Long bone fractures are a commonly presented paediatric injury. Whilst the possibility of either accidental or non-accidental aetiology ensures significant forensic relevance, there remain few clinical approaches that assist with this differential diagnosis. The aim of this current study was to generate a reproducible model of spiral fracture in immature bone, allowing investigation of the potential relationship between the rotational speed and the angle of the subsequent spiral fracture.

Seventy bovine metacarpal bones were harvested from 7 day old calves. Sharp dissection ensured removal of the soft tissue, whilst preserving the periosteum. The bones were then distributed evenly before eleven groups, before being aligned along their central axis within a torsional testing machine. Each group of bones were then tested to failure at a different rotational speed (0.5, 1, 15, 20, 30, 40, 45, 60, 75, 80 and 90 degrees s-1). The angle of spiral fracture, relative to the long axis, was then measured, whilst the fracture location, the extent of comminution and periosteal disruption, were all recorded.

Sixty-two out of 70 specimens failed in spiral fracture, with the remaining tests failing at the anchorage site. All bone fractures centred on the narrowest waist diameter, with 5 specimens (all tested at 90 degrees s-1) demonstrating comminution and periosteal disruption. The recorded spiral fracture angles ranged from 30 - 45 degrees, and were dependant on the rotational speed.

This study has established a relationship between the speed of rotation and the angle of spiral fracture in immature bovine bone. It is anticipated that further study will enable investigation of this trend in paediatric bone, ultimately providing an additional diagnostic tool for clinicians trying to verify the proposed mechanism of injury.

The purpose of this study was to determine the accuracy of MRI scan for the detection of meniscal pathology in our unit. There are published data which show that both sensitivity and specificity can approach 90% when compared to arthroscopic findings.

We retrospectively analysed a single surgeon series of 240 scopes for all indications The arthroscopic reports included an outline diagram of the meniscus upon which the surgeon recorded operative findings. 112 of these patients had also had recent MRI.

We looked at whether the MRI report showed a tear, and this was graded Y/N. The arthroscopic report was graded for tear: Y/N. 66 patients had a positive scan. 64 of these were found to have a tear at surgery. 37 scans were reported as “no tear”, of which 4 were found to have a tear at surgery. Nine scans were not easy to classify as they were descriptive.

In our series of 112 knees, MRI was 90.5% sensitive, 89.5% specific and 90.1% accurate.

When a definite diagnosis of “tear”, or “no tear” was made at scan, there were two false positives and four false negatives. False positives may be unnecessarily exposed to the risks of surgery. Patients with negative scans had a mean delay to surgery of 33 weeks compared to 18 weeks for patients with positive scans. False negatives may wait longer for their surgery. Two of the false negative scans clearly showed meniscus tears which were missed by the reporting radiographer. In our series the scan itself was more accurate than the reporting. It is important to have an experienced musculoskeletal radiologist to minimise the number of missed tears. It is also important for surgeon to check the scan as well as the report.

Frictional resistance to tendon gliding is minimised by surrounding loose areolar tissues. During periods of prolonged immobilisation, for example post tendon-repair, adhesions can form between the two adjacent tissues, thereby limiting function. Whilst agents applied during surgery are recognised to succeed in adhesion prevention, they have also been reported to provide some reduction in friction during in vitro tendon-bony pulley investigations. This study investigated the effectiveness of common anti-adhesion agents in lubricating the tendon-surrounding tissue contact by comparison with a control study. By using a validated apparatus and with reference to the Stribeck curve, it was determined that the natural in vivo contact is likely to be lubricated by a film of synovial-like fluid. Application of all anti-adhesives generated a similarly efficient lubricating system, and hence administration of these agents should be encouraged to all regions of the tendon disrupted during surgery. Minimising frictional resistance to gliding will reduce the likelihood of tendon ‘gapping’ - and subsequently failure - at the repair site.

Background

Many Accident and Emergency units employ a “one size fits all” policy with regard to referring patients with musculoskeletal injury for further review in fracture clinic. This may result in inappropriate timings of review in the clinic wasting patient time, clinic time and hospital resources.

Many of the questionnaire based scoring systems (i.e. Rowe score) require some form of clinical assessment. These clinical components can be very difficult to perform on a large scale particularly when a patient lives a long distance from clinic. We have attempted to counter this problem by asking the patient to asses their own range of motion. The aim of this study was to test the agreement between patient and clinician measured shoulder external rotation range using a photo based self-assessment tool.

