Background: Protein energy malnutrition (PEM) is an accepted predictor of poor outcome in hip fracture patients. There is no universally accepted definition of PEM. Admission screening for PEM is not routinely performed for hip fracture patients. The reported incidence in elderly hip fracture patients varies widely between 9.0% and 88.6%.

Aims: To determine the prognostic relevance of admission serum albumin and total lymphocyte count (TLC), as clinical markers of PEM and predictors of outcome for hip fracture patients.

Methods: Retrospective review of 415 patients with operatively managed hip fracture. Protein-energy malnutrition was defined as albumin < 3.5g/dl and TLC < 1,500 cells/ mm3. Delay to operation, duration of in-patient stay, readmission (< 3 months) and in-patient, 3- and 12-month mortality were assessed as outcome variables.

Results: Survival data was available for 377 patients at 12 months. Of 377 patients, 53% (n=200) had both a serum albumin and TLC levels taken at admission (study), while 47% (n=177) had not (control). Incidence of PEM was 51%. Older patients were more likely to have lower albumin (p=0.03) and TLC (p=0.012). Nursing home patients were also more likely to have lower albumin (p=0.049). In-hospital mortality for PEM patients was 9.8%, compared with 0% for patients with normal values of both laboratory parameters. Patients with PEM had a higher 12-month mortality compared to patients who had normal values of both laboratory parameters (Odds Ratio=4.52; p=0.049).

Conclusion: Serum albumin and TLC in combination are accurate predictors of 12-month mortality in hip fracture patients. These results underscore the clinical relevance of assessing the nutritional status of patients with hip fractures at the time of admission and emphasises the relationship between nutrition and outcome in these patients.

Metal-metal hip resurfacing offers the advantage of conservation of femoral bone stock. In addition, the implant may offer enhanced resistance to dislocation in comparison with conventional total hip arthroplasty.

We present a series of 32 female patients with one to 4 year follow up (mean age 57 ranges 50–70 at time of surgery)

All patients required hip arthroplasty. Careful preoperative selection was carried out with particular attention paid to estimation of bone density. A standard resurfacing operation was carried out. Patients had pre and postoperative WOMAC and SF36 scoring. All patients were followed closely in the post operative period. No significant complications were noted at follow up.

In our study we have shown that given careful patient selection Birmingham hip resurfacing can be safe and reliable form of arthroplasty.

Introduction: Avascular necrosis of the femoral head after resurfacing hip replacement is an important complication which may lead to fracture or failure. We compared the changes in femoral head oxygenation resulting from the posterior approach to those resulting from the anterolateral approach and the trochanteric flip approach.

Methods: In 37 patients undergoing hip resurfacing surgery, a calibrated gas-sensitive electrode was inserted superolaterally in the femoral head via the femoral neck following division of the fascia lata. Inter-operative X-ray confirmed correct electrode placement. Baseline oxygen concentration levels were recorded immediately after electrode insertion. All results were expressed relative to this baseline, which was considered as 100% relative oxygen concentration. Oxygen levels were monitored continuously throughout the operation. 10 patients underwent surgery through the posterior approach, 12 patients through the anterolateral approach and 15 through the trochanteric flip approach.

Results: A similar pattern of intra-operative reduction in femoral oxygen concentration was observed for all reviewed approaches. The average change in oxygen concentration during surgery through the trochanteric flip approach was found to be significantly less than through posterior (p< 0.02) and anterolateral (p< 0.02) approaches. Oxygen concentration following joint relocation and soft tissue reconstruction recovered significantly in the anterolateral and trochanteric flip group only. The posterior approach resulted in significantly lower oxygen concentration at the end of the procedure (22%, SD 31) than the anterolateral approach (123%, SD 99; p< 0.05) and the trochanteric flip approach (89%, SD 62, p< 0.02).

Discussion and Conclusion: The anterolateral and trochanteric flip approaches disrupt the femoral head blood supply significantly less than the posterior approach in patients undergoing resurfacing. The most consistent intra-operative oxygen levels were observed during surgery through the trochanteric flip approach. Oxygen concentration during the anterolateral approach was found to be highly dependent upon leg position. The incidence of complications related to avascular necrosis might be decreased by adopting blood supply conserving surgical approaches.

