The number of total knee arthroplasties continues to increase annually with over 90,000 total knee replacements performed in the United Kingdom in 2018. Multiple national bodies including the British Association for Surgery of the Knee (BASK) and the British Orthopaedic Association collaborated in July 2019 to produce best practice guidance for knee arthroplasty surgery. This study aims to review practice in a regional healthcare trust against these guidelines. Fifty total knee replacement operation notes were reviewed between January and February 2020 from 11 different consultant orthopaedic surgeons. Documents were assessed against 17 criteria recommended by the BASK guidance. Personnel names and grades were generally well documented. Tourniquet time and pressure were documented in over 98% of operation notes however, protection from spirit burns was not documented at all. Trialling and soft tissue balancing was well recorded in 100% and 96% of operation notes respectively. Areas lacking in documentation included methods utilised to optimise cementation technique and removal of cement debris. Protection of key knee structures was documented in only 56% of operation notes clearly. Prior to closure, final assessment of mechanism integrity, collateral ligament was not documented at all and final ROM after implantation of components was recorded 34% of the time. Subsequently authors have created a universal operation note template, uploaded onto the patient electronic notes, which prompts surgeons to complete documentation of the relevant criteria advocated by BASK. In conclusion, detailed and systematic documentation is vital to prevent adverse events and reduce the risk of litigation. By producing detailed operative templates this risk can be mitigated

The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck of femur surgery results in improved documentation when compared to free hand orthopaedic operation notes. A total of fourteen categories were identified from the RCS guidance as required across all the operations identified in this study. All operations for the month of October 2021 were identified and the operation notes analysed. Pre-templated operation notes were compared to free hand operation notes. 97 cases were identified, of which 74 were free hand operation notes and 23 were pre-templated fractured neck of femur operation notes. All fourteen categories were completed in 13 (57%) of the templated operation notes vs 0 (0%) in the free hand operation notes (odds ratio 0.0052, 95% CI 0.0003 to 0.0945, p < 0.001). The median total number of completed categories was significantly higher in the templated op-note group compared to the free hand op-note group (templated median 14, range 12-14, vs. free hand median 11, range 9 to 13, p < 0.001). Logistic regression analysis of operation notes written by Registrars or Consultants identified Registrars as more likely to document the antibiotic prophylaxis given (p = 0.025). Use of pre-templated operation notes results in significantly improved documentation. Adoption of generic pre-templated operation notes to improve surgical documentation should be considered across all operations

Aim. To investigate the impact of waiting for surgical treatment for bone and joint infection (BJI) on patient self-reported quality of life (QoL). Method. Patients presenting to clinic between January 2019 and February 2020 completed the EuroQol EQ-5D-5L questionnaire. Patients were divided into three groups: surgery performed; on the waiting list for surgery; or decision for non-operative management. All patients were followed-up for 2 years. The EQ-index score was calculated and change from presentation to 1-year and 2-year follow-up was compared across the 3 groups. Mortality at final follow-up was measured in all groups. Results. 188 patients were included. Of these, 98 had an operation performed, 50 were on the waiting list for surgery but did not receive an operation and 40 were treated non-operatively. At presentation, all three groups had similar EQ-5D-5L index scores (surgery:0.412 SD0.351; waiting list:0.510 SD0.320; non-operative management: 0.467 SD0.354; p=0.269). There was a significant improvement in QoL in patients who underwent surgery when compared to their pre-operative state (mean increase of EQ-index score +0.241 in the first year (SD0.333, p<0.001) and +0.259 (SD0.294, p<0.001) in the second year. Patients on the waiting list for surgery had a small time-dependent decrease in EQ-index score at 1 year (−0.077, SD0.282, p=0.188) and 2 years (−0.140, SD0.359, p=0.401). Patients treated non-operatively had similar changes in EQ-index scores at 1 year (−0.052, SD0.309, p=0.561) and 2 years (−0.146, SD 0.234, p=0.221). Patients who had surgery had significantly better QoL at 2-years after treatment compared to other groups (mean EQ-index scores: surgery performed 0.671 vs. waiting list 0.431, p<0.001; surgery performed vs. non-operative management 0.348, p<0.001). Mortality in the operated group was 3.1%, which was similar to patients who were on the waiting list for surgery (6.5%, p=0.394) but lower than patients who were non-operatively managed (14.7%, p=0.014). Conclusions. The Covid-19 pandemic created long waiting times for some patients. Selecting patients with BJI who can safely wait for surgery is difficult. QoL for patients with BJI deteriorates over time if surgery is delayed or not performed. When patients decline surgery, they should be counselled that their QoL is likely to be impaired over time. The relationship between waiting time and mortality merits further study

