Background

To investigate whether the interaction between pre-operative widespread hyperalgesia and radiographic osteoarthritis (OA) was associated with pain severity before and after total hip replacement (THR) and total knee replacement (TKR).

Aims: To determine the incidence and pattern of pain in patients with displaced pelvic ring injuries treated surgically. To investigate the link between pain and neurological injury.

Methods: All patients with pelvic ring fractures treated surgically were contacted by a postal questionnaire. Assessment was made from validated pain scores, pain maps, a Visual Analog Scale (VAS) and correlated with outcome scores including SF36 and Euroqol. Injuries were classified using the Young and Burgess (YB) classification.

Results: There was a response rate of 85% (151 of 178 patients). Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3yrs (1–12 yrs). 72% were male. There were 31% Antero-Posterior Compression (APC) injuries, 37% Lateral Compression (LC) injuries and 32% Vertical Shear (VS) injuries. 76% of all patients reported activity related pain; 70% of APC, 73% of LC and 86% of VS injuries (p=0.05, Chi-squared test). These results correlated directly with the pain domain of the Euroqol tool. There were however no statistically significant differences in the interference of pain with work (SF36) or the VAS between injury classes. There was a 15% prevalence of neurological injury in the cohort (9% of APC, 11% of LC and 27% of VS injuries; p=0.03 Chi-squared test). There were no statistically significant differences in the prevalence of moderate to severe pain (Euroqol) or the VAS between those with and without significant neurological injury. The presence of neurological injury significantly affected return to employment but not return to sports or social activities.

Conclusions: These results illustrate the prevalence of significant morbidity in patients with surgically treated pelvic ring fractures. Presence of pain could be linked to injury category but a link with neurological injury was not obvious. This can help give prognostic information to patients suffering displaced pelvic ring injuries requiring surgical reconstruction.

Aims: To determine the incidence and pattern of sexual dysfunction in patients with displaced pelvic ring injuries treated surgically. To investigate a link between sexual and urological dysfunction.

Methods: All patients with pelvic ring fractures treated surgically were contacted by a postal questionnaire. Sexual function was assessed using elements of the validated Sexual Function Questionnaire. Patients were also asked specifically about new-onset sexual and urological dysfunction. Injuries were classified using the Young and Burgess (YB) classification.

Results: There was a response rate of 85% (151 of 178 patients). Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3yrs (1–12 yrs). 72% were male.

31% were Antero-Posterior Compression (APC) injuries, 37% Lateral Compression (LC) injuries and 32% Vertical Shear (VS) injuries.

32% of all patients reported significant new sexual problems (36% of males and 24% of females). Of the males, 31% reported erectile dysfunction (12% absolute impotence), 32% reported decreased arousal and 21% reported ejaculatory problems. Of the females, 16% reported decreased arousal, 5% reported anorgasmia and 3% reported painful orgasms. There were no reported cases of dyspareunia in the female patients.

41% of APC, 15% of LC and 39% of VS injuries reported significant new sexual problems (p=0.02, Chi-squared test).

There was a 12% prevalence of significant new urological dysfunction in the entire cohort, with 27% of those with sexual dysfunction also reporting urological dysfunction. This compares with a 5% prevalence of urological dysfunction in patients without sexual dysfunction (p< 0.0001, Chi-squared test).

Conclusions: This large outcome study of UK patients illustrates the significant prevalence of new onset sexual dysfunction in patients with surgically treated pelvic ring fractures. The results also suggest an association between sexual and urological dysfunction. This can help give prognostic information to patients and plan service provision.

We aimed to determine multi-modality outcomes in surgically treated patients with high energy pelvic ring injuries. A retrospective cohort study of all patients with pelvic ring fractures treated surgically within our specialist tertiary referral unit was undertaken between 1994 and 2007. Case-notes and radiographs were reviewed and patients were contacted by postal questionnaire. Outcome measures were return to work, return to pre-injury sports and social activities, and the Short Form-36 (SF-36) outcome tool. Injuries were classified using the Young and Burgess (YB) classifications.

There was a response rate of 70% (145 of 209 patients), 74% of the study subjects were male. Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3 yrs (1–12 yrs). There were 45 Antero-Posterior Compression (APC) injuries, 51 Lateral Compression (LC) injuries and 49 Vertical Shear (VS) injuries. 58% of the APC injuries had returned to work (including changed roles at work), compared with 68% of the LC injuries and 51% of the VS injuries. 27% of the APC injuries had returned to their pre-injury sports, compared with 39% of the LC and 33% of the VS injuries. 64% of the APC injuries had returned to their pre-injury social activities compared with 77% of the LC and 49% of the VS injuries.

