Introduction

Anterior tibial translation (ATT) is assessed in the acutely injured knee to investigate for ligamentous injury and rotational laxity. Specifically, there is a growing recognition of the significance of anterior medial rotary laxity (AMRI) as a crucial element in assessing knee stability. Anterior cruciate ligament (ACL) injuries are often accompanied with medial collateral ligament (MCL) damage. It has been suggested that Deep MCL (dMCL) fibres are a primary restraint in rotational displacement. This research aims to quantify the difference in rotational laxity of patients with ACL and MCL injuries to deem if the Feagin-Thomas test can robustly capture metrics of AMRI. 2.

Recruits undergoing arduous training at Commando Training Centre Royal Marines (CTCRM) carry a higher risk of femoral neck stress fractures than many other military populations. This injury has serious sequelae and requires urgent operative fixation if it is displaced. Existing literature advocates a low threshold for imaging patients where this injury is suspected, due to the prognostic advantage conferred by early intervention. CTCRM uses a locally produced scoring system based on history and clinical assessment, to guide the requirement for imaging. Since 2015 access to MRI has been possible through a fast track provider. Between 2012 and 2015, 3522 Royal Marine Recruits entered training. Over the period, 95 MRI scans of the hip were performed, of which 12 utilised private pathways. 13 stress fractures of the femoral neck were identified; 23% (n=3) were displaced and required fixation. The overall incidence rate for this injury is therefore 37 per 10,000, with a displaced incidence rate of 9 per 10,000. We compare these data with previous studies, discuss the use and efficacy of the scoring tool, and assess the benefit conferred by the local private MRI agreement.

Anterior Cruciate Ligament injuries are a common cause of downgrade in Service personnel. The Multidisciplinary Injury Assessment Clinic (MIAC) is a service which patients can be referred to for expert musculoskeletal injury management. MIAC has a Fast Track (FT) referral system in place for imaging, and can subsequently refer isolated ACL injuries to a private provider for reconstruction. We examined this pathway in the South West region which has an overall population at risk of 19775. Over 4 years 173 knee injuries were referred to MIAC, of which 32 were ACL injuries. Of the 29 patients referred for MRI, the median time to imaging was 8 days with FT (n=13, range 2–14) and

15 days via the NHS (n=16, range 5–64). The majority of injuries were found to involve multiple pathologies (n=19), excluding them from FT surgery. Time to NHS clinic from point of referral took a median time of 54 days, and onward delay to surgery was 47 days. None of the referrals to the private provider for reconstruction were accepted (n=3). We have identified aspects of current referral and treatment pathways that are inefficient and discuss a current solution utilising Military surgeons.

Fewer delays in starting a trauma list can reduce cancellations. A novel system has been previously described where a patient is identified the day before and optimised for theatre. The patient is listed first and designated “Golden Patient”. This project aimed to assess the impact of introducing a “Golden Patient” system on trauma list start times in a district general hospital.

Two months of first case sending and anaesthetic start times were recorded retrospectively (43 cases). The “Golden Patient” system was introduced with a multi-disciplinary implementation group. Target send time of 0830 hours (hrs) and anaesthetic start time of 0900hrs was agreed. First patients on trauma lists were noted in two cycles, two months apart (Cycle 1: 46, Cycle 2: 38).

Prior to implementation: Mean Send Time (MST) of 0855hrs, Mean Anaesthetic Start Time (AST) of 0921hrs.

Cycle 1: MST fell by 9 minutes (p = 0.03) and AST by 11 minutes (p = 0.023). Lists labelled with a “Golden Patient” (47.8%) were sent 14 minutes earlier (p = 0.004) and started 12 minutes earlier (p = 0.02) than those not labelled “Golden”.

Cycle 2: Implementation produced a 13-minute reduction in send times (p = o.oo3) and start times (p = 0.008) overall. “Golden Patient” cases (42.1%) showed an improved MST of 0836hrs and AST of 0902hrs, 10 minutes earlier than those not designated “Golden”.

Implementation of the “Golden Patient” produced a significant improvement in trauma list starts overall. Specifically, “Golden Patients” help to improve efficiency in sending and anaesthetic start times, by up to 19 minutes on average.

Proximal inter-phalangeal joint (PIPJ) arthrodesis is a commonly performed procedure as a part of hammer and claw-toe correction. Conventional K-wire stabilisation has the potential disadvantages of infection; violation of DIP joint; external protrusion or the wire and necessity of removal.

Newer intra-medullary stabilisation devices are also available, though tend to incur addition costs. We present our technique and results of using a single, buried 1.6 mm K-wire for proximal inter-phalangeal joint fusion

Our objectives were to assess union rates and patient satisfaction following intra-medullary K wires for PIP joint fusion. This involved reviewing 26 consecutive patients (34 toes) who had undergone hammer or claw toe correction. Case notes and radiographs were reviewed to establish results and complications and the need for revision surgery. Initial Radiographs taken at 6 weeks and a telephone survey was undertaken to assess patient satisfaction (16–44 weeks).

Our findings were that of the twenty-one women and five men underwent surgery, with a mean age of 59 years (24–77), stable union was achieved in 33 of 36 toes. No patients had superficial or deep infection and no patient required wire removal or a revision procedure.

In conclusion, PIPJ Arthrodesis with buried K Wires has excellent clinical outcome and high patient satisfaction.

Introduction

Occult hip fractures occur in 3% of cases. Delay in treatment results in significantly increased morbidity and mortality. NICE guidelines recommend cross-sectional imaging within 24 hours and surgery on the day of, or day after, admission. MRI was the standard imaging modality for suspected occult hip fractures in our institution, but since January 2013, we have switched to multi-detector CT (MDCT) scan.

Our aims were to investigate whether MDCT has improved the times to diagnosis and surgery; and whether it resulted in missed hip fractures.

Introduction:

The routine use of posterior hip dislocation precautions is typically utilized postoperatively following total hip arthroplasty via a posterior surgical approach. This has included use of an abduction pillow and limiting adduction, internal rotation and flexion more than 90 degrees for a minimum of 6 weeks postoperatively. This may slow the course of rehabilitation, increase the length of hospital stay and the total cost of the procedure, and add additional anxiety to the patient. We conducted this study to see if posterior hip precautions are necessary after total hip arthroplasty via a posterior approach when the hip meets certain intraoperative criteria for stability.

