Aims

To compare the early management and mortality of older patients sustaining major orthopaedic trauma with that of a younger population with similar injuries.

Aims

We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England.

This paper reports a series of comparative tests in-vitro that examined how lateral meniscectomy and meniscal allografting affected tibio-femoral joint contact pressures. 8 Cadaver knees (age range 81 – 98 years) were loaded in axial compression in an Instron materials testing machine up to 700N for 10 seconds and pressure maps obtained from the lateral compartment using Fuji Prescale film inserted below the meniscus. This was repeated after meniscectomy, then after meniscal allografting with fixation by a bone plug for the insertional ligaments, plus peripheral sutures. Finally, the pressure when the allograft was secured by peripheral sutures alone was measured.

Meniscectomy caused a significant increase in peak contact pressures (p=0.0002). Both of the reconstructive methods reduced the peak contact pressures significantly below that of the meniscectomised knee (p=0.0029 with bone block; p=0.0199 with sutures alone). A significant difference was not found between the peak contact pressures after the reconstructions and that of the intact knee (p=0.1721 with bone block; p=0.0910 with sutures alone). The peak pressures increased slightly when the allografts were converted from bone block to suture-only fixation (p=0.0349).

The principal finding was that both of the meniscal allograft insertion techniques reduced the peak contact pressure significantly below that of the meniscectomised knee, so that it did not then differ significantly from the peak contact pressure in the intact knee. When the two fixation methods were compared, the loss of the bone plug attachment caused a small increase in peak pressure.

This study suggests that meniscal allografting should have a chondroprotective effect and that there is a small advantage from adding bony fixation to suture fixation.

One hundred and sixty-two patients with a diagnosis of scapholunate instability underwent a modified Brunelli procedure over a 7 year period. One hundred and seventeen were assessed with the help of a questionnaire and, of these, 55 patients attended for clinical evaluation. The mean follow-up was 4 (1-8) years. There were 72 patients with dynamic scapholunate instability and 45 patients with static instability. The average age was 38 years. There were 50 males and 67 females. 77 (62%) patients had no to mild pain with a mean visual analogue score of 3.67 (SD=2.5)). The loss in the arc of flexion-extension was due to a reduced range of flexion (mean 31% loss), while 80% of extension was maintained, compared with the contralateral side. The grip strength on the operated side was reduced by 20% of the non-operated side. There was no statistically significant difference (p>0.05) in the range of movement or the grip strength between the static and dynamic group or the claims and non-claims group. Ninety (79%) patients were satisfied with the result of the surgery (good to excellent) and 88% of the patients felt that they would have the same surgery again. We feel that these results compare favourably with the early results published from this unit and recommend this procedure for dynamic and static scapholunate instability

Background: Several approaches to the ACL attachment and drilling methods exist, with little evidence of which method is the best.

Hypothesis: The “Retrodrill” or an “inside-out” drilling technique result in uniform intra-articular tunnel mouths compared with standard “outside-in” conventional ACL drill bits.

Study Design: Controlled laboratory study.

Methods: Sixteen cadaveric knees were divided into Anterograde (A) and retrograde “Retrodrill” (R) groups and ACL tunnels drilled. The femoral tunnel mouths were moulded using PMMA, then Nylon rods of identical diameter containing 1mm diameter K-wires were inserted into the tunnels and AP and lateral X-rays taken. Matching laboratory experiments utilised 10 pig femurs and synthetic bone.

Results: In group A, the mean difference between tunnels and their mouths was 1.6±0.5mm, compared with 0.3±0.2mm for Group R (p < 0.001). The mean femoral tunnel angulation in the sagittal plane for Group A was 45±10 degrees and 78±14 degrees for Group R (p< 0.001); and 30±12 degrees, and 71±12 degrees (p< 0.001) in the coronal plane respectively. There were similar ACL attachment hit rates from the groups. In porcine bone, tunnel mouth widening in the anterograde tibial group was 0.7±0.4mm, 0.04mm±0.1mm for the anterograde femoral group, and 0.06±0.1mm for the retrograde group (p< 0.001). In synthetic bone, the difference between the tunnels and their mouths was 0.8±0.8mm, 0.2±0.1mm and 0.1±0.1mm (p< 0.001) respectively.

Conclusions: The “Retrodrill”, or an inside out antero-grade drilling technique, produced a more uniform tunnel with no difference in ACL attachment hits.

We have reviewed the intermediate term results of 56 out of 61 consecutive Wagner revision stems implanted without bone graft. After a mean of 5 years (range 4 to 7 years) 49 out of 56 hips were graded as excellent or good based on the Harris Hip Score. The clinical result was not related to the degree of femoral bone defect prior to revision.

