This study used a national registry to assess the outcomes of hip arthroscopy (HA) for the treatment femoroacetabular impingement (FAI).

All HAs for FAI recorded in the UK Non-Arthroplasty Hip Registry (NAHR) between January 2012 and September 2023 were identified. Cases were grouped according to the index procedure performed for FAI (cam, pincer, or mixed). Patient outcomes captured included the International Hip Outcome Tool (iHOT)-12.

7,511 HAs were identified; 4,583 cam (61%), 675 pincer (9%), 2,253 mixed (30%). Mean age (34.8) was similar between groups. There was a greater proportion of females in the pincer group (75%) compared to cam (52%) and mixed (50%). A higher proportion of patients had a recorded cartilage injury in association with a cam lesion compared to pincer. The pincer group had poorer mean pre-op iHOT-12 scores (31.6 \[95%CI 29.9 to 33.3\]; n=364) compared to cam (33.7 \[95%CI 32.1 to 34.4\]; n=3,941) and achieved significantly lower scores at 12 months (pincer = 52.6 (50.2 to 55); n=249, cam = 58.3 (57.1 to 59.5); n=1,679).

Overall, significant (p < 0.0001) iHOT-12 and EQ-5D improvement vs baseline pre-operative scores were achieved for all FAI subtypes at 6 months (overall mean iHOT-12 improvement +26.0 \[95%CI 25.0 to 26.9\]; n=2,983) and maintained out to 12 months (+26.2 \[25.1 to 27.2\]; n=2,760) at which point 67% and 48% of patients continued to demonstrate a score improvement greater than or equal to the minimum clinically important difference (>/=13 points) and substantial clinical benefit (>/=28 points) for iHOT-12 respectively.

This study demonstrates excellent early functional outcomes following HA undertaken for FAI in a large national registry.

Aims

Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures.

Abstract

Optimal acetabular component position in Total Hip Arthroplasty is vital for avoiding complications such as dislocation and impingement, Transverse acetabular ligament (TAL) have been shown to be a reliable landmark to guide optimum acetabular cup position. Reports of iliopsoas impingement caused by acetabular components exist. The Psoas fossa (PF) is not a well-regarded landmark for Component positioning. Our aim was to assess the relationship of the TAL and PF in relation to Acetabular Component positioning.

A total of 22 cadavers were implanted on 4 occasions with the an uncemented acetabular component. Measurements were taken between the inner edge of TAL and the base of the acetabular component and the distance between the lower end of the PF and the most medial end of TAL.

The distance between the edge of the acetabular component and TAL was a mean of 1.6cm (range 1.4–18cm). The distance between the medial end of TAL and the lowest part of PF was a mean of 1.cm (range 1,3–1.8cm) It was evident that the edge of PF was not aligned with TAL.

Optimal acetabular component position is vital to the longevity and outcome following THA. TAL provides a landmark to guide acetabular component position. However we feel the PF is a better landmark to allow appropriate positioning of the acetabular component inside edge of the acetabulum inside the bone without exposure of the component rim and thus preventing iliopsoas impingement at the psoas notch and resultant groin pain.

Advanced osteoarthritis of knee is associated with low-backache in a significant number of patients and adversely affects the quality of life. There is a paucity of literature describing outcomes of backache after total-knee-arthroplasty (TKA).

We evaluated backache in patients of advanced knee-osteoarthritis and their functional and radiological outcomes after TKA after approval from Institutional ethics committee.

Fifty-nine patients (40 females and 19 males) were included. Mean body-mass index was 28.7. Mean visual analogue score (VAS) for knee-pain was 7.98 preoperatively and 1.6 in follow-up. For chronic backache, the mean VAS score improved from 6.08 to 2.4, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) improved from 67.5 to 37.8, Knee society score (KSS) from 49.8 to 76.6, Oswestry Disability Index (ODI) Score from 55.44 to 34.65 and SF-36 Quality-of-life score from 44.95 to 74.63. There was a significant correlation between in knee and low-back functional scores. Magnetic resonance imaging-based scoring of degenerative changes (Pfirrmann grading) showed improvement only in 13.5% patients; 56% showed no change and 30.5% showed deterioration of scores.

Chronic low backache is a significant co-morbidity in advanced knee-osteoarthritis. TKA has the potential to relieve backache along with knee-pain and improves quality of life.

Trauma & Orthopaedic Department, Bronglais Hospital & Hywel Dda University Health Board, Aberystwyth, UK

Auto-CAD study is done to observe the effects of head neck ratio (HNR) in joint replacements. Total hip replacement joints were reconstructed on CAD with increasing diameter of the head keeping neck diameter constant in 1997. Simulation was done and Range of Movement (ROM), impingement and stability of the hip joint was noted. A graph was plotted with HNR on X-axis and ROM on Y-axis. It was observed that as the HNR increases the ROM of the joint is increased, impingement is reduced and stability is also increased. It is also observed that diameter of the head and neck is more important than considering only head diameter of the hip joint. The graphical analysis confirms that different diameters of the head may have same HNR depending on the neck diameter. So even in smaller diameter head the HNR may be more due to smaller diameter neck and may be more advantages than larger diameter head with bigger neck having smaller HNR. We conclude that HNR is more important than the head diameter alone in hip replacements.

Auto-CAD study is done to observe effects of head neck ratio (HNR) in hip replacements.

Total hip replacement joints were reconstructed on CAD with increasing diameter of the head keeping neck diameter constant in 1997. Simulation was done and Range of Movement (ROM), impingement and stability of the hip joint was noted. A graph was plotted with Head Neck Ratio (HNR) on X-axis and ROM on Y-axis. It was observed that as the HNR increases the ROM of the joint is increased, impingement is reduced and stability is also increased. It is also observed that diameter of the head and neck is more important than considering only head diameter of the hip joint. The graphical analysis confirms that different diameters of the head may have same HNR depending on the neck diameter. So even in smaller diameter head the HNR may be more due to smaller diameter neck and may be more advantages than larger diameter head with bigger neck having smaller HNR.