Introduction:. Unicompartmental knee arthroplasty (UKA) is becoming an increasingly popular option in single compartment osteoarthritis. As a result, diverse second operations including revisions to total knee arthroplasty (TKA) will also increase. The objective of this study is to investigate the distribution of causes of second operations after UKA. Methods:. We retrospectively reviewed 695 UKAs performed on 597 patients between January 2003 and December 2011. Except in one case, all UKAs were replaced at the medial compartment of the knee. The UKAs were performed on 559 (80.4%) women's knees and 136 (19.6%) men's knees. The mean age at the time of UKA was 61.5 years. The mobile-bearing designs were those that were predominantly implanted (n = 628 mobile, 90.2%; n = 67 fixed). The mean interval between UKA and second operation was 14.1 months. Results:. In our study, the burden of a second operation after the initial UKA was 7.3%, and the total number of second operations was 51 (n = 45 mobile, n = 6 fixed). The most common cause of a second operation after a mobile-bearing UKA was the dislocation of the meniscal bearing (34.8%), followed by component loosening (21.7%), the formation of a cement loose body (15.2%), unexplained pain (13%), infection (6.5%), periprosthetic fracture (4.3%), and others (4.4%). For the fixed-bearing UKA, the causes of a second operation were loosening (n = 2), unexplained pain (n = 2), and bearing wear (n = 1). The main causes of either a revision UKA or a conversion to TKA were multiform operations that included bricement, internal fixation for a periprosthetic fracture, isolated bearing changes, open debridement with bearing changes, or implant removal due to early infection. Conversions to TKA during the second operation were performed in 17 cases. Discussion and conclusion:. The most common cause of a second operation after a mobile-bearing UKA was the dislocation of the bearing, followed by component loosening and the formation of a cement loose body. After a fixed-bearing UKA, component loosening and unexplained pain were the most common. A cause-based approach to the primary and failed UKA may be helpful to minimize the possibility of a second operation and to give rise to a successful outcome of a revision TKA

Introduction: Since 2004 we chose the arthroscopic method of therapy by the retrocalcaneal bursitis and problems caused by prominence of heel Haglund type. Materials and Method: We operated 48 patients (52 heel bones) by arthroscopic method. We do this operation on ventral position with using 2 or 3 paraachilear incisions, we commonly check the progress of the operation using X-rays sciascopy. After operation we recommend light exercises of the movement of the ankle and 3 week walking on crutches with limited weight. Antitrombotic prophylaxis is standard. Results: We checked the results after 2–48 months after operating procedure. The patients were examined clinically and with the help of VAS (Visual Analogue Scale). The condition of all patients has improved, most of them were very satisfied with the operation. We have not noticed any disorders in healing operation wounds, 1 deep trombosis has been diagnosed by the sonography. We compared this arthroscopy method with open operating method. We have been using since the year 2004 both operating methods, but we have been trying to separate the indications for the arthroscopy and for the open approach, because we are the meaning, that the arthroscopy technique is not the best choice in all cases. We have recently set clear indications for both methods in our orthopaedic department. The progress of rehabilitation was noticeably faster than by the open method, postoperative swelling and pain were markedly less as well

