To discover whether orthopaedic surgeons follow the BOA guidelines for secondary prevention of fragility fractures, a retrospective audit on neck of femur fractures treated in our hospital in October/November 2003 was carried out. There were 27 patients. Twenty-six patients (96%) had full blood count measured. LFT and bone-profile were measured in 18 patients (66%). Only nine patients (30%) had treatment for osteoporosis (calcium and vitamin D). Only one patient was referred for DEXA scan.

Steps were taken to create better awareness of the BOA guidelines among junior doctors and nurse practitioners. In patients above 80 years of age it was decided to use abbreviated mental score above 7 as a clinical criterion for DEXA referral. A hospital protocol based on BOA guidelines was made.

A re-audit was conducted during the period August-October 2004, with 37 patients. All of them had their full blood count and renal profile checked (100%). The bone-profile was measured in 28 (75.7%) and LFT in 34 (91.9%) patients. Twenty-four patients (65%) received treatment in the form of calcium + Vit D (20) and bisphosphonate (4). DEXA scan referral was not indicated in 14 patients as 4 of them were already on bisphosphonates and 10 patients had an abbreviated mental score of less than 7. Among the remaining 23 patients, nine (40%) were referred for DEXA scan. This improvement is statistically significant (p=0.03, chi square test).

The re-audit shows that, although there is an improvement in the situation, we are still below the standards of secondary prevention of fragility fractures with 60% of femoral fragility fracture patients not being referred for DEXA scan. A pathway lead by a fracture liaison nurse dedicated to osteoporotic fracture patients should improve the situation.

Aim

To assess the efficacy and ease of use of the Oxford Knee Score (OKS) in soft tissue knee pathology.

Background

In suspected scaphoid fracture the initial scaphoid series plain radiographs are 84-94% sensitive for scaphoid fractures. Patients are immobilised awaiting diagnosis. Unnecessary lengthy immobilisation leads to lost productivity and may leave the wrist stiff. Early accurate diagnosis would improve patient management. Although Magnetic Resonance Imaging (MRI) has come to be regarded as the gold standard in identifying occult scaphoid injury, recent evidence suggests Computer Tomography (CT) to be more accurate in identifying scaphoid cortical fracture. Additionally CT and USS are frequently a more available resource than MRI.

We hypothesised that 16 slice CT is superior to high spatial resolution Ultrasonography (USS) in the diagnosis of radiograph negative suspected cortical scaphoid fracture and that a 5 point clinical examination will help to identify patients most likely to have sustained a fracture within this group.

Cutaneous nerve injury occurs commonly with knee arthroplasty, causing altered skin sensation and, infrequently, the formation of painful neuromas. The infrapatellar branch of the saphenous nerve is the structure most commonly damaged.

The aim of this study was to establish the frequency of cutaneous nerve injury with three incisions commonly used in knee arthroplasty.

Ten knees from five cadavers were studied. Skin strips representing three different incisions, were excised and examined for number and thickness of nerves.

There were more nerve endings found in the dermis layer than the subcutaneous fatty layer. There was no significant difference in the total number of nerves when the 3 studied incisions were compared. The lower part of all incisions was found to have more thick and a higher number of nerves than the upper part (P=0.005).

Careful incision placement is required to avoid damage to cutaneous nerves during knee arthroplasty. This may be of long-term advantage to patients especially those for whom kneeling is important.

Background: The purpose of this study was to assess the anterior femoral cortical line (AFCL) as an additional anatomical landmark for determining intraoperative femoral component rotation in total knee arthroplasty. The AFCL was compared with the Epicondylar axis, the anteroposterior (AP) axis (Whiteside’s line), and the posterior condylar axis. Dry bone, cadaver, MRI and intra-operative measurements were compared.

Methods: Fifty dry bone femora, and 16 wet cadaveric specimens were assessed to identify the AFCL and this was compared against the 3 reference axes discussed above. Photographs were taken of the specimens with K-wires/marker pins secured to the reference axes and then a digital on-screen goniometer was used to determine the mean angular variations with respect to the Epipcondylar axis.

In the clinical trial, 58 consecutive patients undergoing total knee arthroplasty were included. After a routine exposure the AP axis was marked on each distal femur. The AFCL was then identified and the anterior femoral cortical cut was made parallel to this line. The angle between this cortical cut and the perpendicular to the AP axis was measured using a sterile goniometer.

In the MRI study, 50 axial knee images were assessed and the most appropriate slice/s determined in order to identify the AFCL and the other 3 reference axes and then their relationship was measured by an on-screen goniometer.