We conclude that HNR is more important than the head diameter alone in hip replacements.

Tunning fork lines (TFL) were drawn on ankle anterior-posterior radiographs to assess the talar shift in ankle fractures.

A 3-D ankle joint reconstruction was prepared by mapping normal ankle joint using auto CAD in 1997. TFL were drawn using normal anatomical landmarks on saggital, coronal and transverse planes. The ankle joint anatomical relationship with talus was studied in various rotation simulating radiographic anterior-posterior views and talar shift was studied. Between 2006 and 2012 on antero-posterior view of ankle radiographs and PACS, TFL were drawn. The premise is that in a normal radiograph the superior-lateral dome of the talus lies medial to the handle of TFL, and in ankle with talar shift the dome of the talus would cross this line laterally. In two district hospitals 100 radiographs were observed by 4 observers in 67 males and 33 females with mean age of 49 (15–82) years. The TFL confirmed talar shift with sensitivity of 99.2 % showing talarshift and inferior tibio-fibular ankle diastasis.

We conclude that in ankle anterio-posterior view it is possible to comment on the talar shift and diastasis of the ankle joint, even if proper ankle mortise views were not available.

The PFNA is used routinely at the RUH for unstable peri-trochanteric and femoral fractures. Failure of operative treatment is associated with increased morbidity and financial burden. We analysed surgical and fracture factors, aiming to identify those associated with fixation failure.

Retrospective analysis of 76 consecutive patients treated with a PFNA between 2009–2012 was performed. Patient demographics were assessed, along with fracture classification, adequacy of reduction, tip apex distance (TAD) and grade of surgeon. Failure was defined as metal work failure, non-union or need for repeat procedure.

The mean age was 78.9 years (25.9–97.4). 21 were male and 49 female. There were 17 failures (24.3%) (7 required further surgery). 10 failures were per-trochanteric, 2 sub-trochanteric and 5 mid-shaft fractures. Complications included 4 broken and 6 backed-out distal locking screws, 2 blade cut-outs, 1 nail fracture and 4 non-unions. All per-trochanteric were adequately reduced with a TAD <25 mm. 11/17 had consultant supervision.

A high rate of backed-out distal locking screws was identified. We found no concerns with adequacy of reduction, TAD or consultant supervision.

This study assesses the incidence of noise in ceramic on ceramic (COC) bearings compared to metal on polyethylene (MOP) bearings. Noise after MOP implants has rarely been studied and they never been linked to squeaking.

We have developed a noise characterising hip questionnaire and sent it along with the Oxford Hip Score (OHS) to 1000 patients; 509 respondents, 282 COC and 227 MOP; median age 63.7 (range 45–92), median follow up 2.9 years (range 6–156 months).

47 (17%) of the COC patients reported noise compared to 19 (8%) of the MOP patients (P=0.048). 9 COC and 4 MOP patients reported their hip noise as squeaking. We found the incidence of squeaking in the COC hips to be 3.2% compared to 1.8% in the MOP hips. Overall, 27% patients with noise reported avoiding recreational activities because of it and patient's with noisy hips scored on average 4 points less in the OHS (COC: P=0.04 and MOP: P =0.007).

This is the first study to report squeaking from MOP hip replacements. We therefore believe the squeaking hip phenomenon is not exclusive to hard bearings. Surprisingly, only a small proportion of patients described nose from their as a ‘squeak’. Noisy hip implants may have social implications, and patients should be aware of this. We have shown a relationship between noise and a lower OHS. However, longer follow-up and further study is needed to link noise to a poorly functioning implant.

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. Its effect on sesamoid function and the pathomechanics of this joint have not been described.

Fresh frozen cadaveric specimens without evidence of forefoot deformity were dissected to assess the articulating surfaces throughout a normal range of motion. The dissections were digitally reconstructed in various positions of dorsiflexion and plantarflexion using a MicroScribe, enabling quantitative analyses in a virtual 3D environment.

In 75% of specimens, there was some degree of chondral loss within the metatarsosesamoid articulation. The metatarsal surface was more commonly affected. These changes most frequently involved the tibial metatarsosesamoid joint.

The tibial sesamoid had an average excursion of 14.2 mm in the sagittal plane when the 1st MTP joint was moved from 10 degrees of plantarflexion to 60 degrees of dorsiflexion; the average excursion of the fibular sesamoid was 8.7 mm. The sesamoids also move in a medial to lateral fashion when the joint was dorsiflexed. The excursion of the tibial sesamoid was 2.8 mm when the joint was maximally dorsiflexed while that of the fibular sesamoid was 3.2 mm.

There appears to be differential tracking of the hallucal sesamoids. The tibial sesamoid has comparatively increased longitudinal excursion whilst the fibular sesamoid has comparatively greater lateral excursion.

This greater excursion of the tibial sesamoid could explain the higher incidence of sesamoiditis in this bone. The differential excursion of the 2 metatarsosesamoid articulations is also a factor that should be considered in the design and mechanics of an effective hallux MTP joint arthroplasty.

The aim of this study was to characterise noise associated with ceramic-on-ceramic total hip arthroplasty (THA).

A questionnaire was constructed to assess noise associated with THA. 116 patients responded. All had ceramic-on-ceramic hybrid THA at Glasgow Royal Infirmary between 2005 and 2007 using a Trident prosthesis and Exeter stem. Oxford Hip Questionnaires (OHS) were also completed by the patients.

16.4% of respondents reported noise associated with their ceramic hip. The vast majority reported onset at least 1 year after implantation. The most common noise types were ‘clicking’ (47%) or ‘grinding’ (42%), while ‘squeaking’ was least frequently reported (11%). Noise was most commonly brought on by bending and during sit to stand movements.