Introduction

The assessment of the accuracy of reduction of the ankle syndesmosis has traditionally been made using plain radiographic measurements. Recent studies have shown that computerized tomography (CT) scan is more sensitive than radiographs in detecting diastasis. The ethos has now therefore shifted towards CT scan assessment of the syndesmosis. There is however no validated method to scan the syndesmosis and measure it on the CT scans. This exposes the patient to significant radiation risk and also to anxiety from inappropriate interpretation from these scans.

The objectives of this research project are to investigate the current practice of CT scanning the syndesmosis at a University Hospital and to devise a new CT protocol to reduce radiation exposure to patients and to assist surgeons in interpreting the observations.

Roentgen stereophotogrammetric analysis (RSA) is the most accurate radiographic technique for the assessment of three-dimensional micromotion in joints. RSA has been used previously to study the kinematics of the anterior cruciate ligament (ACL)-deficient knee and to measure knee laxity after bone-tendon-bone (BTB) reconstructions. There is no published evidence on its use in assessing hamstring grafts in vivo, in comparing hamstring versus BTB reconstruction, or in-depth analyses of graft performance.

The aim of this project was to use RSA to measure laxity in both BTB and hamstring reconstructions, and to attempt a detailed analysis of graft behaviour in both reconstructions, with particular attention to graft stretching and slippage of the bony attachments.

A prospective study was undertaken on 14 patients who underwent ACL reconstruction. Seven had BTB reconstruction, and seven had four-stranded semitendinosus/gracilis (STG). Tantalum markers were inserted at the time of surgery, into distal femur and proximal tibia, and also directly into the graft itself. Stress radiographs (90N anterior and 90N posterior force) were taken early post-operatively, and then at 6 weeks, and 3, 6 and 12 months.

In addition to measuring total anteroposterior knee laxity, a detailed analysis of the graft itself was possible. The BTB grafts had stretched by an average of 1.54%, and the bone plugs had migrated by 0.50 mm at the femoral end and by 0.61mm at the tibial end. The hamstring grafts had stretched on average 3.94%, and the intraosseous ends had migrated by 3.96mm at the femoral end and by 7.10mm at the tibial end. This is believed to be the most detailed application of RSA in analysing the performance of the two commonly used grafts in ACL reconstruction. Details such as graft stretching and fixation slippage have not been available previously; the data obtained in this study may have implications for clinical practice.

Purpose of the study: Insufficient patellar bone can raise problems for revision total knee arthroplasty and for certain cases of lateral patellofemoral degeneration. Several options are proposed: non-resurfacing, resurfacing on an asymmetrical bone cut, patellar thinning possibly leading to fracture, or patellar bone graft to obtain a regular thick bone.

Material and methods: We report a series of 26 patellar reconstructions among 19 primary osteoarthritis cases with lateral patellofemoral degeneration and five revisions. The patellar reconstruction involved the entire patellar surface in five cases and the lateral facet in 19. For only two cases, a bank graft was used. For the others, the graft was shaped from the tibial resection. Stabilisation used screw fixation in only one case. For the others, two cemented patellar anchor buttons were used to stabilise the graft. All patients were reviewed clinically and radiographically at minimum 12 months. Mean follow-up was 54 months (12–95).

Results: Patellar thickness measured during surgery was improved from 18.1 mm (10–25) to 24.5 mm (21–31). The DMS and function scores improved respectively: 45.5 and 40.7 preoperatively and 89.1 and 72.8 at last follow-up. Seven patients were noted C in the Charnley classification at last follow-up and five used one or two crutches for walking. Twelve patients used the hand rail when climbing stairs and seven needed to use their hands to get up from a chair. All grafts except the allograft fused and all patellar buttons remained stable. There was one lucency at last follow-up. Among the 13 patella exhibited a shift preoperatively, only one remained at last follow-up. There were no subluxations at last follow-up (15 preoperatively).

Discussion: This work shows the pertinence of patellar bone grafts to restore bone stock and avoid complications related to resurfacing asymmetry: pain and patellar shift. Fixation by osteosynthesis does not appear to be necessary. Autographs can be used without risk. Allografts still have to prove their efficacy in this indication.

Background: Acute traumatic rupture of the Tendo-Achilles is a common problem. Review of the published literature shows a conflict between surgical and non-surgical management. Primarily, surgical treatment has repeatedly been shown to have a lower re-rupture rate compared with conservative treatment. However, it is associated with a higher rate of other complications, principally infective soft tissue complications. Debate concerning the method and duration of conservative treatment regimens also remains.

Methods: We aimed to assess the effect of knee position on the gap in acute tendo-Achilles ruptures. Our null hypothesis was there is no difference in tendon gap with variation of knee position. Patients with a history and examination consistent with an acute rupture were collected prospectively. They were imaged by the same consultant musculoskeletal consultant radiologist using ultrasound. Tendon gap was measured with the foot in neutral and full tolerable equinus with the knee both flexed to 90° and fully extended. A pilot study of 10 patients was used to provide data for a power calculation and consequently a total of 25 patients were recruited.

Results: All patients had their clinical diagnosis confirmed and tendon gap measured in each of the 4 positions. A paired t-test was used to compare mean differences between each position. This confirmed there was no significant difference in the tendon gap with the knee flexed or extended providing the foot is in full equinus. This may have considerable implications on the rationale behind conservative treatment and splinting of acute tendo-Achilles ruptures.

Background: The bunionette is a lateral prominence of the fifth metatarsal head. It is usually caused by a wide intermetatarsal angle (IMA) between the 4th and 5th metatarsals with associated varus of the metatarsophalangeal (MTP) joint. Increased pressure placed on the head of the 5th metatarsal results in pain and plantar callus formation. Failure of conservative treatment warrants bony corrective surgery. Various distal, shaft and basal osteotomies have been described in the literature.

