Aim: To study a staged technique for the removal of the Ilizarov fixator following bony union.

Method: A prospective case series of all fractures treated by the senior author between May 2005 and May 2007 were reviewed. When patients were able to weight bear pain free with radiological evidence of healing, the frames were dynamised initially by loosening the rods across the fracture site, then by removing all rods across the fracture site and finally the frame was removed under general anaesthetic. Patients were followed up for 6 months clinically and radiologically.

Results: Of 39 fractures (38 patients) 37 underwent staged dynamisation. No patients required further, casting, bracing or walking aids after frame removal. There were no incidences of re-fracture, non-union or late mal-union at 6 months follow up.

Conclusion: The proposed method of staged dynamisation is a safe and useful technique for confirming fracture union and guiding frame removal

We treated 60 patients with type III Pilon fractures (Ruedi and Allgower Classification) between 1996 and 2005. The fractures were distracted and then fixed with an Ilizarov circular ring fixator, without the use of open surgery. No internal fixation was used for the tibia or fibula. No bone grafting was performed.

The average time from injury to frame application was four days. The patient stayed ib frame for a mean time of 15 weeks. No second operative procedure was needed. All cases united in good alignment.

The patients were reviewed from ten years to nine months after frame removal. Four separate evaluations were performed (functional, objective, radiological and an SF-36). The function and the range of movement were better than the radiological assessment suggested.

This method of treatment gives better results with fewer complications than open surgery with internal fixation

We report our experience in treating victims of the recent Earthquake Disaster in Pakistan. Our experience was based on 2 humanitarian missions to Islamabad. First in October 2005, 16 days after the earthquake and the second in January 2006, three months later. The mission consisted of a team of orthopaedic and a second team of plastic surgeons. The orthopaedic team bought all the equipment for application of Ilizarov External Fixators (IEF). We treated patients who had already received basic treatment in the region of the disaster and subsequently had been evacuated to Islamabad.

During the first visit we treated 12 injured limbs in 11 patients. 7 of these were children (ages 6 – 14). All the cases were complex and severe multifragmentary fractures associated with crush injuries. All of the fractures involved the tibia, which were treated with IEF.

Nine fractures were type 3b open injuries. Eight were infected requiring debridement of infected bone and acute shortening of the limb segment. After stabilization, the plastic surgeons provided soft tissue cover.

During the second, we reviewed all patients treated during our first mission. In addition we treated 13 new patients [Table 3] with complex non – unions. Eight out of 13 non-unions were deemed to be infected. All patients had previous treatment with monolateral fixators (AO type) as well as soft tissue coverage procedures, except one patient who had had a circular fixator (Ilizarov) applied by another team. All these patients had revision surgery with circular frames

The Ilizarov technique can be used to achieve bony union in high energy trauma and in non-union. There is much interest in the augmentation of bone healing using growth factors, GPS II collects the patients own platelets into a highly concentrated formula. Activated platelets release growth factors that may stimulate fracture healing.

We used the GPS II system in 13 cases of either high-energy trauma (2 cases) of non-union (11 cases) treated with the Ilizarov Circular frame in our institution. The group included two tibial fractures, eight tibial, one femoral and two ulnar non-unions. The minimum follow up of a year. The average age of the patient was 45 (22–66). We observed complications and measured time to clinical and radiological union from the start of treatment with circular frame.

No complications associated with GPS. One patient had an infection remotely in the limb resulting in amputation. All fractures and non-unions went on to solid bony union. The average time to radiological union was 21 weeks (range 13–36 weeks). Frame removal in these cases was 6.5 months (range 4–10 months). No patient underwent any further surgical intervention.

This pilot study features a heterogenous group of patients in which it is difficult to assess the role of GPS II. The use of GPS II, however, was uncomplicated in our study. The use of GPS II may act as a adjuvant therapy in the treatment of high energy trauma and non-union treated with the Ilizarov technique. Furthers studies are required to investigate the efficacy of GPS II in the management of non-union.

We aim to assess the long term functional and symptomatic outcome of patients after open reduction internal fixation (ORIF) of the ankle. A retrospective telephone interview of patients (n=113) in years five, six and seven after ORIF of the ankle was conducted. The Olerud-Molander Ankle Score (scale 0–100) and SF-12 Health Survey scores were utilised to assess symptomatic and functional outcome. Fractures were classified in accordance with the Danis-Weber system. All patients were operated upon in the same unit by the same group of surgeons.

