Background

Sub-trochanteric fractures are challenging to treat due to various anatomical and biomechanical factors. High tensile forces contribute to the challenge of fracture reduction. Intramedullary nailing has become the treatment of choice. If anatomical reduction is not achieved, any mal-alignment will predispose to implant failure. Open reduction with cerclage wires can add to construct stability and improve the quality of reduction. There is no consensus or classification to guide surgeons on when to perform open reduction, which is often performed intra-operatively when closed reduction fails often with no planning. This can lead to intraoperative delays as theatre staff would not have prepared the correct equipment necessary for open reduction

Hip fractures are estimated to cost the NHS over £2 billion per year and, with an ageing society, this is likely to increase. Rehabilitation and discharge planning in this population can be met with significant delays and prolonged hospital stay leading to bed shortages for acute and elective admissions. Planning care for these patients relies on a multidisciplinary approach with allied healthcare providers. The number of hip fracture patients in our hospital averages between 450–500/annum, the second largest number in the North West. The current average length of stay for the hip fracture patients is 22.9 days.

We evaluated the impact and performance of a pilot early supported discharge service (ESD) for patients admitted with a hip fracture. The pilot period commenced 22 September 2014 for 3 months and included an initial phase to set up the service and supporting processes, followed by the recruitment of 20 patients during the pilot period. The length of stay and post-discharge care was reviewed.

The journey of 20 patients was evaluated. The length of stay was dramatically reduced from an average of 22.9 days to 8.8 days in patients on the ESD pathway. Family feedback showed excellent results with communication regarding the ESD pathway and relatives felt the ESD helped patients return home (100% positive feedback).

Prolonged recumbency adversely affects the long-term health of these patients leading to significant morbidity such as pressure sores, respiratory tract infections and loss of muscle mass leading to weakness. Mortality is also a significant risk for these patients. Longer hospital stays lead to disorientation, institutionalisation and loss of motivation. Enhancing self-efficacy has been shown to improve balance, confidence, independence and physical activity. This pilot has proven that the Fracture Neck of Femur ESD service can significantly reduce the length of hospital stay and also deliver excellent patient and family feedback. The benefits of patients with a lower length of stay, with effective rehabilitation in hospital and within the home, will provide significant benefits to the Wirral healthcare economy.

The aim of the study was to assess the clinical, radiological and paedobarographic outcome following modified Silver’s McBride’s procedure, in the treatment of Hallux Valgus. Between 1997 and 1999, Modified Silver’s McBrides procedure for Hallux Valgus was performed on 38 foot in 28 patients (18 unilateral and 10 bilateral). The median age was 60 years. The median follow up was 26 weeks. Clinical outcome measures consisted of pain, deformity, mobility, walking ability and shoe wear. Radiological outcome measures were Hallux Valgus angle, Intermetatarsal angle, 1st to 5th Metatarsal distance, 1st to 2nd metatarsal distance, and the DMAA (Distal Metatarsal Articular Angle). Paedobarographic (Musgrave) outcome of peak pressure, total force, time from heel strike to toe lift off post operatively were analysed. Preoperative visual analogue pain score was 5–8 and 0–4 postoperatively (p< 0.001). 34 feet had pain on walking preoperatively and only 11 had pain post-operatively. 12 were wearing special shoes pre- operatively and 5 post-operatively. Hallux Valgus angle was 34 pre-operatively and 19 post-operatively (p< 0.001). IMT angle was 14.53 pre-op and 10.88 postop (p< 0.001). 1st-5th MT distance was 67mm pre- op and 63mm post-op (p=0.001). 1st-2nd MT distance was 15 pre-op and 10 post-op (p=0.004). DMAA was 24.7 degrees. 21 foot an obliquity of the 1st tarsometatarsal joint was seen indicating an anatomical cause of metatarsus varus. Foot pressure studies showed a peak pressure of 1.37kg/cm2 , heel to toe off- time was 936.9ms and maximum load was 65.2 kg. There were 3 cases of superficial wound problems. One patient developed Hallux varus deformity, with no functional disability.

Conclusion: Modified Silver’s McBride procedure for the treatment of Hallux Valgus is a soft tissue procedure and is a safe alternative to the commonly practiced osteotomies for correction of this disorder.

Purpose: To compare the analgesia provided by pure subcutaneous infiltration (Gale technique) of lignocaine with that provided by infiltration of lignocaine into the carpal tunnel in addition to the subcutaneous tissue (Altissimi technique) for carpal tunnel decompression

Methods: 20 patients with bilateral carpal tunnel syndromes were chosen for the study. Patients were randomised to receive one local anaesthetic technique on one side and the other on the other side. The pain scores were recorded intraoperatively and 2 and 4 hours postoperatively.

