The literature shows that interscalene anaesthesia (ISA) offers many advantages over general anaesthesia(GA) for arthroscopic surgery. There are benefits intra-operatively, a decrease in post-operative complications and a decrease in hospital stay. However patient satisfaction and acceptance of interscalene anaesthesia has not been fully assessed. We wanted to prospectively assess patient choice and satisfaction with interscalene anaesthesia compared to general anesthesia.

Fifty patients undergoing subacromial arthroscopic decompression and suitable for either anaesthetic technique, were prospectively identified between August and December 2006. The anaesthetic team discussed the pros and cons of general anaesthesia versus interscalene anaesthesia and the patient choose the type of anaesthesia. The same anaesthetic team and senior author managed and operated on all the patients in the study. Post-operatively patients filled out a questionnaire, which assessed patient choice, experience and satisfaction with type of anaesthesia undertaken.

Forty-sic patients successfully completed the questionnaire (27 female, 19 male, average age 59). Seventy-six percent of patients felt that they really understood the pros and cons of each anaesthetic type. Seventy-eight percent of patients felt that they really had the choice in determining their anaesthesia. Twenty-six choose ISA and twenty choose GA. Post-operative complications were less in the ISA group versus the GA group; pain(5.23ISA, 5.75GA), nausea(11%ISA, 35%GA), vomiting(0 ISA, 1GA), and drowsiness(19% ISA, 70%GA). Hospital stay was shorter in ISA patients compared to GA patients. All patients claimed to be satisfied with their choice and none would in retrospect change it.

Patients who choose interscalene anaesthesia had less post-operative pain, nausea, vomiting, drowsiness and shorter hospital stays then those patients who choose general anaesthesia for their shoulder surgery. This is consistent with the literature. All patients claimed to be fully satisfied with their hospital experience irrespective of the type of anaesthesia undertaken and none would have chosen differently.

The aim of this study was to assess the outcome of a pre-contoured anatomic plate in the treatment of midshaft clavicle fractures.

We treated thirty patients consecutively for middle third clavicle fractures between March 2001 to March 2006. Surgery was performed for acute fractures, non-unions and malunions by a senior surgeon.

Fifteen patients were treated by open reduction and internal fixation with a precontoured small fragment clavicle plate (mean age of thirty-eight years).

Our control group consisted of a consecutive series of fifteen patients treated by internal fixation with conventional plates (mean age of forty-one years). Ten patients had fixation of their clavicles with a reconstruction plate whilst five patients had fixation with a dynamic compression plate (DCP).

Outcomes assessed for both groups were; complications, need for removal of plate, post-operative outcome, and time to union.

All patients were followed up for an average of eighteen months (range eight to thirty months). In the pre-contoured plate group none required removal of hardware. Five patients had complications. Three of these patients complained of numbness around the caudal aspect of the wound which subsequently resolved within six to eight weeks of the operation. The remaining two patients suffered from adhesive capsulitis postoperatively. Their symptoms resolved completely after four months. All patients regained full range of motion. All patients went on to clinical and radiological union with average time to union being 4.7 months (range three to ten months).

In the conventional plate group, nine patients required removal of their plate. Average time to removal of plate from index operation was 7.7 months (range four to thirteen months). Of the nine plate removals there were two plate breakages, five removals for local soft tissue irritation and two persistent painful non-unions. Three patients required subsequent re-plating for non-unions. All fractures united in this group with mean time to union of 5.4 months (range 2 to 14 months).

A pre-contoured clavicle plate provides rigid fixation without compromising plate stiffness and fatigue strength. We have successfully treated patients with acute fractures, nonunions and malunions of midshaft clavicle fractures, where there was gross distortion of normal anatomy. None of our patients required the removal of their plates (minimum follow-up of 8 months). We have also found these plates to be a valuable anatomical template when reconstructing a malunion, nonunion or highly comminuted fracture.

In conclusion, this is the first reported series demonstrating the use of anatomical pre-contoured plates for clavicle fractures. They can reduce time spent on intra-operative contouring, are low-profile and thus far, plate removal has not been necessary.

There is no general consensus amongst Orthopaedic Surgeons on how best to manage the urinary tract and its complications after lower limb arthroplasty. This prospective audit investigates whether post-operative urinary retention can be predicted pre-operatively using the validated International Prostate Symptom severity score (IPSS).

182 patients undergoing lower limb arthroplasty under spinal anaesthetic were given the IPSS questionnaire to complete pre-operatively and an audit into numbers catheterised post-operatively carried out.

69% of males and 39% of females required catheterisation. Following logistic regression analysis there was 0.85 predicted probability that males over seventy years would require catheterisation. The IPSS score was not useful in predicting retention in either sex at any age.