49 Out of 56 hips were seen to subside, but this did not affect the hip score at final review. The mean subsidence was 4.8mm (range 0 – 19mm).Only one stem showed continued subsidence after 12 months post-operatively, and this stem achieved a stable position by 24 months. All osteotomies of the femur united with reconstitution of the femoral bone stock. There was a low incidence of complications; one stem showed catastrophic subsidence within 48 hours of surgery, requiring re-revision to a larger Wagner stem. There was one sciatic nerve palsy. 3 hips dislocated on one occasion in the early post-operative period, but were stable at latest follow-up.

In conclusion, the Wagner stem can bypass major proximal femoral bony defects and achieve initial axial and rotational stability in intact diaphyseal bone. Subsequent stem subsidence does not affect clinical outcome, and proximal femoral bony reconstitution is achieved without the need for bone grafting.

This paper describes the outcome of type III pilon fractures of the distal tibia treated primarily with an llizarov ring fixator.

Only patients with intra-articular fracture of the tibial plafond on plain radiographs that corresponded to type III pattern of Ruedi and Allgower were included. There were thirteen patients with a mean age of 45 (range 29–65), twelve males and one female. The mechanism of injury in all the patients was high-speed road traffic accident. Operative fixation consisted of fracture reduction and stabilisation using the Ilizarov circular frame external fixator and olive tipped wires. Further insult to the already damaged soft tissues was avoided.

Bony union was achieved in all cases. Treatment in the frame lasted between 3 and 10 months (average of 6.3 months). Neither deep infection nor soft tissue complications occurred. Outcomes measured using the Olerud ankle score, modified Ovadia and Beals radiological criteria, and the SF-36 Health Questionnaire and our results compare well with other fixation techniques.

The use of the llizarov circular frame external fixator without any additional internal reduction or fixation procedures is a definite option for the treatment of these high-energy injuries.

This paper suggests that bone-cement interlocking is superior when the cut surfaces of the bone have been prepared using pulsed lavage with saline prior to application of cement and the prostheses during total knee joint arthroplasty.

The aim is to put the case forward for the inclusion of the question whether or not pulsed lavage was used on the National Joint Register questionnaire. This will then in course give guidance as to whether there is an improved outcome when pulsed lavage was used or whether it is a waste of resources.

Review of the 6-month postoperative films of the total knee joint replacements of two senior surgeons was carried out in 1996. Both surgeons use the Genesis total knee system. Surgeon 1 uses pulsed lavage routinely, and surgeon 2 does not. This is the only difference in their techniques. There have been no early aseptic failures in either group at 5 years. A lucent line was consistently seen between the bone-cement interface when pulsed lavage was used. Furthermore, the depth of the cement mantle on the tibia was greater in the pulsed lavage group. We suggest that the use of pulsed lavage at the preparation of the cut bone surfaces before the application of the cement and prostheses improves the bone-cement interface. The significance of this finding is uncertain, but a case can be made for this question to be included in the National Joint Register questionnaire.

This paper describes the outcome of type III pilon fractures of the distal tibia treated primarily with an Ilizarov ring fixator.

Only patients with an intra-articular fracture of the tibial plafond on plainradiographs that corresponded to type III pattern with the system of Rfiedi andAllgower were included.

There were thirteen patients with a mean age of 45 (range 29–65), twelve males and one female. The mechanism of injury in all the patients was high-speed road traffic accident.

Operative fixation consisted of fracture reduction and stabilisation using the llizarov circular frame external fixator and olive tipped wires. Further insult to the already damaged soft tissues was avoided.

Bony union was achieved in all cases. Treatment in the frame lasted between 3 and 10 months (average 6. 3 months). Neither deep infection nor soft tissue complications occurred.

Outcome measurements included the Olerud ankle score, modified Ovadia and Beals radiological criteria, and the SF-36 Health Questionnaire.

Wound and deep infections were successfully avoided and bony union was achieved in all our patients. This compares well with other fixation techniques. The use of the llizarov circular frame external fixator without any additional internal reduction or fixation procedures is a definite option for the treatment of these high-energy injuries.

One hundred and three sequential Stanmore knee replacements were reviewed retrospectively on two occasions with a maximal follow-up period of nine years three months. This knee prosthesis, which is hinged, was successful in alleviating pain, stabilising an unstable knee and modestly increasing the arc of flexion. Walking capacity was increased and flexion contractures were reduced. There were seven cases of infection and four of fracture around the prosthesis. All these proved difficult to treat and two knees with both fracture and infection needed amputation. Eight knees were revised for aseptic loosening and a further 14 were found to have radiological signs of loosening. The results have been analysed by the methods advocated by Tew and Waugh and give a cumulative success rate of 80 per cent at seven years, provided success is judged solely by whether the prosthesis is still in situ. The role of the Stanmore knee as a primary arthroplasty is discussed.