The Oxford Knee Score (OKS) is a valid and reliable self-administered patient questionnaire that enables assessment of the outcome following total knee replacement (TKR). There is as yet no literature on the behavioral trends of the OKS over time. Our aim is to present a retrospective audit of the OKS for patients who have undergone TKR during the past ten years.

We retrospectively analysed 3276 OKS of patients who had a primary TKR and had been registered as part of a multi-surgeon, outcome-monitoring program at St. Helier hospital. The OKS was gathered pre-operatively and post-operatively by means of postal questionnaires at annual intervals. Patients were grouped as per their age at operation into four groups: 60, 61-70, 71- 80 and >80. A cross-sectional analysis of OKS at different time points was performed.

The numbers of OKS available for analysis were 504 pre-operatively, 589 at one-year, 512 at two-year and gradually decreasing numbers with 87 knees ten-year post-operatively. There was as expected a significant decrease (improvement) of the OKS between pre-operative and one-year post-operative period and then reached a plateau. Beyond eight years, there is a gradual rise in the score (deterioration). The younger patients (60) showed a significant increase in their average OKS between one and five-years post-operatively. However beyond five years, they followed the trend of their older counterparts. When the twelve questions in the OKS were analysed, certain components revealed greater improvement (e.g. description of knee pain and limping) than others (e.g. night pain).

The OKS is seen to plateau a year after TKR. According to the OKS the outcome of the TKR is not as good in the younger age group as compared to the older age group. Further investigation is required to ascertain the cause of this observed difference.

Background: This prospective study was done to evaluate functional outcomes after acute avulsion fractures of the fifth metatarsal base. The objective was to compare the results of two different casting methods adopted as a treatment of non-displaced avulsion fractures of the fifth metatarsal.

Methods: Fifty-two patients who sustained an avulsion fracture of the fifth metatarsal base and presented to the outpatient clinic of our hospital system were treated according to the advice of the attending clinicians. A total of 49 patients were available for 3 months follow up. There were eight men and 41 women with an average age of 41.9 (range 17 to 81) years. The lower extremity was placed in a below knee [n=28] or slipper cast [n=21] and patients were allowed to bear weight as tolerated. Baseline data collection consisted of demographic information, and radiographic, and functional evaluation. Patients were seen at regularly scheduled visits for 6 weeks and then at 3 months to obtain follow up information. A Short Musculoskeletal Function Assessment (SMFA) questionnaire was obtained at 3/12 year. Analyses were performed to determine differences in outcome based on demographics and injury information.

Results: Based on self-reports, 10 patients with slipper cast had returned to pre-injury functional status by 3 weeks, compared to 22 patients with below knee cast by 6 weeks. An average of 22 days were lost from work, with 9 patients taking up to 10 days, 13 taking 3 weeks or longer off work. Twenty eight patients were losing more than 6 weeks of work in the other group. All were provided with pain killers, crutches if needed and none required thromboembolic prophylaxis with low molecular heparin. After twelve weeks none of the patients complained about pain. Radiographic consolidation of the fracture was noticed after 7 weeks for the avulsion fractures. As regard to the costing approximately 4 pounds for the slipper cast and 12 pounds were spent on the below knee casting.

Conclusions: Fracture of the fifth metatarsal base often is a source of lost work productivity. Patients can be expected to return to their preinjury level of function with slipper type of cast earlier than below knee cast. Slipper types of casting are cost effective, efficient and offer greater mobility to the patients.

Introduction: We studied prospectively two groups of patients treated operatively for acute achilles tendon rupture admitted in our institution in order to compare post operative morbidity, usage of hospital resources and immobilisation regimen involving immediate weight-bearing with traditional non-weight-bearing. The aim was to assess the benefit of instrument guided surgical method, which reduces hospitalisation cost, post operative wound care cost and reduce requirement of post-operative analgesics together with improved rehabilitation and return to normal activity for young patients [age below 45] with a rupture of the Achilles tendon.

Material and methods: 34 patients had repair of the tendon with an open method as an inpatient under instruction of the admitting consultant. Second group of 25 patients had repair as limited open technique with an Achillon instrument and immediate weight bearing.