No correlation was identified between the incidence of noise and any patient specific factor or demographic variable. The mean OHS at questionnaire follow-up was 39 and there was no significant difference in OHS when comparing noisy and silent hips (p=0.65). Only 1 patient limited social or recreational activities and overall patients felt the noise had minimal effect on their quality of life.

Acetabular component inclination angles were compared on post-operative x-rays. There was no significant difference (p=0.51) in inclination angles of the noisy (47.1°±6.3°, range 30–57°) and silent hips (47.8°±6.1°, range 35–68°). The groups were further analysed for deviation out with the desirable inclination range of 40–45°. Of the noisy hips, a total of 73% were out with this range compared to 63% in the silent hip group.

The incidence of noise within this ceramic-on-ceramic THA group did not appear to be related to patient specific factors, patient reported outcome (OHS) or acetabular inclination angles. Subjective appraisal of the noise revealed that ‘squeaking’ was not common but patients tended to report ‘clicking’ and ‘grinding’ more. The precipitation of noise with bending activities reinforces a possible mechanical cause.

In fractures electrical currents generated by piezoelectric and junctional diode effects initiate and augment healing. Conductive fixators may interfere with these currents causing delayed/nonunion which can be avoided by non conductive fixators, facilitating osteosynthesis. Null hypothesis of no difference and two tailed alternate hypothesis of any could be better was used. Impugn change in Electrical properties for demarcating union rate.

Patients of Gustillo's grade I and II tibia fractures were randomised in conductive and non conductive fixator groups in a blinded manner. Electrical and clinico-radiological properties were compared every two weeks for 20 weeks, recoding magnitude and significant difference. Capacitance(p=0.03), Impedance(p=0.002), Inductance(p=0.01) and Reactance(p=0.02) are the electrical parameters which not only demarcated union rate but orchestrated diagnosis of fracture healing. In Non-conducting group, after removal of fixator at week 10, Local Tenderness was consistently absent, Rust Score was higher at week 18 and 20(p=0.01), absence of abnormal mobility was 58% higher and 100% at week 12(p < 0.05), Presence of weight bearing was higher from week 16(OR=15, p=0.03), presence of transmitted movement was 2.4 times higher at week 10(95% CI=0.17–34.93, p=0.52) and was 100% at week 14.

Fractures heal at a faster rate if fixed by insulated non-conducting external fixators. Electrical parameters can be used to demarcate and monitor fracture healing.

Introduction

Microdiscectomies and microdecompressions are traditionally defined as procedures performed with a small incision using magnification. There are no studies in the literature comparing the magnification techniques used in these operations. We compared magnifying loupes and microscopes as the senior author was trained with both instruments and was equally comfortable using both.

Introduction

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. The movements of the sesamoids in relation to the metatarsal plays a key role in the function of the first MTP joint. Although the disorders affecting the sesamoids are described well, the movements of the metatarsosesamoid joints and the pathomechanics of these joints have not been described. We have performed a cadaver study detailing and quantifying the three dimensional movements occurring at these joints.

Introduction

A prospective study was done using Kirschner (K) wires to internally fix capitellum fractures and its results were analysed.

INTRODUCTION

There is historical evidence of increased incidence of transitional cell tumours of the renal tract in workers exposed to high levels of metal ions. This study was designed to establish any correlation between Metal on metal bearing hip arthroplasty and TCC.

Purpose

Handgrip dynamometry has previously been used to detect pre - operative malnutrition and predict the likelihood of post - operative complications. This study explored whether a relationship exists between pre-operative pinch and power grip strength and length of hospital stay in patients undergoing hip and knee arthroplasty. We investigated whether handgrip dynamometry could be used pre - operatively to identify patients at greater risk of longer inpatient stays.

Tunning fork lines (TFL) were drawn on ankle anterior-posterior radiograph to assess the talar shift.

A 3-D ankle joint reconstruction was prepared by mapping normal ankle joint using auto CAD in 1997. Tunning fork lines were drawn using normal anatomical landmarks on saggital, coronal and transverse planes. The ankle joint anatomical relationship with talus was studied in various rotation simulating radiographic anterior-posterior views and talar shift was studied.

Between 2006 and 2012 on antero-posterior view of ankle radiographs and PACS, ‘Tunning Fork Lines’ (TFL) were drawn. The superior two vertical lines of the TFL were drawn above the ankle joint perpendicular to the distal tibial articular surface. First line tangent to anterior lip of the inferior tibio-fibular joint and second line tangent to the posterior lip of the inferior tibio-fibular joint parallel to each other. The horizontal third line was drawn parallel to distal tibial articular surface perpendicular to first two lines connecting them. The fourth line (handle of the tunning fork) was drawn vertically below the ankle joint midway between the first two lines perpendicular to the third line. In a normal radiograph the superior-lateral dome of the talus lies medial to the handle of TFL, and in ankle with talar shift the dome of the talus crosses this line laterally. In two district hospitals 100 radiographs were observed by 4 observers in 67 males and 33 females with mean age of 49 (15–82) years. The TFL confirmed talar shift with sensitivity of 99.2 % showing talarshift and inferior tibio-fibular ankle diastasis.

We conclude that in ankle anterio-posterior view it is possible to comment on the talar shift and diastasis of the ankle joint if proper ankle mortise view is not available.

Introduction

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. The movements of the sesamoids in relation to the metatarsal plays a key role in the function of the first MTP joint. Although the disorders affecting the sesamoids are described well, the movements of the metatarsosesamoid joints and the pathomechanics of these joints have not been described. We have performed a cadaver study detailing and quantifying the three dimensional movements occurring at these joints.

