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Volume 94-B, Issue SUPP_XIX May 2012 South West Orthopaedic Club (SWOC)

A. Kassianos L. Jeavons L R.J. Kincaid

Rivaroxaban was introduced for thromboprophylaxis at the Royal Cornwall Hospital for hip and knee arthroplasty surgery in October 2009. We identified 140 patients from theatre logbooks who underwent elective joint replacement between October 2009 and March 2010. Patient notes, computer and DVT clinic records and WebPacs data were collected to determine the uptake of the new drug and the incidence of wound problems, DVTs and any other post-operative complications. In our sample 55.7% [78/140] patients received rivaroxaban. 10.3% [8/78] of patients on rivaroxaban suffered wound complications compared with 6.6% [4/62] of patients on alternative anticoagulation. Three patients suffered DVT's, 1 of whom was taking rivaroxaban. There were a further 6 patients, 4 on rivaroxaban, with leg swelling severe enough to merit investigation, all of whom had negative doppler scans. Bleeding events included 4 patients with postoperative haematemesis of which 2 were taking rivaroxaban. Five patients, all under different surgical operators of which 3 had taken rivaroxaban, developed stiff total knee replacements and were offered MUA or physiotherapy.


T.A. Ball L.J. Wilkinson M. Hockings

Aims

NICE recommends oral anticoagulants after lower limb arthroplasty, as they are thought to lead to better outpatient compliance than injected anticoagulants. Having prescribed self-administered Dalteparin for many years, we began using oral Dabigatran in December 2010. The change afforded an opportunity to compare compliance and acceptability of the two treatments.

Methods

Patients were recruited at discharge and telephoned at 28 days. Left over doses were counted to assess compliance. Side-effects, complications and patient views were also recorded.


U. Butt R. Ahmad D. Aspros G.C. Bannister

Wound ooze is common following Total Knee Arthroplasty and persistent wound ooze is a risk factor for infection, increased length and cost of hospitalisation. We undertook a prospective study to assess the effect of tourniquet time, periarticular local anaesthesia and surgical approach on wound oozing after TKA. The medial parapatellar approach was used in 59 patients (77%) and subvastus in 18 patients (23%). Periarticular local anaesthesia (0.25% Bupivacaine with 1:1000000 adrenalin) was used in 34 patients (44%). The mean tourniquet time was 83 minutes (range 38 to 125 minutes). We found a significant association between cessation of oozing and periarticular local anaesthesia (P = 0.003), length of the tourniquet time (P = 0.03) and the subvastus approach (P = 0.01). Periarticular local anaesthesia, the subvastus approach and shorter tourniquet time were all associated with less wound oozing after total knee arthroplasty.


O.J. Bradford H.G.F. Burnand N. Artz M.A. Hassaballa M. Williams A.J. Porteous J. Robinson J. Murray

Background

Body Mass Index (BMI) is used to quantify generalised obesity, but does not account for variations in soft tissue distribution.

Aims

To define an index quantifying the knee soft tissue depth, utilising underlying bony anatomy, and compare with BMI as a measure of individual patient's knee soft tissue envelopes. We performed a practicality and reproducibility study to validate the Bristol Knee Index for future prospective use.


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W.J.C. Thomas A.J. Dwyer P.J. Porter

Aims

To establish if the principles of Enhanced Recovery, an evidence-based, integrated, multi-modal approach to improving recovery following colonic resection are transferable to elective orthopaedic primary arthroplasty surgery. The principles are to reduce the stress response provoked by surgery and eliminate the peri-operative catabolic state by optimally managing patients' metabolism, expectations, postoperative pain and mobility. This combination of interventions has not been tested in Orthopaedics before.

Methods

We conducted a single surgeon, consecutive patient, interventional, cohort study of primary total hip and knee arthroplasties. Our intervention was Enhanced Orthopaedic Recovery (EOR).