Result: Opiates or opiate-based analgesia were used in the open repair group and in the minimally invasive group, patients reported no pain with paracetamol or ibuprofen. Two cases of severe wound infection leading to dehiscence requiring further surgery and 5 cases of minor surgical site infection leading to delayed wound healing were reported as wound complications in the open group. All the patients in the mini invasive group reported their satisfaction with wound healing and minimal scar at the incision site. Based on self-reports, the time taken to return to normal walking was median of 11 weeks in the achillon treatment group and 17 weeks for the open group. There was also an earlier return to normal stair climbing, with a median of 13 weeks [9–21 weeks] in the achillon treatment group and 19 weeks [13–27 weeks] for the opens technique.

Conclusion: This study has shown that mini invasive repair with Achillon instrument may allow us to perform surgery with less bed usage, less consumption of post operative analgesics and other associated indirect cost to the healthcare provider. It also allows faster rehabilitation. It provides further evidence that minimally invasive repair with early weight bearing rehabilitation has advantages over traditional open repair with delayed mobilisation for patients who have undergone surgery for ruptured Achilles tendon. The practical advantages for patients in early weight-bearing mobilisation were earlier return to normal walking and stair climbing than their open group counterparts. We would, therefore, advocate the use of minimally invasive procedure with early weight-bearing mobilisation for the rehabilitation of all patients with acute ruptures of the Achilles tendon.

Objective: This article describes the outcome of a nurseled service developed to manage patients referred with a presumptive diagnosis of carpal tunnel syndrome. We also describe the implementation of a nurse-led preoperative assessment and postoperative care clinic.

Design: We assess the safety, efficacy and outcomes of 402 patients referred to the Department of Orthopaedic, University Hospital Lewisham for carpal tunnel decompression surgery prospectively.

Patients and Methods: The service was developed around the role of a nurse practitioner providing a single practitioner pathway from first clinic appointment to discharge. General practitioners were advised of the service and the criteria for referral, which included patients with symptoms and physical signs, and some response to conservative treatment.

Patients were assessed in the nurse-led preoperative assessment clinic and those deemed suitable for surgery were listed for operation.

Results: 12.7 % patients (51 patients) were referred for electromyographic studies and 5.2% patients (21 patients) were referred to doctors for further consultations. Only 4 patients had trigger finger and a further 4 patients had De Quervians syndrome. Of the remaining 373 patients, 7 patients (1.8%) choose to wait before considering surgery, and 2 patients (0.5%) declined surgery.

Waiting times improved considerably whilst the standard and quality of care was maintained.

Conclusions: We developed a rapid-access service in response to unacceptable waiting times for patients with carpal tunnel syndrome. Implementing such a clinic improved access to care for patients with this particular problem. The safety and efficacy of the program and patient-centred outcomes commend its adaptation and implementation to other institutions.

As the clinical diagnosis of Carpal tunnel syndrome is often easily made, a system of direct referral for carpal tunnel surgery was introduced. The service was an alternative to standard consultants’ outpatient referral. Direct access to a nurse-led carpal tunnel syndrome assessment clinic works well and it will reduce delays and the costs of treatment. Adequate patient information is vital to make the best of the service. There is a role for nurses to perform certain clinic within a well-defined environment.

To describe our experience with computer assisted combined anterior cruciate ligament (ACL) reconstruction and osteotomy. It may provide long-term symptom relief and improved function in patients with medial knee arthrosis and ACL-deficiency, while delaying or possibly eliminating the need for further surgical intervention such as arthroplasty.

Two patients who had medial unicompartmental arthrosis and chronic ACL-deficient knees underwent ACL reconstruction along with femoral osteotomy in one case and upper tibial osteotomy in the other. We used Orthopilot software to perform computer assisted combined anterior cruciate ligament (ACL) reconstruction and osteotomy.

Subjective evaluation at postoperatively indicated significant improvement compared to preoperative evaluation and better scores for patients who obtained normal knee range of motion. Objective evaluation by International Knee Documentation Committee showed improved score postoperatively. Both had minor complications occurred in the immediate postoperative period. The average correction angle of the osteotomy was 7 degrees (7–10).

Computer assisted ACL reconstruction and osteotomy may provide long-term symptomatic pain relief, increased activity and improved function. Only Anterior cruciate ligament reconstruction may not effectively provide pain relief to the ACL-deficient knee with degenerative medial arthrosis. The results of this study suggest that combined high tibial or femoral osteotomy and ACL reconstructions are effective in the surgical treatment of varus, ACL-deficient knees with symptomatic medial compartment arthritis. Computer aided surgery allows precise correction of the axial deformity and tunnel orientation intraoperatively.