Results: In the cadaveric study the AFCL was a mean 1° externally rotated to the epicondylar axis (SD = 5°), White-side’s line was 1° externally rotated (SD = 4°) and the posterior condylar axis was 1° internally rotated (SD = 2°)

By MRI and with respect to the epicondylar axis, the AFCL was a mean 5° externally rotated (SD= 3), White-side’s Line was 1° externally rotated (SD = 2) and the posterior condylar axis was 3° internally rotated (SD = 2).

In the clinical study in 8 patients it was impossible to draw the AP axis because of dysplasia or destruction of the trochlea by osteoarthrosis. In the remainder the mean difference between the anterior femoral cortical line and Whiteside’s AP axis was 4.1 degrees internally rotated (SD = 3.8°). The lateral release rate for this cohort was 4%.

Conclusion: The anterior femoral cortical line provides an additional reference point, completing the ‘compass points’ around the knee. It has been shown in this study to be reliable in the laboratory, on MRI and in a clinical setting for assessing rotation of the femoral component. It may prove particularly useful when one or all of the other reference axes are disturbed such as in revision TKR, lateral condylar hypoplasia or where there has been previous epicondylar trauma.

Purpose: To assess the anterior femoral cortical line (AFCL) as an additional anatomical landmark for determining intraoperative femoral component rotation in total knee arthroplasty. The anterior femoral cortical line (AFCL) is an anatomical landmark which has been used by the senior author for 20 years to assess femoral rotation in over 4000 TKRs. The AFCL describes the alignment of the anterior cortex of the distal femur proximal to the trochlear articular cartilage.

Methods: The AFCL was compared with the surgical epicondylar axis (SEA), anteroposterior axis (Whiteside’s line) and posterior condylar (PC) axis using 50 dry-bone cadaveric femora, 16 wet cadaveric specimens, 50 axial MRI scans and 58 TKR patients intra-operatively.

Results: In the dry-bone and cadaveric femora (measuring relative to the SEA) the AFCL and Whiteside’s AP axis were 1° externally rotated and the PC axis was 1° internally rotated. With MRI (relative to the SEA) the AFCL was 8° internally rotated, Whiteside’s was 2° externally rotated and the PC axis was 3° internally rotated. In the clinical study (measuring relative to a perpendicular to Whiteside’s line alone) the AFCL was 4° degrees internally rotated, which equates to 2–3° of internal rotation relative to the SEA.

Conclusion: The AFCL is another axis, completing the ‘compass points’ around the knee. It may prove particularly useful when one or all of the other reference axes are disturbed such as in revision TKR, lateral condylar hypoplasia or where there has been previous epicondylar trauma. We suggest building in 5° external rotation with respect to the anterior femoral cortical line when judging femoral component rotation.

Aim: To assess the Oxford Knee Score (OKS) for the assessment of soft tissue knee pathology?

Method: In a prospective study, we compared the OKS against the International Knee Documentation Committee (IKDC 2000) and the Lysholm Scores (Lys). We also assessed the OKS with retrograde and antegrade (as currently used in Oxford) numbering. All patients completed 3 questionnaires stating which was the simplest from their perspective. We recruited 73 patients from the orthopaedic and physiotherapy clinics, meeting the following criteria:

Results: Linear regression analysis revealed no significant difference between all 3 scores (R²=0.7823, P< 0.0001). The OKS correlated best with the IKDC (r=0.7483, Fig1), but less so with the Lys (r=0.3278, Fig2). The reversed OKS did not correlate as well (R²= 0.2603) with either the IKDC (r= −0.2978) or the Lys (r= −0.2586). ANOVA showed the OKS to be significantly easier than Lys to complete (p< 0.0001), but not significantly easier than IKDC (p> 0.05).

Conclusion: The OKS is patient friendly and reliable in assessing soft tissue knee injury. This is particularly useful if the OKS is already in use within a department for measurement of severity of degenerative disease.

We sought to determine whether smoking affected the outcome of reconstruction of the anterior cruciate ligament. We analysed the results of 66 smokers (group 1 with a mean follow-up of 5.67 years (1.1 to 12.7)) and 238 non-smokers (group 2 with a mean follow-up of 6.61 years (1.2 to 11.5)), who were statistically similar in age, gender, graft type, fixation and associated meniscal and chondral pathology. The assessment was performed using the International Knee Documentation Committee form and serial cruciometer readings.

Poor outcomes were reported in group 1 for the mean subjective International Knee Documentation Committee score (p < 0.001), the frequency (p = 0.005) and intensity (p = 0.005) of pain, a side-to-side difference in knee laxity (p = 0.001) and the use of a four-strand hamstring graft (p = 0.015). Patients in group 1 were also less likely to return to their original level of pre-injury sport (p = 0.003) and had an overall worse final 7 International Knee Documentation Committee grade score (p = 0.007).

