Introduction: The pilon fracture extending from the distal tibial metaphysis into the ankle joint represents one of the most challenging injuries faced by orthopaedic surgeons. Achieving the ideal of anatomic reduction and stable fixation is often impeded by the frequently severe soft tissue injuries associated with these fractures. In June 2004 we began treating intra-articular pilon fractures by minimally invasive techniques.

Methods: The minimally invasive technique used involves reduction of the fracture by ligamentotaxis with the use of the traction table and manipulation of the foot to correct rotation, varus/valgus, pro/recurvatum. Any further reduction where necessary was performed using an ankle arthroscope and a probe introduced through stab incisions anteriorly. Following reduction a distal tibial locking plate was applied percutaneously to the medial of the tibia. Locking screws were then inserted percutaneously. All significant anterior or posterior distal tibial fragment were fixed separately with an anterior percutaneously inserted interfragmentary compression screw.

We compared all cases of closed intra-articluar fractures (AO types C2 and C3) fixed by the method described above in a one year period (June 2004 – June 2005) – Group 1 (n = 26), with the immediate previous one year period (June 2003 – June 2004) of matched closed fracture pattern fixed by formal open reduction and internal fixation – Group 2 (n = 16).

Mean follow up was 26 months. All bony and soft tissue complications were recorded. A specific assessment of foot and ankle outcome was undertaken using the American Orthopaedic Foot and Ankle Score (AOFAS). Scoring was undertaken on two separate occasions at a mean of 9 and 24 months post operatively, by orthopaedic surgeons blinded to the treatment modality. The mean of the two scores was then recorded. It has been previously demonstrated that the functional outcome in pilon fractures improves for approximately 2 years after injury.

Results: We observed a much higher incidence of complications in the open reduction group when compared with the minimally invasive group. An excellent AOFAS result was obtained in 83% (20/24) of the patients in the minimally invasive group, the same result was achieved in only 12.5% of the formal open reduction and fixation group.

Conclusion – The use of the minimally invasive reduction method described here in combination with the insertion of percutaneous fixation, in the form a medial locking plate with or without additional percutaneously inserted antero-posterior screws represents a valuable method of treating the most complex of closed pilon fractures.

Introduction: The technology available for replacing/resurfacing the hip is constantly evolving. The surgeon can now choose from a wide array of componenets to perform a cemented, hybrid, uncemented total hip arthroplasty (THA) or resurfacing arthroplasty (RSA). The aim of our study was to evaluate and compare the restoration of hip biomechanics following insertion of three different, commonly used constructs.

Methods: We compared the pre and postoperative radiographs from 40 patients who underwent cemented THA, 45 patients who underwent uncemented THA and 40 who underwent RSA. The femoral offset and limb length differences were measured, with reference to the normal contralateral hip.

Results: Resurfacing resulted in a significant reduction in femoral offset, with accurate restoration of limb length. Both cemented and uncemented THA resulted in a significant increase in femoral offset and leg length. Uncemented THA resulted in the greatest degree of leg lengthening.

Discusssion: Restoration of normal hip anatomy optimises biomechanical function and reduces wear of components. The RSA group had the most accurate restoration compared to the two other groups. The reduced femoral offset associated with the RSA group may reduce the lever arm of the abductor muscles however this is unlikely to be clinically important.

Introduction: The pilon fracture extending from the distal tibial metaphysis into the ankle joint represents one of the most challenging injuries faced by orthopaedic surgeons. Achieving the ideal of anatomic reduction and stable fixation is often impeded by the frequently severe soft tissue injuries associated with these fractures. In June 2004 we began treating intra-articular pilon fractures by minimally invasive techniques.

Materials and Methods: The minimally invasive technique used involved reduction of the fracture by ligamentotaxis and manipulation of the foot to correct rotation, varus/valgus, pro/recurvatum. Any further reduction was performed using an ankle arthroscope and a probe introduced through stab incisions. Following reduction a distal tibial locking plate was applied percutaneously to the medial of the tibia. All significant anterior or posterior distal tibial fragments were fixed separately with an anterior percutaneously inserted interfragmentary compression screw.

We compared all cases of closed intra-articluar fractures (AO types C2 and C3) fixed by the method described above in a one year period (June 2004 – June 2005) – Group 1 (n = 26), with the immediate previous one year period (June 2003 – June 2004) of matched closed fracture pattern fixed by formal open reduction and internal fixation – Group 2 (n = 16).