This prospective study is designed to assess intra-operative trauma to soft tissue envelope around the knee joint especially quadriceps due to rigid body fixation on the femur and its influence on rehabilitation outcome obtained using a kinematic navigation system for TKR. We also evaluated the impact of the extra time needed to adopt this system on immediate post-operative rehabilitation.

One hundred and sixteen operations were performed with the aid of the kinematic navigation system. Results, including operation time, radiographic alignment of the prosthesis and complications, were compared with non-navigated group. Outcome measures included preoperative knee function, intra-operative factors, blood loss and postoperative rehabilitation.

The operation time (from skin to skin) in the navigation group was average 32 minutes longer compared historical controls. No major complications such as delayed wound healing, infection or pulmonary embolism occurred during this study. Mean blood loss in both the group showed no difference

A higher incidence and duration of early postoperative quadriceps dysfunction was not associated with computer-assisted TKA through the lateral Para patellar approach. No patient who received surgery had a lag of more than 20 degrees, at 48 hours postoperatively, regardless of the duration of intra-operative time used.

Although the total surgical time was longer, it does not translated into increased postoperative morbidity. Use of a kinematic navigation system has a short learning curve, and requires an additional operation time of less than 32 minutes. We found no impact of patients’ perioperative times on short-term outcomes obtained during our learning curve and next two years. The mechanical axis of the leg was within 3 degrees of neutral alignment along with accurate component alignment. The Computer-assisted TKA through a lateral parapatellar approach was not associated with delayed recovery of the patients during early postoperative rehabilitation.

Purpose: The current clinical Study was compared with historical control in terms of level of pain perception, blood loss and post-operative mobility in patients undergoing arthroplasty of the hip with computer navigation. A secondary objective was to investigate the level of patient satisfaction with the procedure.

Methods: The prospective study was conducted over a 24 month period. 30 Patients were sequentially operated and contralateral hip operated by different surgeons previously compared as control group. Delayed mobility was observed in 6% of patients with managed with computer navigation only. 2 patients had dislocation in early post-operative period, which was relocated Significantly less patients managed with the computer assisted hip arthroplasty complained of pain around the wound site [p< .01]after 48 hours of index surgery. Mean Blood loss was less [725ml Vs 1230ml] and mean length of skin incision [10.8cm Vs 17.5 cm] is lesser than the conventional arthroplasty.

Patient satisfaction was higher in the navigated group and 86% of patients were able to fully mobilize within 72 hours of the index operation.

Conclusion: Soft tissue trauma during surgery is an important cause of post-operative morbidity. Surgical exposure and malposition of the acetabular cup may cause delayed post-operative mobility after conventional hip arthroplasty

Computer aided hip arthroplasty may influence postoperative outcome in otherwise uncomplicated surgery. Although the study was limited by non randomization and other variables, initial results are encouraging.

Increased emphasis has been placed on hospital length of stay and discharge planning after total joint arthroplasty. The purpose of this study was to identify patient characteristics and assistance of surgical innovation could reduce length of stay of an inpatient after TJA.

Method: We analysed demographic and Clinical data 92 consecutive patients who underwent primary TKR with computer assisted surgery [n=46] and compare with another group operated with manual technique[n=46].

Result: Average length of stay: 8.87days (+/− 5.16 SD) in the navigation group and 7.59days (+/− 3.82 SD) in the manual group. Older age, higher American Society of Anesthesiologists class, social circumstances, and female sex were all associated with a higher likelihood of discharge to an ECF.

Conclusion: No Significant differences in length of stay patterns were found in this cohort with respect to discharge disposition at home after knee joint replacement. We believe to reduce length of stay while maintaining quality of care, early discharge home with integrated community services or home care nursing and physiotherapy should be more important than surgical innovation in the NHS in U.K

Objectives: to illustrate our clinical experience with the computer-integrated instrumentation system in knee arthroplasty.

Method: From August 2003 to April 2006, 71 patients with knee osteoarthritis underwent 71 primary TKR operations by the same surgical team. All these operations were performed with the aid of the CT-free kinematic navigation system, Results, including operation time, radiographic alignment of the prosthesis and complications were analysed.

Results: The average wound length was 11.2 centimeters. Patients in the kinematic navigation group achieved accurate alignment in the coronal plane in terms of postoperative mechanical axis (1.89 +/− 0.63 degrees. one perioperative fractures and mediolateral flexion laxity occurred both of which were attributed to patient factors as opposed to operation procedures. No major complications such as infection or pulmonary embolism occurred in this cohort.