Despite the well-known negative effects of smoking on tissue healing, the association with an inferior outcome after reconstruction of the anterior cruciate ligament has not previously been described and should be included in the pre-operative counselling of patients undergoing the procedure.

Aim: To assess the adequacy of reduction of Colles fracture by haematoma block and intravenous sedation and its outcome.

Methodology: Retrospectively reviewed 70 Colles fracture reductions done in the A & E. 30 haematoma blocks and 40 intravenouss sedation. The prereduction radiographs were reviewed for the radial height & inclination and dorsal tilt. The outcome of the reduction was also reviewed.

Results: The mean age was 59 years for haematoma block and 56 years for intravenous sedation. Fracture classifications were similar in both groups using the Frykman and Universal classification. The mean prereduction radial length, radial inclination and dorsal tilt were equal in both groups. There was significant difference in post reduction measurements between the two groups. 30% of the haematoma block group had further manipulation and K wiring done whereas only 15% of the intravenous sedation group had further procedures done.

Conclusions: Our study showed that there was less remanipulation and better reduction in the intravenous group than the haematoma group. We recommend intravenous sedation as a preferred procedure for initial manipulation of Colles fratures for a better outcome

Aim To study the natural history of bone bruising of the knee and to identify the effect of weight bearing and associated internal derangement (ID) on clinico-radiololgical progress of bone bruising of the knee.

Method Patients with an acute knee injury were prospectively assessed by clinical and MRI examination within 48 hours of injury. Patients with fracture, osteoarthrosis, bleeding disorder and previous injury or surgery to the injured knee were excluded. Internal derangement (ID) of the knee joint was identified. Patients with bone bruising (study group) were randomised into weight bearing and non weight bearing groups and followed up for clinical and MRI examination at six weeks, three months, six months and twelve months. At follow up, bone bruising on MRI was classified as Progressive, Static, Resolving or Resolved. Patients without bone bruising (control group) were similarly followed up for clinical examination. This is an ongoing study

Results Twenty-eight patients were available for the follow up. There were 8 patients in the control group and 10 patients each in the weight bearing and non-weight bearing group. Eleven patients had associated internal derangement of the knee joint.

Clinical improvement was better in the control group compared to the study group. Patients with isolated bone bruising were doing better than those with associated ID.

Radiololgically there was a tendency for the bone bruise (BB) to progress in the first six weeks but the majority started resolving by three months time. All isolated BB were resolved by six months but there was delayed resolution of BB associated with internal derangement.

Weight bearing status did not influence clinical or radiological course of bone bruising.

Conclusion Weight bearing does not alter the course of the bone bruising. Internal derangement associated with bone bruising delayed radiological resolution and clinical improvement of the patient.

Transient osteoporosis of the hip is a rare condition of unknown aetiology affecting middle aged men with no risk factors and women in their third trimester of pregnancy. The condition invariably resolves spontaneously, however, due to its rarity and initially normal plain radiographs, the syndrome is often not appreciated early in its development, and particularly represents a diagnostic problem of differentiation from osteonecrosis.

We present a case of unilateral transient osteoporosis of the hip in a 52 year old male and a case of bilateral hip involvement in a 32 year old female in her 35th week of pregnancy. Both cases include the initial and follow-up plain radiographs, MRI and DEXA scan findings, through to symptomatic resolution.

We present a literature review of the disease and analyse the current evidence on aetiology, the problems in diagnosis and the current treatment modalities.

Dual Energy X-ray absorption (DEXA) has been used to measure bone mineral density (BMD) around total hip prostheses. With the recent increase in the use of metal on metal hip resurfacing, such as the Birmingham Hip Resurfacing (BHR), there has been renewed concern over per prosthetic femoral neck fracture and implant loosening. DEXA quantitatively measures bone mineral density and therefore could predict impending loosening and fracture. To the best of our knowledge, there are no recorded studies assessing BMD around metal-on-metal hip resurfacings such as the BHR. Our intention was to produce a reliable method of measuring bone density around a metal-on-metal hip resurfacing, such as the BHR, prior to a prospective study.

We performed DEXA scans on five patients (7 BHR’s), who had undergone resurfacing with the BHR within the last two years, using the Hologic QDR 45000A scanner. Each BHR was scanned twice on the same day with complete patient repositioning between scans. We analysed the data with the Hologic prosthetic hip (v 8.26a: 3) scan analysis software (operating software 9.80D) by identifying a variable number of same-sized regions of interest (ROI) within the femoral neck. These ROI’s were derived from an inter-trochanteric line and the axis of the BHR stem in the femoral neck. Each of the 14 scans was analysed twice, by three of the authors independently; with at least one week between repeat analysis by the same observer. Statistical analysis was carried out by the local University Department of Statistics.