Studies of operation notes have shown they can vary in quality and affect patient safety. This audit compares the quality of operation notes against standards set by the Royal College of Surgeons of England and the British Orthopaedic Association. Information from operation notes was collected prospectively over a two-week period. All operations performed were included and trainees from the region coordinated data collection in 9 hospitals. Data from 1091 operation notes was reviewed. A number of standards were nearly met including legibility (98.4%), the name of operating surgeon (99.3%) and operation title (99.1%). However a number of standards were not met and those with potential patient safety implications include availability on the ward (88.8%), documentation of type of anaesthetic used (78.6%), diagnosis (73.4%) and findings (80.1%). In addition, the postoperative instructions recorded the need for and type of postoperative antibiotics or venous thromboembolism prophylaxis in only 49.7% and 48.8% of cases respectively. The quality of operation notes studied across the region in this period was variable. Software programmes meant some hospitals had better results for date, time and patient identification details. Following this study, awareness of the standards combined with additional local measures may improve the quality of operation notes

British military forces are heavily committed in Iraq and Afghanistan. Operation HERRICK, currently supported by a Role 2(Enhanced) medical facility at Camp Bastion, is predicted to continue for the next 10 years. There has been no large published series on surgical workload on Operation HERRICK. The aim of this study is to determine and plan future medical needs. A retrospective analysis of operating theatre records between 10th October 2006 and 31st Oct 2007 was performed. Data was collated on a monthly basis, to assess seasonal variation, and included patient demographics, operation type and time of operation. During the study period 968 cases required 1262 procedures. Thirty-four per cent were ISAF, 27% were Afghan soldiers, police or enemy forces and 39% were civilians, of which, 43% were children. Ninety-one per cent were secondary to battle injury and 50% were emergencies. The breakdown of procedures, by specialty, was 67% (841) were orthopaedic, 16% (199) general surgery, 8% (96) head and neck, 5% (55) burns surgery and a further 4% (50) were non-battle, non-emergency procedures. During the second half of the study period 655 cases were operated on compared to 313 in the preceding half (p< 0.05). Twenty-eight per cent of cases were performed between 6pm and 8am. Surgical workload remains consistently high throughout the study period, however there was significant seasonal variation with casualty rates being greater in the summer months, this may have bearing on the decision to deploy additional surgeons and trainees in the future

Introduction: Hypothesis:- Posterior lumbar interbody fusion (PLIF) produces improvement in the MOS Short Form 36 (SF36) scores comparable to that seen in total hip replacement. Current consensus holds the surgical treatment of lower back pain as less effective or predictable than interventions performed in most other orthopaedic subspecialties. Detailed clinical and economic outcome studies are vital to justify its use in routine practice. This prospective study presents medium to long-term clinical outcome scores for PLIF which are compared with those of an operation that might be considered a modern orthopaedic gold-standard: total hip arthroplasty. Methods: The authors present 100 consecutive PLIF operations performed by the senior author between 1997 and 2004. SF36, Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) and walking distances were prospectively collected and analysed in the post-operative period. Results were compared to the SF36 healthy population norms and with the outcome scores of standard total hip replacement available in the literature. Results: The mean pre-operative ODI was 49. 12 months following surgery this improved to 22. All outcomes as measured by SF36 improved following surgery. The VAS for back pain improved from 8.5 pre-operatively to 3.21 post-operatively. Leg pain improved from 6.98 to 2.85. Improvements in the SF36 scores were similar to those seen in hip arthroplasty. Discussion: The hypothesis has been proven. The gains in function following spinal fusion are comparable with those seen in hip arthroplasty. In the authors’ opinion PLIF is an effective procedure in an appropriately selected patient population

Dual mobility hip arthroplasty utilizes a freely rotating polyethylene liner to protect against dislocation. As liner motion has not been confirmed in vivo, we investigated the liner kinematics in vivo using dynamic radiostereometry.

