In a prospective randomised controlled trial, 51 patients who did not receive a bone plug during total knee replacement surgery were compared to 49 patients who received a bone plug. The primary outcome measure was the need for allogenic blood transfusion requirement and the secondary outcome was the post-operative blood loss and decline in haemoglobin levels. The patients had autologous re-transfusion from their closed drainage system. The two groups did not differ in the demographics. The mean intra-operative blood loss was slightly more in the no plug group (difference of 41.25 millilitres), which was not statistically significant. There was no statistically significant difference in total post-operative blood loss and drop in haemoglobin levels. Only one patient had two units of allogenic blood transfusion in the no bone plug group while none required allogenic blood in the bone plug group. There was no statistically significant difference in the amount of blood re-transfused from the drain between the two groups. Our findings did not show any statistically significant difference in post-operative blood loss, decline in haemoglobin levels and the need for allogenic blood transfusion in total knee replacement surgery.

The purpose of this prospective audit was to assess the efficacy of local infiltration analgesia in relieving postoperative pain following knee replacement surgery.

Methods and materials: Data was collected on 61 consecutive patients undergoing knee replacement. They formed 2 groups. Patients in Group I (n=33) had 30 mls of Bupivacaine 0.5%, Ketoralac 30 mg, 0.75ml of adrenaline 1:1000 concentration made up to100mls with normal saline while patients in Group II (n=28) had either patient controlled analgesia (PCA) or regional nerve blocks. The group I patients had the local analgesia cocktail infiltrated into the soft tissues before wound closure. Majority of these patients had spinal anaesthesia supplemented with sedation while some had general anaesthesia supplemented with regional nerve blocks. All the patients were prescribed morphine as rescue analgesia and patacetamol/co-codamol and/or naproxene as supplemental analgesia. Pain was assessed with Numerical Rating Scale (NRS 0 – 10) at 1 hr, 3 hr, 6 hr and 8 hrs post-operatively.

Results: The two groups were well matched for age, sex, ASA grade and body mass index. Pain control was generally satisfactory for group I (NRS range 0 – 2) compared to group II (NRS range 0 – 7). Most patients did not require morphine for post-operative pain control in group I (18/27 pts) while additional analgesics were not needed until 6 hours in this group. They were able to mobilise with assistance earlier compared to the other group. Moreover the pain levels as assessed by pain scores were lower with group I patients compared to group II patients. The nursing level of intensity was lower in group I patients as monitoring of PCA was not required compared to group II patients.

Conclusion: Local infiltration analgesia is practical, simple and safe procedure with good efficacy in relieving pain after knee surgery. Moreover monitoring levels are reduced relieving nursing staff to concentrate on other duties.

We undertook a retrospective audit to assess the effectiveness of use of Quixil in reducing the amount of blood transfusion requirements following revision THR. As Quixil was used from mid 2007 for revision THRs, we looked at blood transfusion requirements for 1 year before introduction of Quixil and compared it with requirements after introduction of Quixil for a similar period.

Method and Materials: 44 patients underwent revision THR by the senior author during the period from June 2007 – June 2008 (Quixil group) while 45 patients did not have Quixil during revision THR for the period May 2006 – May 2007 (Non-quixil group). In the quixil group, M: F = 18:26 and average age 75.3 (range: 63 – 88 yrs). In the non-quixil group, M: F = 17:28 and average age 71.3 (range: 47 – 85 yrs). The duration of surgery was similar in both groups. Blood loss during the operation was evaluated by measuring the volume in the suction apparatus and by estimating the amount of lost blood in the swabs at the end of the operation. Drains were not used in these procedures. All blood transfusions were recorded.