Mean follow up was 26 months. All bony and soft tissue complications were recorded. A specific assessment of outcome was undertaken using the American Orthopaedic Foot and Ankle Score (AOFAS). Scoring was undertaken on two separate occasions at a mean of 9 and 24 months post operatively.

Results: We observed a far greater incidence of complications in the open reduction group when compared with the minimally invasive group. An excellent AOFAS result was obtained in 83% (20/24) of the patients in the minimally invasive group, the same result was achieved in only 12.5 % of the formal open reduction and fixation group.

Conclusion: The use of the minimally invasive reduction method described here in combination with the insertion of percutaneous fixation, represents a valuable method of treating the most complex of closed pilon fractures.

Introduction: The technology available for replacing/ resurfacing the hip joint is constantly evolving. The practicing surgeon can now choose from a wide array of components to perform a cemented, hybrid, uncemented total hip arthroplasty (THA), or a hip resurfacing. The potential advantages and disadvantages of all have been widely reported in the literature. The choice of implant depends on a number of factors, such as, patient age and level of activity, hip anatomy, and the surgeons’ preference and expertise. The aim of our study was to evaluate and compare the restoration of hip biomechanics following the insertion of three different, commonly used constructs.

Methods: We compared the postoperative anteroposterior radiographs from 40 patients who underwent cemented THA, 45 patients who underwent uncemented THA and 40 who underwent Articular Surface Replacement (ASR). All procedures were carried out by a single consultant orthopaedic surgeon who was experienced in the insertion of all three different implant designs. The acetabular offset and height, and the femoral offset and limb length were measured, with reference to the normal contralateral hip, using accepted methods.

Results – Hip resurfacing resulted in a significant reduction in femoral offset (p < 0.001), with accurate restoration of limb length. Both cemented and uncemented THA resulted in a significant increase in femoral offset, both also resulted in significant leg – lengthening (p< 0.001), this was more marked with uncemented THA’s. Radiological measurements of the acetabular reconstruction were similar in all groups.

Discussion – Restoration of normal hip anatomy optimises biomechanical function and reduces wear of components. The ASR group had the most accurate restoration in comparison to the two other groups. The reduced femoral offset associated with the ASR group may reduce the lever arm of the abductor muscles however this is unlikely to be clinically significant.

Aim To document an outbreak of Vancomycin Resistant Enterococci in an elective Orthopaedic Unit. To describe the clinical course of the affected patients and treatment options. To describe methods employed in eradicating endemicity following the outbreak and to evaluate the lessons learnt.

Background VRE first appeared in the Microbiological literature in 1988. Very little is known about its effect in the Orthopaedic Realm. To our knowledge, this is the first report of a serious outbreak in such a unit and only the second reporting of peri-prosthetic VRE infection.

Material and methods All patients in the unit over a 1/12 unit formed the cohort for the study. Following identification of the index case, samples were taken form all in-patients. Immediately a nurse specialist in infection control oversaw sampling of all patients. Microbiological data, Clinical Data and antimicrobial therapy data was collected on all positive patients. Rapid laboratory procedure were instituted, environmental screening was preformed and a dedicated cleaning team was formed. The assistance of a Clinical Microbiologist and an Environmental Microbiologist was sought.

Results Following identification of the index case, 11 patietns had microbiological proven VRE. 1 patient had a VRE confirmed peri-prosthetic infection. This necessitated removal and appropriate anti-microbial therapy. However, this patient died. 2 pateints were found to have superficial wound infection, which resolved with oral Linezolid, while 8 patients showed colonization with the organism. No treatment was required other than clinical follow up and staged screening in these patients.

The unit was closed for 9 weeks following the outbreak and deep cleaning resulted in eradication of endemicity.

Conclusion Tracing of the index case and typing allowed us to confirm the source of the outbreak and to take steps to prevent a recurrence. Appropriate microbiological advice is essential in an outbreak situation, management of peri-prosthetic infection and follow up of affected cases. All protocols have been re-evaluated and retraining of all staff in good clinical hygiene has been undertaken. The speed of the outbreak and its devastating effect on a Joint Replacement Facility is alarming and should serve to aid other units in establishing preventative protocols and in preplanning their treatment options and an outbreak team.