16 patients with Anatomical Dual Mobility acetabular components were included. Markers were implanted in the liners using a drill guide. Static RSA recordings and patient reported outcome measures were obtained at post-op and 1-year follow-up. Dynamic RSA recordings were obtained at 1-year follow-up during a passive hip movement: abduction/external rotation, adduction/internal rotation (modified FABER-FADIR), to end-range and at 45° hip flexion. Liner- and neck movements were described as anteversion, inclination and rotation.

Liner movement during modified FABER-FADIR was detected in 12 of 16 patients. Median (range) absolute liner movements were: anteversion 10° (5–20), inclination 6° (2–12), and rotation 11° (5–48) relative to the cup. Median absolute changes in the resulting liner/neck angle (small articulation) was 28° (12–46) and liner/cup angle (larger articulation) was 6° (4–21). Static RSA showed changes in median (range) liner anteversion from 7° (-12–23) postoperatively to 10° (-3–16) at 1-year follow-up and inclination from 42 (35–66) postoperatively to 59 (46–80) at 1-year follow-up. Liner/neck contact was associated with high initial liner anteversion (p=0.01).

The polyethylene liner moves over time. One year after surgery the liner can move with or without liner/neck contact. The majority of movement is in the smaller articulation between head and liner.

Aim To assess the reliability of Stainsby’s operation for dislocated lesser toe metatarsophalangeal (MTP) joints. Method Seventy-four patients underwent this operation between 1998–2003. Sixty-nine patients (93%) were reviewed at mean follow up of 32 months (range 10–67) post-operatively. Forty-eight patients had rheumatoid arthritis, two had psoriatic arthropathy, 19 had other causes. Ninety-four feet were reviewed, 73 had had multiple lesser toe operations, 21 had single lesser toe operations, 52 feet had surgery to the hallux. Assessments were made of pre- and post-operative pain, shoe problems, callosities, alignment and function. Results Out of 94 feet, 89 (95%) had severe or moderate pain pre-operatively. Only 19 (20%) had significant pain at review. Pain under operated toes was relieved in 78 feet (83%). Tender plantar callosities were reduced from 76 feet pre-operatively (81%) to 31 feet (33%) at review, these mainly under un-operated metatarsal heads. Shoe problems were reduced from 89 feet (95%) pre-operatively to 61 feet (65%) at review. American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores were increased from a mean of 19 pre-operatively to 52 at review. Residual valgus of big toe more than 25 degrees persisted in 33 feet (35%). Corrective osteotomy of 44 first metatarsals failed to prevent recurrent valgus in 16 feet (36%). Conclusions The Stainsby operation was effective in relieving pain and skin callosities from under dislocated lesser metatarsal heads, and in reducing shoe problems but we found that varus osteotomy was unreliable in correcting valgus of the big toe. This was probably due to stretching of the repaired medial ligament

The purpose of our study was to evaluate the necessity of blood transfusions in operations for neglected DDH. It is generally known that blood transfusion is necessary in neglected DDH operations. Because of transfusion complications, Erythropoetin and autologous blood donation are proposed for blood replacement. However, these two methods are expensive and not useful in children. We evaluated Hb-Hct levels in 48 children (52hips) operated on from 1992 to 1997. Mean age was 5.7 years (range 1.5 to14). Open reduction and pelvic osteotomy was performed in 40 hips, and open reduction, femoral shortening, and pelvic osteotomy in 12 hips. The authors performed all of the operations. We approached the surgical technique and haemostasis carefully by using a curved ostetom instead of a gigly saw and left the medial apophisis and periosteum intact until the roof surgery. Dissection of the posterior-superior part of the ischiadic notch was avoided, and without using a drain. Oral supplemental ferrum (5 mg/kg) was prescribed to all patients until the Hb value increased to 12mg/dl. There was close clinical status follow-up of the patients for ten days after surgery and Hb–Hct levels were recorded periodically. In the open reduction and modified Salter osteotomy group there were 4/40 hips respectively (10%). In the combined surgery group (open reduction, femoral shortening, pelvic osteotomy) there were 16 hips (33%) that required transfusion. We preferred packed red blood cell transfusion for blood substitution. Transfusions were made within one to five days. Mean loss of Hb was 4.7g/dl. Up to 7g/dl Hb level was well-tolerated by the patients. Digitalisation was required for one patient. There were no mortalities or infections in our patients up to the time of follow-up. The process requires experienced surgeons, a meticulous surgical technique, a shortened operation time by modification of the pelvic osteotomy, and without using a drain. This is one of the most effective and less expensive ways to perform an operation for neglected DDH with a minimal loss of blood

