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.

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 post-operatively. Time of return to work was recorded.

There were two post-operative complications in the group treated with immobilisation in cast; two patients had deep vein thrombosis (DVT). There was one superficial wound infection treated with oral antibiotics and two deep wound infections requiring removal of metal 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. They also returned to work earlier (63.7 days) compared with the ones treated in cast (94.9 days). There was no statistical difference in Quality of Life (SF-36 Questionnaire) at six months between the two groups.

Early movement with the use of removable cast after removal of sutures in operated ankle fractures decreases swelling, prevents calf muscle wasting, improves functional outcome and facilitates 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.

Introduction

Nonagenarian patients with hip fractures present many challenges to the clinician, both in terms of their advanced age and medical co-morbidities with potential orthopaedic complications. Our aims were to assess outcome of hip fractures in a nonagenarian population with respect to pre-operative predictors of outcome, immediate and long-term morbidity, and survival rates.

Hip fractures are a significant cause of mortality and morbidity in the elderly. Malnutrition is a major element of this but no consensus exists as to the detection or management of this condition. Reported incidence in elderly hip fracture patients varies widely between 9.0% and 88.6%.

The aim of this study was to evaluate the nutritional status of 415 patients with operatively managed hip fractures and determine the prognostic relevance of admission serum albumin and total lymphocyte count (TLC) assays. Protein-energy malnutrition (PEM) was defined as serum albumin < 3.5g/dl and a TLC < 1,500 cells/mm3. Delay to operation, duration of in-patient stay, re-admission (< 3 months) and in-patient, 3- and 12-month mortality were assessed as outcome variables.

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, while 47% (n=177) had not. The incidence of PEM was 51%. Inhospital mortality for PEM patients was 9.8%, compared with 0% for patients with normal values of both laboratory parameters. Older patients were more likely to have lower albumin (p=0.017) and TLC (p=0.023). Nursing home patients were also more likely to have lower albumin (p=0.033). Multivariate analysis revealed a significant difference in 12-month mortality, with patients who had both a low albumin and a low TLC 4.6 times (95% CI: 1.0–21.3) more likely to die within 12 months postoperatively than patients who had normal values of both laboratory parameters. This was significant after adjusting for age, gender and domicile (p=0.049).

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

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.

Introduction: Complex foot and ankle surgery requires accurate preoperative planning. In the foot corrective osteotomies and lengthening procedures are challenging and can be associated with a range of complications. The aim of planning is to correct only the deformity and prevent extensive surgery on adjacent rays while maintaining biomechanical integrity. Knowledge of foot and ankle morphometry is vital to preoperative planning model. A 3D coordinate system is required for accurate morphological analysis. To conduct meaningful comparison between different subjects the coordinate system between subjects must be constant. Coordinate systems have been defined for other joints, however, there has been no previous description of a coordinate system for 3D analysis in the foot and ankle. We present a coordinate system for 3D data analysis in the foot and ankle and apply this to morphological analysis in the forefoot for preoperative planning.

Methods: CT images of ten anatomically normal feet were segmented in Materialise’s Interactive Medical Image Control System 10.1 (MIMICS) a general purpose segmentation program for grey value images. These files were then imported to a shape analysis program for biomechanics, Arthron. A coordinate frame was defined in a 3 × 3 identity matrix using the inter-malleolar axis and a fibular diaphyseal centroidal axis in the construction. Centroidal vectors were defined in the metatarsals enabling 3D analysis of the forefoot. Correlation of metatarsal length, inter-metatarsal angles, inter-malleolar distance and stature was carried out using Pearson product moment correlation coefficient, r.

Results: The morphology of the forefoot was examined in relation to the medial and lateral columns. The length of the metatarsals had a strong mathematical correlation within each column and between the two columns (0.525 – 0.965). There was also a strong correlation in the length between the lesser metatarsals (0.76 – 0.97) The 3rd metatarsal at the column junction correlated well (−0.583) with the inter-metatarsal angles. There was also a strong correlation between the individual’s stature and the metatarsal length and the inter-malleolar distance (0.60 – 0.89). Specifically in relation to the first metatarsal length there was a good correlation with inter-malleolar (0.75) and suture (0.65).