A. Golhar E.J.C. Dawe E.J. Mounsey M. Hockings

Introduction

The management of young patients with painful medial compartment osteoarthritis remains controversial. Opening wedge medial high-tibial osteotomy using a locking plate has shown good results in selected patients. This cohort of patients has high physical demands and previous studies have warned against operating on patients with increased body mass index (BMI).

Patients and Methods

Thirty five patients undergoing valgus high tibial osteotomy between Oct 2004 and Feb 2010. Surgical outcome was assessed using Oxford Knee score, pre- and post-operative pain scores, change in employment and patient satisfaction.


M. Dahill A. Stevenson A. Hughes J. Williams

Magnetic resonance imaging (MRI) scans are widely used in the assessment of knees, often prior to arthroscopic procedures. The reporting of chondral damage on MRI scans can be variable. The correlation between MRI reports of chondral damage and that found at arthroscopy is often inconsistent. The aim of this study was to identify how well MRI reports correlated with the extent of chondral damage found at arthroscopy. A retrospective case-note review of a single-surgeon series of 175 arthroscopic procedures was performed. 83 patients were included in the study. The remainder were excluded if an MRI scan had not been performed, or had been performed more than 3 months prior to surgery. The condition of the articular cartilage demonstrated by MRI was compared to that found at arthroscopy. Data was analysed for presence and extent of chondral damage. Comparison between MRI and arthroscopy findings showed high Specificity (90%) and Negative Predictive Values (89%) for chondral damage, but low Sensitivity (46%). Cohen's kappa values < 0.2 revealed very poor correlation for the extent of damage. This study demonstrates that MRI is good at describing whether articular damage is present but does not reliably describe the extent of the damage.


R.O.E. Gardner T. Yousri F. Holmes D. Clark P. Pollintine A.W. Miles M. Jackson

Treatment of syndesmotic injuries is a subject of ongoing controversy. Locking plates have been shown to provide both angular and axial stability and therefore could potentially control both shear forces and resist widening of the syndesmosis. The aim of this study is to determine whether a two-hole locking plate has biomechanical advantages over conventional screw stabilisation of the syndesmosis in this pattern of injury. Six pairs of fresh-frozen human cadaver lower legs were prepared to simulate an unstable Maisonneuve fracture. The limbs were then mounted on a servo-hydraulic testing rig and axially loaded to a peak load of 800N for 12000 cycles. Each limb was compared with its pair; one receiving stabilisation of the syndesmosis with two 4.5mm quadricortical cortical screws, the other a two-hole locking plate with 3.2mm locking screws (Smith and Nephew). Each limb was then externally rotated until failure occurred. Failure was defined as fracture of bone or metalwork, syndesmotic widening or axial migration >2mm. Both constructs effectively stabilised the syndesmosis during the cyclical loading within 1mm of movement. However the locking plate group demonstrated superior resistance to torque compared to quadricortical screw fixation (40.6Nm vs 21.2Nm respectively, p value <0.03).

Conclusion

A 2 hole locking plate (3.2mm screws) provides significantly greater stability of the syndesmosis to torque when compared with 4.5mm quadricortical fixation.


S.A.C. Morris J. Jelski A.J. Kelly

Introduction

Mortality rates following hip fracture are high. There are several scoring systems which aim to predict morbidity and mortality in hospital in-patients. The Nottingham Hip Fracture Score (NHFS) was devised to predict 30 day mortality following hip fracture. Methods: All patients with hip fractures admitted over a 6 month period were reviewed. The NHFS was calculated for each patient and any associations between patient factors, NHFS, and outcome were investigated.

Results

160 patients were admitted during the study period. 148 patients were followed up for an average of 8.5 months. 9.5% patients died within 30 days. The mean NHFS was 4.6. NHFS showed a significant correlation with overall mortality and positive association with both 30 day mortality and length of stay. Delay to operation was not associated with increased mortality, but increasing age was positively correlated to 30 day mortality.


