Introduction

Peri-prosthetic infections due to P. acnes may present as Prosthesis dysfunction without any obvious sepsis. We present our experience of efficient management of total knee prosthesis infection secondary to P. acnes which is one of the biggest case series.

Introduction: The aim of this study was to determine the outcome of Tomofix plate fixation, in joint retaining surgery, for Medial compartment Osteoarthritis of the knee in young patients

Methods: We report on 33 patients (36 knees) who underwent High tibial osteotomy for unicompartmental osteoarthritis of the knee. The mean age was 39.5 (30–49). There were 20 males and 13 female. All the patients had Medial opening-wedge type Osteotomy using the Tomofix device. The mean duration of follow-up was 48 months (44–60 months). The patients were assessed on the basis of pre and post-operative oxford knee score, knee range of motion, radiological evidence of healing of the osteotomy site and alignment of the knee.

Results: There were no nonunions at the osteotomy site and the medial open-wedge filled-in without any need for bone graft or its substitutes. The mean preoperative oxford knee score was 48 (S.D 4.7 Range 38–54). This improved to a mean score of 22 (S.D 5.9 Range 17–31) after 1 year follow-up. The improvement was significant (pvalue= 0.07). The preoperative average knee flexion was 103.1 (S.D 25.2 Range 10–125) which improved after 1 year follow up to 112 (S.D 15.9 Range 0–140). The mean preoperative Femorotibial angle was 10 degrees varus (range 9–15). The mean postoperative Femorotibial angle was 8 deg valgus (range 6–12). Radiologically, there was no loss of correction during our follow-up. One patient had post-operative DVT.

Conclusion: Our study shows that Tomofix plate fixation in High Tibial osteotomy gives immediate stability, good deformity correction and allows early rehabilitation. The osteotomy gap does not require bone grafting and the correction is maintained. The Short term functional results are encouraging. Longer-term follow-up is however needed to establish its effectiveness in deferring joint replacement surgery in young patients.

AIM: Operative treatment is the choice of management for unstable sub-trochanteric fractures because it allows early mobilisation thus preventing serious and fatal complications. This study was conducted to compare the results, advantages and disadvantages of using dynamic condylar screw and interlocking nail for treatment of subtrochanteric fractures.

METHOD: A prospective randomised controlled study was carried in our centre. The study included 64 patients presenting to our Trauma and Orthopaedic unit between July 2000 to November 2003. The criterias for inclusion were an age of less than 70 years, a non-pathalogical sub-trochtanteric fracture less than 4 weeks with no previous history of surgery and a femoral anatomy that allowed osteosynthesis with intramedullary nail or a dynamic condylar screw. The patients were randomly divided in 2 groups which was accomplished with use of computer generated random numbers. The group1 treated with DCS and group 2 was treated with interlocking nail. Both groups were comparable with regard to age, gender, body mass index, medical history according to index of Fitts et al and system of American Society of Aneasthesiologists, mental status and mobility score. The pre-injury functional status of the patients was recorded using Sikor-ski and Barrington pain and mobility scale and parker and palmer mobility score. The estimated intraoperative blood loss, operative time and intraoperative complications were recorded. Follow-up was done at 4th, 12th and 24th week and then 1 year. Patients were assessed for range of hip movements, muscle strength while functional recovery was assessed with Sikorski and Barrington pain and mobility scale. The radiograph at 1 year was used to assess the neck shaft angle.

RESULTS: The mean age of the patients was 49 (range 30–65). There were 38 males and 26 females. The intra-operative blood loss, average hospital stay and operative time was more in case of patients undergoing DCS fixation(p< 0.05). The time fracture union and full weight bearing mobilisation was better in patients who had intra-medullary fixation.1 patient in group1 had screw cut out from femoral shaft, this was treated by change of side plate to longer one with bone graft augmentation.1 patient in group 2 had non-union which was treated by removal of interlocking nail and refixation of fracture with DCS along with bone graft. There was no infection, DVT or mal-union in any group.1 pateint from each group was lost to follow-up. All other patients were evaluated with Sikorski and Barrington’s pain and mobility score. The difference was not significant between the goups(p< 0.05).

CONCLUSION: The results of our study support the use of interlocking nail especially in communited fractures of subtrochanteric region.

Aim: PFC Sigma total knee was introduced in 1997 incorporating a number of design changes. We report our medium-term results of a consecutive series of PFC sigma knees performed between Nov 1997 and Dec 1998.

