Osteoporosis can cause significant disability and cost to health services globally. We aim to compare risk fractures for both osteoporosis and fractures at the L1-L4 vertebrae (LV) and the neck of femurs (NOFs) in patients referred for DEXA scan in the North-West of England.

Data was obtained from 31546 patients referred for DEXA scan in the North-West of England between 2004 and 2011. Demographic data was retrospectively analysed using STATA, utilising chi-squared and t-tests. Logistical models were used to report odds ratios for risk factors included in the FRAX tool looking for differences between osteoporosis and fracture risk at the LV and NOFs.

In a study involving 2530 cases of LV fractures and 1363 of NOF fractures, age was significantly linked to fractures and osteoporosis at both sites, with a higher risk of osteoporosis at NOFs compared to LV. Height provided protection against fractures and osteoporosis at both sites, with a more pronounced protective effect against osteoporosis at NOFs. Weight was more protective for NOF fractures, while smoking increased osteoporosis risk with no site-specific difference. Steroids were unexpectedly protective for fractures at both sites, with no significant difference, while alcohol consumption was protective against osteoporosis at both sites and associated with increased LV fracture risk. Rheumatoid arthritis increased osteoporosis risk in NOFs and implied a higher fracture risk, though not statistically significant compared to LV. Results summarised in Table 1.

Our study reveals that established osteoporosis and fracture risk factors impact distinct bony sites differently. Age and rheumatoid arthritis increase osteoporosis risk more at NOFs than LV, while height and steroids provide greater protection at NOFs. Height significantly protects LV fractures, with alcohol predicting them. Further research is needed to explore risk factors’ impact on additional bony sites and understand the observed differences’ pathophysiology.

For any figures or tables, please contact the authors directly.

Abstract

Aims

Iliopsoas pathology is a relatively uncommon cause of pain following total hip arthroplasty (THA), typically presenting with symptoms of groin pain on active flexion and/or extension of the hip. A variety of conservative and surgical treatment options have been reported. In this retrospective cohort study, we report the incidence of iliopsoas pathology and treatment outcomes.

Hip fractures in young adults are rare but represent an important cohort of patients, of which relatively limited data exists. The aim of this study was to evaluate this distinct subgroup of hip fractures from an epidemiological perspective and assess their subsequent outcomes.

Patients aged 18–50 were identified across an 8 year period from a total of 5326 hip fractures. 46 hip fractures met the inclusion criteria and a retrospective case series analysis was conducted.

25/46 (54%) of fractures were intracapsular and 21/46 (46%) were extracapsular. Only 15/46 (33%) of fractures were sustained from a high energy mechanism and 31/46 (67%) low energy. The low energy cohort was significantly more comorbid with a mean Elixhauser comorbidity score of 1.5 compared to the high energy cohort 0.3 (p<0.0005, unpaired t-test). Alcohol excess was the most prevalent comorbidity present in 24% of patients and was a positive predictor in complication (p=0.006, binary regression). Failure of fixation (non-union/avascular necrosis) in displaced intracapsular fractures sustained following low energy trauma managed by internal fixation 5/11 (45%) was markedly higher than the high energy cohort 0/6 (0%). 5 year mortality was 9% for all hip fractures, six times higher than an aged matched cohort of non-hip fractures (p=0.007, Wilcoxon test).

Representing only 0.86% of all hip fractures in the study period, hip fractures in young adults are rare. A clear sub-division of patients is observed between patients with a low and high energy mechanism, both in terms of level of comorbidity and surgical outcome.

We evaluated an operative technique, described by the Exeter Hip Unit, to assist accurate introduction of the femoral component. We assessed whether it led to a reduction in the rate of leg-length discrepancy after total hip arthroplasty (THA).

A total of 100 patients undergoing THA were studied retrospectively; 50 were undertaken using the test method and 50 using conventional methods as a control group. The groups were matched with respect to patient demographics and the grade of surgeon. Three observers measured the depth of placement of the femoral component on post-operative radiographs and measured the length of the legs.

There was a strong correlation between the depth of insertion of the femoral component and the templated depth in the test group (R = 0.92), suggesting accuracy of the technique. The mean leg-length discrepancy was 5.1 mm (0.6 to 21.4) pre-operatively and 1.3 mm (0.2 to 9.3) post-operatively. There was no difference between Consultants and Registrars as primary surgeons. Agreement between the templated and post-operative depth of insertion was associated with reduced post-operative leg-length discrepancy. The intra-class coefficient was R ≥ 0.88 for all measurements, indicating high observer agreement. The post-operative leg-length discrepancy was significantly lower in the test group (1.3 mm) compared with the control group (6.3 mm, p < 0.001).