Results: 5 patients experienced intra-operative pain with the Gale technique, while one did with the Altissimi technique (p=0.15 using Mann Whitney U test). Postoperative analgesia at 2 hours was significantly better with the Altissimi technique (p= 0.009). Patients with the Altissimi technique also required less number of analgesic tablets over 24 hours post surgery (p=0.01).

Conclusions: We found no statistically significant difference in the intra-operative pain scores with the two techniques. However, postoperative pain relief was much better with the Altissimi technique.

To report the experience with the new device, the Long Proximal Femoral Nail (Long PFN) in patients with impending pathological femoral fractures to identify the advantages and complications associated with its usage. This is the first in the series on the use of Long PFN for patients with femoral metastases.

Between April 2000 and September 2001, twenty-five consecutive patients with femoral pathological lesions were prophylactically stabilised using Long PFN. The nailings were performed using a percutaneous closed technique. Lateral femoral Line (LFL) technique was used for location of the entry point and easy insertion for the nail. Only the proximal one-fifth of the femur was reamed to accommodate the 17 mm diameter of the proximal part of the nail.

We had technical problems in three patients. The overall mobility of the patients improved in twenty patients and the mobility remained the same as pre-operative level in five patients. Good to excellent pain relief achieved in eighteen patients. The pain relief was fair in five patients and poor in two patients. We had no mechanical failure of the implant in our series.

Long PFN, a modified reconstruction nail, can be inserted percutaneously and has an easy operation technique. Our early experience with Long PFN in the management of impending femoral fractures has been favourable.

Aim: To report the technique of reverse femoral LISS [Limited Invasive stabilisation system] plate fixation of pathological fractures of proximal femora with pre-existing deformity due to multiple fractures in a patient known to suffer with Osteopetrosis

Design: Osteopetrosis, a rare heterogeneous condition, is a result of failure of the bone remodelling. The orthopaedic presentations of which include, back pain, deformity of long bones and multiple fractures. Historically, most fractures in patients with Osteopetrosis were treated nonsurgically with good results, but at the expense of malunion. Operative treatment is indicated, to avoid disabling deformity or to treat nonunion of the fractures. The conventional onlay or inlay devices for fracture stabilisation are difficult to use due to malunion and obliteration of medullary canal, caused by previous fractures and hardness of the bone. The new LISS is an extramedullary, internal fixation system and its main features are an atraumatic insertion technique, minimal bone contact, and a locked, fixed-angle construction. The LISS plate can be used to stabilize the whole length of a femur with multiple deformities.

Subject: A 46-year – old lady who is a known case of autosomal dominant Osteopetrosis sustained 5 left femoral and 4 right femoral pathological fractures, over a period of 25 years. They were treated nonoperatively and the fractures were healed with some malunion. During the recent clinical presentation, her bilateral proximal femoral fractures failed to unite by conservative methods and operative treatment was indicated. We used a bilateral reverse femoral LISS plate as the proximal fragments were short and needed axial and rotational control.

Conclusion: The reverse LISS is a useful implant for treatment of femoral fractures, especially when the femur is deformed and the medullary cavity is obliterated as in cases of Osteopetrosis.

Methods and materials: Between August 2000 and August 2002, 28 patients, average age of 78 years (range 62 to 94 years), with distal femoral fractures (33A1 – 17, 33A2 – 1, 33C1 – 6, 33C2 – 4) were treated with DFN. All the patients had sustained the injury following a simple fall. Periprosthetic fractures were excluded from this study. Two fractures required additional procedures in the form of circleage wires. Nailing was performed through a midline mini arthrotomy. Post operative protocol was to mobilise the patient weight bearing as tolerated.

Results: All fractures healed without the need for secondary procedures. Average period of follow up was 8.5 months. Average hospital stay was 18 days (range 10 to 34). Post operative mobility returned to pre operative state in 15 patients. Three patients died within 3 months due to unrelated medical causes. There was no incidence of extension lag or malunion. Knee range of movement was on average 95°. Patients with pre existing knee arthritis had slight worsening of the pain. Hospital for Special Surgery knee scores were on average 78.3. 23 patients were rated as excellent, 4 good and 1 poor. In one patient the distal screws broke without significant functional impairment.

Conclusion: We recommend the use of DFN in supracondylar femoral fractures in the elderly as it produced satisfactory results with low operative and post operative morbidity. It can be performed with minimal soft tissue damage with good purchase in the osteoporotic bone which allows early mobilisation.