Fifty-one professional and semi-professional rugby players were recruited to assess shoulder external rotation range. Each player was presented with a photo based shoulder external rotation range self-assessment tool, which featured four photos of progressive shoulder external rotation in 2 positions, 900 abduction (150, 300, 450 & 600 of external rotation) and 00 abduction (700, 800, 900 & 1000 of external rotation). The players were asked to perform active external rotation in these two positions and mark the image which best matched their maximal external rotation. The player was then independently assessed using the same tool, by a clinician.

The difference between the player's and the clinician's assessment was analysed using a weighted Kappa test. The Kappa for the shoulder external rotation in 900 abduction was 0.75 and 0.71 for left and right respectively, and 0.57 and 0.55 for shoulder external rotation in 00 abduction. Thus, the strength of agreement between the player's and clinician's assessment of shoulder external rotation is good in 900 abduction and moderate in 00 abduction.

These results demonstrate that the photo-based shoulder external rotation range self-assessment tool is a very useful addition to researchers' and clinicians' toolkits and may be most useful when a patient lives a great distance from/or is unable to attend a clinic.

Introduction

Brachial plexus blocks are used widely to provide intra-operative and post-operative analgesia. Their efficacy is well established, but little is known about discharging patients with a numb or weak arm. We need to quantify the risk of complications for improved informed consent.

Purpose: Historically, there have been few surgical options for patients with focal full-thickness cartilage lesions in the knee who have failed or are too advanced in age for biologic resurfacing treatments, yet are also relatively too young or unwilling to undergo conventional total or unicompartmental knee arthroplasty. The UniCAp knee resurfacing arthroplasty provides an option for these patients that is minimally invasive, preserves the menisci and cruciate ligaments, and retains the bony architecture of the knee joint, thereby providing the potential for a rapid recovery to more vigorous activities than might be permitted after conventional knee arthroplasty, while preserving range of motion. The objective of this study was to examine the clinical results of a patient cohort undergoing the UniCAP knee resurfacing in the medial compartment of the knee.

Method: Prospective patients were screened with history and clinical examination, weight-bearing radiographs, and MRI. Patients were offered UniCap knee resurfacing arthroplasty if they had symptomatic full-thickness cartilage lesions in the medial and/or patellofemoral compartments. The cohort included 38 cases in 35 patients who underwent the UniCAP knee resurfacing procedure in the knee with focal medial compartment (with or without patellofemoral) osteoarthritis in the knee joint. In addition, patients were assessed with validated and established outcome scales including the International Knee Documentation Committee Subjective Form, the Knee Injury and Osteoarthritis Outcome Scale, which includes the WOMAC Osteoarthritis Index.

Results: The average age of patients undergoing knee resurfacing was 48.25 years (Range: 23 to 80). There were 24 males and 12 females. Thirty-one patients underwent isolated medial compartment resurfacing and 7 patients received both a medial compartment resurfacing and trochlear resurfacing. Three patients underwent a concomitant ACL reconstruction and 1 patient underwent a concomitant high tibial osteotomy. The mean duration of follow up was 18 months (Range: 12 to 26 months). There was an overall mean improvement from the pre-operative to post-operative scores in the IKDS-SF (P < 0.01), KOOS (all domains, P < 0.01) and WOMAC Index (P < 0.01). There were no major complications such as deep infection, DVT, or implant failure. In addition, there was no evidence of mechanical symptoms/signs or radiographic evidence of loosening at any time point post-operatively.

Conclusion: The short-term results demonstrate that the UniCAP resurfacing arthroplasty in the knee is a viable treatment option for focal full thickness cartilage lesions in the medial compartment of the knee in patients who are no longer candidates for biologic resurfacing procedures and who are also relatively too young or unwilling to undergo conventional total or unicompartmental knee arthroplasty.

Purpose: We hypothesized that glenohumeral joint stability will decrease with increasingly larger humeral head defects.

Method: Humeral head defects were created in 9 cadaveric shoulders to simulate Hill Sachs defects. Defects represented 1/8, 3/8, 5/8, and 7/8 of the radius of the humeral head. Secondary factors included abduction angles of 45 degrees and 90 degrees, and rotations of 40 degrees internal, neutral, and 40 degrees external. Specimens were tested at each defect size sequentially from smallest to largest and at each of 6 conditions for all abduction and rotation combinations. Using a 6 degree-of-freedom robot, the humeral head was translated at 0.5 mm per second until dislocation in the anteroinferior direction at 45 degrees to the horizontal glenoid axis.