Methods: We have used a ‘reverse’ scarf osteotomy in 12 cases (10F: 2M) with a mean follow-up of 12 months (range 5–22 months). All patients filled up a Foot Function Index (FFI) questionnaire pre-operatively and a repeat questionnaire at the latest follow-up. All angles were measured on a weight bearing AP radiograph of the foot. Post-operatively we mobilised the patients immediately using a heel bearing shoe. All osteotomies healed sufficiently at 6 weeks to allow unprotected weight bearing. Full weight bearing was allowed after clinical and radiological union was achieved.

Results: Pre-op mean IMA was 13.1 degrees (range: 10.4–18 degrees) and mean 5th MTP angle was 19.9 degrees (range 12.7–25.5 degrees). Pre-op mean FFI was 34.2 (range 14–71.3). Post operatively, mean IMA was 7.27 degrees (range: 2.0–11.5 degrees); mean 5th MTP angle was 6.36 degrees (range: 2.8–9.0 degrees) and post-operative mean FFI was 5 (range 0–16.7). All except one patient were pleased with the cosmetic correction obtained. One patient did not like the scar but her foot was asymptomatic and her FFI improved from 27 to 0. All patients would undergo the same procedure on the other foot if required and would recommend the same to a friend.

Conclusion: ‘Reverse’ Scarf osteotomy in the correction of bunionette deformity offers promising results in the short term. Further longterm follow-up would help to establish the benefits of this procedure.

We audited all patients who underwent Foot and Ankle surgery at the University Hospital of Wales over one financial year (April 2007 – March 2008).

Patients were identified from the hospital OPCS-4 coding system and all scheduled and unscheduled visits to hospital investigated. Both trauma and elective patients were included. Patients were followed up for a mean period of 9 months (Range 1–14 months) following surgery.

The records for 1052 patients were evaluated. Of these, 77% were elective cases and 23% were trauma related. Overall about 10 % of our foot and ankle patients (100/1052) either attended the A& E Department or had an unplanned clinic visit at some stage of their follow up. Three quarters of these patients were admitted to hospital (median stay 1 day, range 1–51 days).

Twenty five patients (24 A& E; 1 medical) simply re-attended, but were not admitted. The majority of these (58%) had plaster-related problems (8\24) or superficial wound infections (6/24). The remaining patients presented with pain around the operated area, and were discharged after investigation. One patient presented to the physicians 44 days after excision of a Morton’s neuroma with a DVT.

Seventy five patients (7%) were re-admitted to hospital. Two were admitted under the physicians: one with a pulmonary embolus (30 days post ORIF ankle) and one following a cardiac arrest (20 days post ORIF ankle). Out of the remainder 34 patients had planned removal of metalwork, 9 patients had metalwork removed because of infection and 21 patients had soft-tissue infection requiring antibiotics or debridement. Overall, 9 patients underwent revision surgery (0.85%).

The overall infection and thromboembolic rate was 3.42 %(6 A& E + 30 T& O/1052) and 0.28% (1A& E + 2 medical/1052) respectively.

Anatomical variation of Lisfranc mortise has been implicated in the susceptibility of Lisfranc fracture-dislocation. We investigated whether the variations in the dimensions of second metatarsal base makes the joint vulnerable to fracture dislocation.

Patients and Methods: 31 normal (group A) and 23 injured (group B) foot x-rays were compared. The average age of patients was 33(range 16–64) years. Routine AP and 45 degree oblique foot x-rays were used to measure second metatarsal parameters such as L (length of second metatarsal) were measured on x-rays in both groups. Additionally D (height of base of second metatarsal in sagittal plane of foot) was measured in CT scans. Statistical analysis was performed to test the viability of the null hypothesis that states that the relationship of second metatarsal length and height at the base does not correlate with increased susceptibility of Lisfranc injury. Similar analyses of the relevant parameters at the second metatarsal mortice were also calculated.

Results: Mean values of D, L and D/L were obtained in both groups. Statistically the value of D/L was found to be significantly different between injured group and normal group, with a P value of 0.03, while the values of length of second metatarsal itself was not significantly different between two groups (P=0.15). However, no significant correlation was noticed using other parameters of the second metatarsal mortice.

Conclusion: Previously shallowness of the second metatarsal mortice was shown to be significantly correlated with increased risk of Lisfranc injury. However, this study suggests that dimensions of second metatarsal such as, depth/length of the second metatarsal significantly increase the risk of Lisfranc injury. In other words more slender metatarsal dimensions at its base carry increased risk to Lisfranc injury. Thus, anatomical variation at the base of the second metatarsal makes the Lisfranc joint susceptible to injury.

Ankle injuries in cricket fast bowlers are of topical interest with a number of elite pace bowlers recently sustaining injuries. Previous biomechanical research has concentrated on the injury risk to the fast bowler’s lumbar spine with no research focused on the leading leg and specifically the ankle biomechanics of the fast bowler and its predisposition to injury.

We investigate the leading leg biomechanics in maximal and submaximal fast bowling. Ten fast-medium paced bowlers of elite level had their leading leg biomechanics assessed during their bowling action. Using a nine camera infra-red ViconTM 612 motion analysis system linked to a KistlerTM 9281CA force platform the moments of the subjects leading leg during their delivery stride was analysed. Each subject performed ten trials at a maximal ball release speed (> 97km/hr) and ten trials at a submaximal ball release speed (< 97km/hr) with the speed of the ball tracked by a SR3600 radar gun.

All three large joints of the leg were observed and joint moments examined in both directions of all three orthogonal planes giving a total of eighteen joint moments investigated. Of these results only the difference in the ankle plantar flexion was found to be significant. The average ankle plantar flexion peak moment in the maximal and submaximal ball release speed groups were found to be 2.008Nm/kg and 1.790Nm/kg respectively. This difference was statistically significant (p< 0.02)

The increased ankle plantar moment reflects the important role the ankle plays in the generation of extra ball release speed in the fast bowler. However this role does place increased stress on the ankle which may predispose it to injury. This study suggests that the ankle plays a significant role in the fast bowler’s delivery action and post injury rehabilitation needs to take this into consideration.

