Aim

Grade is the most important predictor of the biological behaviour of soft tissue sarcomas. Assigning a pathologic grade is always a difficult task as discordance rate is 30-40% even among experienced sarcoma pathologists. Many of these tumours are heterogeneously large and only small fractions are sampled for biopsy. This emphasizes the need for an objective and accurate assessment of histology. Our aim is to evaluate the role of Choline as a tumour marker in (i) differentiating benign from malignant soft tissue tumour, (ii) to distinguish recurrent/residual tumours using in-vivo MR spectroscopy.

From August 2009, all doctors were subject to the European Working Time Directive (EWTD) restrictions of 48 hours of work per week. Changes to rota patterns have been introduced over the last two years to accommodate for these impending changes, sacrificing ‘normal working hours’ training opportunities for out-of-hours service provision. We have analysed the elogbook data to establish whether operative experience has been affected.

A survey of trainees (ST3-8) was performed in February 2009 to establish shift patterns in units around the UK. All operative data entered into the elogbook during 2008 at these units was analysed according to type of shift (24hr on call with normal work the following day, 24hr on call then off next working day, or shifts including nights).

66% of units relied on traditional 24hrs on call in February 2009. When compared with these units, trainees working shifts had 18% less operative experience (564 to 471 operations) over the six years of training, with a 51% reduction in elective experience (288 to 140 operations). In the mid years of training, between ST3-5, operative experience fell from 418 to 302 operations (25% reduction) when shifts were introduced.

This national data reflects the situation in UK hospitals in 2009, prior to the implementation of a maximum of 48 hours. It is expected that most hospitals will need to convert to shift-type working patterns to fall within the law. This could have significant implications for elective orthopaedic training in the UK.

Introduction: In August 2007, the Department of Health initiative Modernising Medical Careers was implemented. This was a system of reform and development in postgraduate medical education and training. In preparation for the changes, the SAC for T& O outlined a new curriculum. The emphasis of early training, StR years 1 and 2, was to be trauma. We aim to identify how effectively the SAC proposals are being applied, and what difference this makes to the trainees’ operative experience? Furthermore, how do the new posts compare to the historic SHO models?

Methods: A survey carried out by BOTA allowed us to assess post compliance with the SAC recommendations. A compliant job was defined as trauma based for 50% or more of working time. Consent was obtained to evaluate the eLogbooks of trainees in compliant and non-compliant jobs, along with registrars who had previously held traditional SHO grade posts. Overall operative experience over a specified 4 month time period was examined, with focus on routine trauma procedures.

Results: The results of the BOTA and SAC survey revealed that 45% of the new orthopaedic posts were compliant with curriculum guidelines. The eLogbooks of 92 individuals were analysed; 28 historical posts, 34 compliant and 30 non-compliant. The mean total number of recorded entries by trainees in the 4 month period was 73.2 in the historic group, 90.5 in the compliant and 87.3 in the non-compliant job group. The corresponding numbers of trauma operations were 35.7, 48.4 and 41.5.

Conclusions: Operative experience has improved since the introduction of the new curriculum. The new posts are offering more operative and in particular trauma exposure than traditional SHO jobs. If jobs can be restructured such that they all comply with the SAC, educational opportunities in the early years will be maximised.

Introduction: Many types of prosthesis are currently used for total knee arthroplasty. Controversy exists as to whether mobile-bearing or fixed-bearing implants make any difference in achieving earlier or better movement, resulting in earlier patient discharge.

Aim: The purpose of our study was to compare the post-operative recovery and early results of 4 different mobile- and fixed-bearing knee implants.

Method: Between 19/7/05 and 15/6/07 202 knees were implanted into 190 patients. Patients were randomly selected for 1 of 4 implants (2 mobile-bearing, 2 fixed-bearing). Outcomes were assessed using the American Knee Society Score (AKSS) and range-of-movement, both pre-operatively and at 1 year post-operatively. Range-of-movement was also recorded on discharge.

Results: No significant difference was shown between the individual implant groups and the actual mean pre-operative and 1 year post-operative AKSS knee or functional scores or the change in knee score. A difference was noted however in the change in functional score between the 2 mobile-bearing knees (p=0.03). No significant difference was found between the 4 individual implants or the type of bearing used (mobile- or fixed-bearing) with regards to gender, age, length of stay or range-of-movement.