Discussion: We applied our analysis of the forefoot to the well recognised complication of Hallux Valgus surgery, first metatarsal shortening. This may lead to or exacerbate transfer metatarsalgia due to redistribution of force in the forefoot. Osteotomies of the lesser rays aim to relieve symptoms and re-establish the relationship between metatarsal lengths. However, this does not restore the relationship between metatarsal length, stature and inter-malleolar distance which we have shown to be important. Hurst et al proposed distraction osteogenesis of the first metatarsal to re-establishing length. This would return the normal mathematical relationship, which we have described and seems the most probable way to restore normal foot biomechanics and therefore relieve pain.

Conclusion: We have presented a means defining a coordinate system for 3D data analyses in the foot and ankle. We have shown this coordinate system to be effective in the morphometrical analysis of the forefoot. This analysis shows the importance of a proportional metatarsal length within the forefoot but also in relation to stature and the inter-malleolar distance in preservation of a normal biomechanical environment. This coordinate system can now be used for meaningful comparison of anthropological and morphological data between multiple subjects.

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 < 1,500cells/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.

Background: The Wrightington Frusto-Conical 2 (FC2) hip is a tapered stem with derotation flutes designed to withstand physiological loads in normal gait. There is a paucity of literature with regard to the outcome of this stem. This study was designed to determine the medium term outcome of the FC2 hip

Methods: We identified 217 consecutive patients who underwent total hip arthroplasty using the FC2 stem in one institution. Patients were recalled for clinical review. Pain, function and movement were assessed using the Harris Hip Score (HHS) and the D’Aubigne Postel Score. General quality of life and hip specific assessed were made using the WOMAC and SF-36 self directed questionnaires. Statistical analysis was performed.

Results: 86 patients were assessed with a mean follow-up of 7.3 years. Objective clinical outcomes were judged to be good or excellent according to the HHS and the D’Aubigne Postel scores. WOMAC assessment of disease specific outcome demonstrated excellent results particularly in relation to pain and stiffness. SF-36 demonstrated a quality of life score in keeping with an aging study population. There was a 95% survival at 7.3 years.

Conclusions: The FC2 hip has demonstrated a good outcome in the medium term. It shows outcomes that are similar to the Exeter and Charnley hips at this length of followup. Longitudinal follow-up studies are necessary to determine the results of hip implants

Complex foot and ankle surgery and reconstruction require accurate preoperative planning. In the foot procedures are challenging and can be associated with a range of complications. The aim of planning is to correct only the deformity and prevent extensive surgery. Knowledge of foot and ankle morphometry is vital. For comparison between different subjects the coordinate system must be constant. To the authors knowledge there has been no previous description of a coordinate system for the foot and ankle.

CT images of ten anatomically normal feet were segmented in a general purpose segmentation program for grey value images and imported to a shape analysis program for biomechanics. A coordinate frame was defined in a 3 × 3 identity matrix using the inter-malleolar axis and a fibular diaphyseal centroidal axis in the construction. Centroidal vectors were defined in the metatarsals. Correlation of metatarsal length, inter-metatarsal angles, inter-malleolar distance and height was carried out.

The forefoot was examined in relation to the medial and lateral columns. Metatarsal length had a significant correlation within each column and between the two columns notably in the 3rd (0.525 – 0.965) metatarsal at the columns junction. The 3rd metatarsals also correlated significantly (−0.583) with the inter-metatarsal angles. There was a weak correlation between the 1st 3rd and the 3rd 5th inter-metatarsal angles directly however, each had a large correlation with the 1st 5th inter-metatarsal angle (0.734 – 0.950). There was also a large correlation between the individual’s stature and the metatarsal length and the inter-malleolar distance.

We have presented a means defining a coordinate system for three dimensional analyses in the foot and ankle. This coordinate system can be used for meaningful comparison of data between multiple subjects. We have shown that this coordinate system to be effective in practice in the morphometrical analysis of the normal forefoot.

Background: Nonagenarian patients with hip fractures present many challenges to the clinician, both in terms of their advanced age and medical co-morbidities with potential orthopaedic complications. Our aims were to assess outcome of hip fractures in a nonagenarian population with respect to pre-operative predictors of outcome, immediate and long-term morbidity, and survival rates.