Introduction: Increasing medicolegal pressures, as well as problems with continuity of care and trauma patients outlying on non-orthopaedic wards, led to a concern regarding the quality of operation notes, especially with regard to postoperative instructions. A computerised system was introduced to address these issues. Method: The quality of trauma operation notes was surveyed over a period of four weeks, before and after the introduction of the computerised system. Royal College of Surgeons guidelines, as well as additional orthopaedic criteria, were used as the expected standards. Results: Most criteria were met significantly more of the time after the introduction of the computer generated notes, including antibiotic prophylaxis, weightbearing status and outpatient appointment. Discussion: A computerised system is an effective and acceptable way of improving the standard of trauma operating notes. Users should be reminded to sign the resulting printed note until a full paperless record is in place

The trauma and the operation of femoral fractures provoke a double increase inflammatory reaction. We studied the CRP and how it is influenced form the time and the type of operation. 70 patients, without malignancy or infection, age 80 ± 7 years. The values of CRP were measured on admission, before operation and 48 hours postoperative. The patients were grouped:. Group 1: Operation at 1–3 day. Group 2: Operation at 4–6 day. Group 3: operation after 7 day. And in relation with type of operation. TGN 23, DHS 19, HEMIARTHROPLASTY 28. The CRP presents a double increase from the trauma to osteosynthesis and at 48 hours after operation. The first moderate increase is presented from the immediate to late osteosynthesis. The second increase is presented at group of late osteosynthesis and TGN> DHS> HEMIARTH. In conclusion the maximum postoperative inflammatory reaction at patients who sustained fractures of femoral neck is measured at 3d and at 6th postoperative day, while before the operation there weren’t any important and statistically differences of CRP values. In comparison with the type and the method of operation, the CRP presents differences between Hemiarthroplasty and (TGN-DHS)

The goal of the present study was to evaluate the results of a one-stage operation performed on dislocated hips in children with infantile cerebral palsy. Our data indicate that the one-stage operation is a quite useful method to treat hip dislocation in children with infantile cerebral palsy. Based on our experience we emphasize the use of an individual operation plan in every instance. In selected cases it seems to be justified to ignore an element of the method. We used the radiological findings for evaluation by comparing the geometric parameters in the affected hips before and after surgery. During the last ten years, 21 dislocated hips in 13 patients were operated on by the one-stage surgical technique used at the Department of Orthopaedic Surgery of University Medical School of Pécs. The technique consists of the following steps: open reduction, iliopsoas tendon transfer, and femoral varus derotational osteotomy with shortening, modified Tönnis acetabuloplasty, and open adductor tenotomy. Spastic diplegia occurred in eight children and hemiplegia in five. During this period, eight girls and five boys were operated, with 12 procedures on the right hip and 9 on the left. Mean age was 11.4 years. The average age of the children at the time of operations was 6.5 years. In eight hips of five children, all elements of the surgery were carried out in one sitting; in six hips of four children the surgery was performed without acetabuloplasty. In nine hips of seven children there was no need for open reduction, and in six hips of five children we used deep frozen allograft to perform acetabuloplasty. A varus derotational femoral osteotomy with shortening was a part of the surgical approach in all cases. We evaluated Hilgenreiner (H), Wieberg (CE) and collodiaphyseal (CCD) angle preoperatively and postoperatively. The average preoperative H angle decreased from 39.7 to 24 degrees postoperatively. The average preoperative CE angle increased from minus 18.6 to 31.9 degrees postoperatively. The minus means that all of the patients had dislocation in their hips. The average preoperative CCD angle decreased from 165.2 to 131.4 degrees postoperatively. The results were evaluated by the modified Severin classification based on age and anatomical changes of hips: 17 cases were evaluated as excellent, 2 as good, and 2 as acceptable. We did not see any complications such as avascular necrosis of the femoral head, absolute revalgisation (compared to the opposite side), subluxation, re-dislocation, or disturbed development of the acetabulum

