Reconfiguration of elective orthopaedic surgery presents challenges and opportunities to develop outpatient pathways to reduce surgical waiting times. Dupuytren's disease (DD) is a benign progressive fibroproliferative disorder of the fascia in the hand, which can be disabling. Percutaneous-needle-fasciotomy (PNF) can be performed successfully in the outpatient clinic.

The Aberdeen hand-service has over 10 years' experience running dedicated PNF clinics. NHS Grampian covers a vast area of Scotland receiving over 11749 referrals to the orthopaedic unit yearly. 250 patients undergone PNF in the outpatient department annually. 100 patients who underwent PNF in outpatients (Jan2019–Jan2020).

79M, 21F. Average age 66 years range (29–87). 95 patients were right hand dominant. DD risk factors: 6 patients were diabetic, 2 epileptic, 87 patients drank alcohol. 76 patients had a family history of DD. Disease severity, single digit 20 patients, one hand multiple digits in 15 patients, bilateral hands in 65 patients of which 5 suffered form ectopic manifestation suggestive of Dupuytren's diasthesis. Using Tubiana Total flexion deformity score pre and post fasciotomy. Type 1 total flexion deformity (TFD) between 0–45 degrees pre PNF n=60 post N= 85, Type 2 TFD 45–90 degrees pre PNF n=18 post N=9, Type 3 TFD 90–135 pre PNF n=15 post N= 5, Type 4 TFD >135 pre PNF n=1 post PNF N=1. Using Chi-square statistical test, a significant difference was found at the p<0.05 between the pre and post PNF TFD. Complication: 8 recurrence, 1 skin tear. No patients sustained digital nerve injury.

Outpatients PNF clinics are a valuable resource.

Introduction:

Infection as an indication for revision has increased to 12% of the total revisions (UK NJR 9^th report). However, it is next to impossible to find out the cause for a delayed prosthetic infection. With increasing number of arthroplasty procedures, is there a need for prophylactic antibiotics in patients with prostheses?

Introduction:

The awareness of MoM hips in the general public, one would expect, to be good, given the media coverage. This study aims to look at the perceptions and knowledge of patients who have already got a MoM arthroplasty.

Introduction

We conducted an audit on hip fractures to analyse the accuracy of coding and payment by results in our institution.

The last decade has seen a rise in the use of the gamma nail for managing inter-trochanteric and subtrochanteric hip fractures. Patients with multiple co-morbidities are under high anaesthetic risk of mortality and are usually not suitable for general or regional anaesthesia. However, there can be a strong case for fixing these fractures despite these risks. Apart from aiming to return patients to their pre-morbid mobility, other advantages include pain relief and reducing the complications of being bed bound (e.g. pressure ulcers, psychosocial factors). While operative use of local anaesthesia and sedation has been documented for insertion of extra-medullary femoral implants such as the sliding hip screw, currently no literature is present for the insertion of the gamma nail.

We studied intra-operative and post-operative outcomes of three patients aged between 64 and 83 with right inter-trochanteric hip fractures and American Society of Anesthesiologists (ASA) scores of 4 or more. Consent for each case was obtained after discussion with the patient and family, or conducted with the patient's best interests in mind. All patients received a short unlocked gamma nail, and were operated on within 24 hours of admission. Each patient underwent local injections of Bupivacaine or Lignocaine or both, with Epinephrine, and with one patient receiving nerve block of the fascia iliaca. Each patient received a combination of sedatives under the discretion of the anaesthetist including Midazolam, Ketamine, Propofol, Fentanyl, and/or Haloperidol. Operating time ranged from 30–90 minutes. Patients were managed post-operatively with analgesia based on the WHO pain ladder and physiotherapy.

Our results showed no intra-operative complications in any of the cases. All patients noted improvement in their pain and comfort post-operatively without complications of the operation site. Two patients achieved their pre-morbid level of mobility after undergoing physiotherapy and were subsequently discharged from the orthopaedic team. One patient with ongoing pre-operative medical complications died 5 days after the operation.

This study provides a glimpse into the use of local anaesthetic and sedation on high operative risk patients, and this may be a viable alternative to extra-medullary implants or non-operation. Further research is needed to quantify the risks and benefits of operating within this patient group.

Background

A large number of Tendo-Achilles (TA) injuries occur during sporting activity. Typically occurring in males aged 30–50, whom occasionally undertake sporting activities, the so called ‘weekend warriors’.