Methods: All nonagenarian patients with a hip fracture admitted to our unit between January 2000 and Decem-ber 2003 were considered. Eighty-one patients were included, the majority being female (M: F 14: 67). Ages ranged from 90 to 98 years for female patients (mean 92.5 years, SD 2.2) compared to 90 to 95 years for male patients (mean 92.7 years, SD 2).

Results: Delay to surgery was 1.25 days and the median ASA grade was III. The method of anaesthesia used was spinal in 78% and general in 22%. The majority of patients had intertrochanteric fractures and methods of fixation involved internal fixation in 63% and hemiarthroplasty in the remaining 36% of the group deemed fit for surgery. The rate of complications during inpatient stay was 19% and there were eight in-patient post-operative mortalities due to medical complications. Mean survival post hip fracture in our patient group was 474.7 days (median 372.5 days). Within forty days of surgery 25% of patients died, including our inpatient mortality of 10%. However, 50% of the patients were still alive 126 days post-operatively.

Conclusion: Hip fractures must be given special attention in the nonagenarian population because of their advanced age and medical co-morbidities. 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. Lower ASA grades, surgery within 48 hours, and increased pre-operative haemoglobin levels were all associated with favourable outcomes. Medical complications were the major cause of morbidity and mortality with a low rate of orthopaedic complications. The majority of patients were able to return to their previous residence and continued to be mobile with various levels of assistance.

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.

Introduction: Despite exhaustive prophylactic measures, intra-operative contamination still occurs following cemented arthroplasty. We undertook a prospective study to identify the incidence of intra-operative deep wound contamination in cemented joint arthroplasty. Furthermore, we assessed the medium term incidence (at 4 years) of wound contamination in this patient cohort.

Materials & Methods: A total of 82 consecutive patients admitted for elective cemented arthroplasty were enrolled in the study over a 6 month period. Standard medical and dental work up was performed prior to admission to assess fitness for surgery. Pre-operative wound site preparation included Hibitane showers and painting and draping of the operative site in both the anaesthetic room and theatre. All cases were undertaken in an ultra-clean laminar airflow theatre and the surgical team wore isolation suits in all cases. Standard swabs from skin incision and deep in the wound were sent in addition to the blades and suction tip used. Cultures were typed by morphology and identified by standard techniques. A control swab was sent from all cases to exclude contamination occurring in the laboratory setting.

Results: A total of 82 patients were included in the study. Mean patient age was 67.4 years (36–85 years). Of the 82 procedures performed, 59 were total hip replacements and 23 total knee replacements. Five procedures were performed for revision arthroplasty (1 knee and 4 hips). 19 of the 82 cases (23%) examined grew contamination organisms with S. epidermidis being the commonest organism (16). In 16 cases a single specimen demonstrated contamination. 2 patients had 2 contaminated specimens and 1 had 3 contaminated specimens. No significant correlation between the duration of the case, number of personnel in theatre, or the seniority of the operating surgeon was demonstrated. On medium term follow up (mean 49.6 months, 95% CI 3.2 months) no patient had developed clinical evidence of infection.

Conclusion: We noted a high incidence of intra-operative contamination of cemented arthroplasties despite standard prophylaxis. However, this was not reflected by a similar rate of post-operative infection. This may be due to a small bacterial innoculum in each case or possibly may be due to the therapeutic effect of peri-operative intra-venous antibiotic prophylaxis.

Introduction: Urinary retention is a significant complication following hip and knee arthroplasty. Published literature has shown that the insertion of a catheter post-op is associated with an increased incidence of deep joint sepsis, however, pre-operative catheterisation has not.

The International Prostate Symptom Score (IPSS) is an internationally validated scoring system used by Urologists to assess the severity of obstructive urinary symptoms and response to treatment.

The purpose of this study was to quantify the incidence of urinary retention following major joint arthroplasty in an elective orthopaedic unit and to investigate whether a patient’s pre-operative IPSS score could be used to predict the likelihood of post-operative urinary retention.