Purpose of the study: The purpose of this study was to assess at more than twenty years follow-up, the results achieved with the Bankart operation, focusing on functional and radiographic outcome of the glenohumeral joint in patients operated on when they were young. Materials and Methods: This retrospective analysis reviewed clinically and radiographically patients who underwent shoulder surgery for instability between 1971 and 1986. The Bankart operation was performed in all patients followed systematically by immobilisation. Self-controlled rehabilitation was the rule. The clinical assessment used thed Duplay and Rowe scores. The Prieto and Samilson radiographic score (four stages) was noted. Results: Mean follow-up was 26 years for 49 patients (50 shoulders). There were three women and 46 men (sex ratio = 15.3), mean age 25 years at surgery. Eighty percent practiced competition sports (a contact sport for 72%). The time from the first dislocation to surgery was four years on average. The rate of recurrence was 16%. All recurrences were provoked by a violent accident. 94% of patients returned to sports activities (on average 4.6 months after surgery), 80% at the same level. 86% of patients were satisfied. Mean Duplay and Rowe scores were 81.3 and 82.2 respectively. Average deficiency of external rotation was 9° compared with the contralateral side. Normal radiographs were noted for 13 shoulders (26%). The Prieto and Samilson classification was: stage I (n=18), stage II (n=5), stage III (n=5) and stage IV (n=1). Discussion: In this cohort with 80% competition sports athletes and 94% return to sports activities after surgery, the Bankart operation demonstrated its efficacy for contact sports. The rate of osteoarthritis after this operation is comparable with that observed with other types of bone blocks, but the follow-up here was twice as long. The deficit in external rotation was not greater than with non-anatomic operations

Purpose: The aim of this study was to evaluate quality-of-life (QoL) in patients undergoing bilateral hip arthroplasty implanted during the same operation. Material and methods: Sixty-one patients (28 women and 33 men) underwent surgery between November 1989 and February 2002. Average age was 42±14 years (13–76). Indications were primary osteoarthritis (n=24), secondary osteoarthritis (n=31), aseptic osteonecrosis (n=25) and rheumatoid disease (n=6). The implants (Ceraver Osteal) were cemented (50 stems, 11 cups) or coated with hydroxyapatite (72 stems, 11 cups). An alumina-alumina bearing was used in all cases. The Postel-Merle-d’Aubigné score was noted to assess function. QoL was measured prospectively in 27 patients using the SF-36 and the WOMAC, preoperatively and every three months. Results: None of the patients were lost to follow-up. Complications included two intraoperative femoral fractures treated by cerclage, one early dislocation, three thromboemoblic events (including one case of pulmonary embolism). Unipolar revision was required for one hip due to aseptic acetabular loosening at 6.5 years. Surgical cleansing was performed in one other hip for infection. Intraoperative blood loss was 1529±451 ml (540–2550). Mean hospital stay was 13±2.5 days (8–22). At mean follow-up of 49±33 months (12–162), the mean function score was 17.8±0.5 (16–18) versus 10±2.7 (3–14) preoperatively (p< 0.05). Clinical outcome was good or excellent in 98% of the hips. There were no radiological signs of wear. A complete lucent line developed around one cup. The quality of life scores improved significantly (p< 0.01) as soon as three months postoperatively for the items ‘social activity’, ‘physical activity’ and ‘pain’, particularly in men p< 0.05). Discussion: Bilateral hip arthroplasty during the same operative time is not advocated by all authors. It is a difficult surgical situation requiring rigor and skill. The drawbacks include longer operative time, greater blood loss, and in some patients, higher morbidity. This approach however enables treating bilateral disease in one operation, particularly in younger subjects. Use of an alumina-alumina bearing and non-cemented implants is particularly indicated. The results of this series validate the efficacy of this technique which allows rapid improvement in the patients’ quality-of-life