The SF-36 average Physical Functioning Score was better for the LC group (73.2) than the APC (61.7) and VS (63.3) groups. This general trend was repeated when the General Health and Social Functioning scores were reviewed.

These results illustrate the long-term morbidity associated with pelvic ring injuries and relationship with injury subtypes. The LC injuries appear to have better outcomes with all outcome measures than APC and VS injuries. Further studies are underway to look at other factors and their relationship to outcomes.

Introduction: Arthroscopic ankle arthrodesis has been shown in other studies to be a viable alternative to open arthrodesis for end stage arthritis. Its demonstrated advantages include comparable or better rates of fusion, reduced morbidity, shorter hospital stays, quicker times to union and reduced wound complications, especially in patients prone to wound healing problems. However, two main restrictions have been shown in the literature; its limited ability for deformity correction and the subsequent need for metalwork removal, commonly for pain or prominence.

Aims: This study sought to investigate the need for metalwork removal, with the specific question of whether the use of a headless screw fixation system reduces the need for subsequent metalwork removal for pain or prominence.

Materials and Methods: Between 2000 and 2007, 37 arthroscopic arthrodesis using the AcutrakTM headless screw fixation system were carried out by the senior author (AK). We reviewed the case notes of all these patients to determine tourniquet times, length of stay in hospital, time to clinical and radiological union, complication rates and the requirement for metalwork removal for pain or prominence.

Results: Of the 37 patients, 22 (59.5%) were male and 15 (40.5%) were female. The average age at surgery was 67 yrs (range 37–86 yrs), average duration of follow up was 37 months (range 6–94 months). The average tourniquet time was 84 minutes (60–120 minutes). The median length of stay was 2 days (1–5 days)

The average time to clinical union was 14 weeks (6–23 weeks) and the average time to radiological union was 16 weeks (6–37 weeks).

There were 6 (16%) non-unions in this series 2 of which were fibrous non-unions. Both patients with fibrous non-unions experienced minimal or no symptoms and did not require further intervention. Of the 4 other non-unions, 3 were revised using an open technique, the fourth patient again being minimally symptomatic and not wanting further surgery.

1 patient suffered a traumatic displacement of the arthrodesis, requiring an open revision which went on to successful union at 3 months.

There were no other complications in this series and, of note, there were no cases of metalwork removal for prominence or pain.

Conclusion: Headless screw fixation systems have the theoretical advantage of allowing the entire length of the screw to be buried in bone, thus eliminating the problem of metalwork prominence. This should therefore obviate the need for further surgery to remove the prominent screws. Our study corroborates this, with none of our patients requiring metalwork removal for prominence.

Introduction: Injuries to the bony pelvis are a significant group of injuries with often serious implications. The close proximity of the bony pelvis to vital organs, it’s involvement in weight bearing and ambulation, and the high energy mechanisms usually required to produce these injuries produces a variety of injury patterns, associated injuries and possible outcomes.

Aims: To determine the long-term functional outcomes of displaced pelvic ring injuries treated surgically in the United Kingdom

Methods: All patients with pelvic ring fractures treated surgically were contacted by postal questionnaire. Outcomes were measured using the SF-36, as well as ad-hoc tools including return to work and sporting activities. Injuries were classified using the Young and Burgess (YB) classification system.

Results: There was a response rate of 70% (145 of 209 patients). Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3yrs (1–12 yrs).

There were 45 Antero-Posterior Compression (APC) injuries, 51 Lateral Compression (LC) injuries and 49 Vertical Shear (VS) injuries.

69% of the LC injuries had returned to some form of employment, compared with 58% of the APC injuries and 51% of the VS. 39% of the LC injuries had returned to their pre-injury sporting activities, compared with 27% of the APC and 33% of the VS.

The average Physical Functioning Score of the SF-36 outcome tool was 73.2 for the LC injuries, 61.7 for the APC injuries and 63.3 for the VS injuries (scale 0–100, 100 representing best status). These trends were mirrored in the other outcome domains of the SF-36 tool.

Conclusions: These results illustrate the long-term morbidity associated with pelvic ring injuries and relationship with injury subtypes. LC injuries appeared to perform better than APC and VS injuries in all outcome measures utilized. These findings may aid in determining the prognosis and provision of services for patients with pelvic ring injuries.

Aim: To compare the outcomes of autologous versus no drainage in patients undergoing primary hip and knee arthroplasty.

Methods: Retrospective review of patients undergoing primary total hip or knee arthroplasty within our unit was carried out. There were 4 groups, each consisting of 20 patients. These were; total hip arthroplasty with and without the use of autologous drains, and total knee arthroplasty with and without the use of autologous drains. Outcome measures were- requirement for homologous (banked) blood, post-operative drop in haemoglobin and length of stay in hospital.