Introduction: Ankle injuries in cricketers are of topical interest with a number of elite fast bowlers sustaining injuries. Previous research has concentrated on the injury risk to the bowler’s vertebrae with no research focused on the ankle of the fast bowler and exploring the biomechanical basis for its predisposition to injury.

Materials and methods: Ten elite level cricket fast bowlers had their ankle biomechanics assessed during their bowling action. Using a nine-camera infra-red ViconTM 612 motion analysis system linked to a KistlerTM 9281CA force platform the moments of the subjects leading leg ankle during their delivery stride was calculated and analysed. Each subject performed ten trials at their maximum ball release speed (> 97km/hr) and ten trials at less than their maximum ball release speed (< 97km/hr) with the velocity of the ball tracked by a SR3600 radar gun.

Results: All six joint moments of the ankle were examined in both directions of all three orthogonal planes. Of these results only the difference in the ankle plantar flexion was found to be pertinent. The average ankle plantar flexion peak moment in the maximal ball release speed group was 2.008Nm/kg and in the sub-maximal ball release speed group 1.790Nm/kg. This difference was analysed using the paired Student t-test and was statistically significant (p< 0.02).

Discussion: This study shows the ankle plays a significant part in the fast bowler’s delivery action and suggests a biomechanical reason for ankle injuries in these individuals. It is recommended that in fast bowlers with ankle injuries a graduated return to maximal speed bowling is utilised in rehabilitation to prevent further injury and long term morbidity.

Conclusion: The increased ankle plantar moment reflects the important role the ankle plays in the generation of extra ball release speed in the cricket fast bowler.

A recurrence of objectively measured knee laxity after anterior cruciate ligament (ACL) reconstruction has previously been reported in various papers; the purpose of this study was to accurately measure in vivo knee laxity after both bone-tendon-bone (BTB) and hamstring reconstruction using radiostereometric analysis (RSA), and to differentiate between graft fixation slippage and graft stretching and their relative contributions to any increase in laxity.

Twenty patients were studied prospectively after ACL reconstruction. Ten had been operated on using BTB grafts, and ten using hamstring (four-stranded semitendinosus/gracilis) grafts. Tantalum markers were inserted in the distal femur, proximal tibia and into the graft itself. (RSA) was used to measure sagittal laxity, graft stretching and fixation slippage early post-operatively, and then at intervals up to 1 year.

A steady increase in total anteroposterior laxity was found in both groups over the year. For the BTB group, total mean slippage of the bone plugs increased to 1.28 mm at 1 year. For the hamstring group, the tunnel attachments had slipped by a total of 6.82 mm. More stretching was found for the hamstrings grafts than for the BTB grafts and the amount of stretching increased significantly with time post-surgery. The hamstring grafts stretched by a mean of 4.18%, the BTB grafts by 1.18%.

This is believed to be the most detailed application of RSA in analysing the performance of the two commonly used grafts in ACL reconstruction. Details such as graft stretching and fixation slippage have not been available previously; the data obtained in this study may have implications for clinical practice.

Aims: Evaluate the outcome of orthopaedic intervention in children who sustained peripheral ischaemia resulting from meningococcal septicaemia and to assess the benefit of fasciotomies within this group.

Introduction: There have been only two published series on the orthopaedic management of meningococcal septicaemia in children. We carried out a retrospective review of all patients who had undergone this intervention in RHSC.

Methods: Between 1994 and 2004 there were 190 admissions to paediatric intensive care unit (PICU) with meningococcal septicaemia. 12 had significant Orthopaedic/Plastic Surgical input. Case notes were examined to establish admission patterns, limb progress, subsequent operative intervention and eventual outcomes.

All presented with vague viral symptoms and developed rapidly spreading purpuric rashes within 24hours. 8 children were admitted from A& E and 4 were transferred from other hospitals. All received antibiotics, fluid resuscitation, ventilation and inotropic support. One child died within 14 hours of PICU admission. Haemofiltration was used in 11 children (mean 14.8 days, range 2–60 days).

We were able to follow up 8 of the survivors clinically.

Results: All children had some form of surgical treatment. 9 children had one or more amputations. Two children did not require amputations. Seven of the 12 children had fasciotomies performed (mean 34 hours after admission, range 2–96 hours). The child who died from overwhelming sepsis had multiple fasciotomies at 9 hours post admission. The remaining children had varying amputations. The other five children did not have fasciotomies. Of these one child did not require any amputations, three children had partial amputation of a single limb and one child had partial amputations of two limbs. All five within this group required additional split-skin grafts.

8 children were followed clinically. 7 were mobile with walking aids with a mean of 1.3 prosthetic lower limbs (range 0–2).

Conclusion: There is no evidence from our study that early fasciotomies are detrimental to survival, limb function or subsequent wound healing after definitive amputation. In other published series fasciotomy has been advocated within 24hours.

In our study 2 of our 7 patients who underwent fasciotomy the demarcation level receded distally post decompression leading to more distal amputation levels.

Purpose: To correlate arthroscopic appearances of the anterior and posterior meniscofemoral ligaments (aMFL and pMFL respectively) with their appearances on magnetic resonance imaging.

Methods: 50 patients underwent MRI scanning of their knees for a variety of suspected pathologies. The radiological presence or absence of the MFLs was assessed by examination of sequential coronal and sagittal T2 weighted MRI scans. Arthroscopic examination of the knees was subsequently performed, during which the MFLs were identified using several anatomical cues. These included their femoral and meniscal attachments, their obliquity relative to the PCL, and the meniscal “tug test”. Identification was classed as “easy” or “hard” by the operating surgeon.

Results: From 50 knees 44 (88%) aMFLs and 30 (60%) pMFLs were identified on MRI scanning, whilst 47 (94%) aMFLs and 5 (10%) pMFLs were identified arthroscopically. Identification of the presence or absence of the aMFL was classed as easy in 47 (94%), whilst the pMFL was easy to identify in only 5 (10%) of knees, of which 3 (6%) had a ruptured PCL. Using arthroscopy of the aMFL as the gold standard, the sensitivity and specificity of MRI in detecting the aMFL were 94% and 75% respectively. Equivalent values for the pMFL were not calculated due to the difficulty of identifying the pMFL arthroscopically. Thus, with the exception of PCL-deficient knees, it was felt that many pMFLs were missed due to difficulties in identification through anterior portals.