Results: The average blood loss was 1010 mls (range: 300 – 2200 mls) in the quixil group vs. 1021 mls (range: 500 – 2000 mls) in the non-quixil group. The use of cell saver and intra-operative blood transfusion were similar in both groups. The mean pre-op Hb in quixil vs. non-quixil group was 13.0 g/dl (range: 9.7– 16.2) vs. 12.4 g/dl (range: 8.8 – 16.2). The mean post-op Hb in quixil group vs. non-quixil group was 10.2 g/dl (range: 6.4 – 13.2) vs. 9.1 g/dl (range: 5.3 – 12.9)(a difference of 1.1 g/dl). There was a difference in the blood transfused post-operatively between the two groups – 21 vs. 29 patients. Total units of blood transfused in quixil vs. non-quixil group were 60 vs. 86 (a difference of 26 units stastically significant) and total units of intra-op blood transfused in quixil vs. non-quixil group were 16 vs. 23 (a difference of 7 units).

Limitations of the study: Retrospective study, Small numbers of patients

Conclusion: The use of fibrin tissue adhesive in revision total hip arthroplasty seems to be an effective and safe means with which to reduce blood loss and blood-transfusion requirements as well as prevent in the postoperative decrease in the level of hemoglobin.

Introduction: We undertook a questionnaire study to assess the compliance with DVT prophylaxis following lower limb arthroplasty surgery and evaluate reasons for non-compliance (if any).

Method: Following joint replacement surgery, 50 patients (45 had THR, 5 had TKR) were asked to fill in anonymised questionnaire at 6 weeks. They were asked about awareness for DVT, information given, prevention methods, duration and type of prophylaxis given and their compliance with treatment.

Results: Most of the patients (45) were aware of the risk of DVT while 2 were not aware and 3 were not sure. 37 patients were given information during their clinic visit while 7 did not receive any information and 6 can’t remember. 32 patients remembered discussing risk of developing DVT while 9 did not and 9 were not sure. 34 patients (68%) were aware of prophylactic methods. Except for 2 patients, the rest 48 patients (96%) confirmed receiving prophylaxis. 48 patients (96%) had mechanical prophylaxis in the ward while 6 continued at home as well. 46 patients (92%)remembered receiving chemical prophylaxis both in the ward and at home thereafter.

36 patients received chemical prophylaxis (injections) for 10 days, 5 for 7 days, 8 for a few days and 1 patient for 6 weeks post-op. 38 patients (76%) self administrated the injections while 6 had family members help and 3 had district nurse visit. 47 patients (94%) received injections for the complete duration. 3 patients did not receive injections regularly at home (missed nurse visit – 1, not advised – 1, forgot to inject – 1).

Discussion: DVT compliance is still an issue in surgery especially when patients were asked to self-administer the injections. We achieved 94 % compliance with our protocol. This study shows that greater emphasis on patient education, awareness and motivation may help improve compliance.

Introduction: Peri-prosthetic fractures following hip resurfacing arthroplasty are difficult fractures to treat. The surgeon is faced with the task of either attempting to fix the fracture if feasible or revise the resurfacing implant to a conventional total hip replacement.

Method & Results: Here we report of a novel way of fixing a peri-prosthetic fracture following resurfacing hip arthroplasty using Polyaxial locking plate fixation. A 53 year old man sustained a intertrochanteric fracture below his resurfacing metal on metal hip prosthesis following a fall. He had his hip resurfaced 3 years back for osteoarthritis in another hospital. He underwent surgery to fix the fracture using a polyaxial locking plate with no post-operative complications. He was mobilised non-weight bearing for the initial six weeks and weight bearing as tolerated thereafter. He went on to union and was moblising without any problems in three months time. His follow-up x-rays at 8 months showed fracture healed with no evidence of prosthesis problems.

Discussion: There are various methods of treating a periprosthetic fracture of a well fixed resurfaced hip implant. The two types of management are open reduction and internal fixation and revision to a stemmed hip implant. These fractures can be fixed with cannulated hip screws, blade plate device or plating with screws avoiding the stem of the resurfacing prosthesis. We used the polyaxial locking plate device with good result thereby avoiding the need for revision surgery with its attendant risks. Using this implant is a useful alternative for these fracture patterns.

Introduction: We undertook an audit study to find out patient perception of being seen by a nurse practitioner in the clinic for a follow up appointment instead of a consultant and satisfaction with the joint clinic.

