Low molecular weight heparin (LMWH) is frequently used as thromboprophylaxis after major orthopaedic surgery. Varying levels of non-adherence (5% to 45%) with outpatient LMWH has been reported. Oral direct thrombin inhibitors have been recommended by industry due to ease of administration. We aim to audit the compliance rate with outpatient LMWH treatment following primary total hip arthroplasties (THA) in our district general hospital (DGH).

Using the ORMIS computer system, we identified all primary THA performed in Monklands Hospital between July 2011 and August 2012. Patients’ case notes were analysed retrospectively, looking at operating surgeon's postoperative thromboprophylaxis instructions. We then conducted a telephone interview on patients discharged with outpatient LMWH to assess compliance.

There were 58 primary THAs performed during the audit period. 33 patients were discharged on outpatient LMWH, whilst 15 patients and 3 patients were discharged on aspirin and warfarin respectively. Seven patients were excluded as their discharge prescriptions were missing.

We successfully contacted 20 of the 33 patients discharged with outpatient LMWH. All respondents showed 100% compliance to the full course of treatment. 50% of patients self-administered; 30% were administered by district nurses and 20% by family members. 35% of patients preferred an oral tablet alternative, for its perceived ease of administration. Bruising and skin irritation were the reported problems in some patients, but these did not affect compliance.

Contrary to the previous published non-adherence rates, the compliance rate with outpatient LMWH after THA was high in our DGH. The patient counseling, and family/district nurse involvement in may have contributed to this. However, our numbers of patients are low but data collection continues.

Introduction

We analyzed the results of extracorporeal radiated (ECRT) autogenous tumour bone for reconstruction of diaphyseal defects after tumour resection at our institute.

Introduction: Total hip replacement (THR) in young patients is a controversial subject due to high failure rates reported in the literature. The purpose of this study was to show our short term results of primary total hip replacement in patients younger than 30 years of age.

Methods: Patients who underwent THR prior to the age of 30 years between 1998 and 2007 were identified and records of all patients were reviewed together with the radiographs till the last follow up.

Results: Forty three THRs were performed on 36 patients with an average age of 24.4 years (range, 17–30) and an average follow up period of 47 months (range, 7–109 months). There were 5 cases of Juvenile chronic arthritis, 2 Rheumatoid arthritis, 11 DDH, 2 septic arthritis, 1 pseudoachondroplasia, 4 Perthes disease, 2 seronegative arthitides, 2 SUFE and 7 AVN [alcohol, leukaemia, fracture, SLE (2), mannosidosis, idiopathic].

Thirty cemented THRs and 13 hybrid THRs were performed through trochanteric osteotomy approach (23), posterior approach (17), Hardinge approach (2) and anterior approach (1). In the cemented group there were 3 cases of superficial wound discharges, 1 recurrent dislocation, 1 complete femoral nerve palsy, 2 cases of neuropraxia and 1 case with persistent hip pain but no cases of infection. In the hybrid group there was one case of partial femoral nerve palsy. None of the patients has undergone any revision surgery till the latest follow up. Radiologically only one case showed aseptic loosening in both femoral and acetabular components, which is not revised as the patient is asymptomatic.

Discussion: THR is an elegant procedure and should be certainly considered in young patients suffering with disabling arthritic conditions affecting the hip joint. Our results show that THR - both cemented and hybrid types - is a successful and durable treatment.

In situ fixation of mild slips of the slipped capital femoral epiphysis (SCFE) is a safe and reliable method of treatment. Hardware failure and fractures are reported at the time of pin retrieval. Difficulty in removing these pins is well reported. Major problems can be expected when arthroplasty is necessary years later, if the pins are still inside the proximal femur. Hence we have come up with a novel technique to remove these pins during Primary Total hip arthroplasty.

The hip is exposed through posterior approach, dislocated and the neck is then cut at the usual site. It is then segmented in both sagittal and coronal planes into approximately eight to ten pieces and removed piecemeal. The pins are thus exposed, cleared of any bony debris and hammered retrograde.

By using our simple and novel technique to remove these pins we feel it avoids unnecessary trauma to the outer cortex of femur and also reduces the operating time significantly.

Introduction: Fractures of the tuberosity heal well irrespective of the treatment instituted. Fractures distal to the tuberosity have a high incidence of delayed union and non-union. This could be due to disruption of the vascular supply that enters the bone at the metaphyseal-diaphyseal region. It has also been reported that in these injuries, stress fractures occur at a different anatomic site that is more distal to acute fractures.

We present one of the largest reported series of such fractures in which we have explored the above statements.

Materials & Methods: A retrospective review of 300 closed fractures of the base of the fifth metatarsal- 268 were tuberosity fractures (group 1) and 32 were fractures distal to the tuberosity (group 2).