Introduction: Avascular necrosis of the femoral head after resurfacing hip replacement is an important complication which may lead to fracture or failure. We compared the changes in femoral head oxygenation resulting from the anterolateral approach to those resulting from the posterior approach.

Methods: In 22 patients undergoing hip resurfacing surgery, a calibrated gas-sensitive electrode was inserted supero-laterally in the femoral head via the femoral neck following division of the fascia lata. Inter-operative X-ray confirmed correct electrode placement. Baseline oxygen concentration levels were recorded immediately after electrode insertion. All results were expressed relative to this baseline, which was considered as 100% relative oxygen concentration. Oxygen levels were monitored continuously throughout the operation. 10 patients underwent surgery through the posterior approach, 12 patients through the antero-lateral approach.

Results: During the operation patterns were similar for both groups, except following joint relocation and soft tissue reconstruction; oxygen concentration recovered significantly in the anterolateral group only. The posterior approach resulted in significantly lower (p< 0.01) oxygen concentration at the end of the procedure (22%, SD 31) than the antero-lateral approach (123%, SD 99).

Discussion and Conclusion: The anterolateral approach disrupts the femoral head blood supply significantly less than the posterior approach in patients undergoing resurfacing. The incidence of complications related to avascular necrosis might be decreased by adopting blood supply conserving surgical approaches.

In 12 patients, we measured the oxygen concentration in the femoral head-neck junction during hip resurfacing through the anterolateral approach. This was compared with previous measurements made for the posterior approach. For the anterolateral approach, the oxygen concentration was found to be highly dependent upon the position of the leg, which was adjusted during surgery to provide exposure to the acetabulum and femoral head. Gross external rotation of the hip gave a significant decrease in oxygenation of the femoral head. Straightening the limb led to recovery in oxygen concentration, indicating that the blood supply was maintained. The oxygen concentration at the end of the procedure was not significantly different from that at the start.

The anterolateral approach appears to produce less disruption to the blood flow in the femoral head-neck junction than the posterior approach for patients undergoing hip resurfacing. This may be reflected subsequently in a lower incidence of fracture of the femoral neck and avascular necrosis.

Background: The aim of operative treatment for ankle fractures is to allow early movement after internal fixation. The hypothesis of this study was that early mobilisation facilitated by a removable cast after internal fixation of ankle fractures would improve functional recovery of patients compared with that after conventional immobilisation in a cast.

Material and Methods: Sixty two patients between the age of seventeen and sixty five with ankle fractures that required operative treatment were randomly allocated to two groups : immobilisation in a non weight bearing below knee cast for six weeks or early movement in a removable cast ( at two weeks after removal of sutures ) for the following four weeks. The follow up examinations which consisted of subjective (clinical, Olerud-Molander score, AOFAS score, SF 36 ) and objective ( swelling measurement, x-ray ) evaluations were performed at two, six, nine, twelve and twenty four weeks postoperatively. Time of return to work was recorded.

Results: There were no postoperative complications in the group treated with immobilisation in cast. There was one superficial wound infection treated with oral antibiotics in a patient with a previous dermatological condition around the fractured ankle in the group treated with early movement in a removable cast. Patients in group two ( early movement ) had higher functional scores at nine and twelve weeks follow up but not of statistical significance. They also return to work earlier ( 55.5 days ) compared with the ones treated in cast ( 98.7 days ). Patients treated in removable cast had higher mean SF-36 scores, but this difference was significant only for two of the eight aspects investigated.

Conclusions: Early movement with the use of removable cast after removal of sutures in operated ankle fractures decrease swelling, prevent calf muscle wasting, improve functional outcome and facilitate early return to work of patients. Our findings support the use of a removable cast and early exercises in selected, compliant patients after surgery of the ankle.

A review of the first two hundred and ten patients undergoing Birmingham hip re-surfacing between January 2003 and June 2005 was performed. All surgeries were performed by a single consultant orthopaedic surgeon. All resurfacings were carried out utilising the antero-lateral approach to the hip.