Methods and materials: 100 patients were surveyed following their post-operation review with the nurse. Data was collected prospectively over a period of 6 months. Patients were asked to complete the questionnaire on the day of their appointment and to hand the survey prior to leaving. Hence we had 100% response rate.

Results: Majority of the respondents were female (61%) with 50 % having had total hip replacements and the rest had knee replacements. 99% of respondents (94/95) felt that enough time was spent with them during the appointment. All respondents (100%) reported that they were able to ask questions and were answered satisfactorily. The consultant saw 26% of respondents; further 6% was seen by a registrar and the rest 68% were seen by the nurse specialist. Reasons for being seen by a doctor included check up or assessment, reviewing stitches and infection. 42% of respondents (33/79) were referred for further treatment either by the consultant (33%), nurse (64%) or registrar (3%). Reasons for further treatment included physiotherapy, plaster room, and further follow up (check up) appointment at 3–6 months to review the patient following surgery. 100% of respondents (97/97) were satisfied with the combined consultant/nurse clinic. 3 did not record their response. The vast majority of respondents (80%, 79/99) reported that they ‘don’t mind’ who they would have been seen by in the clinic.

Discussion: The results indicate that patients are satisfied with the current clinic arrangements i.e. nurse-led clinic with the consultant being available. Hence there is a definite role for nurse led clinics for joint replacement surgery follow-ups.

Between October 2006 and September 2007, eight consecutive patients with syndesmotic diastasis of the ankle had Tight Rope suture –endobutton fixation. We present our early results following this fixation. There were 3 males and 5 females with a mean age of 42 years (range 21 – 67). All were followed up for a mean of 7 months. Five patients had right side involvement. Majority were twisting injuries. These patients were compared with a cohort group (10 patients) who had diastasis screw fixation for similar fractures during the same period.

Results: The mean post operative Olerud & Molander ankle subjective score was 86 points. The tourniquet time was significantly less in endobutton group compared to the diastasis screw group(mean of 56 minutes vs. 72 minutes). There was some difference in time to mobilisation between the two groups (mean of 10 days). The endobutton group patients were able to return to work and leisure activities earlier (mean of 4 weeks) compared to the diastasis group. Range of motion was similar in both groups. There were fewer complications in both groups with superficial infection and stiffness being the most common. Both groups were satisfied with the fixation.

Advantages of Tight rope fixation: The tourniquet time was reduced; there was no need for 2nd operation with its attendant risks. Earlier mobilisation was possible leading to early return to work and leisure activities.

We recommend the use of this new suture endobutton fixation for ankle diastasis with promising early functional results. Further prospective studies are needed to evaluate this new type of fixation device.

Between 1994 and 2006, 58 patients underwent decompression of radial tunnel. The senior author using an anterior approach performed all procedures. 43 patients were available for follow-up evaluation at an average of 47.3 months (12–156 months). The average age of patients was 49.7 years (35 – 72 years) and the mean duration of their symptoms was 18 months (6 – 56 months). There were 12 patients (13 extremities) over 5 years follow-up. All had a trial of conservative treatment with steroid injections, physiotherapy and ultrasound therapy. All except 2 had nerve conduction studies which were inconclusive. The results were evaluated using Mayo elbow scores and DASH scores. Mayo scores improved from a mean of 62.37 pre-op to 87.13 post-op (p< 0.05) and DASH scores improved from 67.58 pre-op to 40.12 post-op (p< 0.04). 35 patients (81.3%) were satisfied with the surgery while 8 patients were not (4 patients had other pathologies). There were few complications – neuropathic pain-1, neuropraxia – 1 and residual pain – 2. Six patients who had simultaneous release of lateral epicondylar muscles and radial tunnel did extremely well and were satisfied. Hence there is a role for simultaneous decompression of tennis elbow and radial tunnel as recent studies suggest that extensor carpi radialis brevis tendon forms a continuous fascial sheath from lateral epicondyle to radial tunnel structures blending with supinator muscle. Based on our results, surgical decompression of radial tunnel gives good results in majority of patients with persistent radial tunnel symptoms with long-term relief.