Conclusions: This is the first study correlating the MRI appearances of the MFLs with arthroscopic findings. MRI is relatively sensitive in identifying the aMFL, but its accuracy in identifying the pMFL remains undetermined. Accurate identification of the MFLs at MRI is of value when assessing the status of the PCL, as these ligaments may contribute to stabilising the PCL-deficient knee.

Due to their superior wear characteristics, oxidized Zr-2.5Nb heads are used with hip stems made of conventional orthopaedic alloys. Galvanic interactions between Zr-2.5Nb (Zr) and Ti-6Al-4V (Ti), cobalt-chromium (CoCr), and 316L stainless steel (SS) alloys were evaluated.

Galvanic current density was measured for Zr/Ti,Zr/CoCr, Zr/SS, CoCr/Ti, and CoCr/SS couples under static conditions in aneutral Ringer’s solution and in an acidic (1.7 pH) solution. To simulate fretting, one or both coupled alloys in the neutral solution subsequently were abraded by a bone cement pin (82 MPa Hertzian stress). An extended(7-day) static test in the acidic solution was performed for Zr/SS and CoCr/Ti to simulate crevice conditions. The dissolved metal ion concentration was determined using direct coupled plasma emission spectrometry.

Mean initial current densities of the Zr/SS, SS/CoCr,Zr/CoCr, CoCr/Ti, and Zr/Ti couples were 3.0, 0.36, 0.16, 0.05, and 0.04μA/cm2, respectively, in the neutral solution, and 0.57, −0.29, 0.04, 0.02, and 0.03 μA/cm2, respectively, in the acidic solution (positive when first alloy was anode). Within 30 minutes, all values decreased below 0.02μA/cm2. The current densities increased by orders of magnitude under fretting conditions. When both alloys were abraded, the highest values were minus;677 and 464 μA/cm2 for CoCr/Ti and Zr/SS, respectively. In the extended static test of Zr/SS, the mean total metal ion concentration decreased from 8.15 mg/L when the alloys were uncoupled to 4.50 mg/L(p=0.007) when they were coupled. For CoCr/Ti, the change from 1.28 to 1.72mg/L when the alloys were coupled was not statistically significant(p=0.22).

With its strong tendency to passivate, the Zr alloy produced galvanic interactions within the range observed with conventional alloy couples. Its anodic characteristic helped protect SS in a galvanic couple.

Ankle arthrodesis for isolated ankle arthritis has a high patient satisfaction level; however, gait analysis and functional outcome measurements demonstrate substantial disability. The high patient satisfaction may reflect the extent of disability present prior to the intervention.

This study demonstrates that the presence of subtalar or talonavicular arthritis and/or limited motion is a negative predictor for a satisfactory outcome. The risk of developing arthritis of these joints increases with time and therefore the patient can expect a deterioration of their initial result. Ankle arthrodesis should be considered a salvage procedure. Viable alternatives that preserve motion should continue to be explored.

The purpose of this study was to utilize gait analysis and validated outcome measures to assess the results of an ankle arthrodesis and compare these results to a healthy age – sex matched control group.

Isolated Ankle arthrodesis has a high patient satisfaction rate; however, gait analysis and functional outcome scores demonstrate a significant difference when compared to controls. The presence of limited subtalar and midfoot motion and/or arthritis correlates with a poor clinical result.

This study will help the clinician predict outcomes and better educate patients as to the expected results following ankle arthrodesis.

Twenty-six patients with an isolated ankle arthrodesis underwent gait analysis and functional outcome assessment using AOFAS ankle-hindfoot scale, MODEMS (includes SF-36) and Ankle Osteoarthritis Scale (AOS). A radiographic analysis was preformed. Mean follow-up was 3.7 years. Results were compared to a group of twenty-six controls.

Seventy-seven percent were satisfied and eighty-eight percent would recommend it to a friend. These perceived outcomes did not correlate well with their average Functional Outcome scores and gait analysis. The AOFAS score rated 46% as excellent or good. The MODEMS identified significant differences in Physical Function, Role-Physical and Physical Composite means when compared to controls. The AOS identified significant differences in Pain and Disability means. Gait analysis demonstrated significant differences in stride length, cadence, hip flexion, hindfoot flexion, hindfoot inversion and midfoot flexion. Decreased hindfoot and midfoot motion correlated with poorer outcome scores. Poor radiographic scores correlated with decreased hindfoot/midfoot motion and poorer clinical outcomes.

Ankle arthrodesis should be considered a salvage procedure. Viable alternatives that preserve ankle motion should continue to be explored.

This study demonstrates that harvesting a vascularized fibular graft has a significant number of minor complications. These complications do not result in significant morbidity but could be avoided by other newer methods of managing bony defects and avascular necrosis such as porous bone substitute rods.

The purpose of this study was to evaluate functional outcomes of the foot and ankle following vascularized fibula graft harvest, using validated outcome measures.

This study agrees with previous reports in that minor complications are commonly associated with free fibula harvest. Functional outcome scores demonstrate significant differences in pain and disability; however, the disability associated with daily activities is small.

This is the first study to assess the outcomes of vascularized fibular grafts with validated outcomes measures. It is one of a few studies to assess the outcomes of vascularized fibular grafts on an otherwise normal lower extremity.

Twenty-two patients were available for study, with ten attending for examination. All had undergone free fibula transfer for mandibular reconstruction. Functional outcome was assessed using MODEMS (includes SF-36) and Foot Function Index (FFI). A radiographic analysis was performed. All patients had a normal contralateral foot and ankle which was used as a control. Mean follow-up is 3.1 years.

Sixty percent of patients were satisfied following surgery. Subjective complaints of weakness, instability and numbness were reported. Minor wound complications were seen in twenty-three percent of patients and clawing of the lesser toes in eighteen percent. No significant difference was seen in the SF-36 categories when compared to population norms. The FFI identified significant differences in Pain and Disability means when compared to the contralateral side. Radiographic analysis failed to demonstrate increased arthritic change or instability. Two patients had undergone further surgery for toe clawing and persistent ankle pain.