The early surgical management of the anterior cruciate ligament (ACL) tears in children remains controversial. The argument for nonoperative treatment is driven by concerns about the risk of growth arrest caused by a transphyseal procedure. On the other hand, early surgical reconstruction is favoured because of poor compliance with conservative treatment and increased risk of secondary damage due to instability. This paper reports a series of 39 very young children who had an ACL reconstruction using a transphyseal procedure with a hamstring graft. Patients were followed to skeletal maturity or for a minimum of three years. Only those patients with either a chronological age less than 14 years or with a Tanner stage of 1 and 2 of puberty were included in the study. Thirty children were Tanner 1 or 2 and nine were Tanner 3-4 but were younger than 14. The mean age at operation was 12.2 years (Range 9.5-14.2, Median 12.4). The mean follow up was 60.7 months (range 36-129, median: 51) months. Thirty four patients had attained skeletal maturity at the last follow up. The mean Lysholm score improved from 72.4 pre-operatively to 95.86 postoperatively (p<0.0001). The mean Tegner activity scale was 4.23 after injury and it improved to 7.52 after operation (p<0.0001)) which was a reasonable comparison to the pre- injury score of 8.0. One patient had a mild valgus deformity with no functional disturbance. No other growth related abnormalities including limb length discrepancy were noted. There has been one re-rupture but all others had good or excellent outcome. This is one of the largest series reporting the long term results of ACL reconstruction in very young children. Most other studies include children up to the age of 16. Based on our results we can conclude that transphyseal ACL reconstruction modified for very young patients is a safe procedure.

Background

Talar neck fractures occur infrequently and are associated with high complication rates. Anatomical restoration of articular congruity is important. Adequate exposure and stable internal fixation of these fractures are challenging.

To assess whether Patients who are clinically Obese are more likely to require further or revision Surgery following One-Level simple Microdiscectomy compared to Non-obese Patients.

Retrospective, single centre and single Surgeon review of Patients' Clinical notes of consecutive Patients who underwent primary One-Level Microdiscectomy between December 2007 and July 2009.

Background: Obesity in Surgery has become a topical subject given the increasing proportion of Surgical Patients being Obese. This study provides the largest single centre and single Surgeon comparative cohort.

All Patients had undergone One-level simple Primary Microdiscectomy Surgery. Data from the Clinical notes included Patient Demographics, level and side of operation, Length of stay and Re-Operation details. A total number of 71 Patients were eligible for inclusion of which 38 were Female and 33 Male with an average age of 41 years. 25 Patients were Clinically Obese (35%). Average LOS was 1.1 days. 8% of the clinically Obese Patients required further Surgery compared to 8.7% in the Non-obese group.

Revision surgery for recurrent discs and Surgery for dural tear repair were the main reasons for return to theatre. Revision rates were comparable between the two Patient groups. LOS was no different for Obese Patients. This study concludes that Obese Patients undergoing One-Level simple Microdiscectomy do not face a significantly higher risk of requiring Revision Surgery in the future.

Introduction: Tarsometatarsal joint (TMTJ) arthrodesis is traditionally performed through a dorsal approach and is associated with higher incidence of cutaneous nerve damage, prominent metalware and high non-union rates. It is postulated that applying fixation to the plantar (tension) side, rather than the dorsal (compression) side would create a more stable construct with higher union rates. A suitable surgical approach has not previously been described. The aim of this study is to define a plantar surgical approach to the TMTJ’s.

Methods: We dissected 10 cadaveric feet, identifying nerves, vessels, muscles and their innervation on the plantar aspect of the 1st and 2nd TMTJ’s.

Results: We found that in all specimens a plane of dissection could be created between the two terminal divisions of the medial plantar nerve between flexor digitorum brevis and abductor hallucis. Although exposure of the 1st TMTJ was relatively easy, access to the 2nd TMTJ was difficult due to its location at the apex of the transverse metatarsal arch and the overlying peroneus longus insertion. We found that the peroneus longus tendon had a variable insertion not only at the base of the 1st metatarsal but also at the medial cuneiform and the base of the 2nd metatarsal.

Discussion: This is a new surgical approach, following an internervous dissection plane. The feasibility of making an incision over the convex side of the rocker bottom deformity and the biomechanical advantage of a plantarly applied fixation device may make this an attractive surgical approach.

Background: The Calcaneus is the largest of the tarsal bones. 2% of all adult and 60 % of all tarsal fractures involve the Calcaneus. A true consensus regarding the management of these fractures still eludes orthopaedic surgeons. While operative treatment for displaced fractures has gained more acceptance in the last decade, surgical morbidity still remains high.

Aim: A retrospective review of the early complications and radiological outcomes following open reduction and internal fixation of displaced calcaneal fractures in our unit over the last 15 months.

Methods: A consecutive series of 33 patients who underwent surgical fixation of the Calcaneus was selected. Patient records, X rays and scans were reviewed. Mode and nature of injury, life style factors, surgical complications and Bohler’s angles were analysed.

Results: 37 fractures in 33 patients underwent operative fixation. 81 % were male. Mean age at surgery was 37yrs (range19–59). 35 % were operated within 1 week of the injury and 13% after 2 weeks of injury. 43% were Sanders’ type III, 18% type II and 13% tuberosity avulsion fractures. 63% of patients had a reversed or zero Bohler’s angle. Mean post-op Bohler’s angle was 32 degrees. Overall complication rate was 32%, with a combined deep infection rate of 8%. All patients with infection were male, and 70% were smokers. 86% were above 40yrs of age (mean 47yrs). The deep infection rate for intra-articular fractures was 3% and for tuberosity avulsion fractures 40%. Majority of patients with wound complications had been operated within 7 days of injury. 4 patients had persisting pain requiring removal of metal work.

Discussion: Our study highlights that there are significant risks associated with operative management of calcaneal fractures. Male patients over the age of 40yrs who are smokers seem to be at most risk of wound complications. Time to surgery or delay in surgery up to 2 weeks did not seem to have any adverse consequences. Complications increase with fracture complexity, and avulsion fractures have a high risk of wound breakdown. Near anatomical restoration of the articular surface is possible in most cases.