The variation within the same ROI in a given BHR was 0.00353, whereas the variation between all ROI’s was 1.155. The intraclass-correlation was 0.997 (i.e. the correlation between any two assessments of one ROI) with an overall coefficient of variation of 5%. The variation between the two scans for each BHR and between the three assessors was not significant (p=0.87 and p=0.42 respectively). The mean BMD of the individual ROI’s, between the two assessments of the same scans by the same assessor (i.e. intra-observer variation) was lower on the second assessment by 0.0214gcm⁻² (SD=0.0025) representing 0.5% mean density for all ROI’s. This difference was statistically significant (p< 0.001).

This method demonstrates excellent reproducibility of the method. Inter-scan and inter-observer variation was so negligible that a tiny intra-observer variation of 0.5% (of mean bone density) became statistically significant (p< 0.001), despite it making no difference to the overall intraclass-correlation. Statistical advice suggested that this very small difference in mean density (intra-observer) only reached significance due to the highly sensitive measurements and excellent reproducibility.

We have designed and demonstrated a safe, non-invasive and highly reproducible method for scanning BHR implants in vivo using DEXA. We will now use this method to prospectively study our BHR population to detect impending loosening or fracture.

The aim of this study was to demonstrate the benefits of a simple blood transfusion protocol in Primary Total Knee Replacement.

Patients undergoing TKR in the UK usually have either blood cross matched or have an auto transfusion of drained blood postoperatively. Audit of blood requirements of patients undergoing TKR showed that a large amount of blood was wasted. A CT ratio (Ratio of number of units of blood cross matched to number of units transfused) of 4.86 was obtained. Range recommended by the blood transfusion society is 2: 1 to 3: 1. A protocol was then made to Group and Save and Antibody Screen for all patients having a primary TKR, except patients with haemoglobin less than 12.5 gm/dl pre operatively and those patients with multiple red cell antibodies in their blood.

A further study involving 50 patients was carried out using the new protocol. Two units of blood was cross matched for each of 5 patients (3 with Hb < 12 gm/dl and 2 with red cell antibodies). Post operatively the 3 patients with Hb < 12 gm/dl required blood transfusion of 2 units each, reducing the CT ratio to 1.7: 1.

The benefits from above protocol are : a). Patient safety as risks of transfusion are avoided and b). Cost saving for trust on haematology technician time and on transfusion sets which cost around £70 each.

Aim: To prospectively determine the functional outcome of revision total knee replacement (TKR).

Method: We carried out a prospective outcome study recruiting 65 consecutive revision total knee replacements carried out by the senior author between 1992 and 1995. The indications for revision were aseptic loosening in 40 cases, instability in 7, infection in 4, and 16 cases for other causes. All patient was assessed preoperatively and at 3 and 12 months postop using the Nottingham Health Profile (NHP) to measure general health status. As part of this ongoing study, followup data is available for 24 patient at 5 years.

Results: There were 65 revisions in 60 patients, 5 being bilateral. There were 37 females and 23 males, with a mean age of 63 years (range 29 to 86 years). The preoperative scores showed that the patient had significant disability related to their failed TKR. Three months postop, there was a significant improvement in the NHP scores for pain and social isolation. At 12 months, the level of pain was again significantly improved over the 3 month score.

At 5 years, the pain score for the revision group deteriorated but remained better than the baseline level. This is in contrast to post primary TKR, where the improvement in pain score was maintained from 3 months onwards.

Conclusion: This study shows a significant improvement in the level of pain following revision knee arthroplasty. However, patients remain significantly disabled afterwards and do not show the very marked improvement in general health seen after primary TKR.

Aim: To prospectively determine whether social deprivation has an effect on the level of disability at presentation and the outcome from total knee replacement (TKR).

Method: A prospective outcome study was carried out between 1992 and 1996, recruiting over 2500 total knee replacements. All patients were assessed preoperatively and at 3 and 12 months postop using the Knee Society (KS) scores for clinical evaluation and the Nottingham Health Profile (NHP) to measure general health status. The Townsend Score was used as the index of social deprivation and was calculated for each patient on the basis of their address.

Results: There was no significant difference between either the Knee Society or NHP scores at baseline and the Townsend Score. This indicated that social deprivation has no effect on the level of the knee arthritis immediately prior to joint replacement, both in terms of patient disability and health status.

There was also no significant difference between either the Knee Society or NHP scores postoperatively and the Townsend Score. This indicated that social deprivation has no effect on the outcome from knee replacement.

Conclusion: This study shows that social deprivation has no significant effect on the level of disability at presentation and the outcome from total knee replacement. This is contrary to previously published reports which have shown worse outcomes in more deprived patients.