Aims

Hip fracture is a common injury in the elderly. Recent studies in orthopaedic access have demonstrated inequities affecting Māori. This study aimed to compare the demographic differences between Māori and NZ Europeans with hip fractures, identify any deficiencies in initial, surgical and post op care and in outcomes.

Background

Continuous post-operative infusion of local anaesthetic solutions has been implicated as the causative factor in many cases of chondrolysis. Recent in-vitro studies have shown that even a single exposure to local anaesthetic can cause apoptosis and mitochondrial dysfunction leading to chondrocyte death. Glucosamine has been shown to have a protective and reparative effect on articular cartilage.

Background

A pedobarograph is a device that records pressures exerted by the foot on contact with the ground. Clinically most publications using pedobarography investigated diabetic foot pressures for prevention of ulcers, and assessing gait and sway. Only limited work was done on the effects of foot surgery on foot pressures. Any comparison between papers is hampered by the absence of available defined normal ranges of foot pressures.

We report a retrospective review of outcome after shoulder hemiarthroplasty for proximal humerus fractures. All patients managed with shoulder hemiarthroplasty for proximal humerus fractures between 1997 and 2008 were included. Clinical notes were reviewed and surviving patients completed postal Oxford Shoulder Score (OSS) questionnaires. Results were analysed to assess whether there was a difference in outcome for those above the age of 70 years. A total of 96 patients were treated during this period. Female to male ratio was 3.36:1 with mean age 72 ± 9.6 (45–93) years at time of fracture. At time of review 30.2% of patients were dead. Two patients were lost to follow-up after discharge. Complete case notes were available in 68 patients. Response rate to the OSS was 67.2%. There were 20 patients below 70 years and 48 patients above 70 years of age. The ASA grade was II in 60% of patients. Mean follow-up was 52 months. There were 2 in hospital post-operative deaths due to medical complications. Mean OSS was 27 (3–47) of a maximum of 48, with no significant difference between groups. Overall complication rate was 27.9%, with no significant difference between groups. Ten year survival was 96.9% overall with no significant difference between groups. There appears to be no significant difference in functional outcome, complication rate, or implant survival between patients below or above the age of 70 years treated with primary hemiarthroplasty for fracture of the proximal humerus. This procedure however carries a high complication rate in this group of patients.

Background

There are several case reports of chondrolysis following joint arthroscopy. Continuous post-operative infusion of local anaesthetic solutions, especially 0.5% Bupivacaine, has been implicated as the causative factor in many of these cases. Recent in vitro studies have shown that even a single exposure of articular cartilage to different local anaesthetic solutions can cause apoptosis and mitochondrial dysfunction in chondrocytes leading to cell death. There is currently no study looking at methods to prevent this toxicity of local anaesthetic solutions to articular cartilage. Glucosamine has a protective and reparative effect on articular cartilage and a Cochrane review in 2007 found that it provides mild benefit in pain and function in patients with arthritis.

Establish the positive predictive value of clinical examination predicted radicular level to MRI.

To identify the value of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) assessment tool in the assessment of patients presenting with radicular symptoms of lumbar spine source.

8 patients attending the ESP Orthopaedic triage service, presenting with radicular pain in which MRI is clinically indicated.

Prospective study on patients attending ESP Orthopaedic triage service

Patients were clinically examined, both parts LANSS score was completed.

Following the assessment a radicular level was selected.

Following MRI the results were compared.

Positive predicted values (PPV) for clinical examination and sensitivity and specificity of a LANSS score>12 was calculated.

LANSS score

MRI report.

PPV of 75% of therapist predicted level being same level or adjacent level to MRI stated level.

66% specificity and 100% sensitivity of patients in study with LANNS>12 having MRI evaluated radicular nerve root compression.

This pilot suggests that clinical examination and the LANSS score is useful in establishing the presence of radicular nerve root compression. This evidence supports the need for further research.

Research literature suggests sub classification of LBP may improve clinical outcome. Audit aim is to evaluate the outcome of treatment pathways according to sub classification.

Patients had standardised assessment and completed Oswestry Disability Index (ODI) and Hospital Anxiety and Depression Scale (HAD) following assessment and on discharge.