Patients and Methods: Over a 9 month period, 118 patients were enrolled prospectively into this study. 28 patients were admitted for knee replacement(TKR) and 90 patients for hip replacement (THR). All patients were asked to fill out an IPSS questionnaire form on admission. Demographics including age, mode of anaesthetic, intra-operative blood loss and operative time were recorded. Results: In our study group of 118 patients, 43(36.4%) developed urinary retention postoperatively. 29(32.2%) patients following THR developed urinary retention, whereas 14(50%) of the men who had a TKR developed urinary retention post-op. Of the 25 patients with a pre-operative IPSS score > /=10, 14(56%) went into retention. The mean pre-operative IPSS score was 7.74 for those who went into retention, compared to 5.0 for the other patients (p < 0.05). Type of anaesthesia, blood loss and operative time were non-contributory.

Conclusion: This study shows a high rate of post-operative urinary catheterisation in our patient group. Despite the mean IPSS score being higher in patients requiring catheterisation, our results did not show any conclusive evidence that this scoring system could be used to predict the development of post-operatively urinary retention in patients presenting for hip or knee arthroplasty.

Introduction: An arthroplasty database, such as the Swedish Hip Registry, provides a crude means of quality control over the sizable number of prosthetic implants available on the market today. It provides relatively rapid feedback on the performance of orthopaedic devices and surgical techniques, allowing inferior devices and methods to be discontinued. The maintenance of an arthroplasty register is inexpensive and of enormous benefit to the patient. At present, there is no nationwide arthroplasty register in operation in the Republic of Ireland.

Aim: To develop an arthroplasty register which prospectively captures all clinical, radiographic and medical outcome data on patients undergoing surgery in our unit

Materials and methods We are using an existing computer software programme (Bluespier Patient Manager) to capture our information, although our database is stored independently of this.

Data recorded includes medical outcome scores (WOMAC and MOS SF-36), patient data, operative details (including type of prostheses used and operative technique employed), inpatient course, and any postoperative events. For revision procedures, additional data such as location of bony defects (Gruen zones) and acetabular bone loss (Paprosky classification) are also recorded. Follow up in a special Joint Register Clinic is at six months, two years and every five years thereafter for primary procedures. This is reduced to every two years in the case of revision procedures.

To date, a pilot study involving four surgeons has prospectively captured data on 82 patients undergoing both primary and revision procedures in our unit. We aim to enrol all our patients in the register from July 2005, increasing the amount of data collected, which we hope will subsequently benefit patients undergoing hip and knee arthroplasty in the future.

Introduction: The optimal management of ankle fractures in the elderly is controversial, with wide variation in the complication rates reported in the literature. Achieving a satisfactory outcome is essential as reduced mobility exacerbates pre-existing morbidity and diminishes the likelihood of independent living. However, in elderly patients surgery carries increased risks due to osteoporosis, poor skin condition and decreased vascularity.

Methods: We performed a retrospective review of outcome and complications in patients over 70 years of age with ankle fractures. Patients were admitted for manipulation under anaesthetic and application of cast (MUA) or open reduction and internal fixation (ORIF). Data were retrieved from medical and nursing notes relating to pre-operative functioning, type of injury, operative procedure and outcome. All X-rays were also reviewed to confirm fracture grade and union.

Results: A total of 134 patients over the age of 70 were admitted for management of ankle fractures during January 1995 and December 2003 and 117 of these were included in the study. 84 were operatively treated for ankle fractures and a further 27 patients underwent MUA. The mean age in both groups was 76 and there was a female predominance in both groups (89% in MUA, 79% in ORIF). 14.8% of the conservatively managed group were nursing home residents compared to 2.4% of the operatively treated group. The groups were similar with respect to ASA grade and co-morbidities. The median length of stay was shorter for the conservatively managed group (4 vs. 6 days). 7.5% of the MUA group required a second intervention compared to 4.5% of the operatively managed group. There were two below knee amputations in the operatively managed group, both related to open fractures, and one arthrodesis in each group. There were three wound complications in the operatively managed group. The rate of postoperative medical complications was the same in both cohorts. 7.4% of patients treated with MUA and 1.1% of patients treated operatively had reduced mobility at final follow-up.