Introduction and Aims: Achieving bloodless surgical field is vital for any arthroscopy surgery. Olszewski et al showed that dilute adrenaline saline irrigation (1mg/l) improves the clarity of operative field by reducing the bleeding. Jensen et al also showed that dilute adrenaline saline irrigation (0.33mg/l) is beneficial in achieving bloodless field in shoulder arthroscopy.

Method: A prospective, randomised, double blind, control trial was carried out to determine the effect of adrenaline (epinephrine) in knee arthroscopy without tourniquet. Ethics Committee approval was obtained for this study. A Doctors/Dentists Exemption Certificate (DDX) was obtained from Medicines Control Agency (UK govt) for use of adrenaline (epinephrine) in this trial. All patients undergoing knee arthroscopy were randomised into two groups: 1) to have dilute adrenaline (1 mg of adrenaline into three-litre bags of normal saline (0.33mg/l) for irrigation); and 2) not to have dilute adrenaline in normal saline irrigation.

Results: A total of 40 patients (24 male and 16 female) were included in the trial. All operations were performed using pressure-controlled pump system (75 mm Hg). No tourniquets were used. A visual analogue score (VAS) of zero to 10 (worst to best) was used by the surgeon to determine the clarity of surgical field at the end of operation. Mean age was 46.5 years (IQR 27–63 years). Twenty patients had dilute adrenaline saline irrigation and 20 had normal saline irrigation. Mean VAS was 8.5 (IQR 6 – 10). Mean VAS for group 1 was 8.4 and for group 2 was 8.7 (p= 0.59). There were no intra-operative or immediate post-operative complications noted in either group.

Conclusion: The study failed to identify any benefit of using adrenaline (epinephrine) in normal saline irrigation fluid in terms of achieving bloodless surgical field in knee arthroscopy. The study also conclude that pressure controlled pump system provides excellent bloodless surgical field in knee arthroscopy without tourniquet.

Aims: To determine the kneeling ability in 3 groups of patients who have undergone either Unicondylar, Primary, or Revision knee arthroplasty.

Methods: A questionnaire was designed to determine the kneeling ability of patients who have undergone knee arthroplasty surgery. The ‘Kneeling’ questionnaire along with a Western Ontario and MacMaster Osteoarthritis Index (WOMAC) questionnaire was sent to 191 patients of whom, 27 have had Unicondylar, 105 had Primary and 59 Revision knee arthroplasty.

Results: The mean follow-up time for assessment for each of the 3 groups of patients were; Unicondylar = 3.32 years, Primary = 5.30 years and Revision = 5.06 years. The mean total WOMAC scores for the 3 groups were; Unicondylar = 13.96, Primary = 22.10, and Revision = 38.67. The percentage of patients who underwent knee arthroplasty that found it impossible to kneel were; Unicondylar = 18%, Primary = 36% and Revision = 66%. The commonest reasons why patients found kneeling difficult were; pain and stiffness around the knee prosthesis, fear of harming the prosthesis and sensory deficit around the knee. Visual Analogue Pain scores for kneeling in the 3 patient groups were, Unicondylar = 5.6, Primary = 7.12, Revision = 9.18. A minimum of 30% of patients in each of the 3 groups reported their daily lives were moderately-severely affected due to their difficulty in kneeling following knee arthroplasty. At least 60% of the patients in each group reported they would like to have better kneeling ability.

Conclusion: Unicondylar knee arthroplasty patients have better WOMAC scores and find kneeling easier than patients who have undergone Primary knee arthroplasty (p< 0.01). The Primary group have better WOMAC scores and find kneeling easier than the Revision group (p< 0.001). Kneeling is considered important in patients who have undergone knee arthroplasty. Poor kneeling ability in patients may restrict their daily activities.

Aim: To report on the bone histology of patients undergoing intramedullary stabilisation for a pathological fracture or a metastatic lesion in long bones.

Materials and methods: From 1999 to 2002, 36 long bones in 29 patients (seven had stabilisation of two long bones) were stabilised with an intramedullary nail in patients with a known primary tumour. Prophylactic fixation was performed in 19 bones with metastatic tumour and in 17 for a fracture. Of the 17 fractures, 13 were considered pathological and four were simple fracture unrelated to metastasis. Thirty-three nailings were done for proximal femoral lesions and three were for the humerus. Reaming samples were sent for histological analysis. The various sites of the primary tumour were Breast (13), Myeloma (6), Prostate (5), Lung (4), Unknown (3), Bladder (2), Oesophagus (1), Renal (1), Melanoma (1). The histological results were correlated with the clinical diagnosis.