S.A.C. Morris J. Loveridge A. Torrie D. Smart R. Baker A.J. Ward T.J.S. Chesser

There is controversy regarding the optimum method of stabilising traumatic anterior pelvic ring injuries. This study aimed to evaluate the role of pubic symphysis plating.

Methods

All patients who underwent pubic symphysis plating in a regional pelvic and acetabular unit were studied. Fracture classification, type of fixation, complications, and incidence of metalwork failure were recorded.

Results

Out of 178 consecutive patients, 159 (89%) were studied for a mean of 37.6 months. There were 121 males and 38 females (mean age 43 years). Symphysis pubic fixation was performed in 100 AO-OTA type B and 59 type C injuries using a Matta symphyseal plate (n=92), reconstruction plate (n=65), or DCP (n=2). Supplementary posterior pelvic fixation was performed in 102 patients. 5 patients required revision for failure of fixation or symptomatic instability of the pubic symphysis. A further 7 patients had metalwork removed for other reasons. Metalwork breakage occurred in 63 patients (40%). 62 of these 63 patients were asymptomatic and metalwork was left in situ.


G. Wansbrough L. Wilson

Softcast is an attractive alternative to POP for unstable forearm fractures, providing a comfortable, water-resistant splint that can be removed without a plaster saw. Unreinforced Softcast has, however, only been recommended for buckle fractures. A laboratory study was undertaken to compare standardised POP, Softcast and reinforced Softcast splints at clinically relevant endpoints. The load at clinical failure of a 6-wrap Softcast forearm splint was 504N in bending, 202N in kinking, and 11Nm in torsion (equalling 30.4%, 26% and 42.2% of the equivalent values for a circumferential 4-wrap POP). Softcast was however stronger in all modes than a fibreglass-reinforced Softcast splint, such has been recommended for acute fractures. Furthermore, the load to failure in all modes exceeds that which can be exerted by body weight in many paediatric patients. Softcast demonstrated complete recovery of its original shape on unloading, and was 4% lighter than POP. A 6-wrap Softcast splint provides adequate mechanical stability and protection for paediatric patients up to 20kg, not engaged in high-risk activities. The primary risk is not of fracture angulation and loss of position, but temporary indentation of the splint, causing discomfort or pain. Considering its ease of removal, Softcast may be preferable for younger paediatric patients.


L. Corbett N. Howells B. Burston S. Mitchell

Optimal utilisation of operating theatres has a significant impact on the ability of an institution to deliver productive, value for money surgical services. With the recent introduction of the national ‘Productive Theatres’ programme and in the current economic climate it is receiving increasing attention. In addition, it improves patient satisfaction and outcomes, reduces adverse events and has positive influences on staff morale. The aim of this study was to highlight factors influencing trauma theatre utilisation in general, whilst also addressing any problems identified with a view to improving trauma services locally. We conducted a prospective analysis of activity in the trauma theatre at our institution over 1 month. Direct observation was performed by a single independent observer. In the absence of any published guidelines, all theatre lists were assessed against pre-determined standards for each component of the theatre pathway. Overall end utilisation (combined time utilised for anaesthesia and surgery) was found to be low at 65%. A number of factors were found to contribute to inefficiencies including delay in sending for patients (mean 42mins, range 0-105), prolonged patient transit times to theatre (mean 22% of all sessions), late starts to lists (mean 43 mins, range 15-105 mins) waiting for x-ray availability (mean 21mins, range 10-45) and knock on delay from previous lists. Surgeons and anaesthetists were found to be, overall, arriving on time or early for all lists. Strategies for maximising trauma theatre productivity are essential. This study has identified common issues, of potential benefit to numerous institutions when planning trauma services.


A.J. Dwyer M. Davey A.F. Chambler

Introduction

The aim of the study was to compare and contrast the clinical outcome of conversion of practice of a shoulder surgeon from open to arthroscopic shoulder stabilisation for traumatic anterior shoulder instability.