Conclusion: The decision-making process for treatment of ankle fractures in the geriatric population is challenging. We observed significantly better functional results in the ORIF group than the MUA group. These results indicate that open reduction and internal fixation of ankle fractures in geriatric patients is efficacious and safe in selected patients

Introduction: The Sheehan total knee endoprosthesis has been widely used since 1971. It incorporates a semi-constrained hinge with intramedullary stems cemented into the femur and tibia for fixation. This gives a stable polycentric knee mechanism that allows axial rotation as well as simulating other knee movements. This design has certain disadvantages including the large amount of bone resected for implantation and its constrained nature which predisposes to loosening. Revision rate of up to 30% have been reported. We discuss the difficulties encountered during revision and the techniques that need to be used to overcome these.

Patients and methods: We reviewed the records of 21 patients who required revision of Sheehan TKRs between 1987 and 2001. Reason for revision was recorded and all patients were scored using the Knee Society Index of Severity Instrument (Saleh et al CORR 2001). The operative details were examined and technical difficulties at the time of surgery recorded. Per-operative and early post-operative complications related to the revision procedure were also noted.

Results: The average age of patients requiring revision was 65 years old (range 39–79). The average time from primary surgery to revision was 16.2 years (range 8–20 years). The reasons for primary surgery were rheumatoid arthritis in 9 and osteoarthritis in 12. Revision surgery was required for pain associated with tibial subsidence and painful bone on bone contact in 14.Two patients had dislocation of their tibial on femoral component. One patient had a one-stage revision for infection and one had revision for a fractures tibial intramedullary stem. Three patients had revision to anterior flanged femoral components to facilitate patellar resurfacing for patello-femoral pain. The overall complication rate approached 80%!

Discussion: While the Sheehan TKR was of great benefit to a large number of patients it is not without its problems. These results show that prostheses coming to revision did not necessarily fail early and so with time we can expect more to present for revision. The high complication rate and the need for complex reconstructive techniques attest to the difficulty of revising these prostheses. Some of these problems are the legacy of the prosthetic design and should be borne in mind when taking on these cases.

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.

Introduction: The Sheehan total knee endoprosthesis has been widely used since 1971. It incorporates a semi-constrained hinge with intramedullary stems cemented into the femur and tibia for fixation. This gives a stable polycentric knee mechanism that allows axial rotation as well as stimulating other knee movements. This design has certain disadvantages including the large amount of bone resected for implantation and its constrained nature, which predisposes to loosening. While clinically excellent results have been reported in 95% of patient by some authors, other papers have reported much lower rates of successful outcome and revision rates of up to 30%. Few papers however report the difficulties encountered during revision or the techniques that need to be used to overcome these.

Patients and Methods: We reviewed the records of 21 patients who required revision of Sheehan TKR’s between 1987 and 2001. Reason for revision was recorded and all patients were scored using the Knee Society Index and Severity Instrument (Saleh et al CORR 2001). The operative details were examined and technical difficulties at the time of surgery recorded. Per-operative and early post-operative complications related to the revision procedure were also noted.

Results: The average age of patients requiring revision was 65 years old (range 39–79). The average time from primary surgery to revision was 16.2 years (range 8–20 years). The reasons for primary surgery were rheumatoid arthritis in 9 and osteoarthritis in 12. Revision surgery was required for pain associated with tibial subsidence and painful bone contact in 14. Five of these also had varus/valgus instability in excess on 30°. Two patients had dislocation of their tibial on femoral component. One patient had a one-stage revision for infection and one had revision for a fractures tibial intramedullary stem. Three patients had revision to anterior flanged femoral components to facilitate patellar resurfacing for patello-femoral pain. In 14 patients the knee was revised to a second Sheehan prosthesis as the degree of bone loss was insufficient to allow cement removal and bone stock reconstruction. Three patients were revised to stemmed Co-ordinate (DepuyTM) revision prostheses, one to a standard AMK surface replacing prosthesis and one to a hinged Finn prosthesis due to global instability. Seven patients required impaction bone grafting and required structural grafting for severe bone loss. The overall complication rate approached 80%! Two patients had wound breakdown, one required grafting. Five patients had persistent wound ooze successfully treated with antibiotics alone. To patients had cortical perforation, which was bypassed by the prosthetic stem, two suffered post-operative fractures, one requiring ORIF, one bracing. Four patient required re-revision, two to kinemax prostheses and two to further Sheehan prostheses.