Surgeon’s ability to anticipate the implant size requirements for total knee replacements is important to the success of the procedure. Previously, this has been inconsistently accomplished using plain radiographs. The purpose of this study is to assess the accuracy of digital templating software in predicting the size requirements of the femoral and tibial implants in total knee replacements.

Thirty consecutive PFC (DePuy) total knee replacements were templated preoperatively using digital templating software (TraumaCad, Orthocrat Ltd). The knees were templated by two surgeons working independently using standardised digital AP and lateral radiographs. All films were magnification-calibrated using markers of known size. Postoperatively, the predicted implant size was compared to the actual components selected at the time of surgery.

The size of the femoral prosthesis was accurately selected on the AP view in 53.5% and on the lateral in 66% of cases. The size of the tibial implant was correctly selected on the AP view in 65.5% and on the lateral in 70.5% of cases. The tibial prosthesis was always templated within one size. The femoral prosthesis was predicted within two sizes (93% on AP + 98% on lateral +/− 1 size). There was no correlation with failure of the software to recognise the metal marker and inadequate lateral x-rays.

The lateral x-ray was found to be more reliable than the AP on predicting both the femoral and tibial implants. The tibia was more accurately templated than the femur on average. There was good inter-observer and intra-observer reliability for both prostheses (0.75 – 0.85). Discrepancies in templating may have been due to inaccuracies in placement of the metal marker at the time of x-raying or due to fixed flexion deformities, which may have affected the magnification of the x-ray. Overall, templating using digital software was marginally superior to the standard acetate method.

The European Working Time Directive is a directive from the Council of Europe to protect the health and safety of workers in the European Union. The working time directive currently ensures a 56 working hour week and by August 2009 a 48 hour maximum working week. To accommodate such a reduction in working hours, the on call rotas for institutions have had to change. Has this had an affect on trauma exposure for current specialist registrars?

Materials and Methods: Data collection was from electronic logbooks of orthopaedic specialist registrars and locum appointment trainees on the Southwest Thames rotation. From the elogbooks indexed trauma procedures were audited, this included: dynamic hip screw, hemiarthroplasty, open reduction and internal fixation ankle, intramedullary nail femur, intramedullary nail tibia, and intramedullary nail humerus. The data was divided into year groups and then the data was subdivided into on call rotas. Obtained from the data collection was the number of indexed linked operations carried out per 6 months per year group.

Results: The data collection was over an 18 month period October 2006 – April 2008. The total number of trainee logbooks who had the complete data from the logbook available was 90. The number of trainees for each year = n, the total number of operations =x and mean number of operations for each year of training =μ. The results for year groups are as follows:Year 1 n=18, x=4897, μ= 272:Year 2 n=12, x=2853, μ= 238: Year 3 n=22, x=4106, μ= 187:Year 4 n=19, x=3176, μ= 167:Year 5 n=4, x=658, μ=165:Year 6 n=15, x=3249, μ=217.Data for on call rotas were subdivided into the following groups: 1in13, 1in9, 1in8 and 1in7. The number of trainees for each on type of on call rota =n, the total number of operations = x, the mean number of operations for each on call rota group = μ.The results were as follows:1in13 on call: n=12, x=2215, μ=185; 1in9 on call: n=11, x=3195, μ=290

1in8 on call: n=20, x=3754, μ=188; 1in7 on call: n=47, x=9775, μ=208

The results for the number of indexed linked operations carried out per 6 months per year group are as follows:YEAR 1 257.73:YEAR 2 228.24:YEAR 3 173.49: YEAR 4 173.23:YEAR 5 164.50: YEAR 6 208.49

Conclusion: The results show that year groups 1, 2 and 6 have carried out the highest number of procedures. The data also shows that trainees on the lowest frequency of on call rota call have the lowest number of indexed operations. The results for the number of indexed linked operations carried out per 6 months per year group shows that as the year groups progress the number of procedures carried out continues to decrease from year 1 to 5 and then increases again at year 6. The structure of orthopaedic training is being overhauled. The need for effective training has intensified. This audit aims to demonstrate some of the effects of the changes made in higher speciality training in orthopaedics.

Background: Calcaneal osteotomy is performed commonly as an adjunct to many corrective procedures of the abnormal hindfoot. Preservation of the hindfoot joints restores the normal biomechanics and can potentially delay arthritic changes in adjacent joints. Calcaneal osteotomy improves the weight bearing alignment of the foot by reducing varus or valgus deformity without impairing subtalar or mid-tarsal joint function. We are unaware of any studies documenting the complication rates associated with this procedure.

Methods: 36 calcaneal osteotomies (medial and lateral displacement, and Dwyer) were performed on 35 patients between April 2005 and October 2007 by the senior surgeon. Data was collected retrospectively by review of casenotes and assessment of radiographs. Average age was 54 years (range 18 to 81) and mean time of follow-up was 22 months (6 to 36). Indications were varus OA deformity (40%), Posterior tibialis tendon deficiency (30%), Charcot-Marie-Tooth (12%) and pes cavus (17%).

Results: All case notes and radiographs were available for analysis. Eight patients (22%) developed a complication. One patients (5%) had failed to fuse at 6 weeks following surgery. This patients developed a non-union and required re-fusion with bone grafting. Two patients (10%) had sural nerve damage, which persisted and required specialist pain team involvement. Two patients developed symptoms relating to prominent screws. A further two patients had wound breakdown and one had a superficial infection. In total, there were five further procedures (14%) – two directly related to problems with the calcaneal osteotomy. All osteotomies united within a translation distance of 10% in the sagittal plane.

Discussion: Calcaneal osteotomy is a useful adjunct procedure for correcting anatomical malalignment of the hindfoot in several conditions, with an acceptable complication rate and a low re-operation rate.

We aimed to determine whether proximal femoral bone remodelling, as measured by DEXA scan for each Gruen Zone, differed for 3 different femoral stem designs. These were:

Group 1 – Triple taper polished (C-stem J& J DePuy)

Ethical Committee approval was obtained and all patients gave informed consent. All operations were performed by 3 surgeons using a standard lateral approach, third generation cementing technique and a standard post-operative regime.