Several studies have evaluated the association between timing of hip fracture surgery and mortality in elderly patients. The evaluation of functional outcome is lacking. We studied the effect of delayed surgery on the patient’s ability to return to independent living, the incidence of pressure sore and total length of hospital stay. Days of hospital stay included the post-operative period and the rehabilitation admission in the first 4 months following the operation. Patients older than 50 years of age, admitted to two major hospitals in Stockholm during one year were included in the study (n = 853). To eliminate the effect of time interval between injury and admission, all patients who arrived to the hospital later than 24 hours of the injury (n=75) were excluded. Patients with pathological fracture (n = 30) were also excluded. The time intervals between hospital admission and the operation were evaluated against the patient post-operative independent living at 4 months follow up. We divided the patients into two groups depending on delay to surgery. We performed a comparison of those patients who operated within 24 hours with those who hade been operated more than 24 hours after the admission. Moreover we repeated the analysis using 36 and 48 hours cut-off points. After adjustment for age, ASA, walking ability, living with some one, gender and reason for delay, the late operated groups had a significantly decreased OR for return to independent living at 36 and 48 hours cutoff points (OR 0.5 respectively 0.3) but not at 24 hour cut-off point. The incidence of pressure sore in the late operated groups was significantly increased at all 3 cutoff points after adjustment for age, ASA, walking ability, dementia, and duration of surgery (OR 2.2, 3.4 and 4.2 respectively). The median length of hospital stay was significantly increased in the late operated groups (14 versus 18 days at 24 hours, 15 versus 19 days at 36 hours, and 15 versus 21 days at 48 hours cut-off point). Linear regression analysis with adjustment for age, ASA, walking ability, dementia, gender and place of residence showed that there was a significant relationship between waiting time for operation (hours) and length of hospital stay (days) (B 0.148, P 0.002). Accordingly for every 6.75 hours delay in surgery, the total hospital stays increased by one day. Our conclusion is that early operation of patients with hip fracture is associated with a significantly improved ability to return to independent living, a reduced incidence of decubitus ulcers and reduction in the length of hospital stay before the 4-month follow up