Patients were subgrouped into; non specific LBP, radicular pain, LBP with high psychosocial indicators. Patients were allocated to 3 treatment pathways; individual treatment, functional Back class, back care programme.

200 adult patients referred to physiotherapy for low back pain. Exclusion criteria; red flag presentation, patient requiring advice only (n=38).

Pre treatment and post treatment HAD, ODI

Of 162 patients Individual treatment, 87 (40%)Functional Back Class, 41 (19%)

Back Care Programme, 34 (16%).

Each pathway demonstrated a clinically significant change in outcome measures. Patient's achieved an average change of between 11 – 17% dependant on pathway.

This suggests that the sub classification criteria used allowed the correct pathway choice for patients conditions.

To evaluate the patient experience of patients referred to the ESP Orthopaedic Triage Service. To identify the demographic data of the patients

To evaluate patients' expectations and satisfaction of the service

A prospective audit of 50 new patients to the ESP service in Mountain Ash General Hospital and Prince Charles Hospital

The audit was carried out over a 3 month period between December 2008 and February 2009.

Patients were asked to anonymously complete a survey following their appointment. Data was collated independently and analysed with descriptive statistics.

Patients referred to ESP service

Self administered satisfaction survey.

Mean age range 40-59 yrs (range 20 -70yrs). 50% >1 year duration of symptoms.

94% of patient's surveyed rated the service provided as good - excellent. 88% of patient's reported that they were happy to be assessed by the ESP.

96% of patients surveyed agreed they were able to discuss their treatment openly with only 10% preferring to see a Doctor.

The ESP service in Cwm Taff Health board achieves a high level of patient satisfaction.

Background: Dr Foster’s Good Hospital Guide 2005–2006 ranked University Hospitals of Leicester NHS Trust amongst the worst in UK for in-hospital mortality and time to theatre in hip fracture patients. The problem had been recognized in early 2005 and the Fracture Neck of Femur (FNOF) project was launched. This included an increase in trauma coordinators and clinical aides, regular orthogeriatric input, daily hip fracture operating lists, a separate hip fracture ward and a dedicated discharge nurse.

Aim: The aim of this study was to assess the outcome of the FNOF project.

Method: Data on mortality and length of stay was collected from the IM& T department and was cross referenced with the PCT database. Time to theatre data was collected from the trauma coordinators. Study period was five years from January 2003 to December 2007.

Results: 3636 patients were admitted with a hip fracture in the five year period. The length of stay reduced from 31 days in 2005 to 19 days in 2007 (p< 0.001). The in-hospital mortality reduced from 17.0 % in 2005 to 11.3% in 2007 (p< 0.01). 1 year mortality dropped from 36.9% to 27.3% (p< 0.001). The 30 day and 4 month mortality were also reduced but this was not statistically significant. 85% of patients had surgery within 48 hours in 2007 as compared to 47% in 2005–06.

Conclusions: The FNOF project was successful in reducing In-hospital and 1 year mortality, length of stay and time to theatre. However, the 30 day mortality did not show a significant reduction. In-hospital mortality is not a good comparator of hospital performance as it depends on length of stay; 30 day mortality would be more accurate. The national hip fracture database can be used to obtain accurate data for future studies.

Introduction: Cephalosporins have traditionally been the preferred antimicrobial prophylaxis for 90% of orthopaedic surgeons. With a recent increase in Clos-tridium difficile and MRSA infections, antimicrobial prophylaxis is changing. The aim of this study was to conduct a national survey of current orthopaedic antimicrobial prophylaxis regimes. We wanted to ascertain whether there were any recent changes in these regimes and the reasons for these changes. We also aimed to show any relationship between antimicrobial usage and Clostridium difficile rates.

Methods: Information on prophylaxis regimes and Clostridium difficile rates was requested through a five item questionnaire which was sent to all hospitals in the United Kingdom.