Seventy-five patients were randomised prospectively using a stratified randomisation programme for known risk factors in bone density. The randomisation was stratified by age, sex, Charnley Group (A or B), BMI and femoral neck bone mineral density. There were 25 patients in each Group, 5 patients did not have complete data sets and were therefore withdrawn from evaluation.

The Groups were similar with regard to age, sex, BMI, BMD and Charnley Group. Patients were followed up at 3, 6, 12 and 24 months by Nurse Practitioners for clinical and radiological evaluation and DEXA scan at each time of follow-up. There were no catastrophic failures of sepsis or dislocation. All patients functioned well at 24 months by Harris Hip Score.

The bone remodelling pattern will be described for each stem design. Findings are summarised thus. In the lateral Gruen Zones the triple taper and collared stem design faired better and both behaved differently to the double taper design. In Gruen Zone 7, all stems demonstrated reduced bone density as compared to pre-operative scans but this was less with the triple taper design.

Lumps of the foot present relatively infrequently to the orthopaedic service. There have been very few published studies looking at presenting characteristics or the differential diagnosis of such lesions. We report our experience of foot lumps treated surgically looking at the patient demographics, presenting characteristics, diagnoses encountered and the diagnostic accuracy of the surgeon. All patients who underwent excision or biopsy of a foot lump over a period of 4 years were studied; 101 patients were identified. Average age was 47.3 years (range 14–79); there was a significant female preponderance with 73 females and 28 males (p< 0.0001). Pain was the single most common presenting complaint followed by footwear problems. Only three patients attended because of cosmetic reasons and neurological symptoms were very rare with only one patient complaining of paraesthesia. Certain lesions were more commonly encountered in specific zones of the foot. 32 different histological types were identified, ganglion cysts were the most commonly encountered lesions and there was only one malignant lesion encountered in this study. Only 58 out of the l01 lumps were correctly diagnosed prior to surgery.

We have shown that there are a wide variety of potential diagnoses, which have to be considered when examining a patient with a foot lump. There is a low diagnostic accuracy for foot lumps and therefore surgical excision and histological diagnosis should be sought if there is any uncertainty.

Introduction: Patients undergoing surgery to the foot frequently ask when it is safe to return to driving. The ability to drive is important both in social and economical terms. There is currently little data in the literature relevant to foot surgery. We are conducting a prospective cohort control study to asess the effect of forefoot surgey on break-response time. Methods- Individuals attending for first MTP joint arthroplasty and SCARF/Chevron osteotomies for hallux valgus are recruited. A driving simulator was constructed consisting of a steering wheel, foot pedals, an LCD display, a CPU and a control unit. The patient follows an image on the LCD screen using the steering wheel. The examiner then randomly initiates the machine and a stop sign is displyed. The patient would then release the accelerator pedal and depress the brake. The CPU claculates the “respone-time”, the “break-time” and total breaking time. In addition the “stick test” and “stand test” were performed as further measures of lower limb function. Each individual was assessed pre-operatively and at 2 and 6 weeks postoperatively. Both drivers and non-drivers are included and a control population of age and gender matched individuals was included for comparison. Results – 25 individuals are currently enrolled as study cases, 12 of which have 2 week follow-up and 3 have completed the study. Control data is being collected.

Conclusion: Early results indiciate that break response time is increased at 2 weeks post-operatively, however this returns to pre-operative levels by 6 weeks. (204ms vs 256ms vs 206ms) These early results may be validated when all individuals have completed the study. Further study of the period 2–6 weeks after surgery will now be subject to study to assess the optimum time to return to driving.

Crescent fracture dislocations are a well-recognised subset of pelvic ring injuries which result from a lateral compression force. They are characterised by disruption of the sacroiliac joint and extend proximally as a fracture of the posterior iliac wing. We describe a classification with three distinct types. Type I is characterised by a large crescent fragment and the dislocation comprises no more than one-third of the sacroiliac joint, which is typically inferior. Type II fractures are associated with an intermediate-size crescent fragment and the dislocation comprises between one- and two-thirds of the joint. Type III fractures are associated with a small crescent fragment where the dislocation comprises most, but not all of the joint. The principal goals of surgical intervention are the accurate and stable reduction of the sacroiliac joint. This classification proves useful in the selection of both the surgical approach and the reduction technique. A total of 16 patients were managed according to this classification and achieved good functional results approximately two years from the time of the index injury. Confounding factors compromise the summary short-form-36 and musculoskeletal functional assessment instrument scores, which is a well-recognised phenomenon when reporting the outcome of high-energy trauma.

Aim: To evaluate the benefits of suction drainage following primary total joint arthroplasty.

Materials and Methods: A two year retrospective study was conducted on 126 consecutively selected patients who had primary total hip & knee replacements in a district general hospital. There were 63 patients (mean age 69 years) each in drain and non-drain groups. Sex distribution and anticoagulants use in both groups were similar. All patients underwent same operative technique and method of closure. Primary hip replacements were carried out by Hardinge approach and knee replacements by medial parapatellar approach.

Results: Mean postoperative fall in haemoglobin was 3.2 and 3.3 gm/dl in the drain and nondrain groups respectively. Blood transfusion was required in 34 patients with drains and 28 patients without drains. Mean blood transfusion requirements in both the groups were between 2–3 units. There was no statistically significant difference between the two groups in postoperative complications such as hypotension and wound infections (all negative for microbiology culture). The average rehabilitation time in both the groups was 8–9 days. Statistical analysis showed no difference in postoperative fall of haemoglobin, blood transfusion and rehabilitation time between the two groups (p> 0.05).

Conclusion: We concluded that the routine use of suction drain is unnecessary after an uncomplicated total joint arthroplasty.