Discussion: While the Sheehan TKR was of great benefit to a large number of patients it is not without its problems. These results show that prostheses coming to revision did not necessarily fail early and so with time we can expect more to present for revision. The high complication rate and the need for complex reconstructive techniques attest to the difficulty of revising these prostheses. Some of these problems are the legacy of the prosthetic design and should be borne in mind when taking on these cases.

Nosocomial infection with methicillin-resistant Staphylococcus aureus (MRSA) is on the increase and is expensive to treat. MRSA surgical wound infection may have disastrous consequences, particularly in an orthopaedic setting. We studied the rate of MRSA colonization in an important subgroup of orthopaedic patients. 50 nursing home residents were retrospectively reviewed with regard to their MRSA status on admission to an orthopaedic ward with fractured neck of femur. As is policy in our institution, all patients from nursing homes or other institutions are screened for MRSA on admission.

Of the 50 nursing home patients requiring a hemi-arthroplasty, 16%(8) were MRSA positive. 2%(1/50) acquired MRSA infection while I hospital, while the remaining 14%(7/50) were carriers on admission. 4%(2/50) developed sepsis postoperatively, followed by multiorgan failure and death. 4% had their MRSA cleared prior to discharge, while 8% remained positive on discharge. All patients undergoing hemiarthroplasty received cefuroxime, unless allergic, as prophylaxis at induction. These findings of considerable MRSA carriage in nursing home patients is particularly relevant today, as the number of patients in nursing homes continues to grow as the population ages. The patient population in nursing homes is susceptible to infection because of the physiological changes that occur with ageing, the underlying chronic diseases of the patients and the institutional environment within which residents socialize and live.

Nursing home residents presenting to orthopaedic units for surgery are a unique group in repairing careful consideration.

Introduction: The red, hot swollen knee is commonly seen in the A& E department and can present a diagnostic dilemma for the casualty officer. While superficial cellulites and bursitis are the most common diagnoses, anxiety is induced by the spectre of septic arthritis. The potential sequalae from aspirating a knee through infected superficial tissues further emphasise the importance of making an accurate clinical diagnosis.

The lymph drainage of the superficial tissues of the lower limb is via lymphatics that accompany the long saphenous vein and drain to the lower group of the superficial inguinal nodes. Drainage from the knee joint is to a popliteal node situated between the knee joint capsule and the popliteal artery. Efferents from this node ascend in close relation to the femoral vessels and drains to the deep inguinal nodes. We hypothesise that the differences in lymphatic drainage mean that palpable inguinal nodes are more likely with superficial infections than with septic arthritis. We reviewed the clinical findings in a group of patients with superficial or deep infections to test this theory.

Patients and Methods: From January 1995 until June 2000, twenty-seven patients were admitted with septic arthritis of the knee and fifty-one with superficial cellulites or bursitis about the knee. The former were diagnosed on the basis of clinical findings and a knee aspirate, the latter on clinical findings and response to treatment. The presence or absence of palpable inguinal lymph nodes was determined and compared for each diagnostic group.

Results: Joint aspirates from the group with septic arthritis grew organisms in twenty patients (staph aureus in 19, strep pneumoniae in one). The remaining seven patients had no growth but purulent fluid on aspirate with leukocyte counts in excess of 50,000/mm³. Six patients had rheumatoid arthritis and two were HIV positive IVDA’s but the rest had no pre-disposing factors. The average age was 52 (range 16–83). All were treated with arthroscopic washout (average 2.2/patient) and antibiotic chemotherapy.

In the superficial infection group 28 (56%) had pre-patellar bursitis and 23 (54%) cellulites. All were treated with antibiotics while eight of the bursitis group required incision and drainage. In the patients with superficial infection 32 (63%) had palpable inguinal lymphadenopathy while no patient with septic arthritis of the knee had palpably enlarged inguinal lymph nodes. This result is highly statistically significant (p< 0.01).

Discussion: It is well recognised that neoplastic or inflammatory conditions of the superficial tissues of the lower limb may be associated with inguinal lymphadenopathy. A similar association for septic arthritis of the knee has not to our knowledge been described. Our study would suggest that palpably enlarged lymph nodes are unusual in this condition. While it is worth emphasizing that the presence of lymph nodes does not rule out absolutely the possibility of septic arthritis, their presence or absence may be useful in differentiating superficial from deep infections about the knee.