Results: The response rate was 83 %. The top three antimicrobial regimes in trauma and elective orthopaedic surgery were cefuroxime alone (52 %), flucloxacillin plus gentamicin (18 %) and co-amoxiclav alone (8 %). Half of all hospitals had changed antimicrobial regimes and half of these changes were due to Clostridium difficile. The incidence of Clostridium difficile was 70% higher in hospitals using Cefuroxime than hospitals using other antibiotics (0.19% vs. 0.32%)(p < 0.001). Clostridium difficile infection was more common in trauma than elective surgery.

Conclusion: Cefuroxime is still the most commonly used antimicrobial agent but its use has declined mainly due to a surge in Clostridium difficile rates. Reduction in cephalosporin use along with other infection control measures has resulted in a fall in Clostridium difficile infection rates.

Background: Animal studies have shown that 0.9% NaCl causes inhibition of proteoglycan metabolism in articular cartilage yet it continues to be the most commonly used irrigation fluid for arthroscopic surgery. Ringer’s solution and non ionic fluids have been shown to cause less damage. There is currently no such comparison in human articular cartilage. The aim of this study was to assess the effect of different irrigation fluids on arthritic and non arthritic human articular cartilage.

Materials and Methods: Non arthritic cartilage specimens were obtained from femoral heads of hip fracture patients undergoing hemiarthroplasty where there were no radiological or macroscopic signs of osteoarthritis. Arthritic articular cartilage was obtained from tibial plateau of total knee arthroplasty patients or femoral heads with macroscopic signs of osteoarthritis. Cartilage explants were exposed to either 0.9% normal saline or Ringer’s solution, 1.5% Glycine, 10% Mannitol or a control solution of M199 culture medium. 0.5% bupivacaine, which has been shown to be toxic to chondrocytes, was used as a second control solution. The specimens were then incubated in culture medium containing radiolabelled 35-SO4 for 16 hours and uptake was measured as counts per gram per minute.

Results: In non arthritic cartilage, the inhibition of proteoglycan synthesis was 0% with Ringer’s solution (p> 0.05), 3% with Glycine and Mannitol (p> 0.05), 12% with 0.9% NaCl (p> 0.05) and 75% with 0.5% bupivacaine (p< 0.001).

In arthritic cartilage, the inhibition was 15% with Ringer’s solution (p> 0.05), 20% with Mannitol (p> 0.05), 30% with 0.9% NaCl and Glycine (p=0.04) and 85% with 0.5% bupivacaine (p< 0.001).

Conclusion: Normal saline was most harmful to human articular cartilage. Ringer’s solution was the best solution for joint irrigation. We have provided yet more evidence to suggest that 0.5% bupivacaine is severely toxic to articular cartilage.

Background: Ultraclean air (UCA) in the operating theatre has been defined as less than 10 colony forming units (CFU)/m3. Wearing a Body Exhaust Suit (BES) in clear air has been shown to reduce infection from 1.0% to 0.1%. A trial in our unit in 2003 found bacterial air counts of 1 CFU/m3 with Rotecno gowns made from polyester T85392 compared to 0.5 CFU/m3 with BES. The same Rotecno gowns have since been used for arthroplasty surgery in our unit as this difference was not felt to be clinically significant. A new type of gown, manufactured by Gore ltd. was offered to our hospital. These gowns consist of a three layer laminate containing polyester and polytetrafluoroethylene (PTFE) and were advertised as impervious to liquids, bacteria and viruses. Their laboratory results were deemed to be superior to Rotecno gowns on standard testing.

Aim: The aim of this study was to compare bacterial air counts using the existing Rotecno gowns with this new type of occlusive gown made by Gore ltd.

Methods: 56 joint replacements were allocated randomly to either the Rotecno or Gore gowns and also stratified to Total Knee Arthroplasty (TKR), Total Hip Arthroplasty (THA) or Revision THA. Bacterial air counts were measured for the first ten minutes of surgery using a Casella slit sampler which sampled air at 700 lt/min onto a nutrient agar plate. These plates were then incubated for 48 hours at 37 degrees Celcius and colonies were counted.

