INTRODUCTION

Tranexamic Acid (TA) has been shown to decrease peri-operative bleeding in primary Total Knee Replacement (TKR) surgery. There are still concerns with regards to the increased risk of thromboembolic events with the use of TA. The aim of this study was to assess whether the use of pre-operative TA increased the incidence of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) in TKR.

Introduction: With recent concerns about the prevalence of Clostridium difficile, some Orthopaedic departments have changed their antibiotic prophylaxis for hip arthroplasty patients. Are these decisions evidence-based and are the changes in the best interests of the patient? We have gathered information from hospitals across the UK to investigate whether prophylactic regimens are changing and what is driving this change.

Methods: Information was gathered using a questionnaire. This was sent via e-mail to hospitals in the Mersey Deanery, the East Anglian Deanery and other hospitals across the UK.

Results: Replies were received from 21 hospitals in total. The vast proportion is still using cefuroxime 1.5g on induction with 2 post-op doses of cefuroxime 750mg. Those that have changed are mainly using flucloxacillin/gentamicin although decisions regarding prophylaxis are being driven by microbiologists/management (cost implicated in 10%) rather than clinicians/clinical evidence.

Discussion: The AAOS has recommended that antibiotics used for prophylaxis should be carefully selected. They should be consistent with current recommendations in the literature, taking into account issues of resistance and patient allergies. In 2007, the DoH recommended prudent antibiotic prescribing to reduce the use of broad spectrum antibiotics as an important component in preventing and controlling Clostridium difficile. Nelson postulated in a Cochrane Database Review in 2007 that in treating Clostridium difficile-associated diarrhoea in adults, teicoplanin appeared to be the best choice because evidence suggests that it is better than vancomycin for bacteriologic cure and has borderline superior effectiveness in terms of symptomatic cure. The combination of teicoplanin (covering Gram positive organisms including MRSA and enterococci) an gentamicin (covering aerobic Gram negatives and staphylococci) would surely be in the best interests of the patient despite the cost.

Introduction: The management of total hip replacement (THR) dislocations is variable after closed reduction. This study was performed to look at the differences in immediate management of THR dislocations after reduction under anaesthesia.

Method: A questionnaire was sent to all members of the British Hip Society asking them about their management of THR dislocations after closed reduction.

Results: 62 orthopaedic consultants completed the questionnaire. A 34% return rate for our postal survey to the 2004 members of the British Hip Society.

For first time dislocations with a stable EUA 8% always used an abduction brace and 50% never used one. 20% were managed with a period of bed rest. For an unstable EUA, 40% always used a brace and 23% never used one. 31% were managed with a period of bed rest. When a brace was used, the majority (75%) used it for 6 weeks (range 2 to 12 weeks).

For recurrent dislocations, with a stable EUA, 65% used a brace for at least 6 weeks. For an unstable EUA 74% used a brace for at least 6 weeks and 15% managed with a brace permanently or until revision.

50% asked the patient to wear the brace 24 hours a day including whilst asleep, the only exception being for washing. The others were varying from 12 to 16 hours a day.

The commonest criteria for revision surgery were recurrent dislocation (seen as more than three), component malposition, aseptic loosening and instability at EUA. The questionnaire was answered by orthopaedic surgeons who all had experience in revision surgery, the majority having performed over 100 revision THR in the past 5 years.

Discussion: The management of dislocated THR is varied between units. There does not appear to be a pattern of management amongst BHS members. The popularity and efficacy of abduction braces remains unknown.

Introduction Most proximal humeral fractures are treated conservatively. However, treatment for the severely displaced fractures (Neer’s grade IV) is more challenging. This is especially in the adolescent age group where the remodelling potential is reduced. We report on our 8-year experience of fixing severely displaced proximal humeral fractures in children using ESIN.

Method Between 1996 and 2003, we treated 14 children (7 metaphyseal and 7 epiphyseal fractures) using ESIN. 11 were completely displaced and 12 were caused by high energy forces. Our indications included unstable fracture with severe displacement (> 2/3 shaft diameter), age above 12 years and multiple injuries/polytrauma. Manipulation of the fractures and the operative technique is described. Post-operatively, the arm is kept in a sling for 2 weeks. All patients were reviewed on a monthly basis until clinical and radiological healing. Following the removal of the nails, the patients are only discharged when they demonstrate full pain-free range of movement.