Results: Thirty-six reaming samples were sent for histological analysis. Twenty-two samples correlated with the clinical diagnosis. Of the 22 tissue samples, two did not have a initial confirmed histological diagnosis of primary and the reaming samples helped to achieve this. Fourteen biopsies gave false negative results.

Conclusion: Approximately two-thirds of the time the reaming sample has correlated with clinical diagnosis. Sensitivity of this test is 61%.

A fifty year old lady with history of rheumatoid arthritis (RA) for 24 years and COPD for 10 years was admitted for investigation of persistent chest infection and for the control of RA flare-up. She was on Sulphasalazine, NSAIDs and had completed a course of gold injections and on admission started on methotrexate, folic acid, Calcium, bisphosphonates and alendronate. Urinanalysis was positive for Bence Jones’ Proteins (BJP). Four days after admission patient developed spontaneous pain in the right thigh with inability to move the right leg. Radiographs showed a supracondylar femoral fracture through a lytic lesion, which was stabilised with a Distal femoral nail. At surgery bone quality of right femur was found to be very poor. Radiographs of the left femur showed a lytic lesion in the subtrochanteric region, which was stabilised prophylactically with a Proximal Femoral Nail. Histopathological examination of the marrow reamings from right femur showed no neoplastic changes and from left femur showed occasional plasma cells. 24 hour urinanalysis showed BJP of 0.22g/hour and protein electrophoresis showed monoclonal antibodies. Bone marrow biopsy was performed which showed only reactive cells. A week later 24 hour urine BJP was down to 0.13g/hour. At three weeks, symptoms of RA were under control and the protein electrophoresis showed no monoclonal banding. Chest infection resolved with appropriate antibiotics. Computerised Tomography of chest showed bronchiectasis with no evidence of neoplasm.

Discussion: In acute stages of RA there is an increase in antibodies production that may present as positive for monoclonal antibodies on electrophoresis and by the same reason urine may be positive for BJP. The spontaneous fracture in this case could be due to severe reactive osteoporosis confounding the clinical picture of active RA. Without clear evidence of myeloma or plasmacytoma, instituting chemotherapy may lead to further complications in patients with RA.

A 52 year old male presented with a pathological subtrochanteric femoral fracture secondary to multiple myeloma. While stabilising the fracture with a Long Proximal Femoral Nail (PFN) distal femur fracture occurred, while introducing the distal locking screw, which was fixed with two cables. Partial weight bearing was allowed for the first six weeks.

Three months after surgery the distal static locking screw broke. Eighteen months post surgery patient developed sudden spontaneous right hip pain and was treated with further chemotherapy and radiotherapy. Radiographs showed the fracture had not healed but there was no evidence of implant failure. Two years later patient presented with sudden increase in right hip pain with inability to walk. Radiographs showed that the nail had broken at the proximal hip screw hole.

At revision surgery, with difficulty the broken distal locking screws were removed and the broken nail was removed by pushing it from below through the knee. The non union was stabilised with another long PFN. At four months post revision surgery there were radiological signs of bone healing and patient had no symptoms.

Discussion: Reconstruction nails such as long PFN are bio mechanically suited for proximal femoral fractures and metastases. Bone cement augmentation has been reported to provide additional support in metastases. Dynamisation of the fracture leads to fracture impaction and promotes fracture healing. In this case implant failure was probably due to non union and fatigue failure of the implant. In spite of ‘spontaneous’ dynamisation (broken static distal screw), union did not occur initially.

This is the first reported incidence of failure of long PFN in a pathological femoral fracture stabilisation.

Between April 1999 and December 2001 forty-one patients (forty-five femora) with metastatic lesions in the proximal femur involving intertrochanteric and subtrochanteric regions were stabilised with Proximal Femoral Nail (PFN). Thirty-eight patients (forty-two femora) were followed up for a mean period of 20 months (range 3 weeks to 35 months). There was an overall increase in mobility in 60% of the patients and the rest remained the same. Mean Preoperative Visual analog scale rating for thigh pain was 8.1 versus 3.4 for postoperative score (p< 0.01). There were no complications with respect to PFN. There were three post operative complications – chest infection, superficial wound dehiscence and pulmonary embolism. All these complications resolved without any further deterioration. Since these lesions do not usually heal well a cephalomedullary device is ideal to withstand long-term cyclic loading. Minimal operative trauma, mechanical stability, early mobilisation, pain relief and short hospital stay are the advantages of PFN in stabilising impending fractures of the proximal femur.