Results: The new gowns were associated with higher air counts (3.7 CFU/m) than the Rotecno gowns (1.2 CFU/m) (p=0.01). All Rotecno air samples were < 10 CFU/m3 but three of the Gore samples exceeded the clean air standard. The bacterial counts with the Rotecno gowns were the same as those in the 2003 study. TKA was associated with higher air counts than THA or Revision THA (p=0.04).

Conclusions: The new gowns may have been superior on the standard tests but they were not superior at preventing airborne bacterial dispersal. Rotecno gowns made from polyester T85392, although many years old, were still associated with very low air counts. This study highlights the importance of testing new materials in a clinical environment with UCA; in vitro testing alone is not an adequate assessment. This is especially important for TKA which was associated with higher counts.

Background: A good hospital guide published in 2006 identified high in-hospital mortality rates in fracture neck of femur patients at the University Hospitals of Leicester NHS trust. The trust was identified as the worst in the country in terms of the percentage of patients having surgery within the recommended 48 hours from admission. The problem had already been identified and a ‘Fracture Neck of femur project’ was launched in January 2006 to improve outcomes in these patients. This included the introduction of trauma coordinators and clinical aides who prepared patients for surgery, a separate fracture neck of femur ward, a discharge nurse, dedicated hip fracture lists and pre and post operative orthogeriatric input.

Aim: The aim of this study was to assess the impact of the fracture neck of femur project.

Methods: Data on admissions, time to theatre, length of stay and mortality was collected for 3400 patients admitted with fracture neck of femur between January 2003 and September 2007. Mortality rates, length of stay and time to theatre were compared before and after the introduction of the fracture neck of femur project.

Results: The length of stay reduced from 32 days to 18 days in 2007 (p< 0.01). The in-hospital mortality reduced from 16.6 % in 2003 to 10.7% in 2007 (p< 0.01). 30 day mortality showed a minor reduction from 12.4% in 2003 to 11.4% in 2007 (p=0.6). 95% of patients had surgery within 48 hours as compared to 47% in 2005–06 and 85% in 2006–07.

Conclusions: The high in-hospital mortality rates were reduced. The length of stay was also reduced by effective discharge planning. Measures to reduce time to theatre were highly successful. However, the 30 day mortality did not show a significant reduction. We conclude that in hospital mortality is not a good comparator of hospital performance. 30 day mortality would be more accurate.

Background: Clostridium difficile (C diff) diarrhoea is a growing UK hospital problem. However, it is controversial whether patients die with C diff or of C diff. A series of infection control measures were introduced from August 2006 onwards to reduce the rate of C diff infection and to treat patients suffering from diarrhoea. These included a five-day antibiotic stop policy, a diarrhoea treatment policy, a hand washing campaign, increased investment in environmental cleaning and a change in policy for antimicrobial prophylaxis to coamoxiclav instead of cefuroxime. The aim of this study was to assess the impact of these measures on the incidence of C diff infection and to record the mortality associated with C diff. Fracture neck of femur patients were chosen as they are at particular risk.

Method: We assessed data on orthopaedic admissions in particular fracture neck of femur patients, C diff samples, and mortality up to one year. The incidence of C diff was compared between fracture neck of femur patients and other orthopaedic admissions and also before and since the introduction of the infection control policies. This was followed by a comparison of mortality between C diff positive patients and a control group matched by age, sex, ASA grade and place of residence. Mortality data was at 30days, 6 month and 1 year.

Results: Clostridium difficile was much more common in patients with fracture neck of femur (72 out of 1800, 4%) than in other orthopaedic admissions (51 out of 10000, 0.5%, p < 0.001). The incidence of C diff in patients with fracture neck of femur decreased from 49 of 548 (9%) in the 9 months pre-policy to 28 of 562 (5%, p=0.009) in the 9 months since policy Introduction: In those with C diff, mortality at 30 days and 6 months was 10/49 (20%) and 35/49 (71%) pre-policy and 9/28 (32%) and 20/28 (71%) since policy Introduction: Regardless of policy introduction, the overall mortality in 168 C diff positive patients at 30days, 6 months and 1 year was 31 (19%), 112 (67%) and 117 (70%) whilst that in the 168 matched controls was 19 (11%), 43 (26%) and 48 (29%).