Between 1994 and 2006, 83 patients (84 elbows) underwent the Outerbridge-Kashiwagi (OK) procedure by the senior author. Of these, 30 patients with over 5 years follow-up where available for review. There were 24 males and 6 females mean age 59.8 (range 34 – 81). 27 patients had primary osteoarthritis and the rest developed post-traumatic arthritis. Mean duration of symptoms was 25.5 (range 12 – 72) months. 30 patients had more than 5-year follow-up with a mean of 96 months (range 60–150) months. Their mean pre-operative flexion improved from 115° (range 90° – 150°) to 134° (range 100° – 160°) post-operatively (p< 0.001) and mean pre-operative extension deficit improved from 28° (range 10° – 50°) to 13° (range 5° – 30°) post-operatively (p< 0.001). The mean MEPS improved from 52 (range 25 – 70) pre-operatively to 84 (range 55 – 100) post-operatively (p< 0.038). The mean pre-operative DASH score improved from 63 (range 37 – 92) to 41 (range 24 – 75) postoperatively (p< 0.001). The mean pre-operative DEORS improved from 6.3 to 4.9 post-operatively (p< 0.001). Majority of the patients [22 patients (73.3%)] returned to their previous work including all 5 professional sportsmen. There were few complications -2 superficial wound infections, and numbness along ulnar nerve distribution in 1 patient. Of the 17 patients who had recurrence after 5 years, 4 patients had to undergo revision surgery (3 improved). 23 patients (76.6%) were satisfied with the results of the surgery. Conclusions: The OK procedure gives excellent to good results in 70.9% of patients at a mean of 9 years. Both flexion and extension improved significantly with very few complications with this open surgical technique. Although 17 out of 30 patients had recurrence on X ray beyond 5 years, only 4 required revision procedures.

OBJECTIVES: To review the short-term functional results of the surgical treatment of tibial plateau fractures using low profile peri-articular plates.

METHODS: Forty-nine displaced fractures of the tibial plateau in forty-nine patients were treated with open reduction and buttress plate fixation using low profile plate between 2002–2006. All aspects of their care, including tibial plateau fracture type, operative management and associated injuries, were documented. Preoperative and postoperative follow-up radiographs were analyzed for fracture classification and adequacy of reduction. All patients were followed up with clinical assessment and given Iowa knee functional outcome questionnaires. Data were also collected regarding return to work and sporting activities. The average age of the patients was thirty-eight years and the mean follow-up was 25 months, with a range of 12 to 52 months.. Of the forty-nine fractures studied, twenty-six were classified as Schatzker types I, II, or III, and the remaining twenty-three were types IV, V, or VI. Forty-six patients had closed injury while three had open fractures.

RESULTS: 48 of the fractures healed without additional surgical intervention or bone grafting except for one bicondylar fracture which needed amputation because of deep infection and soft tissue problem. Thirty eight patients had follow-up of greater than 1 year. The average time to radiographic callus was 6.2 weeks, and the average time to complete union was 16 weeks. The articular step-off average was 0.8 mm, with a range of 0 to 5 mm. The range of motion of the knee averaged 3° of extension to 120° flexion, which was an average of 87% of the total arc of the contralateral knee. The average Iowa Knee Score was 88 points (range, 72 to 100 points). The postoperative alignment demonstrated 1 patient with a malalignment of 4 degrees procurvatum and 1 patient with 3 degrees of valgus. There were two superficial wound infections and one case of deep infection.

CONCLUSIONS: Open reduction and internal fixation is a satisfactory technique for the treatment of displaced fractures of the tibial plateau, particularly for patients younger than fifty years. The use of low profile tibial plates appears to stabilize complex fractures of the tibial plateau with a low incidence of complications. The low profile plate functioned well in maintaining alignment and obtaining union in these high-energy fractures.