In a prospective study to evaluate the benefits of radial extracorporeal shockwave therapy (ESWT) in patients with longstanding chronic Achilles tendonitis. 34 cases of non-insertional Achilles tendonitis were treated in 32 patients, using radial shockwave treatment. Symptoms had been present for at least ten months and were resistant to conservative treatments. Patients received three shockwave sessions at weekly intervals. Evaluation was performed prior to treatment, at six weeks and three months after the final session. Patients completed a visual analogue score (VAS) for maximal pain (0–100), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot Scale and the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A).

At short-term review all patients reported an improvement in symptoms. The VAS fell from a pre-treatment value of 74 (+/−15) to 22 (+/−17). An improvement in the AOFAS from of 64 (+/−10) to a post-treatment value of 90(+/−7) was seen, and an average from 30 to 70 in the VISA-A score. No complications from the treatment were reported. Four patients previously listed for surgery have improved sufficiently to be removed from the waiting list.

Conclusion: Short-term results using ESWT for the treatment of longstanding non-insertional Achilles tendonitis are encouraging. Longer-term follow-up subsequent to this prospective pilot study is underway to assess if results are reproducible over a greater time period.

Introduction: The aim was to evaluate the outcome of orthopaedic intervention in children who sustained peripheral ischaemia from meningococcal septicaemia and assess the benefit of fasciotomies within this group.

Methods: From 1994–2004 there were 190 admissions to paediatric intensive care unit (PICU) with meningococcal septicaemia. 12 had significant Orthopaedic/Plastic Surgical input. Case notes were examined to establish admission patterns, limb progress, operative intervention and outcomes.

All presented with viral symptoms and developed rapidly spreading purpuric rashes within 24hours. 8 were admitted from A& E, 4 transferred from other hospitals. All received antibiotics, fluid resuscitation, ventilation and inotropic support. One child died within 14 hours of PICU admission. Haemofiltration was used in 11 children (mean 14.8 days, range 2–60 days).

We were able to follow up 8 of the survivors clinically.

Results: All children had surgical treatment. 9 children had one or more amputations. Two children did not require amputations. Seven of the 12 children had fasciotomies performed (mean 34 hours after admission, range 2–96 hours). The child who died had multiple fasciotomies at 9 hours post admission. The remaining children had varying amputations. The other five children did not have fasciotomies. Of these one child did not require any amputations, three children had partial amputation of a single limb and one child had partial amputations of two limbs.. All five within this group required additional split-skin grafts.

8 children were followed clinically. 7 were mobile with walking aids with a mean of 1.3 prosthetic lower limbs (range 0–2).

Conclusion: There is no evidence from our study that early fasciotomies are detrimental to survival, limb function or subsequent wound healing after definitive amputation. In other published series fasciotomy has been advocated within 24hours.

In 2 of 7 patient, after fasciotomy the demarcation level receded distally leading to more distal amputation levels.

Introduction Roentgen stereophotogrammetric analysis (RSA) is the most accurate radiographic technique for measuring three-dimensional micromotion in joints, and is now being developed for the study of anterior cruciate ligament (ACL) injury and outcome after surgical reconstruction. Using RSA a prospective study of ACL reconstruction is being undertaken. The aim is to obtain accurate information on the performance of both bone-patellar tendon-bone (BPTB) and hamstring grafts post-operatively.

Materials and methods 14 patients with a unilateral ACL tear who underwent ACL reconstruction have been studied prospectively. Seven had BPTB grafts, and seven had four-stranded semitendinosus/gracilis. Tantalum markers were inserted at the time of surgery, 4 each into the femur and tibia, and 8 into the graft, at regular intervals along the length. Stress stereo radiographs (90N anterior and posterior draw forces) were taken at 1, 6, 12 and 24 weeks post-operatively. They were analysed using Medis RSA software.

Results Initial results suggest that in addition to measuring total anteroposterior knee laxity, detailed analysis of the graft itself is possible. Beads placed in the bone blocks of the BPTB grafts, and in the intraosseous ends of the hamstrings, enable calculation of slippage of the fixation. The BPTB bone plugs moved 0.6 to 1.2mm by 12 weeks, the Hamstrings fixation was more variable. Beads placed in the intraarticular graft may enable measurement of any post-operative stretching, but are also somewhat erratic. Identification of the site of stretching – around the tunnel entrances, or intraarticularly, should be possible.

Conclusions We believe that this detailed application of RSA in analysing the performance of the two commonly used grafts in ACL reconstruction has not been previously described. We hope to gain valuable insight into the behaviour of both graft types and reasons for graft failure. This presentation will demonstrate the methods developed and include the technical difficulties encountered in this on-going study.

A compartment syndrome is an orthopaedic emergency which can result from a variety of causes, the most common being trauma. Rarely, it can develop spontaneously and several aetiologies for spontaneous compartment syndrome have been described. We describe a patient with diabetes who developed a spontaneous compartment syndrome. The diagnosis was delayed because of the atypical presentation.

Aim: To test the hypothesis that the meniscofemoral ligaments (MFLs) make a significant contribution to resisting anteroposterior and rotatory laxity of the posterior cruciate ligament (PCL) deficient knee.

Methods: The anterior and posterior MFLs of eight cadaveric knees were identified using previously described dissection techniques [1], which were shown not to affect overall knee stability in control studies. These specimens were tested for anteroposterior and rotatory laxity in a materials testing machine. The posterior cruciate ligament was then divided, followed by division of the MFLs. Laxity results were obtained for intact, PCL-deficient and PCL/MFL-deficient knees. Results were analysed using repeated measures analysis of variance and paired t tests.

Results: Division of the MFLs in the PCL-deficient knee significantly increased posterior laxity between 15o and 90o of flexion (p< 0.01). Force/displacement measurements revealed that, at 90° flexion, the MFLs contributed to 28% of total resistance to posterior drawer in the intact knee and 70% in the PCL-deficient knee (p< 0.01). There was no effect on rotatory laxity (p> 0.2).

