The purpose of this study was to investigate the effects of right leg restriction at the knee, ankle or both, on a driver’s braking times. Previous studies have not investigated the effects of knee restriction on braking performance. A total of 23 healthy drivers performed a series of emergency braking tests in a driving simulator in either an above-knee plaster cast, a below-knee cast, or in a knee brace with an increasing range of restriction. The study showed that total braking reaction time was significantly longer when wearing an above-knee plaster cast, a below-knee plaster cast or a knee brace fixed at 0°, compared with braking normally (p < 0.001). Increases in the time taken to move the foot from the accelerator to the brake accounted for some of the increase in the total braking reaction time. Unexpectedly, thinking time also increased with the level of restriction (p < 0.001). The increase in braking time with an above-knee plaster cast in this study would increase the stopping distance at 30 miles per hour by almost 3 m.

These results suggest that all patients wearing any lower-limb plaster cast or knee brace are significantly impaired in their ability to perform an emergency stop. We suggest changes to the legislation to prevent patients from driving with lower-limb plaster casts or knee braces.

Purpose: A single blind prospective randomised controlled trial comparing the Metal-on-polyethylene articulation with the metal-on-metal articulation in THA.

Method: The clinical and radiological findings of the consecutive patients who were enrolled in the RCT at the participating centres were recorded prospectively. The clinical evaluation was performed with the Harris scoring system as well as the Oxford Hip Scoring Sheet. The computer randomised option was revealed to the operative surgeon only after the patient was anaesthetised, during the recruitment period (June 1998 to July 2004). Of the total of 378 patients, 2 died prior to the final review and 63 were lost to follow-up. The final study group contained 315 patients, with 159 patients in the metal-on-polyethylene group and 156 patients in the metal-on-metal group.

Results: The indication for the hip arthroplasty for majority (309 patients) was primary osteoarthritis. The average age at the time of the surgery was 68.2 years and the average duration of follow-up was 85 months (42–115). There was an improvement of the Oxford hip scores from an average of 37 per-operatively to 16 postoperatively. The Harris hip scores also improved from an average of 47.0 pre-operatively to 87.3 post-operatively. The patient groups were statistically similar with respect to age, sex and duration of follow-up, and the final outcome scores revealed no statistical difference between the two groups.

Conclusion: The clinical results obtained with the use of the articulation are comparable to those obtained by the metal-on-polyethylene articulation encouraging the use of this alternative bearing surface.

Aim: Isotope bone scan has become a part of the routine workup for a painful arthroplasty. A retrospective analysis was performed to analyse the significance of isotope bone scan results in the management of painful arthroplasty.

Methods and Materials: The study group included all the 58 consecutive patients who underwent an isotope bone scan for a painful arthroplasty over a one year period. The data collected included: age, sex, date and nature of primary arthroplasty, inflammatory markers, indication, date and result of the bone scan, and the final outcome.

Results: The primary arthroplasty was a TKR (29 patients) and THR (29 patients). The average duration between primary arthroplasty and the bone scan was 44.3 months (Range 5 – 195 months). The duration was less than 1 year for 6 patients. The average age of the patients was 62 years. The male: female ratio was 31:27. 4 of the arthroplasties were uncemented and 54 were cemented. The bone scan results were normal in 32 patients, unclear in 17 patients and abnormal in 9 patients. There was no statistical correlation found between the inflammatory markers and the results of the bone scan.

Discussion: The results of the bone scan made a significant contribution in the management decision of the patient in 8 of the patients and served to reassure the patient/surgeon in most of the rest 50. In 6 patients it was performed within a year of the primary arthroplasty, during which period the results are not very specific. An isotope bone scan involves a significant radiation exposure to the patient as well utilization of time and resources, hence always ask the million dollar question: “Is it going to alter my management plan”

In 1990 an estimated 1.3 million hip fractures occurred worldwide. Clostridium difficile diarrhoea has emerged as a healthcare associated infection of great clinical and economic significance especially in the frail and vulnerable group of fracture neck of femur patients. The major risk factor is peri-operative antibiotic exposure especially cephalosporins. A retrospective audit was performed to study the effect of C. Difficile in operated fracture neck of femur patients.

All the patients who were diagnosed with C. Difficile infection after an operated fracture neck of femur at the District general hospital from April 2004 till March 2007 were included in the present study. All patients received the routine peri-operative antibiotic prophylaxis of three doses of intravenous cefuroxime. Data collected included age, sex, duration between operation and the onset of diarrhoea, length of stay and associated mortality.

A total of 1023 patients underwent surgery for fracture neck of femur during the three years of study period. The average age of the patients was 81 years. 80% of the patients were females. A total of 62 patients suffered from C. Difficile diarrhoea (6%) after the arthroplasty procedure, and within this cohort, 29 patients died during the same admission to the hospital (47%). The average length of stay for a patient with fracture neck of femur was increased from 23.4 to 60 days in those affected with C. Difficile.