The patients were followed up in the outpatients clinic for a mean period of 2 months (group 1) and 16 months (group 2).

The distance of the fracture site from the proximal tip of the metatarsal was measured on the radiographs.

Results:

All group 1 fractures healed well following symptomatic management and none required surgical intervention.

Conclusion:

A standardized classification is important because there is great variability in the types of fractures and appropriate treatment.

Percutaneous fixation is a well recognised technique in the treatment of three-part and four-part fractures of the proximal humerus. Minimal fixation of these fractures do show good functional outcome and may further reduce the incidence of avascular complications. We report a preliminary series of 11 patients who underwent percutaneous minimal fixation of such complex humeral fractures using a new technique. 11 consecutive patients (7 with three-part fractures and 4 with four-part fractures) treated by percutaneous limited fixation in our Hospital were involved in this retrospective study. There were 7 fractures with valgus displacement. Percutaneous technique was employed using small incisions and the fracture was reduced under image guidance. The three-part and the four-part fractures were essentially converted into two part fractures, i.e. only the greater and the lesser tuberosities were re-attached to head with AO cancellous screws after realignment of the fragments. The shaft of the humerus was not fixed to the head in any of the cases. All of these cases had a minimum follow-up of at least 6 months. The results were evaluated using the Constant -Murley Shoulder score. 1 out of 11 cases had to be converted to hemi-arthroplasty due to secondary redisplacement of the fracture. The remaining 10 cases showed good bony union although the greater tuberosity in 2 cases showed a residual superior displacement of 3mm and a residual valgus displacement in 2 out of 7 cases. There were no complications of avascular necrosis in any of the cases. Clinically, compared to the uninjured side the average constant score was 93.7% (range- 68.7% – 100%). 7 patients were very satisfied and 4 were satisfied with the operation. Percutaneous minimal fixation achieves good to very good functional outcome comparable to the conventional methods and theoretically reduces the incidence of infection, avascular necrosis and neurological complications.

Aim: To evaluate and assess the validity and accuracy of various described ways of performing the McMurray’s test in the diagnosis of meniscal tears.

Material & Methods: Prospective study with patients divided into seven groups based on seven described ways of performing McMurray’s test. Twenty-five patients in each group, aged between 15 to 60 years-undergoing arthroscopy of knee for clinically suspected meniscal tear. Exclusion criteria were ACL tear on arthroscopy, radiological or arthroscopic evidence of osteoarthritis and patients within six weeks of injury.

All patients were assessed preoperatively with knee examined in one of seen different methods. EUA followed by arthroscopy. Clinical and arthroscopic findings were correlated and sensitivity and specificity were determined.

The study is ongoing with following results.

Conclusion: Accuracy of McMurrays test ranged between 0 to 95% in various studies. Factors determining outcome include patient selection difference in applying test and interpretation of results. McMur-rays original description included no varus or valgus stress and a click a was positive test. Other descriptions include varus or valgus stress and apart from click pain is also considered a positive test. Comparisons among results in literature are difficult with confusing results. Our study is incomplete but trends suggest Reider’s method may be the most accurate.

Metallosis after shoulder replacement has not previously been described in the literature. We report a patient who developed extensive metallosis after implantation of an uncemented Nottingham shoulder replacement. He underwent a revision procedure.

Examination of the retrieved prosthesis showed that the titanium porous coating was separating from the humeral stem and becoming embedded in the ultra-high-molecular-weight polyethylene glenoid component, resulting in abrasive wear of the humeral component. There was metallosis despite exchange of the modular humeral head. Both components had to be exchanged to resolve the problem.

To assess the functional outcome of operative and non-operative treatment of distal humeral fractures in the elderly, patients above 75 years of age were studied. Demographic data including associated injuries and co-morbid conditions were recorded. The minimum follow-up was 16 months (range 16–92 months). Elbow function was analysed according to the OTA rating system. Radiographs were monitored for possible predictors of final functional outcome

Out of 125 patients with distal humeral fractures, 29 were above the age of 75 years. The mean age at the time of admission was 84.6 years (range 75–100). One patient was lost to follow-up. In total there were 28 patients with 29 fractures. 5 of these were open fractures. As per the AO classification, there were 8 type A, 8 type B, and 13 type C fractures. 8 patients were treated non-operatively (3 type A, 2 type B, 3 type C) and 21 (5 type A, 6 type B, 10 type C) operatively. An olecranon osteotomy was performed in 12 cases, 2 underwent triceps tongue reflection, and 7 had triceps splitting. Local complications included 4 cases (1 deep and 3 superficial) of infection and 3 non-unions (including one at the olecranon osteotomy). In the non-operative group the mean loss of extension and mean flexion achieved were 34.0 and 70.0 degrees respectively, whereas in the operative group the corresponding values were 23.0 and 107 degrees.