Introduction and aims

Low back pain is a common complaint, affecting up to one third of the adult population costing over £1 billion to the NHS each year and £3.5 billion to the UK economy in lost production. The demand for spinal injections is increasing allowing for advanced spinal physiotherapists to perform the procedure. The objective of this study was to investigate outcome following spinal injections performed by consultant spinal surgeon (n=40) and advanced spinal physiotherapists (ASP) (n=40) at our centre.

Blood transfusion requirement in shoulder surgery has been reported from 8.1% to up to 15%. Our observation was that blood transfusion rarely required after open shoulder surgery. We therefore decided to conduct a retrospective case notes study to look at the crossmatch-transfusion ratio for shoulder surgery.

A total of 211 patients were included in the study. Results were analysed using paired T-test from SPSS (15.0). There were 63 elective procedures and 148 trauma procedures during that period. Ten patients (4.8%) required intra-operative or post operative transfusion. Crossmatch-transfuison ratio was 21.

There should be a clear equation between crossmatch and its use, intra-operatively and post operatively. This study highlighted unnecessary cross-matching for shoulder operations which puts extra pressure on the laboratory staff, the blood bank and also has financial implications.

At present patients who require shoulder hemiarthroplasty in our unit routinely have two units of blood cross matched pre-operatively. Our observation was that blood transfusion rarely required after open shoulder surgery. We therefore decided to look at the crossmatch-transfusion ratio for the following procedures in our department; elective shoulder hemiarthroplasty, reverse total shoulder replacement, open rotator cuff repair, shoulder hemi-arthroplasty for trauma, open reduction and internal fixation of proximal humeral fractures.

We undertook a retrospective review of all such patients during the period of 2002 to 2005. All trauma and elective surgery included. Hospital notes were analysed to include age, sex, pre operative haemoglobin level, blood transfusion intra-operatively and post-operatively.

A total of 211 patients were included in the study. There were 63 elective procedures and 148 trauma procedures during that period. No patient required intra-operative or post operative transfusion. Three patients who required transfusions post operatively, due to other associated injury (liver laceration x1, spleen injuries x 2) were excluded from the study. Crossmatch-transfuison ratio was > 2.

There should be a clear equation between cross-match and its use, intra-operatively and post operatively. This study highlighted unnecessary cross-matching for shoulder operations in our unit which puts extra pressure on the laboratory staff, the blood bank and also has financial implications. We recommend, Standardised approach for pre-operative cross match practise, pre-operative group and screen to detect atypical antibodies and efficient hospital pathology services, to provide blood for transfusion within specified time, for atypical antibody negative blood, should it require.

Weight gain is often reported by patients who succumb to impaired activity as a result of progressive osteoarthritis of the hip or knee. Optimistic views of weight loss after joint replacement are often held by patients. We studied the affect of lower limb arthroplasty on body weight.

We reviewed 144 patients having undergone hip and knee arthroplasty and were functionally well. Infected cases were excluded. Average age was 65 years and average follow up was 27 months. The Body Mass Index (BMI) was prospectively measured at follow up and compared to immediate pre-operative BMI.

Our findings demonstrated an average rise in BMI post-operatively which was statistically significant. A rise in post operative BMI was seen in patients who were obese to start with or those who had undergone a total hip replacement (statistically significant). Moderate rises were seen in patients who had underwent hip resurfacing procedures or those who were overweight preoperatively (p=0.06).

These findings are useful in informing patients of achievable expectations following joint replacement surgery and preoperative overweightness should be treated as a separate entity unrelated to co-existing joint degeneration.

We have evaluated in vivo a novel, polymer-based, matrix for tissue engineering of bone. A segmental defect of 15 mm was created in the ulna of New Zealand white rabbits to determine the regenerative properties of a porous polylactide-co-glycolide matrix alone and in combination with autogenous marrow and/or the osteoinductive protein, BMP-7. In this study four implant groups were used: 1) matrix alone; 2) matrix with autogenous marrow; 3) matrix with 20 μg of BMP-7; and 4) matrix with 20 μg of BMP-7 and autogenous marrow.

The results showed that the degree of bone formation was dependent on the properties of the graft material. The osteoconductive sintered matrix structure showed significant formation of bone at the implant-bone interface. The addition of autogenous marrow increased the penetration of new bone further into the central area of the matrix and also increased the degree of revascularisation. The osteoinductive growth factor BMP-7 induced penetration of new bone throughout the entire structure of the implant. The most effective treatment was with the combination of marrow cells and osteoinductive BMP-7.