Results: ANOVA demonstrated significant factors of rotation (p< 0.001) and defect size (p< 0.001). In 40 degrees external rotation, there was significant reduction of distance to dislocation compared with neutral and 40 degrees internal rotation (p< 0.001). The 5/8 and 7/8 radius osteotomies demonstrated decreased distance to dislocation compared to the intact state (p< 0.05 and p< 0.001 respectively). There was no difference found between abduction angles. Post hoc analysis determined significant differences for each arm position. There was decreased distance to dislocation at the 5/8 radius osteotomy at 40 degrees external rotation with 90 degrees of abduction (p< 0.05). For the 7/8 radius osteotomy at 90 degrees abduction, there was decrease distance to dislocation for neutral and 40 degrees external rotation (p< 0.001). For the same osteotomy at 45 degrees abduction, there was decreased distance to dislocation at 40 degrees external rotation (p< 0.001). With the humerus internally rotated, there was never a significant change in the distance to dislocation.

Conclusion: Glenohumeral stability decreases at a 5/8 radius defect and was most pronounced in 40 degrees external rotation and at 90 degrees abduction. At a 7/8 radius humeral defect, there was further decrease in stability at both neutral and external rotation. Internal rotation always maintained baseline glenohumeral stability.

Background: Thumb carpalmetacarpal joint (CMCJ) osteoarthritis has been treated using various combinations of resection, interposition and replacement arthroplasties. The procedure of choice for various stages of CMCJ osteoarthritis remains controversial. This study compares the short term outcomes of trapeziectomy alone and trapeziectomy with PI2 implantation.

Methods: A cross-sectional observational study involving 33 patients (36 thumbs). 18 thumbs had trapeziectomy alone and 18 had trapeziectomy and PI2 implantation. Underlying indication was osteoarthritis in 35 thumbs and trauma in one thumb. Preoperative radiological assessment using the Eaton and Glickel grading for CMCJ osteoarthritis and clinical review including DASH and SF-36 score was performed at a mean follow-up of 18 months. Preoperative and postoperative pain level was assessed using Visual Analogue Scale (VAS) and satisfaction of the surgery using the Likert 5-point scale.

Results: There were 30 women and 3 men. The average age at follow up was 61 years (range 45 to 75). There was no significant difference between the two groups regarding age, duration of symptoms, and stage of disease, preoperative pain score and handedness. The mean DASH score at follow up was 26.8 for trapeziectomy alone group and 35.4 for the PI2 arthroplasty group. Preoperative to postoperative VAS for pain showed an improvement from fair to excellent in 60% of patients in trapeziectomy alone group and 30% of the patients in the PI2 arthroplasty group. There was no significant difference in the SF-36 scores between the two groups in all health domains. 6 out of 16(38 %) patients in the PI2 group had multiple surgeries mainly due to dislocation or subluxation of the implant. The overall Likert 5-point scale scores were highest for trapeziectomy alone group with 70% very satisfied compared to 40% in the PI2 arthroplasty group.

Conclusion: The early results of pyrocarbon PI2 arthroplasty show a high complication rate compared to simple trapeziectomy. The high rates of subluxation and dislocation observed in the early cohort resulting in multiple surgeries may be attributed to steep learning curve of the surgical technique and creation of a shallow groove for the implant. This may have contributed to the low satisfaction levels observed in PI2 arthroplasty group. Simple trapeziectomy provides satisfactory outcome in more than 80% of the patients.

Introduction: Templating of radiographs is part of pre-operative planning in Total Hip Replacement (THR). Digital radiograph technology allows the manipulation of images, altering magnification and therefore affecting accuracy and reproducibility in templating. We have performed a study to investigate templating for hybrid total hip arthroplasty comparing digital hard copies with three computer methods to scale for magnification, in order to assess whether on-screen images can be templated directly with existing acetate templates.