Conclusions: The OrthoPilot system facilitates proper alignment of the component in knee arthroplasty. We found the OrthoPilot system is reliable and reproducible. The preliminary results justify continuing the use of this technologyto help the patients to provide the best possible care. Use of a kinematic navigation system in TKR is easy to use, and requires an additional operation time.

Cervical extrication collars are frequently used in pre hospital stabilization and in the definitive treatment for lesions of the cervical spine. The control of extensionflexion, lateral bending, and rotation given to individual segments is variable with different designs.

Objective: To highlight the patient satisfaction and reported pain perception with immobilization of cervical injury with the extrication collar.

Method: We present prospective cohort of fourteen patients with median age of 28 years with suspected C-spine injury waiting for CT scan. Unreliable patients were defined as those with admission Glasgow Coma Scale score < 15. They were treated with extrication collar immobilization. The initial diagnosis was made by supine cross-table lateral radiograph and then by computed tomographic scan as early as possible. All had no apparent neurologic deficit attributed to the C-spine at admission.

Results: All reported increased level of pain despite administering adequate analgesia. Most patients reported increased pain at the pressure point of the collar.

Conclusion: These cases demonstrate the limitations of current management techniques of suspected cervical fractures in unreliable trauma patients and highlight the lack of appropriate orthosis for cervical immobilization in our institution.

Objective: The objective of this study was to describe the potential therapeutic benefit of joint mobilization and manipulation on acute back pain and sciatica with disc protrusion on MRI. in the conservative management of patients with low back pain waiting to see spinal surgeon.

Methods: A prospective review of outcomes of 102 [19–58 years] patients undergone spinal manipulation. Each patient had exhibited suboptimal improvement with at least a 4 weeks of NSAIDs. Manipulations were done 5 days per week by experienced chiropractors, with a number of sessions which depended on pain relief.

Results: Manipulations appeared effective on the basis of the percentage of pain-free cases number of days with pain and number of days with moderate or severe pain. Patients had low mean VAS scores. There were only three treatment failures. Transient pain migration over the back was noted in some patients.

Conclusions: It offers an additional perspective for considering the integration of spinal manipulation into healthcare policy.

It may cause preexisting asymptomatic disc herniations to become symptomatic. Due to the inconsistencies in manual force application during PA spinal mobilization, clinical standardization of manual force application is necessary. Documentation of mobilization should include detailed descriptions of force parameters and measurement methods. This Information on the care patients routinely receive from complementary and alternative medicine providers will help physicians better understand these increasingly popular forms of care.

Perceived satisfaction levels of patients with acute back pain with chiropractic treatment and reported reductions in associated pain levels and activity restrictions support the clinical rationale for patient treatment.

Background: The use of psoas compartment block provides good analgesia but poor surgical anaesthesia. In Ortho-geriatric care different nerve blockade had been used to avoid the systemic adverse effect of centrally acting agents and provide long duration of unilateral limb analgesia after arthroplasty.

Aim: The aim of the study is to establish the quality of pain control, incidence of side effects and complications achieved with a psoas compartment block (PCB) following surgery for fractured neck of femur.

Study design: Prospective, Non randomised, longitudinal, Cohort. A Pilot Study period January 2003 -December 2004

Materials & Method: 10 patients of mean age 74.8 years (Range 23–93), 3 males and 9 females had unilateral hip surgery with general or a spinal (with no intrathecal opiate administration) as the main anaesthesia and a psoas Compartment Block for continuous infusion of bupivacaine for postoperative pain control (a total dose of 2mg/kg given in theatre and received a continuous infusion of bupivacaine 0.1% at a rate of 25ml/hour for 48 hours) and assessed by nurse led pain team.

Result & analysis: All the patients in this study group had excellent pain control. On the first post operative day only one patient had mild pain, and another had moderate pain. On the second day 3 patients had mild pain [chart 1].

Conclusion: These patients had excellent to good post operative pain control without having any adverse side effects. This study will help us to treat pain among elderly geriatric patients particularly in the demented group in immediate post-operative period. We need randomised comparative study to advocate this practice.

Background: We aim to compare our final results of Autologous Chondrocyte Implantation in full thickness articular cartilage defects of the knee with the outcome as reported in the literature.

Material: 9 patients median age of 29 (range 24 to 42) were operated and assessed clinically with use of International Cartilage Repair Scoring (ICRS), VAS and oxford knee score pre operation and 3, 6, 12 months post operation. 66.6% of the patients had traumatic defect due to sport injury and was located on the medial femoral condyle.