Sixty five patients were male and 48 female. The mean age was 56 (range 15–96). Patients with Weber B fractures (n=83) had a mean OMAS of 89.2. Those with Weber C fractures (n=25) had a mean OMAS of 85.4. Five patients had isolated medial malleolar fractures. At five to seven years post-operatively, 67.3% of patients were symptomatic. Of these, 75% complained of swelling; 39% of pain and 30% of stiffness whilst 19.5% of all patients felt they had not returned to their pre-operative functional level. Regardless of fracture type or follow up time, patients under 40 years old, had a significantly higher mean OMAS (90.7) as compared to those between 40 and 65 years old (85.3) (p=0.024). There was no significant difference in the mean OMAS of patients followed up at five or seven years post operatively or between those with Weber B or C fractures.

Patients suffer ongoing symptomatic and functional problems up to seven years after ORIF of the ankle and a significant number do not return to their pre-injury functional state. Patients under 40 years old had a better outcome as compared to older patients, whilst Weber type or year of follow up did not affect outcome. Surgeons should counsel patients pre-operatively regarding possible long term problems when undertaking ankle fracture fixation.

Introduction: The use of Ilizarov frames is contraindicated in patients with psychiatric conditions, thought to be due to non compliance. We present our experience of treating five fractures with Ilizarov frame in four patients who sustained their injuries through parasuicide.

Method: Consecutive series of patients treated by a single surgeon at our institution. Five fractures in four patients, (one bilateral fracture) were treated with an Ilizarov fine wire frame. All fractures were comminuted distal tibia (pilon): one was B3.3, two C3.2 and a further two C3.3 using the AO system. Four out of five fractures were open Grade IIIA. Outcome was based on functional score (Olerud and Molander); SF 12 and radiological assessment.

Results: There were three females and the mean age was thirty-one years. Of the five fractures, three united successfully, at eight months; one achieved a malunion and one an aseptic non-union at 1 year

Discussion: Our experience suggests complex fractures can be treated favourably with circular frames in parasuicide patients. The patients were generally compliant with frame care and the outpatient monitoring was no different from any other patient with similar injuries.

Aims: To compare rates of blood transfusion post knee arthroplasties for patients treated with and without tranexamic acid (TA) and assess for any haemoglobin change perioperatively between the groups.

Methods: This retrospective observational study included 207 patients undergoing primary unilateral knee replacement surgery who were divided by administration of TA intraoperatively (n=120) or without (n=87). The TA group was further subdivided into patients undergoing a standardised autogenic retransfusion procedure (n= 86) and those without (n=44). Case notes and laboratory results were used to study pre and post operative haemoglobin, administration of TA and blood products. The exclusion criteria consisted of patients in ASA classes III & IV, revision surgery, and patients undergoing bilateral or unicompartmental knee replacements. Analysis of haemoglobin change was undertaken using the student t-test. Significance was concluded when p < 0.05.

Results: The average haemoglobin drop in the TA group (without auto-transfusion) was 1.96g/dL versus 1.8g/dL in the no drug group which was not significant (p= 0.459). The average drop in the TA group (with auto-transfusion) was 1.78g/dL, also not significant (p=0.922). 3 of the 44 patients (7%) from the TA group (without auto-transfusion) required blood transfusions compared against 7 of the 87 non tranexamic acid group (8%) which was not significant.

Conclusion: There was no significant difference between all three groups. This study raises questions over the efficacy of TA treatment as a means to reduce perioperative blood loss in total knee replacements. Further, TA does not reduce blood loss and transfusion requirements even when autogenic retransfusion was used.

Introduction: Though Cutaneous nerve injury following ACL reconstruction is a recognized complication, we identified an undescribed pattern of numbness involving the entire shin from the knee to the ankle.

Methods: A review of 143 Hamstrings ACL reconstructions performed between 1999 and 2004 was done. Mean age was 34.8 years (17–57) and the follow-up was 40.2 months (9–80).