Mean review post-operatively was at six weeks. The following clinical parameters were evaluated: length of in-hospital patient stay, intra-operative blood loss and post-operative range of joint movement. In addition, the following radiological measurements were made: the acetabular inclination angle, the head-shaft angle and evidence of leg-length discrepancy.

One patient experienced fracture of the femoral neck and two other patients underwent revision surgery. Our results demonstrate that the anterolateral approach represents an alternative approach, with short-term results comaprible to the posterior approach for hip resurfacing.

As our population ages, the incidence of hip fractures per annum is increasing rapidly. Within this patient group are an increasing number of very elderly (over 90 years old). These patients present many challenges to the clinician, both in terms of medical co-morbidities and orthopaedic complications. While the mortality and morbidity of hip fractures in general are well recognised, this study looked exclusively at the outcome in these very elderly patients following admission.

We reviewed 100 patients admitted between May 2000 and June 2002. The average age of our patient group was 92.5 years, 18% were male and 82% female. 60% were resident in nursing homes prior to admission, 26% lived with their families and 14% lived alone in the community. 56% of the fractures suffered were intertrochanteric, 40% were intra-capsular and 4% sub-trochanteric.

Following admission, these patients waited on average 1.5 days before undergoing surgery, the predominant cause for pre-operative delay being maximisation of pre-operative medical condition. Median pre-operative ASA score was three. The method of anaesthesia used was spinal in 78% and general in 22%. 64% of the group underwent internal fixation and 34% had a hemiarthroplasty. Two patients were deemed unfit to ever undergo surgery. Following surgery, mean in-hospital stay was 9.3 days.

There were 8 in-patient post-operative mortalities. Major post-operative morbidities occurred in 8% and included: 3 myocardial infarctions, 2 acute onset cardiac failure and 1 prosthetic dislocation. 11% of patients required a blood transfusion. 25% of the patients died within forty days of surgery, however, 50% of the patients were still alive 126 days post-op. Overall, the mean survival was 195 days. Post-discharge morbidity included two patients who had failure of internal fixation and 8 patients with severe immobility.

We conclude that hip fracture surgery in the nonagenarian population is as well tolerated as surgery in younger patients. Careful pre-operative assessment and medical maximisation combined with prompt surgical intervention yielded a good outcome and return to pre-injury status for most patients.

It is now well established that operative repair of Tendo Achilles (TA) ruptures reduces re-rupture rate compared with conservative treatment. Operative repair has been reported to be associated with significant morbidity in 11–29% of cases, in particular wound related complications. In 1977 Ma and Griffith described a percutaneous repair of the TA, however initial results showed a disappointingly high re-ruputre rate of approximately 10%. The senior author has modified the technique initially described in attempt to reduce the re-rupture rate.

After marking out the course of the sural nerve, a 2 Ethibond suture is passed into the ruptured tendon end via a stab incision, and passed proximally as in a modified Kessler suture. The suture is then passed first proximally and then back distally in a criss-cross pattern via further stab incisions and brought out at the tendon stump. A second suture is passed into the distal stump in a similar fashion and the sutures tied with the foot in equinus.

We recruited a cohort of patients who had undergone percutaneous repair in the last 5 years, and a cohort of age and sex matched controls who had undergone open repair. Both groups of patients were managed postoperatively in equinus cast for 8 weeks. Subjective outcome was measured using the Foot and Ankle Outcome Score (FAOS). Statistical analysis was performed using the Mann-Whitney U-test for non-parametric data.

Fifteen patients, mean age of 41.3, underwent percutaneous repair. There were 9 men and 6 women. The median time from injury to repair was 2 days in the percutaneous group and 1 day in the open group. Post-operatively there was no statistically significant difference between the two groups in relation to time taken to return to work (12 (percutaneous) versus 10 (open) weeks). However the percutaneous group returned to sport sooner 6 (percutaneous) versus 12 (open) months; p=0.6). There were no re-ruptures in either group. There were two sural nerve injuries in the percutaneous group and none in the open group. There was no significant difference in mean FAOS between the two groups (466 percutaneous versus 468 open).