We propose that all males over seventy years undergoing this type of surgery should be catheterised pre-operatively and all other patients should be catheterised post-operatively with close monitoring of bladder volumes to prevent established urinary retention.

Purpose To determine which patients respond best to viscosupplementation injections for osteoarthritis of the knee.

Methods and Results We undertook a prospective study of all patients undergoing Hylan G-F 20 injections in the knee recording the indication, severity of symptoms, baseline demographic details and the WOMAC score. Outcome data was collected at 3, 6 and 12 months at an independent telephone interview to determine if patients were improved, the same or worse, and by postal WOMAC score.

100 patients were studied. 3 records were excluded, as there was no follow-up recorded. The demographics on 97 were: mean age 67 (range 37–91), male 56%, mean duration of symptoms 8.8yrs and primary OA in 65%.

Overall 43% were improved at 3 months, 31% at 6 months and 29% at 12 months. When the results were analysed according to indication, patients with ‘moderate non-mechanical osteoarthritic symptoms after failed medical management and not severe enough for arthroplasty’ did best (49% at 3 months and 38% at 6 months). Patients with ‘persisting arthritic symptoms after attempted arthroscopic debridement for mechanical type knee symptoms’ had less predictable results (42% improved at 3 months and 23% at 6 months). Patients with ‘severe or deteriorating symptoms while awaiting knee replacement’ or who were ‘too medically ill for TKR’ had a low rate of improvement (18% at 3 months).

Conclusion Viscosupplementation is unreliable in patients with end stage OA awaiting TKR. This study allows for better targeting of this useful expensive treatment modality.

Background: Relatively little is known about the risk factors for carpal tunnel syndrome (CTS) in the community. Previous studies have generally assessed smaller numbers of patients in specialist clinics, or in particular occupations. Therefore, we have performed a case-control study using the West Midlands General Practice Research Database.

Methods: Our cases were all patients with a recorded diagnosis of CTS; four controls per case were individually matched by age, sex and general practice. Information on constitutional, hormonal and musculoskeletal factors was extracted and analysed by conditional logistic regression.

Results: Our dataset included 3,391 cases; 2,444 (72%) were female, mean age at diagnosis was 45.8 years: and 13,564 matched controls. Multivariate analysis showed that the risk factors associated with CTS were previous wrist fracture (OR = 2.29, 95% CI: 1.67–3.12), rheumatoid arthritis (OR = 2.23, 95% CI: 1.57–3.17), osteoarthritis (OR = 1.89, 95% CI: 1.65–2.17), BMI (BMI 30–40, OR = 2.06, 95% CI: 1.79–2.38), diabetes (OR = 1.51, 95% CI: 1.24–1.84), the use of insulin (OR = 1.52, 95% CI: 1.06–2.18), sulphonylureas (OR = 1.45, 95% CI: 1.07–1.97), metformin (OR = 1.20, 95% CI: 0.84–1.72) and thyroxine (OR = 1.36, 95% CI: 1.08–1.70). Smoking habit, hormone replacement therapy, the combined oral contraceptive pill and oral corticosteroids were not associated with CTS.

Conclusions: Rheumatoid arthritis, wrist fracture, osteoarthritis, and an increased Body Mass Index were the most important risk factors for CTS that we identiþed. The combined oral contraceptive, hormone replacement therapy, prednisolone and smoking are not associated with CTS.

Background: Presently the aetiology of this common condition remains unclear. Previous research suggests that diabetes or epilepsy might increase the prevalence of the condition, but the evidence is inconsistent.

Methods: Our cases were all patients diagnosed with Dupuytren’s Disease, with two controls per case individually matched by age, sex, and general practice. Information on all diagnoses of diabetes and diabetic medication, and epilepsy and anti-epileptics was extracted. All analysis was adjusted for consulting behaviour to reduce ascertainment bias.

Results: There were 821 cases (1,642 controls), 588 (72%) of which were males. Mean age at diagnosis was 62 years. Prevalence = 0.2%. Diabetes was significantly associated with Dupuytren’s (OR 1.82). Insulin use was strongly associated with Dupuytren’s (OR = 4.33), as was metformin (OR = 3.67); the association was also present for sulphonlyureas (OR = 1.89). There was no association with epilepsy and Dupuytren’s (OR = 1.05). None of the treatments for epilepsy were associated with Dupuytren’s disease.

Conclusion:Diabetes is a significant risk factor for Dupuytren’s Disease. There is an increased risk for treated diabetes rather than diet controlled diabetes. Epilepsy and anti-epileptic medication are not associated with Dupuytren’s Disease. Ascertainment bias may explain the association observed in previous studies.

Aim. To validate the implementation of relatively inexpensive and reliable laboratory tests in everyday clinical practice for the early recognition of malnutrition in patients with a hip fracture. Correlation of malnutrition with clinical parameters.