The patients with fracture neck of femur are generally elderly with poor body reserves. C.difficile infection in such patients not only adds to the morbidity, but also causes significant increase in the mortality rate. Propagation of simple infection control measures such as hand-washing and isolation and change of peri-operative antibiotic protocol led to a statistically significant reduction in the incidence of C.Difficile infections after fracture neck of femur surgery.

Aim: Isotope bone scan has become a part of the routine workup for a painful arthroplasty. A retrospective analysis was performed to analyse the significance of isotope bone scan results in the management of painful arthroplasty.

Methods and Materials: The study group included all the 58 consecutive patients who underwent an isotope bone scan for a painful arthroplasty over a one year period. The data collected included: age, sex, date and nature of primary arthroplasty, inflammatory markers, indication, date and result of the bone scan, and the final outcome.

Results: The primary arthroplasty was a TKR (29 patients) and THR (29 patients). The average duration between primary arthroplasty and the bone scan was 44.3 months (Range 5 – 195 months). The duration was less than 1 year for 6 patients. The average age of the patients was 62 years. The male: female ratio was 31:27. 4 of the arthroplasties were uncemented and 54 were cemented. The bone scan results were normal in 32 patients, unclear in 17 patients and abnormal in 9 patients. There was no statistical correlation found between the inflammatory markers and the results of the bone scan.

Discussion: The results of the bone scan made a significant contribution in the management decision of the patient in 8 of the patients and served to reassure the patient/surgeon in most of the rest 50. In 6 patients it was performed within a year of the primary arthroplasty, during which period the results are not very specific. An isotope bone scan involves a significant radiation exposure to the patient as well utilization of time and resources, hence always ask the million dollar question: “Is it going to alter my management plan”

One of the many challenges in revision hip arthroplasty is massive bone loss. Subsidence of the collarless stem with impaction allografting has been reported by several authors. Impaction grafting has emerged as a useful technique in the armamentarium of the revision total hip arthroplasty surgeon. The original technique proposed by Ling has been associated with complications, including femoral shaft fractures, recurrent dislocations, and uncontrolled component subsidence. Modifications in that technique seem to be associated with a reduction in complications.

The aim of this study was to assess the functional outcome of radial impaction grafting in femoral bone defects and the use of collared long stem prosthesis.

A total of 107 patients underwent radial impaction allografting and collared long stem prosthesis during revision THA between 1997 and 2005. The patients with Paprosky type II, IIIA and IIIB defects were included in this study. Average duration between the primary and revision surgery was 9.4 years (Range 6–23 years). Assessment was done using Oxford Hip Score, Harris Hip Score and with plain X-rays. Three patients were lost to follow-up and three patients died due to unrelated causes.

The follow-up period lasted between 12 to 114 months (average – 68.8 months). Three patients who sustained post-operative peri-prosthetic fracture had standard stem inserted in them. None of the patients with long stem sustained peri-prosthetic fracture. Four patients had infection and underwent revision procedure. In this study, using revision for any cause as the end-point, survival of the femoral stem was 93.8%. Subsidence was not recorded in any of the patients in this study. Oxford Hip Score improved from mean pre-operative value of 41.2 to 19.2 post-operatively. Mean Harris Hip Score improved from 40.8 pre-operatively to 83.4 post-operatively.

Subsidence of the prosthesis is commonly encountered with collarless stems and this was not a problem in this study. The risk of peri-prosthetic fracture can be reduced by using long stem prosthesis which bypasses the existing cement mantle by at least two femoral diameters. The radial impaction grafting technique permits the use of revision femoral components with variable stem lengths, neck lengths, and neck offsets.

We conclude that radial imaction graftind along with collared long stem prosthesis is a good solution for massive femoral bone defects while performing total hip arthroplasty.

Introduction: In 1990 an estimated 1.3 million hip fractures occurred worldwide, a figure which is expected to double by 2025 and increase to 4.5 million by 2050.

Clostridium difficile associated diarrhoea (CDAD) has emerged as a healthcare associated infection of great clinical and economic significance especially in the frail and vulnerable group of fracture neck of femur patients. A major risk factor for the development of CDAD in patients who undergo operation for fracture neck of femur is the perioperative antibiotic exposure, with cephalosporins being particularly implicated. The type ‘027’ strains of C. Difficile are multi-resistant and cause severe morbidity and mortality. A retrospective audit was performed to study the effect of C. Difficile infection in operated fracture neck of femur patients.

Material and Methods: All the patients who were diagnosed with C. Difficile after an operated fracture neck of femur at the District general hospital during the three year study period from April 2004 till March 2007 were included in the present study. All patients received the routine peri-operative antibiotic prophylaxis of three doses of intravenous cefuroxime. Data collected included age, sex, duration between operation and the onset of diarrhoea, length of stay and associated mortality.