Percutaneous repair of TA ruptures results in a similar functional outcome as the traditional open repair. The increased incidence of sural nerve injury may be associated with the learning curve of the procedure as both of these cases were early in the series. We propose that percutaneous repair is safe and effective. The avoidance of a large skin incision may reduce wound related complications.

Aims: To investigate the prevalence and significance of a high-intensity zone in a group of patients asymptomatic for low back pain.

Methods: A prospective observational study of the prevalence of abnormal MR imaging in normal volunteers without a significant history of back pain. All volunteers underwent physical examination, psychometric testing, plain radiograph, magnetic resonance imaging, and dexa scanning. Films were blindly assessed for the prevalence of degenerative disc disease, osteoporosis, high intensity zone, disc prolapse and spinal stenosis.

Results: Following history, clinical examination and psychometric testing 13 of 63 (20%) patients were excluded from the study on the basis of previous back injury, leg pain or abnormal clinical findings. 50 volunteers were eligible for inclusion in the study. The presence of a high-intensity zone or annular disruption was determined by standardised criteria on T2-wieghted magnetic resonance images. The prevalence of a high-intensity zone in the patient population was 12 of 50 patients (24%). 32% of all disc prolapses were at the L4/5 level, 33% were at L5/S1 and 17% were at L3/4 the remainder were at various other levels.

Conclusions: The presence of a high-intensity zone does not reliably indicate the presence of symptomatic internal disc disruption. Magnetic resonance imaging is accurate in determining nuclear anatomy, however positive findings do not always correlate with history and clinical findings. The presence of abnormal imaging in asymptomatic patients reinforces the need for a detailed history and clinical examination in the evaluation of the lumbar spine.

Introduction: Five occipitocervical implant systems were compared biomechanically in vitro using nondestructive testing.

Methods: A composite material model of the occiput and upper cervical spine was developed and validated. The specimens were tested using an in-vitro purpose build test rig. Instrumentation was from the occiput to C5 and included five constructs in current clinical use. Biomechanical testing parameters included axial rotation, flexion/extension and lateral bending. Nondestructive pure moments were applied to C5 using a system of cables and pulleys loaded by a materials testing machine (Hounsfield Ltd. UK) Angular displacement of the specimen under load was measured using the Zebris System (Zebris Medizintechnik, GMBH, Germany) which collects and stores three-dimensional space co-ordinates by means of attached ultrasonic markers. Mean maximum angular displacement was calculated from a series of five test cycles for each construct. Statistical significance was determined using a one-way analysis of variance (ANOVA) combined with a LDS test at 95% confidence.

Results: Statistically significant differences were shown in the initial stiffness of current implant constructs used for stabilization of the occipitocervical junction. The Zebris system was also validated as an accurate and efficient 3-D motion analysis for cervical spine biomechanical research.

Introduction: Occipito-cervical fusion has evolved from the used of simple onlay bone grafts to the use of sophisticated modular implants. Initial stiffness prevents micromotion and allows a higher fusion rate.

Methods: A composite occipito-cervical model (OCM) was developed and validated using data obtained from cadaveric specimens. A jig was designed to pot the OCM, which allowed the application of independent moment forces to simulate flexion, extension, lateral flexion and rotation. The following implants were used 1 ) Grob plate with C1/C2 transarticular screw fixation.2) Grob Plate without C1/C2 transarticular screw fixation.3) Cervifix rod system 4) A Ransford loop system 5.) Olerud plate fixation. A three dimensional ultrasonic motion analysis system (Zebris Inc.) was used to record motion at three positions: 1)C0 2) C2 3) C4.A separate OCM was used for each instrumentation system.

Results: The Grob plate with C1/C2 transarticular fixation was found to confer the greatest initial stiffness. The Ransford loop construct was found to confer the least initial stiffness. Plate fixation offered greater stability then rod or loop constructs. We found the three dimensional motion analysis system to be ideal for displacement analysis in complex spinal instrumentation constructs.