Are national guidelines for total hip replacement in the UK reflected in practice?

INTRODUCTION

A cross-sectional study was performed to compare the practice of total hip replacement (THR) in the UK against national guidelines.

MATERIALS AND METHODS

A postal questionnaire was sent to all fellows of the British Orthopaedic Association.

RESULTS

Of the 1587 questionnaires sent out, 966 (60.9%) were returned. Of these, 706 (73.1%) were available for data collection and analysis.

CONCLUSIONS

Consensus was observed in several areas including the use of pre-admission clinics and modern cementing techniques. Facilities deemed necessary for THR surgery such as HDU/ITU back-up, ultra-clean air and dedicated orthopaedic wards are almost universally available. However, a lack of consensus is evident in many areas including the process of obtaining written consent, thrombo-embolic prophylaxis, duration of antibiotic prophylaxis, supervision of trainee surgeons and follow-up arrangements. The proliferation in the range of implants, particularly aimed at 'younger' patients, available to surgeons has once again been highlighted.

Pre-operative analgesia for patients with femoral neck fractures using a modified fascia iliaca block technique

Adequate pre-operative analgesia for elderly patients with femoral neck fractures is difficult to assess and is often an overseen aspect of their care. We aimed to assess the efficacy of fascia iliaca blocks inserted via plexus blockade catheters in the pre-operative period. Our simple technique allowed the block to be administered safely without the need for a nerve stimulator. We assessed the effectiveness of the block with a novel objective sitting score and by assessing the degree of passive hip flexion that could be achieved comfortably. Visual analogue scores were also used. We studied 30 consecutive patients, regardless of their mental state. One hour following the block, there was a significant improvement in the sitting scores as well as the passive hip flexion (mean increase 44 degrees ). Visual analogue scores also score improved significantly from 7.2 to 4.6 (S.D. 2.4) in the 18 patients without cognitive impairment. We conclude that fascia iliaca blocks can provide significant benefit in the pre-operative period and allow patients to sit up more comfortably while they await surgery.

Nonprogressive abduction contracture of the shoulder joint. A case report

Nonprogressive abduction contracture of the shoulder joint in a 32-year-old woman became clinically obvious only when the shoulder became painful following minor trauma. The tether in the deltoid muscle appears to have been present from an early age, but had been well compensated by abnormal scapular posture. No etiological factors could be discovered, but there was an unsubstantiated family history of similar problems. Only one comparable case has been found in the literature, and this unusual presentation seems not to have been described previously. The patient responded well to conservative treatment.

Factors affecting the outcome of Colles' fracture: an anatomical and functional study

A prospective radiological and functional assessment has been performed on 235 consecutively treated displaced Colles' fractures. The age and sex of the patients, as well as the initial displacement, involvement of articular surface and the adequacy of reduction of the fracture, were all analysed. Because of their greater potential for collapse, the better reduced fractures tended to lose more position during treatment. Despite this, in general, the better the reduction, the better was the final anatomical position of the fractures. The functional result at 3 months was related to the severity of initial displacement of the fracture and, to a lesser extent, to the anatomical result. Involvement of the radiocarpal and the distal radioulnar joints did not seem to affect adversely the patients' rehabilitation, but this was slower and less complete in the elderly. At 6 months, 60 per cent of patients had good or excellent function in the hand and wrist.

The hand complications of Colles' fractures

Two hundred and thirty-five patients with displaced Colles' fractures were followed to union, and 209 patients to six months, specifically searching for hand pathology. The incidence of carpal tunnel syndrome was seventeen per cent at three months and twelve per cent at six months. The patients with the syndrome were significantly older and their fractures showed significantly greater residual dorsal angulation. Sixteen patients developed Dupuytren's disease between three and six months, when the incidence was eleven per cent. These patients were significantly older and had average fractures and anatomical results. All cases were mild, with only two contractures. Twenty-one patients were reviewed at a mean of 20.7 months post-fracture, when no case had significantly progressed.

Functional cast-bracing for Colles' fractures. A comparison between cast-bracing and conventional plaster casts

The use of Orthoplast cast-bracing to allow early hand function in the treatment of displaced Colles' fractures was investigated in 243 patients. They were randomly allocated into three groups: in the first a conventional Colles' type plaster was used; in the second an above-elbow cast-brace with the forearm in supination; and in the third a below-elbow cast-brace. Radiographic measurements were made at each stage of treatment, and the final anatomical result was scored using Sarmiento's (1975) criteria. Function was assessed at three months and at six months. The anatomical result was not influenced by the method of immobilisation but was related to the efficacy of reduction. Loss of position in the braces was no greater than in plaster. The functional result at three months also was uninfluenced by the method of immobilisation; it was, however, related to the severity of the initial displacement, and (to a lesser degree) to the anatomical result, an effect which was lost at six months. Early hand function and the supinated position advocated by Sarmiento were found to confer no anatomical or functional advantage; we could see no reason to change from the use of conventional plaster casts in the treatment of uncomplicated Colles' fractures.