Conclusion: The type of implant used does not affect the early or 12 month outcomes in relation to range-of-movement, length of stay or AKSS knee scores.

An audit of fractured neck of femur patients indicated that the delay in acquiring an echocardiogram was delaying surgery (time to echo 5.4 days ± 3.4SD (n=72), time to surgery 7.5 days ± 5.5SD (n=72)). This instigated a change in policy with the introduction of routine ‘targeted’ echocardiography performed by a cardiac technician at the patient’s bedside.

A re-audit has demonstrated an improvement in service (time to echo 1.0 days ± 0.7SD (n=96), time to surgery 2.9 days ± 1.9SD (n=118)). A targeted echocardiogram consists of an evaluation of left ventricular function expressed as normal, mild, moderate and severe (left ventricular ejection fraction > 50%, 40–50%, 30–40% and < 30%), the aortic valve (normal, non severe aortic stenosis, severe aortic stenosis, aortic regurgitation and aortic gradient). A targeted echo gives less information than a departmental echo where more parameters are measured, however the information provided is enough to guide the anaesthetists choice of anaesthesia and intraoperative anaesthetic management. Senior Echo technicians perform the investigation at the patients bedside on the trauma ward in the mornings of the working week using a portable machine. Each echocardiogram takes 2 to 5 minutes to perform. If obvious significant other pathology is seen, the patient is referred for a full departmental echocardiogram.

A total of 28.4 patient bed days per month were saved following this change in practice, assuming days waiting for echo preoperatively equate to extra days spent in hospital. The total cost saving per month was £4435, based on the cost of routine targeted echocardiography (£10), departmental echocardiography (£60) and bed cost (£155 per night).

Expedient surgery within this group of patients should not be compromised by delays in obtaining timely echocardiography. The cost of routine ‘targeted’ echocardiography is low and this change in practice can be justified in both clinical and economic terms.

Good medical practice predicates a contemporary knowledge of the literature to guide ones practice. The British edition of the Journal of Bone and Joint Surgery [JBJS (Br)] is considered one of the leading peer reviewed journals, guiding orthopaedic practice in the UK and abroad. Whilst seeking guidance on proposed changes to departmental policy, informal discussion with some high profile units raised concerns regarding the implementation of their published clinical recommendations. We intended to contact the publishing departments, to establish their routine practice with respect to the topic on which they have written in the literature.

We reviewed all articles published in JBJS (Br) over a 24 month period. Specifically we were seeking papers making recommendations for a change in practice. The originating department was contacted by telephone and communication sought from an individual not directly involved in the publication, but whom the change in practice stated in the literature would have direct impact.

Seventy-nine papers representing the work of 87 separate hospitals from 22 different countries were identified as making recommendations in any aspect of practice. We found that published articles were being followed in 56% of cases, 42% were not.

Our study demonstrates that a large proportion of institutions making clinical recommendations are not practicing them. Should the author’s own institution not follow their guidance, then how can the wider orthopaedic community be expected to follow? As such, have we exposed a fundamental flaw in the publication of clinical research?

In conclusion, we do practice what we preach… sometimes.

Introduction – Patients who have sustained a fracture of the hip should have their surgical treatment with 48 hours of admission to hospital. A delay results in increased morbidity and mortality.

This elderly cohort of patients often have confounding co-morbidities. A pre-operative echocardiographic assessment to guide the anaesthetic is frequently requested upon clinical grounds. A delay in acquiring the echocardiogram was observed thus delaying surgery. This instigated a change in policy within the department whereby all patients over 70 years old who sustained a hip fracture underwent echocardiographic assessment with 24 hours of admission.

Method: An audit was performed assessing delays in acquiring the echocardiograms and measuring the time taken to perform the operation.

Results: Period 1 – Selective Echo: Mean time to echo 5 days, mean time to theatre 7 days. Period 2 – Unselective Echo: Mean time to echo 1 day, mean time to theatre 2 days.

Conclusion: As a result of the unselective policy to perform echo cardiograms on all patients admitted with a fractured neck hip, the delay to perform surgery has been reduced significantly.