Results: The patterns of numbness were classified into non-scar related and scar related. 76 patients (53 %) had non-scar related numbness. Among this 7 (5%) had numbness of the entire shin from the knee to the ankle. This pattern of numbness is significant considering the large area involved. 38 patients (27%) had scar related numbness.

Non-scar related numbness corresponded to the innervation of the branches of the Saphenous nerve. Only 39% of patients with non-scar related numbness and 47% with scar related numbness recovered completely. None of the patients who had numbness of the entire shin recovered. Interestingly only 3 patients reported that this numbness bothered them.

Conclusion: Anatomical studies have shown that it is difficult to identify a safe zone for tendon harvest. Efforts should be made to minimize the risk of such nerve damage, by making the incision more horizontal and keeping the knee in flexion while harvesting the graft. Patients should be warned of this complication while taking consent.

We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study.

Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality.

We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 vs 40.4 minutes, p < 0.001; and 40.3 vs 54 minutes, p < 0.001, respectively). There was an increased mean blood loss within the DHS group versus the Holland nail group (160 ml vs 78 ml, respectively, p < 0.001). The mean time to mobilisation with a frame was shorter in the Holland nail group (DHS 4.3 days, Holland nail 3.6 days, p = 0.012). More patients needed a post-operative blood transfusion in the DHS group (23 vs seven, p = 0.003) and the mean radiation time was shorter in this group (DHS 0.9 minutes vs Holland nail 1.56 minutes, p < 0.001). The screw of the DHS cut out in two patients, one of whom underwent revision to a Holland nail. There were no revisions in the Holland nail group. All fractures in both groups were united when followed up after one year.

We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip.

We report the outcome of 58 knees with anteromedial osteoarthritis in which the Oxford unicompartmental arthroplasty was inserted. These were performed in a district general hospital by three surgeons.

All the knees had only anteromedial disease, an intact anterior cruciate ligament and correctable varus. The indication for replacement in all cases was pain. The mean follow up was 24.5 months (6–48). Outcome was assessed by patient satisfaction and the Oxford knee score. Complications, revisions, time to mobility and time to return to work were also noted.

The average age of the 26 women and 23 men at time of operation was 65 years. 31 of the patients were very happy with the outcome, 12 were happy, 5 were unhappy, and one was very unhappy. Mean pre-operative Oxford knee score was 43 (27–53) this improved post-operatively to 18 (12–45) a significant improvement (p< 0.005, paired t-test). Time taken to mobility was an average of 36 hours (24–72), 24 of the patients were in full or part time employment at the time of operation, all returned to their former posts at an average of 6 weeks (2–24).

Three patients have ongoing pain and are booked for revision to TKR. One patient had a dislocated femoral component and required this to be revised twice with a meniscus change at the same time; this patient is now happy. 2 further patients had revision of the meniscus to a larger size for meniscal dislocation. One patient had an infection treated with debridement and antibiotics; infection settled. Our results show that there is a learning curve; all of the insert revision occurred early in the series. Patient selection is important, those with disease in other compartments have continuing pain. Appropriate selection of patients and good surgical technique are the key to obtaining a good outcome.

Introduction Hip resurfacing is a method of treating the degenerative hip joint in higher demand patients. In this study we present the results of the first four years of using this technique in a typical District General Hospital.

Materials and Methods This is a review of the outcome of 303 consecutive hip resurfacing procedures performed at Ashford and St. Peter’s Hospitals NHS Trust. All the operations were carried out through a posterior approach to the hip joint, followed by standard resurfacing using metal on metal components. The patients were evaluated radiographically and clinically pre-operatively and post-operatively. All patients had regular follow up.

Results The mean age was 56 years old with a range from 24 to 75 years. There was a statistically significant improvement between the pre-operative Harris Hip Score and the score at the latest follow up. All patients achieved a full range movement in the hip within twelve weeks following surgery. There were four fractures of the femoral neck, one was intra-operative and was converted to a traditional total joint arthroplasty. Three fractures occurred later, two were revised to a hybrid standard hip arthroplasty with a cemented stem and uncemented cup and one was treated conservatively. Two patients had transient femoral nerve palsies. There were no cases of dislocation or deep infection. All the prostheses remain well fixed with no signs of osteolysis.

Three procedures were performed because of avascular necrosis of the femoral head; none of these show signs of further collapse.

