The Pronator Quadratus (PQ) is commonly damaged in the surgical approach to the distal radius during volar plating. This study explored the functional strength of the PQ muscle, 12 months after volar plating of a distal radial fracture.

Testing of treated and contralateral forearms was carried out using a custom-made Torque Measuring Device (TMD) and surface Electromyography (sEMG). To assess both the direct and indirect function of PQ in participants treated with volar plating and compared to the contralateral non-injured forearms. The angle of elbow flexion was varied from 45o, 90o and 135o when measuring forearm pronation. Mean peak torque of the major pronating muscles, PQ and Pronator Teres (PT) was directly measured with the TMD and the indirect activation of the PQ and PT was measured with sEMG.

In total 27 participants were studied. A statistically significant reduction in mean peak pronation torque was observed in the volar plated forearms (P<0.05 SE 0.015, CI 95%). This is unlikely to be of clinical significance as the mean reduction was small (13.43Nm treated v 13.48Nm none treated). Pairwise comparison found no statistically significant reduction in peak torque between 45o, 90o and 135o of elbow flexion. There was an increase in PQ muscle activation at 135o compared to 45o elbow flexion. The converse was identified in PT.

The small but statistically significant difference in mean peak torque in treated and uninjured forearms is unlikely to be of clinical significance and results suggest adequate functional recovery of the PQ after volar plating.

Aims

To establish if the principles of Enhanced Recovery, an evidence-based, integrated, multi-modal approach to improving recovery following colonic resection are transferable to elective orthopaedic primary arthroplasty surgery. The principles are to reduce the stress response provoked by surgery and eliminate the peri-operative catabolic state by optimally managing patients' metabolism, expectations, postoperative pain and mobility. This combination of interventions has not been tested in Orthopaedics before.

Enhanced Orthopaedic Recovery (EOR) is an evidence-based, integrated, multi-modal approach to improving recovery following elective orthopaedic surgery. The principles of EOR are to reduce time to functional recovery of postoperative patients safely with subsequent benefits to their length of stay in hospitals, their quality of life and health economics and outcomes. The combination of interventions used has been shown to be effective following major gastro-intestinal surgery but have not been tested in Orthopaedics until now. They aim to reduce the stress response provoked by surgery and the peri-operative catabolic state by optimally managing patient metabolism, post-operative pain, mobility and expectations.

Simple interventions along the patients’ journey include pre-operative educational classes, pre-operative carbohydrate loading, a (short) two hour fast ensuring surgery performed on anabolic patients, post operative pain and metabolic optimisation, empowering patients with ownership of their post-operative recovery and proactive post-discharge management. We found that these simple interventions translate well into elective orthopaedic arthroplasty surgery, can be achieved without additional cost and have little impact on intra-operative practice.

We conducted a single surgeon, consecutive patient, interventional, cohort study of lower limb primary joint arthroplasty surgery (primary total knee and primary total hip arthroplasty) in a busy district general hospital, 30 bed orthopaedic department. We reviewed the preceding 141 primary joint replacements (75 total hip and 66 total knee arthroplasties) before prospectively assessing the next 50 total hip and 32 total knee arthroplasties. A Mann-Whitney test between the two periods showed a highly statistically significant fall in time to discharge (median hospital stay 6.5 - 4 nights, p< 0.001). We noted no adverse effects as a result implementing EOR.

We have shown that by implementing EOR, reduced time to functional recovery and subsequent hospital discharge can be safely achieved with consequent quality of life and health economic benefits.

The management of leg-length inequality following total hip replacement remains controversial. Many leg length discrepancies are well tolerated and need no treatment. Some patients require only a heel raise, but some patients remain dissatisfied after their hip replacement surgery.

A recent report has suggested that leg-lengthening following total hip replacement does not correlate with patient satisfaction nor joint-specific or generic health scores[1]. This is not our experience. While many patients find leg lengthening an inconvenience, others have major disability following this complication. We report 4 patients who experienced unremitting pain and functional limitation following leg-lengthening as a result of primary hip arthroplasty.

All 4 patients underwent revision surgery which equalised leg length and resulted in immediate and complete resolution of their symptoms. We discuss the clinical findings, x-ray appearances and surgical technique employed to correct this problem. We have never had to revise a hip because of a shortened leg on the operated side.

The Wroblewski golf ball acetabular cup was introduced by surgeons using the trochanteric osteotomy approach for revision total hip replacement (THR) in order to reduce the rate of dislocation. We have routinely used the Ogee long posterior wall (Ogee LPW) and the Wroblewski angle bore cups in THR. Although the new Wroblewski golf ball cup performed well there was a significant early rate of dislocation of 20%. Our rate of dislocation over a period of ten years using the Ogee LPW and Wroblewski angle bore cups had been 0.52%. We present our findings and an investigation as to why the new cup has such a high rate of dislocation when used with the posterior approach. We show that a relatively small change in the design of the acetabular component resulted in significant adverse clinical results.

This study was designed to determine the outcome following carpal tunnel decompression in relation to patient age. The outcome measure used was a previously published self-administered validated questionnaire which measured symptom severity and functional status in a prospective study of 91 patients undergoing carpal tunnel release. Diagnosis was made on clinical grounds and pre-operative electrophysiology tests. Patients with inflammatory disease, metabolic disorders, pregnancy and carpal tunnel syndrome secondary to trauma were excluded.

Each patient completed the questionnaire and underwent nerve conduction studies prior to surgery, and both were repeated 6 months after surgery. The change in symptom-severity and functional status scores were calculated. Four patients failed to attend review, leaving 87 patients in the study. There were 50 women and 37 men, with a mean age of 59. 8 years (range 31–91).

Ninety percent of patients improved on symptom score and 82% on function score. There was a negative correlation between symptom improvement and age (p=0. 003), and functional status and age (p=0. 046). The greatest difference in outcome was between those patients over 60 years and those 60 or under (p=0. 001 for symptoms and p=0. 034 for function). Both age groups, however, improved significantly in symptom and function scores following surgery (p< 0. 001 for both groups). There was no age group which did not show a significant improvement in outcome, including the very elderly.

Improvement in nerve conduction tests also declined over 60 years of age (p=0. 027).

However, there was no correlation between pre-operative questionnaire scores and nerve tests.

There was also no correlation between outcome and patient sex or symptom duration.

Ten patients expressed dissatisfaction with surgery (7 over 60 years), and a further 10 patients scored their surgery as neutral (7 over 60). These results show that patients over 60 show lower improvement in symptoms and function following carpal tunnel release than younger patients, and 1:3 fail to express satisfaction with the outcome of surgery.

Decompression of the carpal tunnel is a common surgical procedure. Although the incidence of the carpal tunnel syndrome increases with age, there is no clear information available on the outcome of surgery in relation to age. We studied prospectively 87 consecutive patients who underwent decompression, using a validated self-administered questionnaire, and found that improvement in symptoms and function decreased with increasing age. This was most marked in patients over the age of sixty years.