The management of the patella during total knee replacement is controversial. In some studies the absence of patellar resurfacing results in residual anterior knee pain in over 10% of patients. One form of treatment which may be used in an endeavour to reduce this is circumferential patellar rim electrocautery. This is believed to partially denervate the patella. However, there is no evidence of the efficacy of this procedure, nor do we know if it results in harm.

A retrospective comparative cohort study was performed of 192 patients who had undergone a primary total knee replacement with the porous coated Low Contact Stress rotating platform prosthesis without patellar resurfacing between 2003 and 2007. In 98 patients circumferential electrocautery of the patellar rim was performed and in 94 patients it was not. The two groups were matched for gender and age. The general Oxford Knee Score and the more specific patellar score for anterior knee pain were used to assess patient outcomes a minimum of two years post-operatively.

No statistically significant differences were noted between the groups for either scoring system (p = 0.41 and p = 0.87, respectively). Electrocautery of the patella rim did not improve the outcome scores after primary total knee replacement in our patients.

Introduction: Various techniques are being currently used for the internal fixation of scarf osteotomies. We conducted a prospective study on 23 consecutive cases of hallux valgus treated with scarf osteotomy, which was internally fixed with AO mini fragment screws. The aim of our study was to evaluate the clinical efficacy of the AO mini fragment screws in these cases.

Method: Sixteen women and one man (twenty three feet) were included in our study. Mean age was 46 years at the time of surgery. The mean follow-up time was 18 months. A single surgeon performed surgery. Patients were assessed by clinical and radiological evaluation. Preoperative and postoperative American Orthopaedic Foot and Ankle Society score was obtained.

Results: All the osteotomies united without any failure of fixation or hard ware problems. One patient developed superficial wound infection, which responded to antibiotics. At the time of follow-up all the patients were very satisfied. The mean AOFAS score improved significantly from 55 points pre-operatively to 91.95 at follow-up (p < 0.001). The intermetatarsal and hallux valgus angles improved from the mean pre-operative values of 15.86° and 31.18 degrees to 9.09° and 15.18°, respectively. These improvements were significant (p < 0.0001).

Conclusion: We report no failure of fixation in our series and conclude that this is a safe and simple technique. It is cost effective, provides stable fixation and maintains correction till the union of osteotomy.

To study the survival analysis of the Accord TKR and to analise the causes for its failure. 111 Accord knees were implanted in 106 patients between 1986 and 1996. All components were cemented. Eighty-seven patients were followed up and assessed according to the Knee Society Clinical Rating System.

Life table analysis of this implant using revision as the end point shows a survival of 25% at 11–12 years.

Of the 87 knees, only 31 were still in situ and of these 7 showed radiographic signs of severe loosening. However, the average knee score for these 31 was only 65/100 and average functional score was down to 42/100.

56 implants have been revised, 21 due to aseptic loosening, 11 due to gross valgus/varus instability, 9 due to deep infection, 8 due to loosening of the patella liner and 7 due to mobile bearing complications.

All 21 (24%) cases of aseptic loosening were found to have a loose femoral component; however, 56% of the total showed significant radiographic osteolysis around the stem of the tibial implants.

Retrieved implants in 5 patients showed significant delamination of the UHMWP at its margins and also revealed a track through the tibial baseplate into the medullary cavity of the tibia.

Conclusion: Early failure of this implant is due to increased debris formation from the UHMWP due to edge loading and early delamination probably as a consequence of the shape of its articulating surface. This situation was significantly aggravated by a design fault in the tibial baseplate, which encouraged unrestricted access of debris into the medullary cavity of the tibia and hence early and severe osteolysis.

A study of 50 consecutive osteoporotic pelvic rami fractures has been carried out to investigate the full extent of injury following low energy falls.