Introduction: Latarjete operation for anterior shoulder instability, first described by Latarjete in 1954 consists of transfer of the coracoid process through the sub-scapularis tendon to the neck of the scapula. Many modifications were described in the English literature as described by Mc Murray in 1958, by Bonin in 1969 or May in 1970. In 1985, Braly and Tullos emphasized that the Bankart lesion, when present, should be corrected. Rockwood transplants the entire coracoid process onto the neck by “laying it flat” onto the neck of the scapula using two screws instead of one, which gives a larger base for the coracoid transplant. The disadvantages of this procedure, as described in the English literature, are relative shortening of the sub-scapularis tendon, thereby decreasing internal rotation power, limited external rotation and the possibility to damage the musculocutaneous nerve. Purpose of the Study: To demonstrate that transplantation of the coracoid process with its tendon attachments through a split in the subscapularis muscle and tendon without shifting the capsula gives better results then transplant of the coracoid process with capsule-labral repair. The goal of this report is to review the result of our series. Patients and Methods: Between January 2000 and June 2005, 26 Latarjete operations (Rockwood modification) were performed by the senior author. The indication for surgery was failed artroscopic Bankart repair or anterior shoulder instability associated with anterior inferior glenoid deficiencies (“inverted pear” deformity). Five cases were excluded having less than 6 months follow-up. In the first 5 cases in addition to the coracoid process transfer, labral repair with capsular shift was performed whereas in the next 21 cases only coracoid process transplant with excision of the damaged labrum/scar tissue and no capsular shift was performed. The postoperative rehabilitation program was the same for both groups. The patients age and sex was very close in both groups. The parameters for comparison between the two groups were: range of motion, stability after 6 months, return to work and sport activity, satisfaction, and complication rate. Results: 6 months after surgery all patients of both groups returned to full work and sport activity including contact sports. No recurrent dislocation was encountered during this short period of follow up. All patients who underwent this procedure, with or without capsule-labral repair, were satisfied with the procedure. In the small group that included capsulo-labral repair an average of 10 degrees decrease of external rotation was encountered compared to the opposite shoulder. In the second group no decrease in range of motion was found. Conclusion: Transfer of the coracoid process through the subscapularis tendon alone has better results then Latarjete operation complemented with capsulo-labral repair in regard of range of motion. The procedure is simple and of short duration giving the best solution for failed artroscopic procedures or for cases of shoulder instability having anterior inferior glenoid deficiencies. The authors are aware that longer follow up is mandatory

Objective: To evaluate the long term results of an operation developed to decompress the roots at the stenotic level, preserve the midline structures, and not use instrumentation or fusion. Design: A retrospective clinical and radiological review of consecutive patients operated on for spinal stenosis secondary to lumbar spondylosis. Subjects: One hundred and sixty patients (eighty seven female and seventy three male) with a mean age at operation of sixty eight (range 40–90). Sixty one patients (38%) had a degenerative listhesis causing stenosis. The mean post operative follow-up was twenty two months (range two months to fourteen years). Summary of background data: Lumbar spondylosis, commonly involving degenerative listhesis, is the commonest cause for spinal stenosis in the lumbar spine. Surgery offers the only permanent cure. The standard procedure remains a laminectomy with fixation and fusion in the presence of possible instability. The laminectomy destabilises the spine and the instrumented fusion makes it a much bigger operation in patients often not best placed to cope with it. There is a need, therefore, for an effective operation that does not compromise spinal stability. Results: At six weeks one hundred and forty one patient (85%) reported relief of leg pain and a further nine patients were improved at three to six months. 52% of the patients reported a concomitant improvement in back pain. The results were sustained at follow-up. The operation was not responsible for the development of a new spondylolisthesis. A minimal increase in an existing degenerative listhesis was seen in two patients only without compromise of their good results. There was no revision surgery at any of the operated levels. Conclusions: The operation of segmental spinal decompression for degenerative lumbar spinal stenosis has been found to be effective, safe, and give good long term results, without compromising the existing spinal stability. Patient selection and attention to operative technique are essential

Introduction The geographical & temporal position of surgical assets in the evacuation chain during war fighting is controversial. Manning, equipment and command issues can conflict with clinical experience and evidence as to the ideal location and configuration for Field Surgical Teams. Method Details of casualties presenting to 2 Air Attack Surgical Groups were collected prospectively during the ground war phase of Operation Telic. Mechanism and time of injury, wound type and classification, patient demographics, times and details of treatments carried out, evacuation details and outcomes were noted for both coalition and Iraqi patients. Results The mean time to life and limb saving surgery for coalition casualties was 4 hours, significantly shorter than during previous conflicts in the region. Air case-vac requests generated within the area of responsibility failed in all cases to move patients from point of wounding to fixed hospital assets within agreed clinical timelines. Discussion We argue that in order to keep life and limb saving surgical resuscitation within agreed clinical guidelines Field Surgery Teams must be capable of deploying to a forward environment within the Medical Regiment organization. Manning and equipment templates used by this unit provide a template for this capability