Introduction

The American Joint Replacement Registry (AJRR) is the largest registry of total hip and knee arthroplasty (THA and TKA) procedures performed in the U.S. The National (Nationwide) Inpatient Sample (NIS) is a public database containing demographic estimates based on more than seven million hospitalizations annually. The purpose of this study was to analyze whether AJRR data is representative of the national experience with TJA as represented in NIS

Introduction

Minimally invasive Achilles tendon repair has recently gained popularity amongst foot and ankle surgeons. This study aims to quantify the risk of sural nerve injury when using the Achillon device (Integra), as well as delineate its anatomical relationship to the Achilles tendon.

A clinical evaluation of the effect of MRI scan to bring about a change in surgical management of elderly patients who present with hip fracture with no history of trauma or a suspicious looking lesion on x-rays. Many of these patients present with or without history of previous malignancy or bone disorder.

We evaluated that if the delay in treatment within 36 hours as per national guide lines is justified to benefit patients.

We present the British Military's experience of treating devastating lower limb injuries in personnel returning from Iraq and Afghanistan. We evaluate current surgical practice of attempting to maximise stump length through sequential debridement, rather that early amputation outside the zone of injury. Following an observation that the frequency of sequential amputation had appeared to increase during spring 2009, it was speculated that there may be factors which would predict which patients would require a more aggressive early amputation.

The Joint Theatre Trauma Registry was interrogated for all cases of amputation between Apr 06 and Sep 09. The following data were collected: demographics, mechanism of injury, requirement for massive transfusion, use of combat applied tourniquet, number of stump debridements and echelon of care performed at, all microbiology and final level of amputation. A regression analysis was performed to establish correlation between each data-set and final level of amputation. 95 cases were identified; 21 were either digits or upper limbs and excluded. Clinical notes of the remaining 74 cases were requested, of which 48 were available representing a total of 66 lower limb stumps.

No significant relationships were established between sequential amputation and any of the variables we examined. It was not possible to identify factors with predictive value with respect to which patients would benefit from a more aggressive early amputation approach. These results support current practice by demonstrating that attempts to balance maximal stump length with sufficient debridement to eradicate infected tissue, does not expose patients to unnecessary operative “hits”.

The femur is the largest and strongest bone with a very good blood supply. Large forces are required to result in a fracture. However once a fracture does occur, there can be significant displacement due to the strong musculature surrounding it and loss of blood. As a result of this, the patients are prone to neurovascular and circulatory compromise, which can lead to significant mortality and morbidity. In an open fracture, there is the added potential for infection.

We have conducted a case review of military patients with femoral fractures sustained in hostile zones admitted to RCDM for definitive treatment.

Retrospective analysis of military patients with femoral fractures admitted to RCDM. Factors to be considered include mechanism of injury, type of fracture (Gustillo Anderson and AO classification), pre- and post-transfer operative treatment, complications, microbiology, length of hospital stay, and discharge status. The presentation will include case discussion of interesting patients.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

There is still much debate on the appropriateness of taking post operative radiographs especially in the presence of high quality radiography that image intensifiers now provide. The aim of this study was to determine current UK practice regarding the use of check radiographs and to compare this practice with the implant related complications.

A postal performa was sent to 450 randomly chosen UK Trauma and Orthopaedic Consultants to assess their practice regarding check radiographs following hip fracture surgery. In addition a case note review of all patients undergoing hip fracture surgery over the three years of 2001 to 2003 at Selly Oak Hospital, was performed. Patients undergoing revision surgery in the same admission were identified. The decision to revise was noted to determine whether check radiograph influenced the decision.

Response rate to the performa was 66.7% (300/450). 96% routinely took postoperative radiographs following Hemiarthroplasty. Of these, 87% allowed the patient to mobilise before checking the radiograph. In the DHS group, 61% took check radiographs. Of these, 75% allowed the patient to mobilise prior to reviewing the radiograph. Following Cannulated screw fixation, 58% routinely performed check radiographs and 67% allowed the patient to mobilise before reviewing the radiograph. 1265 hip fracture surgeries were performed in our unit in three years. Only one decision to revise was based on a problem identified on a routine check radiograph.

We highlight the lack of national consensus on the use of post operative radiographs. We recommend the use of post operative radiographs only when clinically indicated, hence sparing the patient from discomfort, unnecessary exposure to radiation as well as allowing more effective utilisation of radiological and human resources.

The clinical diagnosis of an acute compartment syndrome is most reliably based on increasing pain and pain on stretching the affected muscle groups. These signs cannot be elicited in the presence of epidural or regional blocks, or if the patient is unconscious. We present a national audit of consultant trauma and orthopaedic surgeons on the use of compartmental pressure monitoring in such patients. The postal questionnaire also asked whether a departmental protocol was in use and whether regional and epidural blocks were withheld in patients at risk of developing an acute compartment syndrome.

17% of consultants had such an agreed protocol, 53% did not have access to a continuous pressure monitoring device, 58% would request for an epidural/regional block to be withheld with only 2% routinely measuring compartment pressures in the presence of such a block.