OTA grading revealed 3 excellent, 9 good, 7 fair and 2 poor results in the operated group whereas in the non-operated group there were 0 excellent, 2 good, 3 fair, and 3 poor results. There was direct correlation between loss of anterior tilt of the distal humerus and adverse outcome.

Conclusion: Our study showed that improved functional outcome can be achieved following surgical treatment in these difficult fracture This study supports the view that we need to re-examine the conventional view of ‘bag of bones’ method as blanket treatment and signifies the need for further studies on similar cohorts of patients.

Between 1990 and 2000, 15 patients with open 3C fractures of the lower extremity were treated at our institution. Demographic data such as age, sex, associated injuries and co-morbidities were recorded. The mechanism of injury, ISS [Injury Severity Score] and MESS [Mangled Extremity Severity Score] were ascertained. The minimum follow up was 2 years. All the fractures were classified according to the AO system. The patients received a combined treatment by the orthopaedic and plastic surgeons and when necessary by the vascular surgeons. Treatment options, were based on the extent of soft-tissue damage and the configuration of the fracture. Intra-operative details including arteries and nerves involved, type of flap cover, quality of fixation and need for fasciotomy were recorded and analysed. A final follow up was carried out at a special clinic and the outcome was analyzed using SF-36 and EUROCOL. MESS and ISS were analyzed for possible predictors of final functional outcome.

The patients were predominantly males. The main mechanism of injury was due to a road traffic accident and 6 of the patients had associated injuries in other parts of the body. In two thirds of the patients the fracture site was in the tibia, and in 3 cases there was a combined fracture in femur and tibia. The posterior tibial artery was involved in the vast majority of the cases, which was either disrupted or avulsed. The Salvage and reconstruction was carried out in 13 patients, which accounted for 77% of the cases and 2 patients underwent immediate amputation. Both had a Mangled Extremity Severity Score of 10. The bone fixation was mainly achieved by plating, or nailing. Half of the patients underwent fasciotomy, in the rest the compartments were decompressed due to the nature and extent of the injury. All the patients required secondary procedures, the mean total number of operations was 2.6.

Although only one-fifth of the patients had some problems with self care, half experienced some problems with mobility. Anxiety and depression was a problem in two thirds of the patients, and about the same proportion of patients experienced moderate to severe pain. The mobility was correlated to the MESS score.

Conclusion: the functional outcome was most closely related to the severity of injury and the injury-surgery interval. Our study showed that improved functional outcome is possible following surgical treatment of these challenging injuries especially when prompt response is instituted by combined ortho/plastic/vascular surgical teams.

32 consecutive patients who suffered open [Gustilo grade IIIB] distal tibial [AO type 43B and C] ‘Pilon’ fractures were prospectively studied in order to assess long-term functional outcome. All patients had radical debridement with immediate [within 24hrs] skeletal stabilisation and early soft tissue cover with a vascularized muscle flap as per our hospital’s protocol for management of severe open tibial fractures. The minimum follow-up was one year [range 1–8 years]. The superficial infection rate was 13% [4/32], deep infection rate was 6% [2/32] and the amputation rate as 6% [2/32]. There were no long-term problems with union and none of the patients required an ankle fusion. Patients were assessed using the SF-36 questionnaire. There were sig-nificant differences from the US norm in physical function score [p< 0.01], role physical score (p< 0.05) and physical component score (p< 0.01). Physical component score of 38.5 was significantly better (p< 0.01) when compared with amputees from severe lower extremity trauma. Our protocol for management of severe open pilon fractures resulted in a good functional outcome with low infection and amputation rates.

We prospectively studied 29 patients with distal femoral fractures stabilised using the less invasive stabilisation system [LISS]. Four patients were excluded from the final follow up [3 deaths and 1 case of quadriplegia]. The mean age of the remaining 25 patients [9 males] was 60.9 years and the mean follow up 18 months [12–24]. Eleven patients were tertiary referrals from other hospitals [7 cases were referred due to failure of primary fixation]. Overall, there were 12 cases of high-energy trauma [7 open fractures]. According to the AO classification there were 5 Type 33A, 2 Type 33B and 12 Type 33C fractures and 4 Type 32A, 1 Type 32B, 1 Type 32C fractures. Functional assessment was performed using the Modified HSS and the Schatzker and Lambert scores. The average time to union in 22 cases was 3.5 months [range, 2–5]. None of the acute cases required bone grafting with a 100% union rate. There were 3/7 cases of non-union in the salvage group still undergoing treatment. The overall results in the acute cases were good and in the salvage cases fair. While this is a small series of patients, our preliminary data indicate favourable results using the LISS in stabilizing acute distal femoral fractures. However, when the LISS is used as a revision tool despite the concept of preserving the bone biology, the results seem to be less satisfactory. The system appears to be user friendly and no technical difficulties were encountered.