Conclusion: The matched group data indicates that C diff increases mortality. It does not simply colonise the most frail. The percentage of deaths in C diff positive patients was no different after the diarrhoea treatment policy Introduction: The incidence of C diff was reduced by 43% using infection control measures. Our results indicate that the best way to reduce mortality due to C diff is to reduce the incidence, our current treatment policy was ineffective or in other words, ‘prevention was better than cure’. We recommend that similar measures could be introduced in other orthopaedic units in order to reduce the incidence and mortality in fracture neck of femur patients from Clostridium difficile.

We report the 15 year follow-up of displaced intra-articular calcaneal fractures from a randomised controlled trial of conservative versus operative treatment. Of the initial study, 46 patients (82%) were still alive and 26 patients (57%) agreed to review.

The clinical outcomes were not different between operative versus conservative treatment. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale: p = 0.11; Foot Function Index (FFI): p = 0.66; and calcaneal fracture score: p = 0.41. The radiological outcomes also were not different between both groups. Böhler’s angle: p = 0.07; height of calcaneum: p = 0.57; and grade of osteoarthritis of the subtalar joint: p = 0.54. There was no correlation between Böhler’s angle and the outcome measures in either group.

The results of this 15 year follow-up of displaced intra-articular calcaneal fracture randomised controlled trial demonstrate similar findings to those at one year follow-up.

Arthrodesis of the ankle joint gives satisfactory short and medium-term results; however, in the longer term, it frequently leads to sub-talar and mid-tarsal osteoarthritis which is difficult to treat. Use of mobile bearings have significantly improved the results of ankle replacement. This a mid term follow up (1 to 5 years)of Buechel-Pappas ankle replacements performed by the senior author.34 total ankle replacements performed by one surgeon from October 1999 to May 2004 were reviewed retrospectively. Pre and post operative VAS scores, AOFAS scores were evaluated to find patient satisfaction and outcome. Tourniquet time as recorded in operation notes showed the learning curve for the procedure. Males : Females- 1:1.4. Mean age was 65 years (range : 33 to 83). Indication for surgery was primary osteoarthritis in 13, post traumatic arthritis in 14 and rheumatoid arthritis in 8. Average VAS score was 8.2 pre operative and improved to 2.0 at follow-up. AOFAS score improved from 39.1 to 72. Operating time averaged 113 minutes in 1999 and 85 in 2004. Significant complications were medial impingement (8) out of which 3 patients needed further surgery, intra-operative malleolar fractures (medial 4, lateral 1 and posterior 1, all healed successfully) and injury to cutaneous nerves (4) 3 patients had superficial infection which settled with antibiotics, but there were no cases of deep infection. 58 % were very happy, 32.5 % were happy, 9.5 % were not happy with the result. 2 patients had ankle fusion on the opposite side earlier, both were happier with the replaced side. Ankle replacements appear to offer a good alternative to fusion in selected patients. There is a significant risk of minor complications. Medial impingement may need further debridement at a later stage.

Ankle replacements appear to offer a good alternative to fusion in most arthritic conditions. Use of mobile bearings have significantly improved results of ankle replacement. These have a significant minor complication rate including nerve injury, fractures. One of the significant complications noted in our series was medial impingement. 34 Buechel-Pappas total ankle replacements performed by the senior author from October 1999 to May 2004 were reviewed retrospectively. Mean follow up of 2.8 years. 8 patients reported medial impingment symptoms at follow up. 3 patients underwent repeat surgery for this problem. One patient underwent arthroscopic debridement of scar tissue and impinging bone by another surgeon which gave good symptomatic relief. Two other patients had tibialis posterior tendonitis and underwent surgical decompression of the tendon. Both were found to be having degenerative tendons with partial tears. We discuss the findings, literature review and other complications of ankle replacements as well. Whether medial impingement is due to implant design or inherent pathology of ankle has to be studied further. Other implant designs like Agility may treat arthritis in medial and lateral gutters but can still cause soft tissue impingement. Whether these are due to implant design, residual arthritis in medial recess or soft tissue pathology is uncertain. This may be caused by the cylindrical shape of talar component (the physiologic talus has a cone shape with smaller radius on medial side). This has not been proven yet, but has been addressed in newer designs like Salto and Hintegra prostheses.