Method: Arthroscopically slivers of cartilage (300 to 500 mg) were obtained from the upper minor load-bearing area of the medial femoral condyle of the injured knee for cell culture. Implantation was performed by open procedure following periosteal cover technique and use of fibrin glue as a bioscaffold 4 weeks after the biopsy.

All the patients started knee exercise with CPM from next day and allowed to bear partial weight on the operated knee for 8 weeks.

Result: 3 patients still had pain after one year follow-up. One case had mosaicoplasty after 8 months, which we consider as a failure and two of them had second Arthroscopy, trimming of part of repaired cartilage. 67.2% of the patients had a good or excellent result.

Conclusion: All patients showed improvement of clinical symptoms except one patient who failed at 8 months. We found our results are comparable as reported in the literature in this small cohort. This kind of surgery may be performed in a non referral hospital.

Background: Acute rupture of Tendo achillis can be treated by open, percutaneous surgery and minimally invasive technique. Open method reported to have high complication.

Objective: We report the outcome and length of hospital stay with minimally invasive technique with achillion

Design: Non randomised prospective observational study form October 2002 to December 2005

Materials and Methods: 9 male non professional athletes of mean age 38 years (range 23-73) presented with closed rupture were treated surgically using achillon technique were treated with same preoperative cast, post operative orthosis and rehabilitation protocol. All the patients had suture removed at 10 days after the surgery and followed up at 3 weeks, 8 weeks, 12 weeks and 6 months and yearly.

Results: The average operating time is 38 mins [range 27-58mins]. Mean length of incision is 3.4cm. No patient had clinical DVT, sural nerve disturbance and failure of repair and no bed stay.

Summary: Achillion Method helps to repair tendon under direct visualization, preserving its vascularity. We found no complication in wound healing. This surgical technique reduces financial burden in terms of bed use and wound care to the care provider. Randomised control studies may be necessary to highlight potential cost effectiveness

Introduction: Doctors spend less consultation time giving information to the patients [Cegala] and underestimate the patients’ desire for information [Teutsch C 2003]. The communication gap is more visible when people with chronic arthritis present themselves for treatment. This also may initiate medico legal claims in NHS.

We aim to set up a nurse practitioner clinic to bridge the gap. Secondary aim is to reduce patients’ complaint about the services.

Materials: 100 questionnaires filled up by the patients on the waiting list for joint replacement, attending the specified clinic over a period of 24 months were randomly selected for analysis. Equal no of males and females were taken to eliminate gender bias on the outcome.

Methods: Patients were given detailed generic information about pre and post surgery nursing care, the operative steps and complications. They were asked to fill up 6 item questionnaires to assess the qualitative aspect of service at the end of the clinic and another 12 item questionnaires to fill up separately 6 weeks prior to their operation.

Result: 98% reported the information provided is excellent. 93% reported the clinic is excellent, as they have been told about the complication and pre and post surgery events. There is a reduction of rate of cancellation of elective joint replacement surgery from12.4% to 4.6%

Conclusion: This kind of informal group discussion enable patients with arthritis needing joint replacement to get information and aware of the kind of support available to cope in the community. We found there is a reduction of patients’ complaints about the service and effectiveness of this programme in reducing postoperative complications and use of bed days, use of own transport to return home. This may potentially lessen financial burden to the care provider.

Introduction: Primary manifestation of Non Hodgkin’s lymphoma in the urinary tract has been sporadically reported [1,2,3,4,5]. 2.7% of extra nodal Non Hodgkin Lymphoma manifest in urinary tract and commonly disseminate in the vertebrae. We report an unusual presentation of primary B cell lymphoma, presenting as upper back pain and acute retention of urine in a female. To our knowledge it has never been repoted in the literature.

Material: Illustrative Case report of a 63 years non smoker retired old female presented to us with a history of acute urinary retention and back pain.

Discussion: Upper back pain and urinary retention in a female is very uncommon presentation. It may be associated with sinister pathology. In our case study extra nodal manifestation of B cell lymphoma in the female urethra with dissemination and its rare clinical presentation is unique early diagnosis and multidisciplinary involvement is essential.

Introduction: The potential medical applications of cannabis in the treatment of painful muscle spasms and other symptoms of multiple sclerosis are currently being tested in clinical trials. The active compound in herbal cannabis, Delta(9)-tetrahydrocannabinol, exerts all of its known central effects through the CB(1) cannabinoid receptor. Research on cannabinoid mechanisms and antinociceptive actions is evolving.