Method: Between November 1997 and December 1998 a consecutive series of 166 TKAs (156 patients)were carried out using the PFC Sigma total knee replacement system at Wrightington Hospital. Out of the 156 patients 9 were lost to follow-up. This left 147 patients (156 knees) with a mean follow-up of 90 months (range 84 – 96 months). 137 patients (88%) had primary osteoarthritis, 14(9%) had R.A and 5(3%) had post-traumatic arthritis. The mean age was 70 yrs (53 – 88 yrs).85 were female and 62 male. All patients were followed at 3 months, 6 months,1 year and then yearly. Clinical evaluation was done by American Knee Society and Oxford knee scores. Knee society score was used to assess the postoperative radiographs.

Results: The mean Knee society score improved from the preoperative mean of 45 (range 30 – 65) to postoperative mean of 84 points(range 45 – 92). The mean preoperative functional score was 38(range 25 –5) and mean postoperative functional score was 73 points(range 50–95). According to the final scoring 90 % of the knees were rated excellent, 4% good, 4 % fair and 2 % poor. The mean preoperative Oxford knee score was 43 (range 33–52) and mean postoperative score was 17 (14–29). Range of motion improved from a mean of 90(range 50–125) to 105(range 65–130). There was no significant difference (p = 0.03) in the American Knee Society score and Oxford knee score when comparing patients with and without resurfacing of the patella and PCL-retaining with PCL-substituting implants.1 knee (0.6%) was revised within 18 months due to aseptic loosening.1 knee(0.6%) had superficial wound infection which cleared with oral antibiotics.2 patients(2 knees) developed deep infection out of which one resolved following early debridement, the other developed chronic infection requiring long term suppressive antibiotics. 3 patients had proven below knee deep venous thrombosis; one of them developed a non-fatal pulmonary embolism. Radiological review using radiological knee society scoring showed radiolucent lines under 35 % of the tibial components(56 knees)and 11 % of Femoral components(18 knees). For survivorship analysis, the actuarial life- table method was used with calculation of the numbers at risk and the survival rates at annual intervals. The 95% confidence limits were calculated by the method of Rothman. The survivorship at the end of eight year follow-up was 99.40. None of the patellar components failed.

Conclusion: Our study shows excellent clinical results of PFC Sigma Total knee replacement after almost eight years follow-up. We plan to continue monitoring this cohort of patients for long-term results.

INTRODUCTION: CTS is the most common nerve entrapment syndrome. Repeated flexion and extension activities of the wrist coupled with certain finger flexion causes oedema and compression of the median nerve within the carpal tunnel of the wrist. Several treatment options, both conservative and surgical are available to relieve the pressure on the median nerve. Although studies support the efficacy of splinting for CTS the length of splinting, type of splints, day or night use and the effects on other variables are still less agreed.

MATERIALS AND METHODS: A Randomised control trial with subjects randomised to a splint and a control group. 44 patients(60 hands) evaluated at recruitment, 2,8 and 12 weeks. Difference in Levine’s symptom and functional severity scores, between the two groups, used as the primary outcome measure.

STATISTICAL METHODS: Repeated measure analysis(ANOVA) and paired t test used for statistical analysis between the two groups.

RESULTS: There was no difference between the two groups at baseline. Improvement in symptom severity score in the splinted group at the end of 12 weeks(p< 0.05). No difference in functional severity between the two groups.

CONCLUSION: Splintage helps to improve symptoms related to carpal tunnel syndrome in a short term period. This is the duration that the patients referred by GP’s have to wait before seeing a hand specialist. Hence they can be treated with splints during this period to give them symptomatic relief.

Objectives: Dislocation is one of the common complications of total hip Arthroplasty. Posterolateral approach and small femoral heads have been shown to be high-risk factors for dislocation of the implanted total hip prosthesis. The use of a posterior capsulorraphy has also shown to decrease the rate of dislocation with a posterolateral approach. The objective of this study was to evaluate the early dislocation rate using size 22 mm head and a Posterolateral approach augmented with a posterior capsulorraphy.

Methods: Questionnaire and case notes review of 148 patients operated at one institution by 3 different senior surgeons from Aug’03 to Jan’05. A posterior capsulorraphy was performed in all the patients. The primary outcome measure was the dislocation of the prosthetic hip within the first year of surgery.

Results: 4 of the 148 patients (2.7%) had an episode of dislocation during the first year of surgery. 3 patients were treated conservatively and 1 required operative intervention in the form of PLAD. Radiographic analysis of this patient showed excessive anteversion of the socket(28⁰⁾.