Conclusions The short and medium term results that have been achieved in a District General Hospital are comparable to those that have been achieved in the originator’s institution.

Analysis of the different phases of the gait cycle has been shown to demonstrate differences in pathological osteoarthritic gait. These differences can be quantified and their improvement following total hip arthroplasty has been shown, allowing use of gait analysis as a tool in evaluating function after total hip replacements.

The purpose of this study was to determine the degree of improvement in gait attained after resurfacing hip arthroplasty.

Ten patients with monoarthritic hips were evaluated using gait analysis preoperatively and 1 year postoperatively.

The results indicate that there is a significant improvement in the patients gait during the first postoperative year following resurfacing arthroplasty.

There is a 30% increase in the Harris Hip score, 100% increase in the velocity of walking. 51% increase in stride length, 30% improvement in the ground reaction force and 33% improvement in cadence at 1 year.

These improvements in gait mirror those shown previously following Total hip arthroplasty and show that following resurfacing procedures gait parameters are comparable to able-bodied controls.

We have concluded that resurfacing hip arthroplasty can greatly improve the gait characteristics of patients with unilateral degenerative hip arthritis.

Aim: To describe a radiographic biomechanical classification of tibial plateau fractures which dictates treatment. To compare the intra- and interobserver reliability and reproducibility of this, the Chertsey (C1-3) classification, and the Schatzker (SK1-6) classification.

Method: This classification system has been used at this institution for 8 years by the orthopaedic trauma consultants and consists of C1 – valgus fractures, C2 – Varus fractures and C3 axial fractures. Our treatment regime is based on this classification and results presented in a sperate study. These consultants were excluded from the study on reliability and reproducibility. 2 Orthopaedic consultants, 2 orthopaedic registrars and 2 radiologists were selected randomly to classify 30 sets of AP and Lateral radiographs, of randomly selected patients treated in this institution with tibial plateau fractures, consisting of 9 SK1-3/C1, 8 SK4/C2 and 13 SK5,6/C3 fractures, and again with the same radiographs in a random order 1 month later. Radiographs of fractures treated conservatively were excluded. Statistical analysis included Kappa concordance according to Landis and Koch, and the Mann-Whitney U test.

Results: The Schatzker system was only moderately reliable (K=0.66), and the Chertsey classification system significantly more reliable (K=0.82) (p=0.03) with regards to interobserver reliability. Excellent reproducibility (intra-observer reliability) was seen amongst all observers. The consultant orthopaedic surgeons were significantly more reliable than the radiologists, but not the orthopaedic registrars. No particular fracture type in any classification proved to be significantly more difficult to classify.

Conclusion: We present a classification used in our institution based on plain radiographs, which depicts investigations and treatment. The Chertsey classification is significantly more reliable between observers than the Schatzker classification and is reproducible.

Introduction: Patellar alignment and tracking are very important to a successful surgical outcome in total knee arthroplasty (TKR) and difficult to assess in arthroscopies of the knee. The need for and use of a tourniquet in TKR’s and knee arthroscopies are debatable. One factor against its use is the possible alteration in the extensor mechanism dynamics making intraoperative assessment of patellofemoral (PF) tracking unreliable.

Aim: To assess whether an inflated tourniquet affects patellofemoral tracking.

Method: 10 Healthy male subjects, between 25 to 30 years of age, with no history of anterior knee pain; lower limb trauma, deformities or previous operations; or systemic disorders were admitted to the study. Dynamic sequence (Fast Field Echo scans) MRI scans over 57secs (flexed and extending against resistance to full extension), were performed without a tourniquet, on both knees, on all subjects as a control. A tourniquet, placed around the thigh, inflated to 300mmHg. Dynamic MRI scans were then obtained of each PF joint. PF tracking was then compared statistically.

Results: Of the 20 knees compared, sulcus and congruence angles were within normal limits. There was no significant difference in patellar tilt angle or patellar displacement. A trend of increased femoral external rotation was seen.

Conclusion: An inflated tourniquet placed around the upper thigh with the leg in extension does not alter patellofemoral kinematics in normal subjects. We believe the femoral external rotation seen is a mechanical adaptation of the tourniquet in the groin.

Objectives: To compare the efficiency of long, locked, trochanteric entry intramedullary nail (Holland nail) against Dynamic Hip Screw in the operative stabilisation of inter-trochanteric femoral fractures.