The Exeter technique is reproducible and leads to a lower incidence of leg-length discrepancy after THA.

Cite this article: Bone Joint J 2015;97-B:154–9.

The aim of our study was to assess the outcome of caudal epidural injection for patients with low back pain in relation to fatty infiltration of spinal muscle. This is a prospective study. The spinal muscles were graded on sagittal section T1 MRI at the lower border of lumber 4 vertebra from 3 to 12 depending on the severity of fatty infiltration. The outcome of the intervention was assessed by improvement in pre and post intervention oswestry disability index score as well as visual analog pain score. Patients with significant fatty changes don't respond well to the caudal epidural injection.

Introduction:

Early stabilization has the potential to expedite early return to function and reduce hospital stay thus reducing cost to health care. A clinical audit was performed to test the hypothesis that early surgical stabilization lowers the rate of soft tissue complications and is not influenced by choice of distal fibular implants used for stabilization of ankle fractures.

The ideal treatment for traumatic anterior dislocation of the shoulder in the skeletally immature patient is controversial. The aim of this study is to evaluate the outcomes after either conservative and/or surgical treatment using the Latarjet technique. A retrospective series of 49 out of 80 patients were reviewed. We found no significant differences between either treatment method regarding functional scores and pain levels. Although not statistically significant, post-surgical patients showed better signs of shoulder stability than others who have a higher rate of recurrence. Further, 92% of the post-surgical group had returned to the same level of activity versus 52% in the non-surgically treated group. We found no contraindications to operate on a skeletally immature patient.

Cite this article: Bone Joint J 2014;96-B:354–9.

Introduction

There has been a recent surge in the interest of the role of vitamin D in chronic musculoskeletal pain however there are limited studies that have investigated the link of vitamin D hypovitaminosis with low back pain. The aim of our study was to determine the prevalence of low vitamin D levels in patients who present with low back pain in an outpatient setting in the UK.

Leg length discrepancy (LLD) can adversely affect functional outcome and patient satisfaction after total hip arthroplasty. We describe a novel intraoperative technique for femoral component insertion.

We aimed to determine if this technique resulted in the desired femoral placement, as templated, and if this was associated with a reduced LLD.

A series of fifty consecutive primary total hip replacements were studied. Preoperative digital templating was performed on standardised PA radiographs of the hips by the senior surgeon. The preoperative LLD was calculated and the distance from the superior tip of the greater trochanter to the predicted shoulder of the stem was calculated (GT-S). Intraoperatively, this length was marked on the rasp handle and the stem inserted to the predetermined level by the surgeon. This level corresponded to the tip of the greater trochanter and formed a continuous line to the mark on the rasp handle. Three independent blinded observers measured the GT-S on the postoperative radiographs. We assessed the relationship between the senior author's GT-S (preoperative) and the observers' GT-S (postoperative) using a Person correlation. The observers also measured the preoperative and postoperative LLD, and the inter-observer variability was calculated as the intra-class correlation coefficient.

There was a strong correlation of preoperative and postoperative GT-S (R=0.87), suggesting that the stem was inserted as planned. The mean preoperative and postoperative LLD were −4.3 mm (−21.4–4) and −0.9 mm (−9.8–8.6), respectively (p<0.001).

This technique consistently minimised LLD in this series. This technique is quick, non-invasive and does not require supplementary equipment.

Introduction

The advantages of metal on metal (MOM) hip replacement are decreased wear rate, preservation of bone stock, anatomical restoration and enhanced stability. Large amounts of metal wear particles and metal ions are released which may induce adverse reactions including local soft tissue toxicity, hypersensitivity reactions, bone loss and risk of carcinogenesis. Aseptic loosening can be the result of a peri prosthetic osteolysis generated as a result of a biological response to particulate wear debris.

Our aim in this study was to determine whether a steeply inclined acetabular component would give rise to a higher concentration of metal ions.

INTRODUCTION

The advantages of large diameter metal on metal total hip arthroplasty (MoM THA) and hip resurfacing arthroplasty are decreased wear rate, preservation of bone stock, anatomical restoration and enhanced stability. Large amounts of metal wear particles and metal ions are released which may induce adverse reactions including local soft tissue toxicity, hypersensitivity reactions, bone loss and risk of carcinogenesis. Aseptic loosening can be the result of a peri-prosthetic osteolysis generated as a result of a biological response to particulate wear debris.

No reports in the literature exist as to whether circulating levels of Chromium (Cr) and Cobalt (Co) decrease upon removal of a symptomatic large diameter MoM implant or whether levels remain high due to the effect of metal ions debris left behind in the soft tissues after revision surgery.