This study highlights a major deficiency in the clinical approach to a relatively common condition that may result in limb and life threatening complications and supports the recommendation for compartmental monitoring equipment to be made available.

Easier access, organised holidays targeting differing age groups, an ageing population and lower fares have resulted in a varied air-travelling population of all ages. Medical issues surrounding air travel such as thromboembolic events and the so called ‘economy class syndrome’, as well as dramatic medical intervention at 36,000ft do make for equally dramatic headlines in the popular press. As passengers are more aware of the medical vulnerability of air travel, airlines too are conscious of the medical support they can offer to their passengers. The British Medical Association (BMA) has recently raised concerns over training of flight staff and equipment carried during flights. Issues under debate include whether it is correct for airlines to rely on ‘Samaritan’ doctors or nurses that happen to be on board, or whether qualified medical staff should be part of the aircrew.

Our study reports the analysis of medical emergencies occurring on a major international airline over a period of six months. We looked at the nature of the medical complaint, the treatment received and who gave this treatment. This airline ensures cabin crew receive 30 hours of training in first aid and basic life support during their introductory training period that is followed by annual updates. Senior aircrew, usually the purser are trained in the use of an automated defibrillator. The aircraft carries a first aid kit that all cabin crew are trained to use. In addition there is a medical kit that can be used by any doctor, nurse or paramedic who may respond to an assistance call. In addition in-flight advice is available from Medlink, an independent company that will give direct advice including medical diversion and arrange support for patients on landing

Exacerbation of pre-existing medical problems accounted for the majority of in-flight emergencies. Pre-flight advice, screening and an increased vigilance by ground staff may recognise passengers who are medically unfit to fly.

Syncope accounts for 91% of new in-flight emergencies and appear related to a prolonged period of sitting. In-flight advice as part of Deep Venous Thrombosis (DVT) prevention is given on many long haul flights. This advice should also emphasise the importance of an exercise regime prior to getting up from the sitting position to reduce the number of syncopal episodes.

With adequate cabin crew training, in flight telephone support from commercial companies and careful selection of drugs, the need for ‘Samaritan’ medical help can be greatly reduced.

The importance of correctly identifying and treating ankle syndesmosis injuries is paramount to achieving a good functional result. Although it is clear that anatomical correction is essential the practical aspects remain disputed. Controversial issues include diagnosing and determining which injuries need treating, the number and size of screws for fixation, the number of cortices engaged, a screw removal strategy and the use of biodegradable screws or other forms of fixation. We report the results of a survey of 440 orthopaedic surgeons to determine current UK practice, this is then compared to best practice as determined by literature review.

When analysis was performed for the group and by sub-speciality (foot and ankle, trauma and general orthopaedics) we found large differences in practice. Furthermore it appeared that some aspects of treatment varied considerably from published evidence, for instance four out of five screws were removed much earlier than clinical studies have recommended.

Aims: Our objectives is to evaluate the functional outcome of tibial nailing in 29 patients operated at the South Birmingham Trauma unit in the period between 1992–1996. Methods: This is a retrospective study; all patients included had a tibial nail inserted for two or more years. Assessment was made by reviewing the notes, interviewing and examining the patients. A pro-forma was for each patient was collected covering various activities and outcomes. Results: The results showed that the majority of patients demonstrated a compromised activity level, both in their leisure activity and occupation. No statistical difference was observed between reamed and unreamed nails in their functional outcome measurements. Conclusions: Our conclusion that the functional outcome of tibial nailing is not as good as the anatomical restoration would predicts.

We report 33 cases of femoral supracondylar fracture in elderly or debilitated patients treated by Zickel supracondylar nails. Most of the patients were female and their mean age was 79 years. All had concurrent medical problems and only nine could walk unaided. The operating time averaged one hour and mean blood loss was 100 ml. Postoperative management was by mobilisation in a cast brace or plaster. Six patients died before fracture union; all the others achieved union at an average of 12 weeks. The results were excellent in terms of pain relief, movement and function; there were no infections or nonunions. The locking screws backed out or broke in 26% but this did not prejudice the outcome. Use of the Zickel system is recommended for this group of frail patients.

The results of treatment in 242 patients with intracapsular fractures of the neck of femur treated with Garden screws are presented with reference as to whether the screws were crossed or parallel. The incidence both of nonunion and of avascular necrosis was less in those fractures treated with parallel screws. The outcome was also superior if the reduction was good.

Seven hips with protrusio acetabuli which showed complete or partial resolution of the protrusion after replacement with Ring's prosthesis are reported. It is suggested that this prosthesis offers a simple and effective method of treating painful protrusion into the pelvis; it allows healing of the medial wall of the acetabulum while avoiding many of the hazards of other methods of treatment.

One hundred patients who had sustained a fracture of the tibial shaft and had been treated by internal fixation were reviewed to obtain information on residual ankle and subtalar disability. This study reinforces the belief that early mobilisation of patients with tibial shaft fractures does help to preserve subtalar movement.