauma through the release of chemokines such as VEGF, promotes rapid mobilisation of CEP from born marrow, which have the potential to contribute to reparative neovascularisation. Strategies to enhance CEPs kinetics may accelerate this process and offer a therapeutic role in aberrant fracture healing.

The aim of this study was to evaluate the effect of traction on the compartment pressures during intramedullary nailing of closed tibial shaft fractures.

The study design was a randomised prospective trial. The period of the study was Sept ’99 to Dec 2000. 30 consecutive patients with Tscherne C1 fractures were randomised into two groups.16 patients underwent intramedullary nailing of the tibia with traction and 14 patients without traction. Compartment pressures were measured before the application of traction or commencement of the procedure and at the end of the procedure. The method described by Gulli and Templeman was used to measure all the four compartments of the injured limb. The pressures were measured with a Stryker® pressure monitor. The absolute and differential compartment pressures were recorded. All patients were followed up for the duration of at least 8 months and until fracture union.

The data collected was analysed using paired student t-test. There was no statistically significant difference (p> 0.05) in the preoperative mean compartment pressures for both groups when all the four compartments were measured individually. The mean postoperative measurements were higher (range 9–10 mmHg) in all four compartments in the traction group. This was statistically significant (p< 0.05). None of the pressures reached the critical level as they were more than 30 mmHg below the diastolic pressure (differential pressure).

These results show that traction increases compartment pressures during intramedullary nailing of tibial shaft fractures. The group considered did not have compartment syndrome possibly due to less soft tissue injury. With greater soft tissue injury and greater preoperative compartment pressures, compartment pressures can reach a critical level necessitating decompression.

We conclude that intramedullary nailing without traction reduces the chances of significant increase in compartment pressures and advocate the procedure be done without traction.

Aim: A prospective randomised clinical trial was performed to evaluate two forms of immobilisation in the treatment of colles fractures not requiring manipulation.

Methods: Patients were randomised to either plaster cast (PC) or a removable splint: wrist splint (FWS) according to date of presentation. Patients who had associated injuries to the same upper limb, previous wrist fracture, and open fractures, below 20 years or impaired cognitive function were excluded. The hospital ethical committee approved the study and informed consent was obtained from patients. Patients were reviewed at one week, two weeks, six weeks and twelve weeks following enrolment into the trial. Radiographs were performed on the first four visits. Subjective data was obtained using a patient questionnaire. Levels of pain, comfort in cast, swelling and any modifications to the cast were documented. Was used at six and twelve weeks to assess Clinical assessment was performed by a qualified physiotherapist using the demerit score of Sarmiento which combines range of motion, grip strength and functional assessment.

Results: There were thirty-seven patients in the PC group and thirty-four in the FWS group. They were well matched in terms of age and sex distribution One patient in the PC group required manipulation under anaesthesia due to loss of position at one week. There was no statistical difference between either treatment method in radiological position. Nine patients in the PC group required change of cast due to loosening or discomfort. A further eight patients in the PC group required cast trimming. Visual analogue scores for pain and cast discomfort were lower in the FS group (p< 0.05). Grip strength compared to the opposite side was higher in the FS group (55.9% Vs 47.8% at week six, 71.8% Vs 65% at week twelve). Functional assessment demonstrated a higher score in the FS group at six weeks. However the difference did not reach statistical significance at repeat examination at twelve weeks.

Conclusion: In this study there was no difference in either method in maintaining fracture position. However there was greater patient satisfaction and earlier rehabilitation in those patients treated in a futura wrist splint. Patients treated in plaster cast required a greater use of plaster room resources. We feel that the use of a removable wrist splint in suitable patients with either undisplaced or minimally displaced distal radial fractures is validated by this study.

Introduction: Cement removal in revision total hip arthroplast;y can be technically challenging. Traditional methods can be associated with femoral fracture or uncontrolled cortical perforation and bone loss. A new technique has been developed tha.t permits segmental extraction of bone cement from the femoral canal. Fresh cement is introduced into the old cement mantle and a threaded rod is placed into the wet cement and held in place while the cement hardens. The thread-forming rod is then removed leaving a threaded channel in the cement. Extraction rods are then screwed 1.5 to 2.5 cm into the threaded channel. A slap hammer, which attaches to the opposite end of the extraction rod, is used to remove 1.5- to 2.5-cm segments of cement. The old cement – cancellous bone interface fails before the new-old cement interface and the old/new cement is removed in segments. This allows minimal removal of cancellous bone.

Patients and Methods: Patients who had contra-indications to segmental cement removal such a discontinuous cement mantle were excluded. Twenty-five consecutive cases of revision arthroplasty were entered into the study. The indications were for aseptic loosening in twenty-three cases and deep infection in two cases.

Results: In twenty-two cases the cement was removed completely. In five cases the cement was removed en-bloc in one single extraction rather then in segments. In two cases there was failure of the new cement to bond to the original cement and alternative methods were used. In a further case the cement was removed using a combination of segmental and conventional techniques. There were no cases of cortical perforations or perforaltions in this series. We have found it to be a reliable and safe method of cement removal. The cost of the system is offset by reduced operative time and blood loss.

The effects of infection following implantation of an orthopaedic prosthesis are devastating. The prevention of perioperative contamination is therfore of the utmost importance in arthroplasty. We undertook a prospective study to assess bacterial contamination in elective arthroplasty surgery. Splash bowls containing sterile saline are used to store and clean instruments used during the course of a procedure. The incidence of bacterial proliferation in splash bowls was examined as a marker of intra-operative contamination. A 100mL aliquot of fluid was removed from the splash basin at the end of the procedure and passed through a grid membrane using a vacuum pump. The membrane filter was then plated on chocolate agar and colony counts recorded at 24 and 48 hours. Organisms were identified by standard techniques. Demographic data, and perioperative data including the duration and type of procedure, the number of scrubbed and other personnel in theatre and the type of skin preparation and gowns used were also noted. A total of 43 cases were examined. 14 samples yielded positive cultures. Staphylcoccus was the most commonly cultured organism (9 cases). Four patients grew Pseudomonas species. Five patients grew other Gram-negative organisms including Neisseria and bacillus subspecies. Five patients grew multiple organisms. Mean duration of follow up was 8.4 months (range 6 – 18 months). None of the patients with contaminated samples developed any clinical signs of infection in the perioperative period; nor was there clinical or radiological evidence of infection or loosening on subsequent follow up. Despite the use of a laminar airflow system in all cases, in excess of 30% of cases were contaminated. This study underlines the importance of adhering to rigorous protocol in theatre including minimising theatre traffic and the use of antibiotic prophylaxis.