Aim: To report our experience with a newly devised Long Proximal Femoral Nail [Long PFN] for treating complex subtrochanteric femoral fractures. The nail has the advantage of providing rotational as well as axial stability in the proximal femur with its hip pin in addition to the strong hip screw and easy operation technique. Methods: Twenty-four consecutive patients with twenty-four displaced subtrochanteric femoral fractures were treated with long PFN. The fractures were classified according to the Seinsheimer’s criteria. In 9 patients, the proximal femur had posteromedial wall comminution with displacement. The average age of the patients was 68.7 years. Closed reduction of the fracture was attempted in all cases and when it failed to achieve satisfactory reduction, a limited open reduction and cerclage cabling of the fracture was performed prior to the nailing with a particular emphasis on the postero-medial wall reconstruction. Result: The average follow up period was 49.7 weeks. All fractures in our series achieved bony union with an average time to union of 24.5 weeks. No patients had implant failure and no deep infection noted in the patients who had limited open reduction. Two patients had chest infection and one had non-fatal pulmonary embolism. Conclusion: Long PFN is a reliable implant in the treatment of complex subtro-chanteric fractures. Posteromedial wall reconstruction of the proximal femur is mandatory when treating sub-trochanteric fractures with Long PFN to avoid mechanical failure and non-union.

Aim: To report the experience with the new device, the Long Proximal Femoral Nail (Long PFN) in patients with impending pathological femoral fractures to identify the advantages and complications associated with its usage. This is the þrst in the series on the use of Long PFN for patients with femoral metastases. Methods: Between April 2000 and September 2001, twenty-þve consecutive patients with femoral pathological lesions were prophylactically stabilised using Long PFN. The nailings were performed using a percutaneous closed technique. Lateral femoral Line (LFL) technique was used for location of the entry point and easy insertion for the nail. Only the proximal one þfth of the femur was reamed to accommodate the 17 mm diameter of the proximal part of the nail. Results: We had technical problems in three patients. The overall mobility of the patients improved in twenty patients and the mobility remained the same as preoperative level in þve patients. Good to excellent pain relief achieved in eighteen patients. The pain relief was fair in þve patients and poor in two patients. We had no mechanical failure of the implant in our series. Conclusion: Long PFN, a modiþed reconstruction nail, which can be inserted percutaneously and has an easy operation technique. Our early experience with Long PFN in the management of impending femoral fractures has been favourable.

Hips and knees are commonly replaced joints for which several types of prostheses are available. As newer versions of the prostheses are brought in, older versions are phased out. When revision is for an isolated component failure as in, wear of acetabular cup, isolated revision of the acetabular cup is an accepted procedure. If the plan is to revise just the isolated component then that particular model of prosthesis should still be available.

In an attempt to check the availability of revision components for joint replacements we wrote to ten prostheses manufacturers enquiring the availability of prosthetic components. To have a comparison, we also wrote to eighteen leading car manufacturers enquiring about the duration and any guarantees on the availability of car spare parts.

From our survey we found that the availability of the revision implants was satisfactory in that all the prostheses manufacturers were eager to provide as much assistance as possible. The draw back is that there are no regulations to ensure the availability of these prosthetic components for any length of time after discontinuation of a particular model.

The car manufacturers are not under any obligation to provide spare parts for discontinued models. The argument put forward by some manufacturers for providing spare parts up to ten years from discontinuing the model was that “it would not reflect well on the company” if it were for any lesser length of time.

Conclusion: At present though there are no regulations on the time period of availability of total joint prosthetic components. The manufacturers have taken it upon themselves to provide the prosthetic components whenever a specific request is made. If the manufacturers say they can not provide the implants there is nothing in the governmental regulations that provide for recourse.

Up to 75% of patients develop metalwork related problems following ankle fracture fixation and require further open surgery to remove them. This second procedure can lead to significant morbidity. To minimise these complications, we developed a technique, for removing the metalwork percutaneously. This technique was used in 12 patients with metalwork problems related to malleolar implants. The majority of problems occurred with the distal fibular plate and the screws.

One stab incision was placed mid way between every two screws so that two screws could be removed though one incision. The plate was stripped from the distal fibula using a narrow osteotome and extracted through the distal or proximal stab wound. Lag screws were also removed through an anterolateral stab incision. When we were unable to palpate the screw head, we used a guide wire under image intensifier to locate the screw head and railroaded a cannulated screwdriver over the wire to lock into the head of the screw. Medial malleolar screws were removed in a similar fashion. The technique was undertaken as day case surgery. No complications were encountered. All patients remained symptom-free postoperatively.

We conclude that percutaneous removal of metalwork around ankle joint is a safe and effective technique, allowing the patient to quickly regain their preoperative level of activity.