Conclusions: Studies have consistently shown an increased rate of dislocation with a Posterolateral approach and use of a size 22mm head. A recently published study by Berry et.al has shown a 12.1% dislocation rate with the use of this approach and size 22mm head. However posterior capsulorraphy was not performed in patients in this study group. Our study shows that performing a posterior capsulorraphy can reduce early dislocation rates using Posterolateral approach and size 22 mm head. The dislocation rate (2.7%) is comparable to any other approach and the use of a larger head size.

These patients continue to be monitored to evaluate long term outcomes with this approach. (301 words)

Purpose Of The Study: Description of a new operative technique of trochleoplasty for patellar instability and its short-term results.

Method: we report a new technique of trochleoplasty for Trochlear dysplasia, using Mitek anchor sutures. The purpose of the procedure is to remove the anterior femoral boss associated with Femoral Trochlear dysplasia and make the floor of the trochlea level with the anterior femoral cortex. The operation entails undermining of the trochlear and lateral condylar articular cartilage to a new corrected level where it is held with the use of No 2 Ethibond Mitek anchor sutures. These anchors are placed in the subchondral bone, suture needle passed through the articular cartilage and the sutures tied over it. Approximately 4 -5 anchor sutures are placed to hold the trochlear cartilage down to the new corrected level. This procedure can be combined with proximal and distal patellar realignment.

So far, using this technique, we have operated on six patients with trochlear dysplasia and chronic patellar instability. The patients include 4 females and 2 male with an average age of 33 yrs (range 29 – 40). Average follow up is 16 months (range 8 – 24 months). There has not been any recurrence of patellar instability in the operated patients.

Conclusion: Short-term follow up of a new operative technique of troachleoplasty for patellar instability shows promising results.

Objective: The quality of femoral cementation is related with the long-term survival of hip prosthesis. We set out to identify if the quality of femoral cementing as assessed on the first postoperative AP radiograph was significantly different when operations performed by trainees were compared with those done by consultant staff.

The Barrack scoring system was used as a tool to evaluating cementation quality in all cases.

Material and Method: The cohort included 70 patients undergoing primary Exeter hip replacement. 41 cases were performed by consultants and 29 by trainees. The mean age of the consultant patients was 80 while in the second group this was 78. The ratio of “Funnel shaped” to “stove-pipe” femurs was 1/2.3 in the consultant group and 1/2.1 in trainees group. Thus the two groups were similar. The 1^st postoperative AP hip x-rays were numbered randomly and digital images were then graded using the method of Barrack by one observer (I.R) who was blinded to the seniority of surgeon.

Results: Of the total cohort of 70 patients, 35 (50%) were grade A, 28 (40%) grade B and 7 (10%) grade C. In the consultant cases 18(44%) were grade A, 19(46%) grade B and 4(10%) were grade C. The results in for training grade surgeons were 17 (58%) grade A, 9 (31%) grade B and 3 (11%) grade C. There were no grade D cases in either group. The standard deviation in consultant group was 23.46 while in case junior grade surgeons it was 25.46.

Conclusion: The results in this series of operations suggest that in our institution, the quality of femoral cementing was not significantly different when the operations carried out by consultants were compared to those where a trainee was the primary surgeon (p=0.087). As Barrack scores have been shown to correlate with the long term survival of hip arthroplasties, these results would suggest that patients undergoing operation undertaken by an adequately experienced and supervised trainee are not at increased risk for implant failure compared to the individuals where the Consultant is the primary surgeon.

Objective: We set out to identify if the quality of femoral cementing as assessed on the first postoperative AP radiograph was significantly different when operations performed by trainees were compared with those done by consultant staff.

The Barrack scoring system was used as a tool to evaluating cementation quality in all cases.

Material and Method: 70 patients with primary hip replacement were included. 41 cases performed by consultant while 29 by training surgeons.1st post-operative hip x-rays were taken between 3–5 days postoperatively. The x-rays were numbered randomly and their digital images were graded using Barrack grades by one observer (I.R) who was blinded to the seniority of surgeon who had carried out the case.

Results: Of the total cohort of 70 patients, 35(50%) were grade A, 28(40%) grade B and 7(10%) grade C. In the consultant cases 18(44%) were grade A, 19(46%) grade B and 4(10%) were grade C. The results in for training grade surgeons were 17(58%) grade A, 9 (31%) grade B and 3(11%) grade C. There were no grade D cases in either group.

Conclusion: The quality of femoral cementing was not significantly different when the operations carried out by consultants were compared to those where a trainee was the primary surgeon (p< 0.01). These results would suggest that learning curve (Figure) from trainees to consultants was quite satisfactory. Patients undergoing operation undertaken by an adequately experienced and supervised trainee are not at increased risk for implant failure compared to the individuals where the Consultant is the primary surgeon.