Background

Ultrasound and MRI are recommended tools in evaluating postoperative pain in metal-on-metal hip (MoM) arthroplasty.

We hypothesised that an independent Notch Trial is essential on the same lines as other Component Trials-Femoral, Tibial and Patellar - in posterior stabilised total knee arthroplasty. Therefore we evolved Notch Trial to visually ascertain the adequacy of intercondylar resection and eliminate the possibility of femoral intercondylar fractures. We undertook a retrospective study to evaluate Notch Trial by the frequency of the need to remove osteophytes or file uneven surfaces in intercondylar resection by using the detachable box part of the trial femoral component, assess occurrence of distal femoral intercondylar fractures and demonstrate Notch Trial in posterior stabilised total knee replacement.

We studied 206 patients, 113 females and 93 males, who underwent consecutive primary posterior stabilised total knee replacements applying Notch Trial between 2000 and 2008 in a District General Hospital under our team. Outcome Measurements were 1) frequency of the need to remove osteophytes or file uneven surfaces in intercondylar resection and 2) occurrence of distal femoral intercondylar fractures intraoperatively or on postoperative radiographs. We had to remove the osteophytes and file the cut surfaces in 183 (88.88%) of patients after Notch Trial. We had no distal femoral intercondylar fractures intraoperatively or on postoperative radiographs.

Notch Trial allows the surgeon to directly visualise and ascertain the adequacy and precise fit of femoral notch cut with cam part of femoral component to ensure a press fit femoral component in condylar posterior cruciate substituting total knee replacement. Notch Trial prior to Femoral Component Trial effectively pre-empts intraoperative distal femoral intercondylar fractures. We recommend that Notch Trial should become part of the protocol for cruciate substituting total knee replacement and implants of all companies should have the option of a detachable box component for Notch Trial.

Aim

Thromboprophylaxis in total hip replacement (THR) and total knee replacement (TKR) remains controversial, conspicuous by absence of consensus. Because of protracted and variable mobilisation, there is an extended risk of Venous Thromboembolism (VTE). We hypothesised that a combination of low molecular weight heparin and miniwarfarin would minimise the initial and extended risk. Therefore we evolved a protocol of enoxaparin sodium 40 mgs for 5 days starting preoperatively and miniwarfarin 1-2mg for 6 weeks following surgery. We undertook a retrospective study of total hip and knee replacements in a District General Hospital between January 2000 and December 2005 to determine the effectiveness of the protocol.

Management of open tibial fractures remains controversial. We hypothesised that unreamed intramedullary nail offers inherent advantages of nail as well as external fixation. We undertook a prospective randomised study to compare the results of management of open tibial fractures with either an external fixator or an undreamed intramedullary nail until fracture union or failure.

Our study included 30 consecutive open tibial fractures (Gustilo I, II & IIIA) between 4 cm distal to knee and 4 cm proximal to ankle in skeletally mature adults, who presented to a level-1 trauma centre. Alternate patients were treated by either external fixation and unreamed nailing i.e. 15 in each group. Standard protocol for debridement and fixation was followed in all cases. All external fixators were removed at 6 weeks. All cases were followed up until fracture union, the main outcome measurement. 26 (87%) were males and 4 (13%) females; age range was 20-60 years (average 33.8).

All fractures in both groups united. Time to union averaged 7.9 months for both groups. Incidence of wound problems, infection, hardware failure and delayed union were comparable. However, there was higher incidence of angular deformities and stiffness of knee and ankle in external fixation group, although not statistically significant.

We found no statistically significant difference between unreamed intramedullary nailing and external fixation for the management of open tibial diaphyseal fractures, although ease of weight bearing as well as absence of angular deformities and joint stiffness were distinct advantages in the nail group. Therefore we recommend unreamed nail for Gustilo I, II and IIIA open tibial fractures.

As management of open tibial fractures remains controversial, we hypothesised that unreamed intramedullary nail offers inherent advantages of a nail as well as external fixation, while limiting the morbidity of external fixation.

We undertook a prospective randomised study to compare management of open tibial fractures with external fixator or intramedullary nail until fracture union or failure. Our study included 30 consecutive open tibial fractures (Gustilo I, II & IIIA) between 4 cm distal to knee and 4 cm proximal to ankle in skeletally mature adults, who presented to a level-1 trauma centre. Alternate patients were treated by external fixation or unreamed nail i.e. 15 in each group. Standard protocol for debridement and fixation was followed. External fixators were removed at 6 weeks. All cases were followed until fracture union, the main outcome measurement.

26 (87%) males and 4 (13%) females; age 20–60 years (Mean 33.8). All fractures in both groups united. Time to union averaged 7.9 months for both groups. Incidence of wound problems, infection, hardware failure and delayed union were comparable. However, there was higher incidence of angular deformities and stiffness of knee and ankle in external fixation group, although not statistically significant.

We found no statistically significant difference between unreamed intramedullary nailing and external fixation for the management of open tibial diaphyseal fractures. Ease of weight bearing as well as absence of angular deformities and joint stiffness were distinct advantages in the nailing group. Therefore we recommend unreamed nail for Gustilo I, II & IIIA open tibial fractures.