Discussion: Previous studies have demonstrated a high prevalence of the MFLs in knees1 and that these ligaments have a strength similar to the posterior fibre bundle of the PCL [2]. The current in vitro study suggests that they contribute to overall resistance to posterior drawer, especially in the PCL-deficient knee. If this is confirmed in vivo, patients with PCL injuries may have a reduced posterior drawer sign if their MFLs are intact, and this may result in a more stable knee. Thus the MFLs should be accurately identified and assessed during MRI scanning and arthroscopy [3].

Conclusion: This is the first study demonstrating a function for the MFLs as secondary restraints to posterior drawer in the PCL-deficient knee. The integrity of these structures should be assessed during both MRI scanning and arthroscopy of PCL-injured patients, as this may affect the diagnosis and management of such injuries.

Aims: To evaluate different surgical techniques of lateral meniscal allograft transplantation in cadaver knees, and to assess how these techniques affect tibial contact pressures.

Methods: The femoral and tibial shafts of five human cadaver knees were cemented into steel pots. Fresh-frozen irradiated human meniscal allografts were supplied by the East Anglia Tissue Services Department of the National Blood Service.

The knees were mounted into an Instron materials testing machine. Paddles of pressure-sensitive Fuji Prescale Film were inserted into the lateral compartment of the knee, underneath the lateral meniscus. Each knee was then loaded to 700N for 10 seconds. The Fuji Film paddles were digitally scanned and then analysed using Scion Image Analysis software to determine the intra-articular contact pressures.

Contact pressures were then determined after (i) total lateral meniscectomy, (ii) lateral meniscal allograft transplantation using a bone plug-keyhole technique to secure the horn attachments, and (iii) after insertion of the graft by suturing only.

Results: Total lateral meniscectomy led to a mean increase in maximum contact pressures of 103% (s.d. 63). Mean maximum contact pressures after lateral meniscal transplantation with a bone cylinder were 59% (s.d. 60) greater than the intact state, and after suturing only of the graft, were 85% (s.d. 74) greater than the intact knees.

Conclusions: Overall, lateral meniscal transplantation did partially restore contact pressures within the knees, and the use of a graft attached to a bone cylinder appeared to be more effective than just simple suturing of the graft. However, the results varied greatly between the different knees. In two knees, the results of meniscal transplantation were excellent. However, results were poor in knees with inaccurate graft-to-host size matching or where there was significant articular degeneration.

Introduction: Accurate size-matching of meniscal allografts is essential to maintain tibiofemoral congruity, and therefore function, especially when the surgical technique of using a bony bridge is employed.

Methods of accurately assessing the required dimensions of an ideal meniscal allograft for each patient are limited. One popular method used is to choose the appropriate graft according to the bony tibial plateau dimensions of the patient, as determined from plain radiographs.

Aims: To correlate meniscal dimensions with the bony dimensions of donor tibial plateaus.

Methods: 22 left and right pairs of donor tibial plateaus with intact meniscal allografts were obtained, giving a total of 88 individual meniscal allografts. Using a digital micrometer, the following meniscal dimensions were measured: anteroposterior length, medial-lateral width, and the radial width at the mid-point of the meniscal body. Peripheral circumference was measured using flexible steel wire. Medial and lateral bony tibial plateau width and length, and total plateau width were also recorded.

Linear regression analysis was used to obtain a formula, relating each meniscal dimension to the various bony plateau measurements. The resulting equations were used to calculate an expected meniscal dimension from the measured plateau dimensions, and this was compared to the size of the actual dimension measured.

Results: The magnitude of the meniscal dimensions measured approximately fitted a normal distribution amongst all the specimens studied. The tibial plateau widths ranged from 69.2mm to 88.4mm (mean 78.5mm, s.d. 5.4mm), a 28% difference. The mean difference between meniscal measurements between the left and right knee of each pair was 7.3%. However, the greatest individual difference observed was 41.8%.

The mean percentage error between meniscal dimensions calculated from specific compartmental tibial plateau dimensions, and the actual measured meniscal dimensions was 5.3% (s.d. 4.1%). When using just total bony tibial plateau width to calculate meniscal dimensions, the percentage error was 6.2% (s.d. 4.9%). This difference was not statistically significant. The maximum error between calculated and actual meniscal dimensions was 32%.

Conclusions: This anatomical study shows that the use of plateau dimensions as a determinant for the sizing of meniscal allografts can be used to predict meniscal dimensions. However, mean errors are in the region of 5% – 6%, and can be as high as 32%. The potential mechanical effects of such graft to host size mismatching must be carefully borne in mind.

Aims: A prospective study to evaluate the beneþts of extracorporeal shockwave therapy (ESWT) in patients with chronic Achilles tendonitis. Methods: 34 cases of non-insertional Achilles tendonitis were treated in 32 patients, using radial shockwave treatment. Symptoms had been present for at least ten months and were resistant to conservative treatments. Patients received three shockwaves sessions at weekly intervals. Evaluation was performed prior to treatment, at six weeks and three months after the þnal session. Patients completed a visual analogue score (VAS) for maximal pain (0–100), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot Scale and the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A). Results: At short term review all patients reported an improvement in symptoms. The VAS fell from a pre-treatment value of 74 (±15) to 22(±17). An improvement in the AOFAS from of 64 (±10) to a post-treatment value of 90(±7) was seen, and an average from 30 to 70 in the VISA-A score. No complications from the treatment were reported. Four patients previously listed for surgery have improved sufþciently to be removed from the waiting list. Conclusion: Shortterm results using ESWT for the treatment of longstanding non-insertional Achilles tendonitis are encouraging. Longer Ðterm follow-up subsequent to this prospective pilot study is underway to assess if results are reproducible over a greater time period.

