Purpose: The role of hip aspiration as a preoperative investigation for the painful hip remains controversial. Since 1999, we have performed hip aspiration under local anaesthetics in the X-ray department. This paper reviews our experience with this technique.

Results: Hip aspirations were carried out subsequently on 182 patients from November 1999 to November 2002. Out of 68 patients that underwent revision hip surgery, 63 were included in the study. Three of the five patients excluded had received antibiotics at induction prior to obtaining the operative samples and two did not have any operative samples taken at the time of surgery. Fifteen (23.8%) of the 63 hips were found to be infected based on operative tissue cultures. The sensitivity and specificity of the test were 80% and 87.5%, respectively. Positive and negative predictive values were 66.6% and 93.3% respectively and the accuracy was 85.7%.

Conclusion: Hip aspiration in the Radiology department is a simple, cost effective and reliable preoperative test when used selectively. When used in combination with other laboratory and radiological investigation it can act as an important preoperative investigation in the diagnosis of sepsis. There is an added advantage of identifying the microorganism along with its antibiotic sensitivities. This can guide clinicians in choosing the correct antibiotic for the cement and also for the postoperative antibiotic therapy.

Children with osteogenesis imperfecta(OI) have multiple long bone fractures with subsequent deformities. The mainstay of treatment is correction with multiple osteotomies and intramedullary fixation. The Shefffield intramedullary telescoping rod system has been successful in the treament of long bone fractures and deformities (Wilkinson et al ,JBJS-B,1998) Bisphosphonates (Pamidronate -1- 1.5mg/kg/day)have been used as adjuvant therapy in the treatment of OI since the last five years. The perceived benefits include reduction in fracture frequency, improvement in bone density and a general feeling of well being.

We present our experience of five cases of OI who developed infections around thier Sheffield telescoping rods while on Pamidronate therapy. There was only one case of sepsis over a ten year period(over eighty patients)in a previously reported series from our centre.

The time interval between the start of Pamidronate therapy and the diagnosis of infection varied between 12–36 months ie. between 4–12 cycles of Pamidronate (parenteral administration over a three day period at three month intervals). All patients had their intramedullary rods in situ from anywhere between 2–7 years. The infections were low grade with a 2–3 month period of dull ache prior to actual presentation. Intrestigly though all patients had multiple rods in situ, only one of their femoral rods was affected and they did not have any other infective focus at the time of diagnosis. Three patients presented with thigh abcesses while the other two presented with ipsilateral knee pain and effusion. All had raised inflammatory markers, radiological signs of sepsis with Staph Aureus the commonest infecting organism.

Those cases presenting with abcesses were treated by drainage and rod removal, however only antibiotics were sufficient in the rest. The relationship between Pamidronate therapy and these infections is not absolutely clear and has not been reported previously. The possible links are discussed and a high degree of suspicion is recommended for those cases of OI on bisphosphonate

This study was designed to assess the standard of orthopaedic training of Senior House Officers in the U.K. and to determine the optimum time that should be spent in these posts before registrar training.

Two MCQ papers were constructed. One for the pre test and one for the post test. Questions covered all aspects of orthopaedics and trauma including operative surgery. The paper was firstly tested on controls including medical students, house officers, registrars of various grades and consultants. There was no statistical difference in the results for the two papers within the groups indicating that pre and post test papers were of similar standard. In addition the average scores in the tests increased proportionately to the experience and grade of the control.

129 SHOs from 25 hospitals in 10 different regions were tested by MCQ examination at the beginning of their 6-month post. They were again tested at the end of the job. The differences in score were compared. This difference was then correlated with the experience and career intention of the SHO.

There was no statistical difference between pre and post test results in all groups of SHOs in the study (student t test). The best improvement in scores during this six month period were seen in SHOs of 1–1.5 years orthopaedic experience. SHOs of more than 3 years experience demonstrated the smallest improvement in their score. There was a net loss of seven trainees with a career intention of orthopaedics to other disciplines.

In the vast majority of Senior House Officer posts in this country, very little seems to be learnt during a six-month attachment. This is especially so for those who are doing orthopaedics for the first time as well as very experienced SHOs.

This study examines the value of a proforma in improving the standards of orthopaedic operation notes.

The standard of operation notes in orthopaedic surgery is notoriously poor. This has clinical, medicolegal and research implications. There is no published study on the influence of a proforma on the quality of orthopaedic operation notes.

An audit of the quality of operation notes in the orthopaedic department of Chesterfield and North Derbyshire Royal Hospital was undertaken. 1, 928 cases were identified from theatre log books and 88 randomly selected casenotes were scrutinised by a single observer for the legible inclusion of parameters based on Royal College of Surgeons guidelines. An operation note proforma was devised and used routinely over a period of six weeks. The effectiveness of the proforma was assessed by examining operation notes randomly selected from the procedures performed during that period. Identical parameters were assessed. Results from the two groups were compared and statistically analysed using the Wilcoxon signed ranks test. To investigate the longer term impact of proformas an identical audit was undertaken in a neighbouring unit in which a proforma had been in use for five years.

Following introduction of the proforma in Chesterfield there was a statistically significant increase in the inclusion of the assessed parameters (p=0. 001). Criteria such as the patient ID number, pre-op diagnosis, tourniquet use and time, prophylactic antibiotic administration, prosthesis details and post-op instructions showed a marked improvement. No parameter showed a significant reduction in its documentation rate. The results from Rotherham were comparable to those achieved following the introduction of the proforma in Chesterfield.