We studied 51 patients with osteo-articular tuberculosis who were divided into two groups. Group I comprised 31 newly-diagnosed patients who were given first-line antituberculous treatment consisting of isoniazid, rifampicin, ethambutol and pyrazinamide. Group II (non-responders) consisted of 20 patients with a history of clinical non-responsiveness to supervised uninterrupted antituberculous treatment for a minimum of three months or a recurrence of a previous lesion which on clinical observation had healed. No patient in either group was HIV-positive. Group II were treated with an immunomodulation regime of intradermal BCG, oral levamisole and intramuscular diphtheria and tetanus vaccines as an adjunct for eight weeks in addition to antituberculous treatment. We gave antituberculous treatment for a total of 12 to 18 months in both groups and they were followed up for a mean of 30.2 months (24 to 49). A series of 20 healthy blood donors served as a control group.

Twenty-nine (93.6%) of the 31 patients in group I and 14 of the 20 (70%) in group II had a clinicoradiological healing response to treatment by five months.

The CD4 cell count in both groups was depressed at the time of enrolment, with a greater degree of depression in the group-II patients (686 cells/mm³ (sd 261) and 545 cells/mm³ (sd 137), respectively; p < 0.05). After treatment for three months both groups showed significant elevation of the CD4 cell count, reaching a level comparable with the control group. However, the mean CD4 cell count of group II (945 cells/mm³ (sd 343)) still remained lower than that of group I (1071 cells/mm³ (sd 290)), but the difference was not significant. Our study has shown encouraging results after immunomodulation and antituberculous treatment in non-responsive patients. The pattern of change in the CD4 cell count in response to treatment may be a reliable clinical indicator.

We report the case of a young woman who, over a period of five years was diagnosed and treated for a giant-cell tumour of bone, osteomalacia and fluorosis. A review of the literature revealed a correlation between these three diagnoses, the primary pathology being fluorosis and the remaining symptoms being secondary manifestations. It is important to be aware of this association, especially in regions with endemic skeletal fluorosis.

NHS Patients can wait up to 15 months for non-urgent spine surgery. The intended procedure is determined by the outpatient MRI scan. Do changes occur within the spine during the wait for surgery? Would the changes affect the operative decision?

In a prospective study, 105 patients listed for elective lumbar spine surgery at a district general hospital If the MRI scan is over 6 months old, a second scan is performed prior to surgery. Changes that alter the operative decision are noted.

44% Discectomy, 17% decompression, and 19% fusion plus decompression patients cancelled surgery due to improvement in symptoms. None of the spinal fusion patients cancelled.

14% discectomy; 12.5% decompression; 25% fusion; 19% fusion plus decompression and 65% fusion plus discectomy patients had different procedures after the second MRI.

Changes seen include disc resolution, prolapse at a new level, progressive modic changes and compression at other levels.

We do not support the fact that patients may have to wait upto 18 months before having elective spinal surgery. However, we found that significant numbers of discectomy and decompression patients found that their symptoms improved enough to decline surgery. No patient that had been listed for fusion alone got better.

Due to changes seen on the second MRI scan, 1 in 6 operations were different to the initial planned procedure. Could a surgeon failing to request a further up to date scan prior to surgery therefore be considered negligent?

Tuberculosis of short tubular bones is uncommon after childhood. “Spina Ventosa” is considered the classical radiological presentation and hallmark of this disease. The short tubular bones are uncommon loci for the manifestation of adult skeletal TB. We report our experience with 31 cases of tuberculosis of hand (excluding wrist) with the intention to call attention to its occurrence in infrequently documented areas, to stress upon its morphologic variability and to illustrate little emphasized radiological signs.

Material & Methods: (n=31) Age range 1–68 years; M:F – 11:20; duration of symptoms-3 weeks to 2 years; history of Incision and Drainage before presentation −12 (38%) cases; Epitrochlear lymph node enlargement seen in 22 (71%) cases. Radiologically-classical spina ventosa seen in 5 cases; primarily diaphyseal involvement of metacarpal in 9, lesion in metacarpal head in 4, juxtraarticular metacarpal head erosion in 3, metacarpal base lesion in 3, phalangeal involvement in 2, carpometacarpal joint involvement in 2 and primarily small joint involvement in 3 cases. Majority of them were treated conservatively. Follow up is 1–5 years.

Discussion: Tuberculosis of hand might mimic several other inflammatory or neoplastic diseases. Disease might be initially painless and constitutional symptoms may be absent. Rapid collection because of lax skin on the dorsum of hand might tempt the surgeon for incision and drainage. FNAC of Epitrochlear lymph nodes may be diagnostic which may be enlarged in 60–70% cases. The clinicoradiological presentation, differential diagnosis and treatment with special reference to dynamic finger traction will be discussed.

The diagnosis of painful heel syndrome is quite common in any busy orthopaedics OPD. Though neoplasm and infections are not uncommon in calcaneum, the surgeon does not suspect infection unless there is an obvious history of punctured wound or constitutional symptoms. As such till date there is no series of large number of cases of calcaneal tuberculosis. We present our experience with 39 cases of calcaneal tuberculosis which include 2 cases of simultaneous bilateral symmetric involvement and 13 cases of tubercular lesion at the site of the attachment of Tendoachilles and Plantar Fascia. A classification of calcaneal tuberculosis is proposed.

Material & Methods: (n=39) age 6–60 years; male: female – 20:19; duration of symptoms – 2 weeks to 8 years; “Heel up” sign present in 19 cases; X-ray showed erosive lesion at the site of Tendoachilles attachment (enthesitic type lesion) – 8 cases; erosive lesion at the site of Plantar Fascia attachment – 5 cases; Intraosseous lytic lesion(s) without subtalar joint involvment – 23 cases; subtalar joint involvemnet – 3 cases. FNAC was positive in 17 cases and core biopsy revealed tubercular material in 12 cases. All cases except one were treated conservatively.