Bioreactors used in tissue engineering are mostly batch-fed with media added and removed periodically. Continuous flow bioreactors help increase ECM accumulation and cell proliferation, due to continuous flow of fresh media, thus, maintaining a steady extracellular nutrient environment. In previous work, we found chondrocytes cultured in continuous flow bioreactors with 20mM HEPES, accumulated considerably more matrix than static cultures. Hence, the objective of this study is to determine if NaHCO3 helps maintain a more physiological extracellular pH in the bioreactor, thus, enhancing ECM accumulation.

Cartilaginous tissue constructs were generated from isolated chondrocytes harvested from the metacarpal joints of 12-18 month old calves. Cells were seeded in high-density 3D cultures (2 million cells/construct). Constructs were cultivated in a continuous flow bioreactor, with and without 14 mM NaHCO3 supplemented media, for 5 weeks, at 37 degrees Celsius, 95% relative humidity and 5% CO2. After 5 weeks of culture the tissue weight, thickness, pH and ECM deposition were determined.

From the results obtained (Table 1), it is evident that chondrocytes cultured in the continuous flow bioreactor with 14mM NaHCO3 and 20mM HEPES, proliferated more extensively and produced more ECM than chondrocytes cultured in only 20mM HEPES. Additionally, the NaHCO3 constructs accumulated ECM in both the vertical (thickness) and horizontal (outgrowth) planes. The question then arises, are the effects mediated by improved buffering, or by addition of NaHCO3 itself. There was a significant difference between the pH of media with (pH 7.41) and without NaHCO3 (pH 6.95) supplementation, with no exposure to cells or tissue; when allowed to equilibrate with 5% CO2 at 37 degrees Celsius. However, there was little difference between the media after exposure to cells; after five weeks of culture in the bioreactor (Table 1). Thus, in the bioreactor with bicarbonate present, because of increased cell number and activity, the pH fell 0.54 pH units during the 7 hour residence time in comparison to the bioreactor with no bicarbonate supplementation. With no NaHCO3 supplementation, the extracellular pH of the medium fed to the cells was never above pH 7.0 (Table 1); low pH could account, at least in part, for lower ECM and cell numbers.

Purpose

In revision hip surgery, Type IIIB femurs have presented the greatest historical challenge to achieving stable fixation and osseous integration. This study evaluated the intermediate term outcome of a modular, tapered, distal fixation revision femoral component used in a consecutive revision hip series with special attention to its performance in the defective Type IIIB femur.

Patients with peripheral primary bone tumours are often identified and referred at an early stage to a regional tumour service according to established guidelines. In patients with primary bone tumours of the spine, however, the definitive management or outcome of such patients is being prejudiced by preliminary intervention from non-specialist services prior to their referral.

Objective: To audit the standards of management of patients with primary bone tumours of the spine referred to a regional tumour service.

Retrospective review of case notes and radiology.

Subjects: Patients with primary bone tumour of the spine managed at the Orthopaedic Spine Unit with the Regional Bone Tumour Service in Newcastle Upon Tyne Hospitals NHS Trust.

Referral to tumour service, prior intervention, operative treatment, survival, factors affecting definitive management

31 of 39 (16 benign, 23 malignant) patients were initially referred from primary care to services other than the regional tumour service, most commonly neurosurgery (11/39) and paediatric oncology (4/39). Seven of 39 of these patients had undergone interventions prior to their referral to the tumour service, which may have negatively impacted their definitive management or curative surgery.

These tumours present complex issues regarding their definitive management to optimise outcome. Closer links between departments are required to enable the multidisciplinary management of primary bone tumours of the spine. Prior surgical intervention may compromise cure. Those involved in their management should be encouraged to liaise with their regional bone tumour service to improve outcome.

Background: From August 2009, all doctors were subject to the European Working Time Directive (EWTD) restrictions of 48 hours of work per week. Changes to rota patterns have been introduced over the last two years to accommodate for these impending changes, sacrificing ‘normal working hours’ training opportunities for out-of-hours service provision. We have analysed the elogbook data to establish whether operative experience has been affected.

Methods: A survey of trainees (ST3-8) was performed in February 2009 to establish shift patterns in units around the UK. All operative data entered into the elogbook during 2008 at these units was analysed according to type of shift (24hr on call with normal work the following day [traditional on call], 24hr on call then off next working day, or shifts including nights).

Results: 66% of units relied on traditional 24hrs on call in February 2009. When compared with these units, trainees working shifts had 18% less operative experience (564 to 471 operations) over the six years of training, with a 51% reduction in elective experience (288 to 140 operations). In the mid years of training, between ST3-5, operative experience fell from 418 to 302 operations (25% reduction) when shifts were introduced.