Method. Retrospective study including all elderly patients operated for a hip fracture during a five year period. Patients were evaluated according to two laboratory parameters: serum albumin and total lymphocyte count. Both parameters are established and widely used nutritional indexes. Based on the results, patients were divided into four groups: Patients in group A had both parameters within normal limits. Group B had a low total lymphocyte count and a normal albumin level. Reversibly, patients in group C had a low albumin level and a normal total lymphocyte count. In group D both values were abnormal. The groups were compared according to three clinical parameters: waiting time to operation, duration of hospital stay and one year postoperative mortality.

Results. Three hundred and twenty nine patients were included in the study. Statistically important differences were found for all three clinical parameters between malnourished patients (group D) and those with normal values (group A).

Conclusion. Serum albumin levels and a total lymphocyte count are reliable nutritional indexes in patients with a hip fracture. Their implementation in clinical practice can contribute to the early recognition and appropriate treatment of patients with a worse prognosis.

Adverse effects of different preparations of Botulinus Toxin were studied. 97 episodes of injections in 67 children with cerebral palsy carried out between 1994 and 2001 were available for study. A telephonic interview was carried out according to a format in which the nature of adverse effects and the onset and duration of beneficial effect were recorded. 52 children had diplegia, 27 had hemiplegia and 18 had quadriplegia. 69 injections were made using Botox and remainder were made using Dysport. The dose for botox was up to 12 units per kilogram body weight and for dysport up to 40 units per kilogram body weight. The average age at injection was 94 months. The diagnoses were evenly distributed between the groups. A total of 72 adverse effects were noted in 44 episodes. Botox group accounted for 35 episodes and dysport for 9 (p=0.23). Thirty-three children had at least one adverse effect. Botox group accounting for 23 and Dysport group for 10 (p=0.45). The commonest adverse effect was pain at the injection site. The student t test was carried out to test statistical significance. There were no significant differences in the occurrence of adverse effects or the onset and duration of beneficial effect.

It may be concluded that botulinum therapy for cerebral palsy provided a high degree of patient/carer satisfaction. It produced few adverse effects and is generally well tolerated. The effects of botox and dysport were comparable.

14 systems for anterior cervical stabilisation were evaluate under flexion-compression bending using test procedures conforming to Static and Fatigue Test Methods for Spinal Implant Assemblies using Corpectomy Models Part 2a [ISO/TC 150/SC5 N127C]

Plates of standardised active length were tested in an in-vitro model of a single corpectomy of the lower cervical spine using composite test blocks manufactured by Sawbones to have physical properties similar to cervical vertebrae.

Results reveal a wide range in final yield strengths with bi-cortical systems significantly stronger than uni-cortical ones. There was a fourfold difference in ultimate load between the stronger and weakest systems.

We found that mode of failure was influenced by plate thickness, screw length and screw placement.

Ulnar drift is a common deformity in the hands of patients with rheumatoid arthritis. There is little in the literature regarding the value of crossed intrinsic transfer with MCPJ arthroplasty (Hellum 1968, Stothard et al 1991). In addition the significance of recurrent ulnar drift on hand function is unknown. The aim of this study is to assess if the addition of crossed intrinsic transfer to metacarpophalangeal arthroplasty has an effect on the recurrence of ulnar drift and to overall hand function.

This is a retrospective comparative study. 73 hands in patients with rheumatoid arthritis undergoing primary 2nd to 5th metacarpophalangeal joint (MCPJ) replacements were studied. In 28 hands a crossed intrinsic transfer was performed and in 45 hands it was not . A similar splintage and rehabilitation programme was followed in each group. Mean follow up was 50 months.

Ulnar drift and active range range of motion, Sequential Occupational Dexterity Assessment (SODA) functional score, patient satisfaction , grip strength.

The two groups had similar preoperative ulnar drift (crossed intrinsic transfer group mean 27 degrees, comparative group 29 degrees, p=0.44). At follow up the crossed intrinsic transfer group had statistically less ulnar drift (crossed intrinsic transfer group mean 6 degrees, comparative group 14 degrees, p=0.01). There was no difference at follow up in active flexion, extensor lag, SODA score, grip strength and patient satisfaction (both groups had 70% improved function).

The rigidity of a sliding compression screw and three cannulated lag screws in the treatment of subcapital fractures was compared in five pairs of female cadaver femora. There were no significant differences between the compressive strength, bone density, cortical thickness or Singh index of the bones in each pair. A subcapital fracture was standardised using a perpendicular saw cut across the femoral neck. A uniaxial 'load test system' with force and length measurement facilities was used to mimic cyclical stressing applied in vivo at a frequency of 0.5 Hz from 0 to 3 times body-weight. There was no significant difference between the fixation afforded by the sliding compression screw and three lag screws. Bone quality was the single most important factor in the stability of the bone implant unit.