The majority of diaphyseal forearm fractures in children are treated by closed reduction and plaster immobilisation. There is a small subset of patients where operative treatment is indicated. Recent reports indicate that elastic intramedullary nailing (EIN) is gaining popularity over plate fixation. We report the results of EIN for diaphyseal fractures of the forearm in 44 children aged between 5 and 15 years during a three-year period. The indications were instability (26), redisplacement (14), and open fractures (4). Closed reduction and nailing was carried out in 18 cases. A single bone had to be opened in 16 cases and in 10 cases both bones were opened for achieving reduction. Out of the 39 both bone forearm fractures, 35 patients had stabilisation of both radius and ulna and in 4 cases only a single bone was nailed (Radius 3, Ulna 1).

Union was achieved in all the 44 cases at an average time of 7 weeks with one delayed union. All patients regained full flexion and extension of the elbow and wrist. Pronation was restricted by an average of 20° in 30% patients.

Complications were seen in 10 patients (20%). 4 patients had prominent metal work which required early removal. There was refracture in one case, which was treated by nail removal and re-fixation. Two patients developed post operative compartment syndrome requiring fasciotomy. EIN of the radius alone in a patient with fractures of both the bones of forearm, led to secondary displacement of the ulna. This resulted in ulnar malunion and a symptomatic distal radio-ulnar joint subluxation. This was successfully treated by ulnar osteotomy.

Compared to forearm plating EIN involves minimal scarring, easier removal and less risk of nerve damage. We therefore recommend EIN for the treatment of unstable middle and proximal third forearm fractures.

Arthrodesis of the first metatarsophalangeal joint (MTPJ) has been recommended for various big toe deformities. We present a new technique of internal fixation for achieving dynamic compression at the first metatarso-phalangeal joint arthrodesis using memory compression staples. The memory compression staple is fabricated from equiatomic Nickel-Titanium (Ni-Ti) alloy. This alloy has a property by virtue of which it becomes easily malleable at a low temperature and reverts back to its original shape at a higher temperature. This property is known as the Shape Memory Effect. This principle is employed to provide compression at the arthrodesis site. Thirty feet were operated in 27 patients. There were 24 females and 3 males with a mean age of 61.2 years. Two memory compression staples were used at right angles to each other to achieve compression at the fusion site. The post-operative regime allowed full weight-bearing in a rigid sole shoe. A standard questionnaire was used for the subjective assessment, which included questions regarding level of pain, ambulation and patient satisfaction. Objective assessment was performed by a clinical and a radiological examination. Post-operatively there was a reduction in the pain score from 4.6 to 1.6 (p< 0.0001). Ambulation ability improved from 4 to 2.5 (p< 0.0001). There was 96.7% of radiological fusion with an average fusion time of 8.2 weeks. Patients reported 86.6% excellent to good results. The only significant post-operative complication was a single non-union.

We advocate memory compression staples for the internal fixation of the first metatarsophalangeal joint arthrodesis, which is a low profile implant, does not require post-operative cast immobilisation and has a predictable success rate comparable to previously reported methods.

We matched 78 patients with a loose cemented Charnley Elite Plus total hip replacement (THR) by age, gender, race, prosthesis and time from surgery with 49 patients with a well-fixed stable hip replacement, to determine if poor bone quality predisposes to loosening. Clinical, radiological, biomechanical and bone mineral density indicators of bone quality were assessed.

Patients with loose replacements had more pain, were more likely to have presented with atrophic arthritis and to have a history of fragility fracture, narrower femoral cortices and lower peri-prosthetic or lumbar spine bone mineral density (all t-test, p < 0.01). They also tended to be smokers (chi-squared test, p = 0.08). Vitamin-D deficiency was common, but not significantly different between the two groups (t-test, p = 0.31)

In this series of cemented hip replacements performed between 1994 and 1998, aseptic loosening was associated with poor bone quality. Patients with a THR should be screened for osteoporosis and have regular radiological surveillance.