The aim is to study whether cannabis has any role as a pain relief agent in chronic degenerated disc disease without spinal stenosis.

Method: Prospective audit observational study

Material: During two years periods 17 afrocarribean male patients who are regular cannabis user and MRI confirmed disc disease participated in this survey who had opiates and epidural injection therapy.

Result: All had used cannabis such as marihuana, hashish as a recreational drug before the onset of their illness. 64.7% of the patients stated the symptoms of their illness to have ‘much improved’ after cannabis ingestion, 29.4% stated to have ‘slightly improved’. 76.4% stated to be ‘very satisfied’ with their therapeutic use of cannabis.

Conclusion: This survey reveals use of cannabis products for symptomatic relief of back pain. However it is limited by highly selected patient group, no conclusions can be drawn about the quantity of wanted and unwanted effects of the medicinal use of the plant for particular indications. Physician supervision of medical marijuana use would allow more effective monitoring of therapeutic and unwanted effects. Medicines based on drugs that enhance the function of endocannabinoids may offer novel therapeutic approaches in the future.

Aim: We present a pilot study on the conservative treatment of chronic low back pain (LBP) using an orthosis. It consists of a pneumatic custom made lumbar vest (Orthotrac), which permits both support-stabilisation and decompression. This system allows patients to perform any activity while wearing it.

Material: The study included 9 patients with radicular pain due to degenerative discopathy including: dark disc, discal protrusion with neural foramina involvement, stenosis of the foramina. Patients had to wear the Orthotrac vest according to a precise protocol, 60 minutes 3 times a day for 5 weeks.

Results: 5 patients (55.5%) have showed a significant subjective and clinical improvement with subsequent better quality of life. All patients referred a decrease or disappearance of radicular pain. Outcome measures were evaluated VAS pain scale and SF-36 follow up questionnaires. Two (22.2%) patients reported to have no benefit.

Conclusion: The pneumatic vest can play an important role in non-surgical therapy for low back pain. The system seems to give an effective spinal decompression and deserves a careful consideration when lumbar discal disease is treated non operatively.

Introduction: Spinal stenosis may present as intermittent claudication and may be indistinguishable from vascular claudication as both could co exist. These patients often required expertise from both the speciality. Combined Vascular and spinal clinic after primary screening with the help of MRI scan may reduce the waiting time to the appropriate speciality.

Aim: We prospectively reviewed all the patients referred to senior author from vascular unit to assess the final outcome and evaluate whether primary to referral to vascular surgeon was unnecessary.

Study Design: Prospective study from November 2004 to May 2005

Methodology: Review of Hospital case notes – 23 patients were referred to us from one of the vascular surgeons’ unit after excluding vascular etiology as the cause of the leg pain and MRI confirmation of spinal stenosis.

Result: Mean waiting time to see the spine consultant 103 days [20–195] from the date of referral by the vascular team. The waiting time to primary referral to vascular team was 164 days [43–194]. 43.5% of the referred patients required to have spinal decompression.

Conclusion: To improve the waiting time primary physician should have access of MRI scan to delineate the pathology and combined vascular and spinal clinic may achieve waiting time target.

Background: To highlight the higher incidence of sub-trochanteric fracture following cannulated screws fixation for the neck of femur fracture, which may be due to surgical errors and osteoporotic bone

Method: Illustrative case report of a 78 years old demented independently mobile female patient who was admitted with an intracapsular Neck of Femur fracture, treated with cannulated screws. 2 weeks post operatively, she developed subtrochanteric undisplaced proximal femoral fracture without any trauma. She was treated with cemented hemiarthroplasty.

Conclusion: The valgus impacted neck of femur fracture, treated with cannulated screws is associated with some inherent problems. The cannulated screws can become incarcerated during initial open-reduction internal fixation and break. The incidence of subtrochanteric fracture following hip operation is greater with an entry point in the lateral cortex below the level of the most inferior edge of the lesser trochanter. Although in our case study, we placed the screw above the lesser trochanter. It has been reported that two screws in the inferior part of the femoral neck create a stress riser in the sub-trochanteric region, potentially inducing a fracture in the weakened bone, and it may be induced by a trauma. In this case study failure may be due to multiple drill holes on the lateral cortex during insertion of the guide wire [fig 2].

Subtrochanteric fracture following cannulated screws may occur without trauma. Osteoporosis may have a major role to play. We recommend one screw infe-riorioly and entry point above the lesser trochanter as reported previously.