Results: A total of 1023 patients underwent surgery for fracture neck of femur during the three years of study period. The average age of the patients was 81 years. 80% of the patients were females. A total of 62 patients suffered from C. Difficile diarrhoea (6%) after the arthroplasty procedure, and within this cohort, 29 patients died during the same admission to the hospital (47%). The average length of stay for a patient with fracture neck of femur was increased from 23.4 days to 60 days in those affected with C. Difficile diarrhoea.

Discussion: The patients with fracture neck of femur are generally elderly, frail and with poor body reserves. C.difficile infection in such patients not only adds to the morbidity, but also causes significant increase in the mortality rate. The broad spectrum peri-operative antibiotics used to prevent infection generally render the patient vulnerable to this highly lethal hospital bug. Introduction of simple infection control measures such as hand-washing and isolation, and change of peri-operative antibiotic protocol led to a statistically significant reduction in the incidence of C. Difficile infections after surgery for fracture neck of femur.

Introduction: Clostridium difficile associated diarrhoea (CDAD) has emerged as a healthcare associated infection of great clinical and economic significance. C. difficile is thought to cause about a quarter of cases of antibiotic-associated diarrhoea overall, but accounts for a greater proportion of more severe disease. The type ‘027’ strains are multi-resistant and cause severe morbidity and mortality. A retrospective audit was performed to study the effect of C. Difficile infection in elective orthopaedic surgery patients (hip/knee arthroplasties)

Material and Methods: All the patients who were diagnosed with C. Difficile after a primary elective joint arthroplasties, performed at the District general hospital during the three year study period from April2004 till March 2007 were included in the present study. All patients received the routine peri-operative antibiotic prophylaxis of three doses of intra-venous cefuroxime. Data collected included age, sex, duration between operation and the onset of diarrhoea, length of stay and associated mortality.

Results: A total of 1430 patients underwent primary hip or knee arthroplasties during the three years of study period. A total of 32 patients suffered from C. Difficile diarrhoea (2.2%) after the arthroplasty procedure, and within this cohort, 5 patients died during the same admission to the hospital (0.35%). The average length of stay for an elective lower limb joint arthroplasty was increased from 10 days to 43 days due to the affection with C. Difficile diarrhoea.

Discussion: C. difficile infection not only adds to the morbidity, but also causes significant increase in the mortality rate after elective joint replacement. The broad spectrum peri-operative antibiotics used to prevent infection after a joint replacement generally render the patient vulnerable to this highly lethal hospital bug. Introduction of simple hygiene measure such as hand-washing and change of peri-operative antibiotic protocol lead to a statistically significant reduction in the incidence of C. Dificcile infections after elective joint replacement surgery without compromising arthroplasty results.

Aim: To assess the implications of nerve conduction study for carpal tunnel syndrome.

Methods and Materials: A retrospective audit of the patients who underwent carpal tunnel release at the district general hospital from July 2000 till June 2005. Due to the un-availability of facility for nerve conduction study at our district general hospital, the patients had to be referred to other hospitals in the region for the same. A total of 263 carpal tunnel releases were performed during the study period in 206 patients (57 were bilateral). 61 patients were males and 145 were females.

Results: Of the classical presentation group, the nerve conduction study was requested in 76 of the 172 patients while in the atypical presentation group 53 of the 91 patients had a nerve conduction study prior to the operative treatment. The intra-operative findings of thickened flexor retinaculum and thinned median nerve were statistically similar in the 2 groups: Nerve conduction not performed and Nerve conduction study performed.

Discussion: The average duration between the first consultation and the operative treatment was 72 days in the patients who did not undergo the nerve conduction study, whereas the average duration between the first clinic appointment and the operative treatment for the patients who had the nerve conduction study was 180.5 days. The request for nerve conduction study in cases with classical presentation leads to an average 108.5 days delay in the final management of the patient’s problem. It also causes a significant loss of time and finances.

Aim: To assess the implications of implementation of the NICE Guidelines for indication for CT scan in head injury patients.

Methods and Materials: A retrospective audit of the patients attending our district general hospital with head injuries over a period of one year from October 2004 till Sept 2005. A total of 3150 patients attending the A & E during the study period were diagnosed to have head injuries. The study involved review of the case notes and radiology results of the 135 patients requiring inpatient treatment for head injury. During this tenure the CT scan was requested depending of the clinical judgement of the attending physician.

Results: Rigid compliance with the NICE Guidelines during the study tenure would have entailed an additional workload of 36 patients requiring a CT scan, of which 28 patients justified the scan during out of hours period.

One elderly patient with a fatal intracerebral bleed was found to have justified an early CT scan on the criteria of more than one vomiting episode and a history of unconsiousness.

