Purpose: The aim of this study was to analyze the outcome of AO cannulated screws for undisplaced fracture neck of femur and find out the correlation in outcome with respect to co-morbidities in a general trauma unit in UK.

Method: A retrospective study was conducted using data from electronic patient record, clinical coding information, clinic letters and GP’s. 315 patients who underwent AO screws for fracture neck of femur during 2000 to 2004 were included. We looked into age, place of living, classification, mechanisn of injury, comorbidities, mobility before fracture, allergy, addictions, whether patient was anticoagulated, delay for theatre with reasons, length of stay in hospital, complications and treatment for complications. We assessed reasons for other admissions later on, need and type of another operation, consequently developed comorbidities, patient getting fracture of other side and its treatment, time and cause of death if happened?

Results: There were 81 males and 234 females in the study. Mean age of patients was 72 years (range 50–96 years). Non-union occurred in 19 patients (6%) and avascular necrosis occurred in 49 patients (15.5%). Reoperation with an arthroplasty was required in 69 patients (21.9 %). The incidence of avascular necrosis with internal fixation at 1 year was 31 (9.8%). Fifty-one (16%) patients died in 2 year period. The age, walking ability of the patient, and associated co-morbidities were of statistical significance in predicting fracture healing complications. We correlated our complications with comorbidities and found them more in patients with end-stage renal failure, steroid intake, osteoporosis and diabetes mellitus etc.

Conclusion: The rate of fracture healing complications and reoperations in patients with undisplaced fractures was high in our series with two year follow up. It was even higher in patients with age greater than 80 years and some specific comorbidities. We should also consider co-morbidities and age before deciding for internal fixation rather than only the fracture configuration (Treat patient not the X-rays). Outcome is multifactorial and depends on many predictive factors. Each patient should be evaluated carefully and we should treat the physiological age and not the chronological age.

Purpose: The aim of the study was to analyze the outcome of AO cannulated screws for fractures neck of femur in patients with Diabetes mellitus.

Method: Sixty-two patients aged 50 years or more (17 males & 45 females) who underwent AO screws for fracture neck of femur over seven years (1999–2005) and followed-up for a minimum of two years formed the study population. A retrospective review of data from electronic patient record (EPR), clinical coding, clinic & GP letters was made. Age, residential placement, Garden’s classification of fracture, mode of injury, associated other co morbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected.

Results: The mean age of patients was 67 years (range 52–96 yrs). Eleven patients died in two years time. Forty-one patients were less than 75 years of age and 21 patients were more than 75 years of age. All the patients more than 75 years of age had undisplaced intracapsular fractures. Thirteen patients were type I and 49 patients were type II diabetic. Non-union and avascular necrosis occurred in nine (17%) & 13 (26%) patients respectively. Revision surgery in the form of total hip replacement or hemiarthroplasty were performed in 21 (41%) cases. The incidence of avascular necrosis following osteosynthesis at one year was 14%. Age, control of diabetes, postoperative complications, pre-fracture mobilization status etc. Complications like wound infection were more principally in patients who had poorly-controlled diabetes.

Conclusion: Patients with diabetes mellitus have metabolic bone disease due to vasculitis. This increases the risk of complications associated with fracture fixation such as non-union, cut-through and avascular necrosis (AVN). The complications and revision surgery rate was high in patients with displaced fractures and with poorly controlled diabetes. Comorbidities like diabetes and patient’s age were also strong predictors of healing in addition to fracture configuration. Looking at very high complication and re-operation rate, our recommendation in patients with diabetes is primary hemiarthroplasty irrespective of femoral head displacement, if there age is more than 75 years.

Purpose: The aim of this study was to compare the results and length of stay of patients of early ankle fracture fixation with conventional fixation in a busy District General Hospital in UK.

Method: A retrospective study was conducted using data from case records, electronic patient record, clinical coding information, clinic letters and Picture Archiving and Communications System (PACS). Two hundred patients who underwent ankle fracture fixation from July 2004 to June 2005 were included. We looked into age, place of living, Weber classification, mechanism of injury, comorbidities especially diabetes and peripheral vascular disease, addictions mainly smoking, whether patient was anticoagulated, delay for theatre with reasons, length of stay in hospital and complications if any. Other things to looked at were, overlying skin condition, the amount of swelling at the time of presentation to A& E, associated ankle dislocation or talar shift needing reduction, injury types-open or closed or with associated neuro-vascular injury. In-operative management – what method was used ie malleolar screws, diastasis screw, fibular plating, calcaneotalotibial nail or external fixater etc.

Results: In the 12-month retrospective review, there were 200 ankle fractures that required surgical intervention. Only twenty-two of these had surgery within 12 hours (mean length of stay, 3.3 days), and sixty-seven of these had surgery within 48 hours (mean length of stay, 4.9 days), and 111 had surgery after 48 hours (mean length of stay, 9.4 days). Finally we calculated the cost (784 bed days – £235 thousands) incurred to the trust in terms of extra bed occupancy and treating the complications as a result of wait.

Conclusion: This study shows that early operative intervention for ankle fractures reduces the length of hospital stay. Intensive physiotherapy and co-ordinated discharge planning are also essential ingredients for early discharge. We want to emphasise on the ‘Window of Opportunity’ ie initial 12 hours to fix ankle fractures to decrease overall morbidity and cost.

Purpose: To assess moderate-term outcomes of silastic joint replacements of the first metatarsophalangeal joint.