Discussion: The diagnosis and treatment of calcaneal tuberculosis are often delayed because the surgeon is unaware and signs and symptoms of calcaneal osteomyelitis are less dramatic than seen in osteomyelitis of long bones. The diagnostic and radiological features will be discussed.

Objective: NHS Patients can wait up to 18 months for non-urgent spine surgery. The intended procedure is determined by the outpatient MRI scan. Do changes occur within the spine during the wait for surgery? Would the changes affect the operative decision?

Design: A Prospective study.

Subjects: 105 patients listed for elective lumbar spine surgery at a district general hospital

Outcome Measures: If the MRI scan is over six months old, a second scan is performed prior to surgery. Changes that alter the operative decision are noted.

Results: Forty-four percent discectomy, 17% decompression, and 19% fusion plus decompression patients cancelled surgery due to improvement in symptoms. None of the spinal fusion patients cancelled. Fourteen percent discectomy; 12.5% decompression; 25% fusion; 19% fusion plus decompression and 65% fusion plus discectomy patients had different procedures after the second MRI. Changes seen include disc resolution, pro-lapse at a new level, progressive modic changes and compression at different levels.

Conclusions: We do not support the fact that patients may have to wait up to 18 months before having elective spinal surgery. However, a significant numbers of discectomy and decompression patients found that their symptoms improved enough to decline surgery. No patient who had been listed for fusion alone got better. Due to changes seen on the second MRI scan, one in six operations were different to the initial planned procedure. Could a surgeon failing to request a further up to date scan prior to surgery therefore be considered negligent?

We present a surgical technique through an axillary incision to perform scapular neck osteotomy and insertion of bone graft for recurrent anterior dislocation of shoulder. Fifty patients in the age group 09–40 years with the history of anterior dislocation of shoulder more than three times were operated during 1988–1998. The dominant shoulder was involved in all cases and there was no history of epilepsy, addiction to drugs and psychosomatic ailments. The surgery was performed through an axillary incision. The lateral border of the scapula was palpated and infraglenoid tubercle identified. The scapular neck was osteotomised parallel to the glenoid margin, from infraglenoid tubercle to the lateral border of the base of coracoid leaving the superior cortex intact. The osteotomy was prised open and a 3 cmx1.5 cmx1 cm corticocancellous bone graft was wedgedwhich projected 10 mm anteriorly and 6 mm inferiorly. The graft remained secure and compressed in the osteotomy without any need of metallic fixation.The shoulder was immobilised in arm chest bandage for 4 weeks followed by mobilisation aimed to regain full movements in 12 weeks. The bone graft got incorporated in all patients in 6 months.There were no recurrence at follow up of 2–10 years. All the patients returned to their previous occupation. Rowes shoulder evaluation revealed excellent result (85–100 units). This surgical technique is extra-capsular, requires no muscle cutting, blood transfusion or metallic fixation. The projecting bone block anteriorly increased the depth of glenoid resulting in glenohumeral stability in larger arc of shoulder movements.

The lateral condylar fractures of the humerus are the second most common injury around the elbow in children. Treatment of patients presenting late is controversial. We report our experience of treatment of these fracture over last thirteen years in 78 children seen between 1987 and 2000. Average age- 5.2 years ; 53 patients presented early and 25 patients presented more than 3 weeks after injury . In latter, 11 patients were treated conservatively and rest by internal fixation. Pseudovarus was observed in 30% cases on long term followup. Of 25 patients presenting late, open reduction, internal fixation with bone grafting was carried out in eight cases (those who presented between 3–6 weeks) and rest of the 17 cases were kept under observation on regular follow up. At final follow up, the cases operated late (n= 8) had preservation of 70–80 % of Flexion Extension Arc. Of the 17 cases kept under observation, 8 (showing non union) developed cubitus valgus. 9 cases (showing malunion) continue to have stiff elbow . The elbow function was better in the former group. We suggest that every effort should be made to fix the lateral condylar fragment in patients presenting even more than 3 weeks especially if the metaphyseal chunk is large, the fragment is not widely displaced and rotated and the fracture is type II Milch in a very young child (as those patients rapidly develop very severe cubitus valgus deformity with translocation of ulna).

Introduction: Despite a very high fusion rate (90%) achievable by present techniques, the clinical success rate for curing back pain is in the range of 50%. We hypothesise that disc degeneration gives rise to abnormal stress patterns in the bone. Although the cages integrate fully, load is taken by the cage producing abnormal stress patterns in the vertebrae. Unless a near normal stress pattern in the vertebrae is established, pain may continue.

Method: A simple finite element model of a disc and its adjacent vertebral bodies was developed using ANSYSS software. The dimensions of the model were based on the human lumbar disc. The normal disc was modelled as a fluid with a bulk modulus of 1720 MPa. The degenerate disc was modelled as having the same material properties for the nucleus and the annulus. Fusion of the disc was modelled by replacing the nucleus with commonly used cages. In all the models, the material properties of the cancellous bone (E=100 MPa; v=0.3) and the cortical bone (E=12000 MPa; v=0.3) remained the same. The model was loaded axially with 1.5 kN.

Results: The vertical and horizontal stress patterns around a loaded degenerate disc showed areas of increased loading in the endplate and the cancellous bone confirming the authors’ previous work using load transducers. The introduction of the cages in the model changed the stress distribution – they caused an increase in the compressive stresses in the cancellous bone, and a high concentration of tensile and compressive stresses at the point of contact with the cages.

Conclusion: This study has shown that fusion cages alter the pattern of stress distribution in the adjacent vertebral bodies similar to that of a degenerate disc. It supports the concept that abnormal weight transfer is a more significant cause of back pain as compared to abnormal mobility.

We report 18 cases of pain and tenderness in the mid-part of the patellar ligament in athletes. The condition may be disabling, but it responds to surgery. Ultrasound and CT scans were positive in all 17 confirmed cases, but ultrasound gave a better distinction between the cysts, granulation tissue, metaplasia, mucoid degeneration and congenital defects found at operation.