Discussion: The NICE Guidelines were found to be implemented in most cases admitted during working hours. A reluctance to perform CT scan was encountered during out of hours. A strict compliance with the guidelines would entail on average one additional CT scan every fortnight during the ‘out of hours’ period. Implementation of NICE Guidelines was found to tighten the net (justify CT scan) in order not to miss subtle early signs of potentially fatal head injuries.

Introduction: A retrospective audit to evaluate the results of Austin Moore hemiarthroplasty conversion to Total hip arthroplasty for suspected aseptic loosening.

Materials and Methods: A consecutive cohort of patients who had conversion of Austin-Moore hemiarthroplasty to Total hip arthroplasty performed at our district general hospital between August 2000 and May 2006 were included in the study.

The total of 41 patients were divided into two groups depending on the duration between the primary hemiarthroplasty procedure and its revision to total hip arthroplasty – (1) Less than one year (16 patients) and (2) More than one year (25 patients).

The data collected included: age, sex, classification of the fracture, date of primary operation, surgical approach, inflammatory markers, indication and date of revision to total hip arthroplasty, and the final outcome.

Results: The rate of infection after the revision to total hip arthroplasty was found to be 25% (4/16 patients) in patients who underwent the revision operation within 1 year after the primary operation, whereas the infection rate was 8% (2/25 patients) for those who had the revision operation more than a year after the primary operation. The difference in infection rates between the two groups was found to be statistically significant despite the small numbers.

Discussion: The patients who have early loosening of the Austin-Moore hemiarthroplasty within the 1 year of the primary procedure should raise a suspicion of occult infection. Despite near normal inflammatory markers, a two-staged conversion to total hip arthroplasty should be seriously considered.

AIM: The purpose of this retrospective study was to assess the results of a novel surgical technique for chronic lateral ankle instability using dynamic extensor digitorum brevis (EDB) muscle transfer.

METHODS: 15 patients underwent dynamic EDB muscle transfer for symptomatic chronic lateral ankle instability. All patients were quite fit and physically very active. 9 male and 6 female patients, mean age 27 (range, 22–32) were operated by single surgeon (ALP) between March 2003 and August 2005. All patients had standard procedure involving proximal transfer of the origin of EDB muscle whilst preserving its neuro-vascular pedicle. All patients went through a standard post-operative physiotherapy protocol including pro-prioceptive training. Mean follow-up was 24 months (range, 12–36 months). The mean functional Karlsson scores improved from 26.5 before surgery to 86.5 at 12 months after surgery. At follow-up, all patients had normal range of ankle movements and were functionally stable. All patients regained their pre-injury activity level at 12 months after surgery. There were no early or late complications in our series.

DISCUSSION: Ankle sprains are the most common injuries sustained during sports and physical exercise. Treatment is usually conservative because most of these injuries heal without consequence. However, symptomatic chronic lateral ankle instability is a difficult problem to treat and several surgical techniques have been described. EDB muscle not only acts as a dynamic substitute for the deficient ligament but also overcomes the problem of over-tightening of the ligament leading to restricted supination.

CONCLUSION: Dynamic EDB muscle transfer is a safe, clinically effective and reliable surgical option for symptomatic chronic lateral ankle instability.

Introduction: The aim of this study was to study the intermediate term (5-10 year) results of the ‘Metasul’ type of metal-on-metal hip arthroplasty.

Method: A prospective analysis was performed of the clinical and radiological findings of the patients who underwent the ‘Metasul’ hip arthroplasty by the senior author (Mr. Benke). The clinical evaluation was performed with the Charnley’s modification of the Merle d’ Aubigne scoring system as well as the Oxford Hip Scoring Sheet. All the patients operated from February 1995 till July 2000, were included in the study. Of the total of 99 patients, 5 patients died prior to the final review and 4 were lost to follow-up. The final study group hence contained 90 Hip Arthroplasties in 77 patients.

Results: The results were analysed using the Charnley categories, and as expected the patients of Category ‘A’ achieved the best final results with the d’Aubigne score rising from 8.6 to 17.2 and Oxford scores of 5.7/60. The patients of Category ‘B’ had good results (Final Oxford score of 7.3/60, and d’Aubigne score of 16.9). The Category ‘C’ patients had moderate results with the d’Aubigne score of 15.1 and Oxford score of 17.7/60. Three patients needed revision hip arthroplasty for the following reasons: aseptic acetabular loosening (1), infection (1) and massive osteolysis (1).

Discussion: The clinical results obtained with the use of the ‘Metasul’ articulation are comparable to those obtained by the metal-on-polyethylene articulation. The clinical success, the retrieval data of low wear from laboratory studies and the historical data of 40 years with an absence of clinical consequences of elevated serum Co ion levels, encourages the use of this alternate bearing surface.