Study Design: Prospective randomised control study

Method: 190 patients were recruited over 12 months and followed up to fracture union. Patients were randomised into two groups: Holland nail (92) and DHS (98). Variables looked at preoperatively were mini mental test; pre-op mobility; fracture pattern and ASA grading. Operative variables analysed were ease of fracture reduction; surgical time; quality of implant fixation; operative blood loss and radiation time. Post operatively, time to frame; wound problems; time to discharge; rate of fracture union and chronic pain were analysed.

Results: The two study groups were comparable. There was a statistically significant increase in surgical and radiation time with the Holland nail group but this was surgeon dependent. Patients receiving Holland nail had less operative blood loss (p< 0.001). The time to mobility with frame in the Holland nail group was quicker in the fitter patients (ASA 1& 2) (p< 0.005). Holland nail group had lower infection rate (p< 0.01).

Conclusion: Patients with inter-trochanteric fractures who received Holland nail had less blood loss; fewer wound problems; mobilised quicker; had shorter hospital stay and less pain at 6 months compared to patients who had DHS. Fracture union rate was identical in both groups.

Introduction: Hip resurfacing is a method of treating the degenerative hip joint in higher demand patients. In this study we present the results of the first four years of using this technique in a typical District General Hospital.

Materials and Methods: This is a review of the outcome of 303 consecutive hip resurfacing procedures performed at Ashford and St. Peter’s Hospitals NHS Trust. All patients had a posterior approach to the hip joint, followed by standard resurfacing using metal on metal components. The patients were evaluated radiographically and clinically pre-operatively and post-operatively. All patients had regular follow up.

Results: The mean age was 56 with a range from 24 to 75 years old. There was a statistically significant improvement between the pre-operative Harris Hip Score and those at the latest follow up. All patients achieved a full range movement in the hip within twelve weeks following surgery. There were four fractures of the femoral neck, one was intra-operative and was converted to total joint arthroplasty. Three further fractures occurred, two were revised and one was treated conservatively. Two patients had transient femoral nerve palsies. There were no cases of dislocation or deep infection. All the prostheses remain well fixed with no signs of osteolysis.

There were three cases of avascular necrosis, all of which show no signs of further collapse.

Conclusions: The short and medium term results that have been achieved in a District General Hospital are comparable to those that have been achieved in the originator’s institution.

Fragility fractures of the ankle occur mainly in elderly osteoporotic women. They are inherently unstable and difficult to manage. There is a high incidence of complications with both non-operative and operative treatment.

We treated 12 such fractures by closed reduction and stabilisation using a retrograde calcaneotalotibial expandable nail. The mean age of patients was 84 years (75 to 95). All were women and were able to walk fully weight-bearing after surgery. There were no wound complications. One patient died from a myocardial infarction 24 days after surgery. The 11 other patients were followed up for a mean of 67 weeks (39 to 104).

All the fractures maintained satisfactory alignment and healed without delay. Six patients refused removal of the nail after union of the fracture. The functional rating using the scale of Olerud and Molander gave a mean score at follow-up of 61, compared with a pre-injury value of 70.

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.

Non-unions of the supracondylar area of the humerus are uncommon but they produce profound functional disability. We have successfully treated a series of these non-unions surgically using the Coventry hip screw. This is a large metaphyseal screw which is applied through both humeral condyles and then compressed on to a single 4. 5mm narrow tibial plate applied to the lateral aspect of the humeral shaft.

Between 1993 and 2000 we operated on thirteen consecutive patients aged 20 to 81 years (mean age 51 years). All the patients had a severe functional disability. The mean time to surgery was 23 months following their accidents. The average follow up was 16 months (range 8–18 months). All but two of the thirteen patients went on to bony union. The mean time to radiological union was six months (2 to 12 months). The mean arc of flexion doubled to 90 degrees.

Until now, the recommended operative technique for stabilisation of non-unions of the distal humerus is identical to that described for primary fracture repair, and involves fixation with two 3. 5 mm plates at 90 degrees. In our experience, this was the technique usually used at the initial operation/s, and is therefore likely to fail again. This correlates with the reported 6–12% non-union rate in the literature. In this series, stable fixation was achieved by using the Coventry hip screw.