Patients and Methods

Comparison of a cohort consecutive series of 24 patients treated by open stabilisation and a prospective consecutive cohort series of 30 patients treated by arthroscopic stabilisation. Clinical outcomes were assessed with Oxford Shoulder Score Instability (OSS-I) and a Patient Satisfaction Survey at a minimum of 1 year follow up. The operation time as well as cost analysis were also evaluated.


A.D. Maclean N.R. Howells N. Blewitt

Scaphoid injuries remain a challenge in both diagnosis and subsequent management. Untreated scaphoid non-union leads to inevitable osteoarthritis. Non-unions are picked up via an established management pathway in out trust and treated surgically with a standardised technique of non-vascularised bone grafting and retrograde screw fixation. Patients that underwent primary screw fixation and grafting for scaphoid non-union between 2004-2008 were reviewed. These patients were followed up clinically and radiologically. They were assessed for time to union, complications, DASH score, patient satisfaction and return to work. In addition comparison was made between the use of Herbert screw and Twinfix screw fixation and between tricortical iliac crest graft and corticocancellous distal radial bone graft. Forty-two consecutive patients underwent surgery of which 35 (83%) were available for follow up. Mean follow up was 39 months (range 13-72). 31 (89%) patients had gone on to radiological union. Of those united the mean DASH score was 11. Mean time to union was 4.4 months (range 2-15 95% CI 3.3 – 5.5). 95% of patients were satisfied with their operation and would recommend it to a friend in the same situation. No significant difference in outcomes were identified between Herbert screw and Twinfix screw fixation or between iliac crest or distal radial bone grafting techniques. This study has shown encouraging results for an established protocol for management of scaphoid non-union. Outcomes are as a good as any published comparable series in the literature and provide further support to the use of this technique.


T.A. Ball C. Day D. Strain P.J.A. Cox

Aims

We investigated the local epidemiology of Developmental Dysplasia of the Hip (DDH), in order to define incidence, identify risk factors, and refine our policy on selective ultrasound screening.

Methods

Data were recorded prospectively on all live births in the Exeter area from January 1998 to December 2008. We compared those treated for DDH with all other children. Crude odds ratios (OR) were calculated to identify potential risk factors. Logistic regression was then used to control for interactions between variables.


J. Aird S. Noor P. Rollinson

Introduction

HIV is known to affect many of the processes involved in fracture healing. Recent work has suggested that CD4 cells may act as suppressor in the regulation of fracture healing. There are no clinical studies looking at fracture healing in patients with open fractures in these patients.

Study question

Is there an association between HIV and risk of non union in open fractures treated with surgical stabilisation.


A. Thompson S. Walter L. Brunton G. Pickering S. Mehendale G. C. Bannister

Background

Venous thromboembolism deterrent (TED) stockings are recommended for all orthopaedic patients. Clinical evidence supporting their use is limited and the risk of DVT increases four-fold if pressure gradients are reversed. This study aims to investigate the efficacy of TED stockings and their application using pressure gradients as the outcome measure.

Methods

We audited TED stockings over two discrete periods. In the first, cases were assessed for sizing, cutting in and tolerance. In the second we added pressure measurements along the saphenous vein; before and 2 and 3 days after surgery. Between the 2 series, a more rigorous sizing and re-sizing protocol was implemented.


E.J.C. Dawe T. Ball S. Annamalai J. Davis

Introduction

Minimally Invasive foot surgery remains controversial. Potential benefits include a reduced incidence of wound complications, faster return to employment and normal footwear. There are no studies published regarding the results of minimally invasive dorsal cheilectomy.

Patients and Methods

Thirty eight patients with painful grade I hallux rigidus underwent dorsal cheilectomy between April 2006 and June 2010. Minimally invasive cheilectomy (MIC) was introduced in August 2009. AOFAS scores, satisfaction, return to normal shoes and employment were assessed.