100 fibula fractures sustained at or below the syndesmosis were studied retrospectively. They were consecutive trauma clinic referrals with an initial conservative treatment plan. All initial radiographs studied were taken prior to application of below knee plaster splintage. Weber A and B classification was n=47 and 53 respectfully. Serial radiographs showed that none of the 100 ankles developed further displacement during their treatment. There was 5.6 and 6.6 individual radiographs and 4.2 and 4.3 clinic reviews for Weber A and B respectfully. We conclude that Weber A and B fractures without talar shift are stable injuries. Once the decision has been made to treat them conservatively, no further radiographs need be requested. This will result in reduction to two clinic reviews and one single initial anteroposterior and lateral radiograph. Significant cost savings to the health service and reduction in ionising radiation exposure to the patient will result.

Fractures about the radial or ulnar aspects of the base of the proximal phalanx or the metacarpal head represent collateral ligament avulsion injuries. Unlike such injuries in the metacarpophalangeal joint of the thumb these injuries are rare and have received scant attention in the literature.

The results of open reduction and internal fixation, highlighting the surgical approach and technique, of collateral ligament avulsion fractures about the metacar-pophalangeal joints of the fingers are presented.

Over a five year period sixteen patients presented to the hand injury service with the above injury. Thirteen of these fractures occurred at the base of the proximal phalanx. Fourteen were acute injuries and two non-unions. These fractures affected a predominantly young population (average age 24 years) and the majority were sustained during sporting activities. All were treated by ORIF except for one in which the patient declined operative treatment. Metacarpal head fractures are assessed through a standard dorsal approach but as the collateral ligament inserts into the volar - lateral aspect of the proximal phalangeal base access to this fracture is best achieved via a volar approach to the digit. Fractures were stabilized with a single interfragmentary screw.

Surgical fixation gave satisfactory results in fourteen cases. All these patients had a full range of finger movement within 3 weeks. One patient developed symptoms suggestive of RSD. At 3 months review all fractures treated by ORIF had united. The patient who declined surgical treatment developed a symptomatic non-union.

Conservative treatment of these unstable fractures leads to non-union. The surgical anatomy dictates the surgical approach, with fractures at the proximal phalangeal base best accessed via a volar approach. ORIF restores joint surface congruity, establishes union and provides stable fixation to allow early mobilisation and return to normal activities.

The objective of this study was to examine patients’ use of the Internet to obtain medical information, their opinions on the quality of medical Web sites and their attitudes towards Internet-based consultations.

The study made use of a questionnaire given to 398 patients, aged 10 to 95 years (mean 55 years), visiting the orthopaedic outpatient clinics of a London district general hospital over a 2 week period. The major outcome measures were; 1) the rate of Internet use by patients, 2) the perception of the quality of medical websites, 3) future intentions and attitudes towards internet-based consultations, and 4) concurrence between information obtained from Web sites and advice given by the orthopaedic surgeon in the clinic. Results were considered significant at p< 0.05. The Chi² test was used to compare proportions. Spearman’s correlation coefficients were used to quantify correlation.

From 369 respondents (response rate 91%), 55.3% of patients had accessed the Internet. Of these 52.0% had obtained medical information from this source. Access was linearly correlated with age (r² =0.975, p< 0.01) and was also related to social status. Of the 12.3% of patients who had researched their particular orthopaedic condition, 20% reported that the advice received from the surgeon in the clinical contradicted that obtained from the Internet. A total of 37.5% of patients would undergo an Internet-based consultation, whilst a further 25.5% would consider this, depending on the medical condition in question.

This is the first detailed UK study examining patient attitude towards Web-based medical learning. Over half of the patients were willing to access the Internet for medical information, with younger patients more likely to undertake this activity. As the commercial advantages of a captive patient population become apparent, there is the potential for inaccurate or misleading information, that has not undergone peer review, to be disseminated over the Internet The increased use of medical Websites by patients raised important issues regarding the need for quality control, which orthopaedic surgeons and their institutions both need to address. This also impacts significantly upon the changing nature of the surgeon-patient relationship.

The Cincinnati incision is widely utilized in clubfoot surgery and allows excellent access to the medial, lateral and posterior structures involved. Closure of the skin at the end of the procedure without undue tension may be difficult. Wound necrosis and excessive scarring may occur and may lead to inadequate correction. One alternative is to splint the foot in an initial equines position post-operatively with repeat cast changes to achieve optimal position once soft tissue swelling has decreased. A further method is to leave the wound open and allow it to granulate.

The healing and final cosmetic appearance of wounds allowed to heal by granulation following the Cincinnati incision were reviewed.

We reviewed 14 feet in 10 patients who had undergone partial closure of the Cincinnati incision following peritalar release. The majority of the children were male and the average age at surgery was 28 weeks. All corrections were performed as primary procedures on patients with idiopathic CTEV. At the end of the procedure an above-knee plaster was applied. The plaster was changed weekly in the outpatients department until the wound had healed. Patients were maintained in plaster for 12 weeks.

All final wounds were cosmetically acceptable both to the surgeon and the parents. The widest scar was 3 mm and the average time to heal four weeks. No infection had occurred although two wounds were treated for overgranulation.

Partial wound closure of the Cincinnati incision avoids undue tissue tension and allows a fully corrected position of the foot to be maintained at the end of the initial procedure. A second anaesthetic to obtain further correction is therefore avoided. Partial wound closure leaves cosmetically acceptable scarring with minimal complications. Parents should be warned about the initial appearance of the wound but may be reassured regarding final outcome.

We analysed the short-term outcome after varus osteotomy for Perthes’ disease in 48 older children from south-west India, comparing them with 30 historical controls.

The children were between 7 and 12 years of age at the onset of the disease. All had stage-I or stage-II disease, with half or more of the epiphysis involved. The operated children had an open-wedge subtrochanteric varus osteotomy with derotation or extension and a trochanteric epiphyseodesis. Weight-bearing was avoided until late stage III. The non-operated children had been treated symptomatically by conservative methods.

At the time of healing, 62.5% of the operated group had spherical femoral heads compared with 20% of those treated non-operatively (p < 0.001). Of the operated children with Catterall group-IV involvement, 48% had good results as against 24% of the non-operated group (p < 0.05). The percentage increase in the radius of the affected femoral head compared with the normal side was significantly lower in children who had operations (14.68 v 25.65; p < 0.001).

We have shown that the short-term results of early surgical containment in children over seven years of age are satisfactory.