Aims: To evaluate whether in children with knee pathology there is any correlation between clinical diagnosis, magnetic resonance imaging and arthroscopy. Methods: Between 1993 and 2001 children age 3–16 years old, who presented in the orthopaedic clinics of our institution with knee pathology were included in this study. All of them underwent MRI investigation. Their history, physical examination and clinical diagnosis were ascertained from their case notes. Some of these children underwent arthroscopic surgery of the knee and þndings were also recorded. Clinical data, MRI þndings and arthroscopic þndings were computerised and analysed. Results were analysed and compared in the following 3 groups: a) clinical data versus MRI þndings, b) clinical data versus arthroscopic þndings and c) MRI report versus arthroscopic þndings. Comparisons were rated in one of three categories: total agreement, partial agreement or total disagreement. Partial agreement was deþned as the partial correlation of þndings. Results: 130 children (131 knees, one bilateral) were included in this study. The mean age was 8.5 years (range 3–16). Conclusion: In this study 1/3 of the knee MRI was normal and there was only 26% of total agreement between the clinical and MRI þndings. Further more in 50% of cases that underwent arthroscopy, there was no correlation of arthroscopic and MRI þndings.This study supports the view that knee MRI investigation in children may not provide a reliable diagnosis and guidance in children with knee pathology.

Aims: To evaluate whether in children with knee pathology there is any correlation between clinical diagnosis, magnetic resonance imaging and arthros-copy.

Methods: Between 1993 and 2001 children age 3-16 years old, who presented in the orthopaedic clinics of our institution with knee pathology were included in this study. All of them underwent MRI investigation. Their history, physical examination and clinical diagnosis were ascertained from their case notes. Some of these children underwent arthroscopic surgery of the knee and findings were also recorded. Clinical data, MRI find-ings and arthroscopic findings were computerised and analysed.

Results: were analysed and compared in the following 3 groups: a) clinical data versus MRI findings, b) clinical data versus arthroscopic findings and c) MRI report versus arthroscopic findings. Comparisons were rated in one of three categories: total agreement, partial agreement or total disagreement. Partial agreement was defined as the partial correlation of findings.

Results: 130 children (131 knees, one bilateral) were included in this study. The mean age was 8.5 years (range 3-16). 81 were male and 49 were female, ratio 1.7:1. 38 (30%) patients underwent arthroscopy. 43 (33%) of the MRI scans were reported as normal. Lesions reported on MRI included meniscal and ACL tears, osteochondritis dessicans, osteochondral fractures and discoid lateral meniscus. Overall, the results between the comparison of the 3 groups are summarised as follows:

Conclusion: In this study 1/3 of the knee MRI were normal and there was only 26% of total agreement between the clinical and MRI findings. Further more in 50% of cases that underwent arthroscopy, there was no correlation of arthroscopic and MRI findings.This study supports the view that knee MRI investigation in children may not provide a reliable diagnosis and guidance in children with knee pathology.

To evaluate whether in children with knee pathology there is any correlation between clinical diagnosis, magnetic resonance imaging and arthroscopy.

Between 1993 and 2001 children age 3–16 years old, who presented in the orthopaedic clinics of our institution with knee pathology were included in this study. All of them underwent MRI investigation. Their history, physical examination and clinical diagnosis were ascertained from their case notes. Some of these children underwent arthroscopic surgery of the knee and findings were also recorded. Clinical data, MRI findings and arthroscopic findings were computerised and analysed. Results were analysed and compared in the following 3 groups: a) clinical data versus MRI findings, b) clinical data versus arthroscopic findings and c) MRI report versus arthroscopic findings. Comparisons were rated in one of three categories: total agreement, partial agreement or total disagreement. Partial agreement was defined as the partial correlation of findings.

130 children (131 knees, one bilateral) were included in this study. The mean age was 8.5 years (range 3–16). 81 were male and 49 were female, ratio 1.7:1. 38 (30%) patients underwent arthroscopy. 43 (33%) of the MRI scans were reported as normal. Lesions reported on MRI included meniscal and ACL tears, osteochondritis dessicans, osteochondral fractures and discoid lateral meniscus. Overall, the results between the comparison of the 3 groups are summarised as follows:

In this study 1/3 of the knee MRI was normal and there was only 26% of total agreement between the clinical and MRI findings. Further more in 50% of cases that underwent arthroscopy, there was no correlation of arthroscopic and MRI findings. This study supports the view that knee MRI investigation in children may not provide a reliable diagnosis and guidance in children with knee pathology.