We report the results of anterior plate fixation for symptomatic, mid-shaft clavicle non-union. The superior surface is most commonly used for plate fixation. To the best of our knowledge, there are no clinical reports where anterior plate fixation of the clavicle was used.

We included 12 consecutive patients, with symptomatic mid-shaft clavicular non-union, aged between 23 and 56 years during a four-year period (1998-2002). The injury was secondary to RTA in 6 cases, sports-related in 5 and skiing in one. In three patients, the non-union was secondary to superior plating using one third tubular plate, in acute fractures. The most common complaint was anterior shoulder pain (12 cases) followed by brachialgia (4 patients). The operation was performed through an anterior approach. A 3.5mm reconstruction plate was contoured and fixed onto the anterior surface of the clavicle. Bone graft was used in all cases. The average follow up was 22 months. All 12 patients achieved union at an average union time of seventeen weeks.

Compared to superior plating, anterior plating has the distinct advantage that the longer screws can be used (as the clavicle is a flat bone, and the AP diameter is larger compared to superoinferior diameter) thus improving the stability of fixation. Our results show that anterior clavicle fixation is safe and effective in achieving union, even in cases following failed superior plate fixation. We therefore recommend anterior plate fixation and bone grafting in symptomatic nonunions of mid third clavicle fractures.

Echocardiograms are requested in patients presenting with hip fractures and the finding of a cardiac murmur. The opinion amongst anaesthetists in our department is that general anaesthetic (GA) is safer in patients with significant aortic stenosis, mitral regurgitation, or left ventricular impairment compared to spinal anaesthetic (SA).

A retrospective review was carried out and data on fifty patients were collected, who had presented with fractured neck of femur with the finding of a heart murmur and required an echocardiogram pre-operatively.

Our results demonstrated :

Focussed history and examination was rarely performed;

Our audit suggests that many echocardiograms are ordered unnecessarily. Effective use of clinical skills and investigations are rarely utilised by orthopaedic doctors, in requesting an echocardiogram. There is delayed operating times, cost implications and increased workload for the cardiology department. There is no indication that the results of these echocardiograms significantly influences anaesthetic choice.

A second audit cycle was performed prospectively with the use of a proforma. An echocardiogram was not ordered if a recent echocardiogram (within last the last year) was normal or if the history, examination and ECG findings in a patient were all insignificant. This demonstrated a reduction in ordering of echocardiograms by 40%. Local guidelines have been implemented in our department.

Revision surgery is an important outcome of hip and knee arthroplasty among patients with osteoarthritis (OA). The objective of this study was to determine the risk of revision over time in a large, geographically defined population in North America, and to assess the effects of age, sex, and socioeconomic status (SES) on knee and hip revision rates in this population.

We used data on admissions to all acute care hospitals in British Columbia (BC), Canada (population of four million people) from 1986 until 2004 (eighteen years of follow-up). Primary knee and hip replacement surgery for OA and revision procedures were identified using diagnostic (ICD-9, ICD-10) codes and surgical procedure codes. We excluded cases admitted due to injury or neoplasm. SES was assigned based on residential address linked to census data at the level of enumeration area (ecological variable), and analyzed according to quintiles or deciles of the distribution. In the analysis, we used Kaplan-Meier survival curves to describe the risk of first revision following first primary replacement surgery over time and parametric (Weibull) survival regression models to analyze the effects of joint (hip vs. knee) age, sex, and SES on revision rates. Death, emigration, and another primary joint replacement were treated as censoring events.

Between 1986 and 2004, we observed 24,169 first primary hip replacements and 22,875 first primary knee replacements. In these patients, there were 1,313 hip revisions and 914 knee revisions following a primary replacement. The risk of revision at five, ten and fifteen years after primary replacement according to joint and sex were identified The overall risks were 10.1% for the hip and 8.7% for the knee at ten years, and 15.5% and 14.7%, respectively, at fifteen years. Risk of revision (%) following first primary joint replacement surgery Hip Knee Years Men Women Men Women 5 5.0 3.9 4.6 3.8 10 11.0 9.4 9.7 8.0 15 17.8 14.1 18.5 12.4 In a multivariate survival regression model including joint, age, sex, and SES, only age and sex were significantly associated with revisions. The hazard ratio was 1.2 for men compared with women (p< 0.0001). Revision rates were higher in younger persons, with hazard ratios increasing from 1.7 for age 70–79 (p< 0.0001) to 3.9 for age < 49 (p< 0.0001) compared with age 80+. After adjusting for age and sex, SES was not significantly associated with revision risk following primary hip or knee replacement surgery in this population (p=0.75).

This is one of the largest and longest cohort studies in North America to look at the epidemiology of revision procedures following hip and knee replacement for OA. Higher rates in men and in younger persons are consistent with previous reports. The lack of association between revision risk and SES in BC is an important finding given current concerns about socioeconomic disparities in access to and outcomes of treatment for OA.