Method: The thirty-two patients (37 feet) that had silastic implants inserted were reviewed at an average of 2 years and 4 months (ranging 7 months to 5 years and 4 months). The mean patient age was 63 years. These patients answered a subjective questionnaire, had their feet examined clinically and radiographically and a pre-operative and post-operative AOFAS score was calculated for each.

Results: The follow-up assessment revealed that every patient described that their pain had decreased after surgery and 17 feet (46%) were completely pain free. There was a significant improvement in patients’ subjective pain scores after surgery (t value = < 0.0001). Pre-operatively, the mean pain score for all 37 feet was 8.14, whereas post-operative the mean pain score was 1.32. The mean AOFAS score before surgery was 39.97. This increased to a mean score of 87.40 after surgery (P = < 0.0001). This again is a significant improvement. No patient was dissatisfied with the outcome with their surgery.

Conclusion: These moderate term results are encouraging, with good subjective and objective results. However, long-term follow-up will be required to assess the longevity of this implant.

Purpose of the study: Our aim was to look at, how we are following the British Orthopaedic Association (BOA) guidelines regarding the clinic times. The decrease in doctor working hours and increase in sub-specialisation has added to the problem.

Methods: 55 Orthopaedic clinics were observed and time mapped to the nearest second by an independent observer. 5 clinics observed for each of 11 clinicians (5 Consultants and 6 Registrars). The patient factors viz age, sex, mobility, BMI, site of disease were recorded. The clinician factors viz. seniority, sub-specialisation were also recorded.

Results: Of total Clinic time, 45% spent for consulting follow-up cases, 26% for new cases and 29% lost in in-between patient transit time. Of the total clinic time, patient time was 75%, procedures 4%, investigations 3%, consent 4%, dictation 13%, teaching 1%. Mean time for consultation was 13 minutes 6 seconds for new and 8 minutes 43 seconds for follow up patients which was significantly less than that recommended by BOA guidelines (15 – 20 minutes for new and 10 –15 minutes for follow up patients).

Conclusion: Since the British Orthopaedic Association (BOA) guidelines in 1990, there has been a change in patient’s expectation, responsibility of the clinician towards well informed patients, detailed investigation, consenting in clinics etc. Despite the clinics over running in time the BOA guidelines are not being adhered to potentially compromising quality consultation and training at the cost of pressures to see the recommended 22 unit patients per clinic. There is a need to revise BOA guidelines regarding clinics to provide more time in clinics per patient to maintain quality of care and training.

Background: The British Orthopaedic Association (BOA) guidelines regarding consultation time were published in 1990. There has been a change in the expectation of the patient and the responsibilty of the clinician to provide more information to the patients and more detailed investigation and consent forms to fill with a greater emphasis on clinical governance and increasing awareness of the patients over the years. The decrease in doctor working hours and increase in sub specialisation can not be ignored.

Methods: 55 Orthopaedic clinics were observed and time mapped to the nearest second. 5 clinics observed for each of 11 clinicians (5 Consultants and 6 Registrars). From the time the clinician entered the consultation room to start the clinic till the time he left after finishing the clinic the entire span of time was mapped with a stop watch by an independent observer. The patient factors viz age, sex, mobility, BMI, site of disease were recorded. The clinician factors viz. seniority, sub-specialisation were also recorded.

Results: Of total Clinic time, 45% spent for consulting follow up cases, 26% for new cases and 29% lost in in-between patient transit time. Of the total clinic time, patient time (time spent by clinician with the patient) was 75%, 4% spent on procedures, 3% on investigations, 4% on consent, 13% on dictation, only 1% on teaching. The mean time for consultation was 13 minutes 6 seconds for New patients and 8 minutes 43 seconds for Follow up patients which was significantly less than that recommended by BOA guidelines (15 – 20 minutes for new and 10 –15 minutes for follow up pateints in Orthopaedic clinics).

Conclusion: Despite the clinics over running in time the BOA guidelines are not being adhered to potentially compromising quality consultation and training at the cost of pressures to see the recommended 22 unit patients per clinic. There is a need to revise guidelines to provide for more time in clinics per patient to maintain quality of care and training.

Introduction This study was conducted to quantify the incidence of gastrointestinal morbidity and identify risk factors for developing gastrointestinal morbidity following spinal surgery in children.

Method A retrospective review was conducted on 253 surgical spinal procedures performed over a 5 year period at Starship Children’s Hospital. Multivariate logistic regression analysis was used to identify significant risk factors. Co-morbidity included co-existing cardiac, respiratory, genitorurinary or central nervous system problems, or delayed development.

Results Seventy eight (77.9%) percent of the study population developed gastrointestinal morbidity and this significantly prolonged the median post-operative hospital stay (8 days vs.4 days; p< 0.0001). Emesis (50.6%), paralytic ileus (42.3%) and constipation (22.5%) were the most frequent gastrointestinal morbidities. Significant risk factors for developing gastrointestinal morbidity were fusion surgery (p< 0.01), co-morbidities (p-value) and duration of post-operative opioid use (p-value).

Discussion There is a high incidence of gastrointestinal morbidity after paediatric spinal surgery. The consequent prolonged hospital stay has clinical implications to both the patient and the institution. We have further identified risk factors for developing gastrointestinal morbidity, of which the duration of post-operative opioid use is modifiable. Awareness of those with the other significant risk factors identified by this study could assist in the timely implementation of appropriate treatment.