Results: For the knee arthroplasty groups, the homologous transfusion rate was 25% in non-drain patients compared with 5% in patients with drains. The average drop in Hb was 3.3 g/dl in the no-drain group compared with 2.7 in the drain group. The average length of stay was 6.35 days in the no-drain group compared with 6.75 days in the drain group. For the hip arthroplasty groups, the homologous transfusion rate was 10% in the non-drain group compared with 15% in the drain group. The average drop in Hb was 3.9 in the no drain group compared with 3.3 in the drain group. The average length of stay was 6.8 days in the no-drain group compared with 6.9 days in the drain group.

Conclusion: These results demonstrate improvements in the transfusion requirements as well as post-operative Hb drop in knee arthroplasty, but not hip arthroplasty when autologous re-transfusion drains were used. The length of stay was not significantly altered by the usage of drains. Based on these results, we would therefore recommend the use of autologous drains in primary total knee arthroplasty but not in primary total hip arthroplasty.

Aim: To determine the effects of the different types of headgear on bacterial shedding in laminar flow theatres.

Material and Methods: Sham experiments were carried out using standard theatre clothing, sterile gowns and face masks with visors. Three experimental groups were utilised; no headgear (control), surgeons hoods or fabric balaclavas (known colloquially as “chicken hats”). The sham experiments consisted of two surgeons, scrubbed and gowned, both wearing the same headgear, talking and moving hands for 30 minutes over a sterile mock operating field. 5 bacterial plates were placed on the sterile sheets to capture shed bacteria. An additional 5 plates were placed above head height in the laminar flow enclosure. An air sampler was positioned within the laminar flow and set off for the middle 5 mins of the experiment. Plates were then incubated for 48hrs at 37oC and the number of colony forming units at head and waist height as well as in the air sampler were counted. Each experiment was repeated 5 times.

Results: The bacterial shedding rate at waist height was 0.2 CFUs/plate (314 CFUs/m2/hr) for the control experiment, 0 CFUs/plate (0 CFUs/m2/hr) for the surgeons hoods and 0.08 CFUs/plate (126 CFUs/m2/hr) for the fabric balaclavas.

Conclusion: These experiments show very low bacterial shedding rates with standard clothing and headgear in laminar flow theatres. Although these results demonstrate worse bacterial shedding with fabric balaclavas (which contradicts conventional thinking), the low rate of shedding rates means the results are not statistically significant. It therefore raises the question as to whether we should be using the more expensive fabric balaclavas without proven benefit, and the possibility of increased bacterial shedding.

Introduction: Approximately 60000 patients are admitted each year in the UK with neck of femur fractures, the vast majority of whom are elderly presenting with multiple medical comorbidities, including a history of ischaemic heart disease and stroke. They are often on a number of regular medications which may include aspirin, warfarin and more recently, clopidogrel. Clopidogrel and aspirin are associated with an increased bleeding time especially if present as a combined therapy. As such, they can lead to bleeding complications in patients undergoing surgery, increasing the need to transfuse such patients and increasing the risk of cardiovascular events as a result of anaemia. Although clopidogrel is often stopped for patients undergoing elective surgery for a period of 7–10 days, to our knowledge, no such guidelines are available regarding the discontinuation of clopidogrel in patients undergoing surgery for femoral neck fractures. The aim of conducting this survey was to investigate the current practice of various orthopaedic units in the UK with regards to stopping clopidogrel in such patients.

Methods: A telephone questionnaire survey was conducted on junior doctors (House officers, Senior House Officers and Registrars) in orthopaedic departments in the UK which routinely admit and treat patients with fractured neck of femurs.

Does your trust/department have a policy on discontinuing clopidogrel in patients who are due to have emergency trauma surgery such as operative fixation for femoral neck fractures?

Results: 184 NHS trusts in the UK were involved. 45% of trusts stop clopidogrel routinely prior to performing surgery on patients with femoral neck fractures. The number of days clopidogrel is stopped prior to surgery varied from 1 – 7 days. 55% of trusts did not routinely stop aspirin prior to surgery. 97% of trusts routinely stopped warfarin prior to surgery and the target INR varied from < 1.0 – < 3.2.

Conclusions: It is clear from this study that a wide range of policies exists amongst orthopaedic departments in the UK regarding the routine discontinuation of clopidogrel, aspirin and warfarin in patients with femoral neck surgery who are awaiting surgery. This highlights the need for further debate and guidelines regarding the routine discontinuation of clopidogrel.