50 consecutive elderly patients with fresh fractures of the pelvis were each investigated with an MRI scan of the pelvis in order to assess the competency of the pelvic ring. The 50 patients consisted of 45 female and 5 males with a mean age of 77.7 years. 44 patients had unilateral pubic rami fractures. The mechanism of injury in all cases was a simple fall in the home environment. On admission 96% of the patients complained of sacral pain and were tender in the sacral or posterior pelvic region. On MRI, 90% of patients had a sacral fracture associated with the pubic rami fractures and in all but 4 of these the posterior pelvic pain was directly related to the sacral fracture site. At 6 month follow-up, 82% still complained of posterior pelvic tenderness. Areas of tenderness corresponded to the sites of the fractures. Before the injury, 38 of the final 44 reviewed were reasonably independently mobile, whilst at review 39 were significantly disabled.

Conclusion: The study shows that the apparently benign traumatic pelvic rami fracture in the elderly has a high association with sacral fractures. After discharge from hospital, attention should be paid to treatment of the on-going anterior and posterior pelvic pain.

Our aim was to review the efficacy of the wound vacuum-assisted closure (VAC) system in the treatment of deep infection after extensive instrumentation and fusion for spinal deformity in children and adolescents.

A total of 14 patients with early deep spinal infection were treated using this technique. Of these, 12 had neuromuscular or syndromic problems. Clinical and laboratory data were reviewed. The mean follow-up was 44 months (24 to 72). All wounds healed. Two patients required plastic surgery to speed up the process. In no patient was the hardware removed and there was no loss of correction or recurrent infection.

We believe that the wound VAC system is a useful tool in the armamentarium of the spinal surgeon dealing with patients susceptible to wound infections, especially those with neuromuscular diseases. It allows for the retention of the instrumentation and the maintenance of spinal correction. It is reliable and easy to use.

Introduction Kirschner wire (K-wire) pinning is a widely accepted technique for fixation of distal radius fractures. Potential exists for injury to the soft tissues. This cadaveric study evaluates the safety of percutaneous pinning of distal radius fractures using a technique of intrafocal placement of K-wires.

Methods Three K-wires (1.6 mm diameter) were inserted percutaneously into 18 cadaveric wrists 18 mm proximal to the radial styloid. A radial wire was placed between the first and second extensor compartments. A dorso-radial wire was placed proximal to Lister’s tubercle. A dorsoulnar wire was placed between the fourth and fifth compartments. The wrists were dissected along the wires to the bone.

Results The superficial radial nerve (SRN) was pierced twice (11%), the abductor pollicis longus six times (33%), the extensor pollicis brevis and the extensor carpiradialis brevis once (6%). Extensor pollicis longus (EPL) was entered five times (28%), the fourth compartment four times (22%) and the fifth compartment once (6%). Only four wrists (22%) escaped injury to any important structure.

Conclusions The incidence of SRN injury by percutaneous insertion of K-wires is similar to that reported for the mini-open approach of around 12%. Rupture of EPL has been reported at around two percent. Aetiology of rupture is unclear and a K-wire that is subsequently removed may not increase the risk of rupture.

Aim: To ascertain the accuracy of partial weight bearing.

Method: 6 healthy volunteers with a below knee plaster cast, 10 patients with uncemented hip replacements and 12 patients with lower limb fractures were trained to partial weight bear. They were asked to place the affected leg on a bathroom scale and to press on it till the prescribed limit. This process was repeated till the subject formed a mental image of the amount of load they must put through the limb. The ability to partial weight bear was tested in a gait lab by making them walk on a walkway incorporating a Bertec force platform. Exact magnitude of weight bearing was calculated from the vertical ground reaction forces produced.

Results: 4 out of 6 volunteers exerted mean weight of 20.3 kg above and the remaining 2 exerted 5.6 kg below that prescribed. Of the 22 patients, 19 exerted mean weight of 24.3 kg above and 3 patients exerted mean weight of 7.5 kg below that prescribed. As per Spearmanñs rank correlation test, the relationship between the prescribed weight bearing and the actual weight bearing was non-signiþcant (p=0.399) i.e., there is little relationship between the prescribed and actual weight bearing.

Conclusions: Neither patients nor healthy volunteers could partial weight bear to the extent required. They were either above or below the prescribed level of partial weight bearing. Current method of teaching partial weight bearing is inaccurate and has poor reproducibility. Such methods use static loading situations whereas walking is a dynamic activity. An inexpensive, easy to use, dynamic device is required to train patients to partial weight bear.