Methods: 20 patients undergoing hybrid THR had pre-operative radiographs taken with a 10 pence coin attached to the skin overlying their greater trochanter. On-screen computer images were manipulated using either the 10p coin as a marker to scale for magnification, or two digital line methods using computer software against external ruler scales. Templating were performed for acetabular size, femoral offset, stem offset and stem size by three grades of observer, and the on-screen images were compared with hard copy digital prints. Intraclass Correlation (ICC) analyses were performed to assess intra-observer and inter-observer variability for the four methods. Comparisons were also made between templated results and the sizes of the inserted prostheses.

Results: All methods showed good reproducibility with all ICC values for intra-observer variability greater than 0.7. Inter-observer variability was less consistent, and the two digital line methods were the least reliable, with accuracy of sizing compared with the inserted prostheses varying between −1.6% to +10.2%. The hard copy radiographs showed better reproducibility than the 10p method, but less accuracy with 3.7% under-sizing. The 10p method was most accurate, with no significant differences for offset or acetabulum compared with the inserted prostheses, and templated under-sizing of only 0.9%.

Discussion: On-screen templating of digital radiographs with standard acetate templates is accurate and reproducible if a radio-opaque marker such as a 10p coin is included when taking the original radiograph.

Aims: Palacos cement is one of the commonest types of bone cements used in joint replacement surgery. It contains peanut oil which is used as a diluent for Chlorophyll to give the green colour. The manufacturer’s instruction states that it is a contra-indication to use Palacos cement in patients allergic to peanut. The aim of our study was to check the awareness among the orthopaedic surgeons of this contra-indication and find their views on using Palacos cement in patients allergic to peanuts.

Methods: We conducted a postal questionnaire survey among all the orthopaedic surgeons and trainees in Wales, enquiring about their prior knowledge of the contra-indication and their views on what should be done if the patient undergoing arthroplasty has peanut allergy.

Results: There was a response rate of 71%. Only 20% of the consultants and only 40% of the trainees were aware of the contraindication. There were widely conflicting views on what should be done if the patient has peanut allergy. Those views included using different cement, using uncemented implant, seeking second opinion and some suggested they would still continue to use Palacos cement despite history of peanut allergy.

Conclusions: Majority of the orthopaedic surgeons in our study were not aware of the contraindication. This is surprising as peanut allergy could be life threatening. But we are unaware of any reported case of allergic reaction in peanut allergic patients. Review of the literature also suggests that as the peanut oil in Palacos cement is highly refined peanut oil, it is very unlikely to produce allergic reaction in peanut allergic patients. There is no evidence-based reason to support the manufacturer’s advice that Palacos cement should not be used in patients allergic to peanuts.

Condensing osteitis of the clavicle was first described as a disease entity in 1974. There is painful localised swelling of the clavicle of undetermined origin, with increased radio-density, but an infective aetiology has not been excluded by previous authors. We report three children with the clinical and radiological findings of 'condensing osteitis'. Two of them had raised levels of antistaphylolysin titres and all responded to antibiotic therapy. We conclude that condensing osteitis is due to low-grade staphylococcal osteomyelitis; biopsy and treatment by antibiotics is recommended.

There is a high incidence of spinal deformity in children with the Prader-Willi syndrome. We have encountered major complications following spinal surgery in this condition. We report our experience and conclude that spinal surgery is a formidable undertaking and the risks should be appreciated by the surgeon and the parents.

We examined the structure of the digital flexor sheath by dissection and histology. The inner aspect of the sheath was found not to be a continuous smooth surface, as depicted in anatomical and surgical texts. The thin parts of the sheath often overlapped the pulleys before attaching to their superficial aspects, so that the pulleys possessed free edges within the sheath. The frequency of occurrence and sizes of these overlaps were studied in 48 cadaveric fingers; the largest and most frequent overlap was at the distal end of the A2 pulley. Functional studies showed an intricate mechanism of pulley approximation and sheath bulging during flexion. Sutured or partly cut tendons triggered on the free edges; this could be a major contributor to the failures of tendon repairs in "no man's land".

Thirty-nine patients with neuralgic amyotrophy were reviewed. In addition to the clinical findings reported in the neurological literature, we commonly found pain throughout the upper limb, and diffuse involvement of the brachial plexus. Five patients had spinal accessory nerve lesions and five had glenohumeral instability. Sixty-four per cent of the patients had had an orthopaedic consultation during their acute illness. It is therefore important that orthopaedic surgeons are aware of this clinical syndrome and its management. The prognosis is excellent with non-invasive treatment.