This study clearly demonstrates the effectiveness of a proforma in improving the standard of operation notes. The results from Rotherham suggest that high standards can be maintained long after the introduction of the proforma. We recommend the routine use of operation note proformas in orthopaedic surgery.

To review healing rates, complications, alignment, length and function in non-unions treated with Mono-lateral External Fixation.

A cohort of 110 patients (113 segments) treated for non-union, by mono-lateral external fixation in Sheffield between 1987 and 1996 is reviewed. There were 83 males and 27 females with a mean age of 37.2 years. 67 patients had high-energy injuries and there were 56 open fractures. There were 60 tibiae, 38 femora and the rest were upper limb long bones with a mean of 3.2 previous procedures. The mean duration of non-union was 23.4 months (range 3–123). There were 64 monofocal procedures with 41 supported in neutralisation, 20 in compression and three in distraction. There were 49 bifocal procedures (33 compression distraction and 16 bone transport). 71 segments required a bone graft.

The success rate using the initial fixator was 90%. Clinical and radiological union was achieved in 109 segments (96.5%) although seven required further fixation and one subsequently went on to amputation for ischamia. All five amputations were in smokers and three were directly related to vascular failure.

The mean hospital stay was 21.12 days and the mean number of operations per patients was 2.55.The mean time to bony union was 12.69 months (range 2.5-64). The Length gained mean 4.5 cm (range 1.5-12 cm). Angular correction achieved 12° (range 2-39°); The bony and functional results were assessed at the end of treatment by system described by Paley & Catagni (JBJS 77A, 1995).

Monolateral external fixation can provide stable fixation for the treatment of established non-unions. The fracture environment may be carefully controlled and angulation and length corrected simultaneously. Interestingly 11 out of 12 problem cases were in smokers.

As the number of patients being offered multifocal procedures in limb reconstruction surgery has increased a study was performed to compare single stage and staged procedures.

A retrospective analysis of all multifocal procedures (more than two sites) performed between 1988 and 1997 was carried out looking at treatment times, results and complication rates. A total of 51 multifocal procedures were performed. The mean number of sites operated on was 3.8 per patient for single stage and 4 per patient for staged. There were 18 single stage and 33 staged operations. There were 29 performed on the paediatric age group for indications such as achondroplasia and short stature. The rest were in adults where the main indications were related to complex trauma management and their complications. External Fixation was the principle method of treatment.

The total hospital stay averaged 18 days for single stage procedures and 29 days for staged. Of the single stage cases 12 had one operation with a mean of 1.33 operations (including surgery for complications) compared to staged procedures which had an average of 2.8 operations (range 2–5 ). In addition, the total treatment time (time of first surgery to discharge) was more for staged surgery, 5 years compared to 3.6 years. In the single stage group 9 patients (50%) had at least one significant post operative complication (2 severe, 7 moderate) and in the staged group 19 (57%) had significant complications (3 severe, 16 moderate). There was no detectable difference in the final clinical result obtained between the groups.

From this study we would conclude that single stage procedures carry no increased risk and are of benefit to patients because of the shorter hospitalisation, reduction in the number of operations and general anaesthetics and the reduced time to final outcome.

Background: In an effort to reduce the waiting times for outpatient appointments and surgery ‘Direct Access Arthroscopy Services’ have been set up in some centres whereby GP’s assess patients with acute knee injuries.

The value of a physiotherapist in the Back Pain clinic is well known, however their effectiveness in an Acute Knee Injury Clinic has not been documented despite the fact that they have already been used in some centres to triage these injuries.

Purpose of study: This study was therefore set up to determine if an experienced physiotherapist can accurately diagnose an acute knee injury and formulate a treatment plan.

Methods: 50 consecutive patients with acute knee injuries were seen in the fracture clinic. They were each assessed and a diagnosis made and treatment plan formulated by the consultant, an orthopaedic SHO and two experienced physiotherapists in random order. Evaluation was by history, examination and X Rays. Final diagnosis was based on arthroscopic findings, further investigations or response to conservative treatment.

Results: We found no statistically significant difference in the clinical diagnosis and treatment plans made by the consultant and the orthopaedic physiotherapist p> 0.05 (Mc Nemar’s Test). In addition the physiotherapist had a higher proportion of correct diagnoses compared to the SHO. Again this difference was not statistically significant.

Conclusion: The results suggest that an experienced physiotherapist can safely and effectively be used to assess patients with an acute knee injury in the outpatient clinic setting.

Background: The decision on how to manage a patient with an acute ACL tear diagnosed at arthroscopy is still very subjective. Since 1995 all such patients in a single surgeon practice were managed either surgically or conservatively based on a modification of criteria described by Daniel. This essentially takes into consideration the presence of associated injuries and the activity level of the patient.

Purpose: This study was conducted to determine if these criteria used were effective in selecting our patients for surgery or conservative treatment.

Methods: We randomly selected 100 patients treated with at least 2 years follow up. The operatively and conservatively treated groups were compared based on the Tegner activity scale, the Lysholm-II1 score before and after treatment and the IKDC score after treatment. These scores were calculated using information from case notes, X Rays, patient questionnaires and outpatient clinic assessments.

Results: There were 42 patients treated conservatively and 58 treated by ACL reconstruction. The average age was 32 years for the operative group and 34 years for the conservative group.

We found no statistically significant difference between the Lysholm-11 scores and the IKDC scores between the two groups.

Conclusion: The criteria used to determine the management of our patients with acute ACL injuries is effective and as such we recommend its use.