Results The double nail technique was used in the first 2 cases and a single nail was used for the subsequent 12 cases. The fracture was reduced by open technique in 1 case. In another, the nail was inserted antegrade. Time from injury to surgery was 2.4 days. The mean operation time was 65 minutes and hospital stay 2.1 days. Time to clinical healing (complete pain-free range of movement) was 2.4 months and radiological healing 3.2 months. All nails were removed by 6 months. Shoulder and elbow range of movement returned to normal at 3.5 and 3.2 months. Complications included 4 cases of elbow stiffness due to nail prominence and 1 case of nail breakage during removal. 1 patient had 10 degrees of varus and in 2 other patients, 5 degrees of varus and 1 cm of shortening and 1.5 cm of shortening respectively. At the final follow-up (14.6 months), all patients had symptom free full range of movement.

Conclusion ESIN is a valid treatment for the severely displaced proximal humeral fractures in the adolescence. It avoids lengthy and awkward immobilization and allows early post-operative mobilization. The single nail technique proved to be adequate to maintain alignment and allow fracture healing, keeping the invasiveness of the procedure to a minimum.

Introduction ESIN is an established method of treatment of long bone fractures in children, which has been in regular use in our institution since 1996. We report on our 7-year experience of using ESIN for the treatment of long bone fractures in children.

Method 92 fractures were nailed (26 femoral, 12 tibial, 17 humeral and 37 forearm). The average age was 12 years (7–15) and average follow-up 15 months. Main indications included unstable and severely displaced fractures, failure of conservative treatment and polytrauma or head injury. Data collection included mechanism of injury, fracture configuration, treatment delay, operation time and technique, length of hospital stay, rehabilitation, healing, nail removal and complications.

Results 49% of fractures were caused by road traffic accidents. All were diaphyseal apart from 14 proximal humeral fractures. The average surgery delay was 7 days and operation time 78 minutes. Open reduction was performed in 3 femoral, 1 humeral and 18 forearm fractures. Single nailing was used for the proximal humeral and forearm fracture. The average hospital stay was 5.8 days, ranging from 12 days for femoral to 2 days for forearm fractures. Clinical healing was achieved at 3.5, 4.3, 2.4 and 2.1 months respectively for femoral, tibial, humeral and forearm fractures.

The commonest complication (25%) was skiin irritation around the entry site, which invariably resolved after implant removal. Delayed union occurred in 2 femoral and 2 tibial fractures (all healed following bone marrow injection). 2 tibial fractures mal-united and 1 tibial fracture was complicated with compartment syndrome. The average nail removal time was 9 months. The nails could not be removed in 4 cases.

Conclusion ESIN is minimally invasive and has a low complication rate. It avoids the lengthy immobilization of conservative treatment, and the surgical trauma of plating without the association of refractures or nerve damage. We believe it represents a valid option in the treatment of long bone fractures.

Study Design: A prospective cohort study of patients undergoing surgery for prolapsed intervertebral disc.

Objective: To assess a patient’s ability to recall information discussed pre-operatively at the time of informed consent six weeks following surgery.

Subjects: Sixty-one consecutive patients undergoing discectomy for prolapsed intervertebral disc with follow up six weeks after surgery.

Outcome measures: Patients were assessed, using a pre-prepared questionnaire, to establish their understanding of disc surgery prior to signing a consent form. All information on the questionnaire had previously been given to the patient at the time of being put on the waiting list via a copy of the clinic letter to the general practitioner. If patients were unable to complete the questionnaire, they were then tutored using visual aids such as posters and models until they were able to answer the questions correctly. The consent form was then signed. Six weeks following surgery, patients were then asked the same questionnaire to establish their ability to recall the information discussed pre-operatively about disc surgery.

Results: Prior to tutoring, 20 % of patients were unable to recall that their symptoms were due to disc pathology and that surgery to remove the disc would relieve their symptoms. They were also unable to recall the success rate of surgery. Following surgery, only half of this group of patients could recall these facts. Only 32% of patients were able to recall two or more risk factors of surgery prior to tutoring. This improved to 45% following surgery. Pre- and post-operative questionnaire scores were analysed using a paired t-test. There was no statistical improvement in questionnaire scores long term following tutoring.

Conclusion: In this group of patients, extensive tutoring with the use of visual aids as an adjunct, does not statistically improve their ability to recall important information about surgery for prolapsed intervertebral disc and the risks associated with it.