Discussion: The eLogbook is a powerful resource that provides accurate data for the purpose of supporting orthopaedic training. This national data reflects the situation in UK hospitals in 2009, prior to the implementation of a maximum of 48 hours. It is expected that most hospitals will need to convert to shift-type working patterns to fall within the law. This could have significant implications for elective orthopaedic training in the UK.

Introduction: In August 2007, the Department of Health initiative Modernising Medical Careers was implemented. This was a system of reform and development in postgraduate medical education and training. In preparation for the changes, the SAC for T& O outlined a new curriculum. The emphasis of early training, StR years 1 and 2, was to be trauma. We aim to identify how effectively the SAC proposals are being applied, and what difference this makes to the trainees’ operative experience? Furthermore, how do the new posts compare to the historic SHO models?

Methods: A survey carried out by BOTA allowed us to assess post compliance with the SAC recommendations. A compliant job was defined as trauma based for 50% or more of working time. Consent was obtained to evaluate the eLogbooks of trainees in compliant and non-compliant jobs, along with registrars who had previously held traditional SHO grade posts. Overall operative experience over a specified 4 month time period was examined, with focus on routine trauma procedures.

Results: The results of the BOTA and SAC survey revealed that 45% of the new orthopaedic posts were compliant with curriculum guidelines. The eLogbooks of 92 individuals were analysed; 28 historical posts, 34 compliant and 30 non-compliant. The mean total number of recorded entries by trainees in the 4 month period was 73.2 in the historic group, 90.5 in the compliant and 87.3 in the non-compliant job group. The corresponding numbers of trauma operations were 35.7, 48.4 and 41.5.

Conclusions: Operative experience has improved since the introduction of the new curriculum. The new posts are offering more operative and in particular trauma exposure than traditional SHO jobs. If jobs can be restructured such that they all comply with the SAC, educational opportunities in the early years will be maximised.

Introduction: Majority of children with cerebral palsy patients suffer from fixed flexion contractures of their knees. Procedures commonly used to correct knee flexion deformities include hamstring release, anterior femoral hemiepiphyseodesis and femoral extension osteotomies. The latter procedure can cause neurovascular complications. Femoral stapling procedures are not very popular because of a theoretical risk of permanent physeal closure. We present our initial experience in correction of knee flexion deformity by using the 8-plate technique. This uses guided growth in the distal femoral physis to achieve gradual correction of the knee flexion deformity.

Materials and Methods: We reviewed a consecutive series of 25 children with fixed flexion deformity of the knee who underwent anterior femoral hemiepiphysiodesis using a two-hole plate (8-plate) between April 2005 and April 2008. The pre-operative and postoperative knee flexion deformity (in degrees) and complication rates were also recorded. Paired t-Test was undertaken to assess the correction in the fixed flexion deformity post-operatively

Results: Total number of patients – 25, male:female = 19:6. Total number of limbs – 46

The mean age of the patients was 11.04 years (range between 4–16). Mean follow up time for the patients after they had undergone the procedure was 16.2 months (range 3 – 34). The Mean correction achieved − 21.52 degrees (range 5 – 40). Mean correction per month − 2.05 degrees. A paired ‘t’ test showed the correction was found to be highly statistically significant (p value < 0.001).

Conclusion: We conclude that this is a simple technique with few complications to date. The learning curve for this procedure is 1 case. All patients in our series have shown promising results, with sustained gradual correction to date.

Purpose: To assess moderate-term outcomes of silastic joint replacements of the first metatarsophalangeal joint.

Method: The thirty-two patients (37 feet) that had silastic implants inserted were reviewed at an average of 2 years and 4 months (ranging 7 months to 5 years and 4 months). The mean patient age was 63 years. These patients answered a subjective questionnaire, had their feet examined clinically and radiographically and a pre-operative and post-operative AOFAS score was calculated for each.

Results: The follow-up assessment revealed that every patient described that their pain had decreased after surgery and 17 feet (46%) were completely pain free. There was a significant improvement in patients’ subjective pain scores after surgery (t value = < 0.0001). Pre-operatively, the mean pain score for all 37 feet was 8.14, whereas post-operative the mean pain score was 1.32. The mean AOFAS score before surgery was 39.97. This increased to a mean score of 87.40 after surgery (P = < 0.0001). This again is a significant improvement. No patient was dissatisfied with the outcome with their surgery.

Conclusion: These moderate term results are encouraging, with good subjective and objective results. However, long-term follow-up will be required to assess the longevity of this implant.

An online survey has been carried out to evaluate the compliance with the OCAP learning tools, and the availability of clinical experience to early years’ trainees in Trauma and Orthopaedics in 2007–8. Three surveys were planned over the year, and we present the results from the first two surveys. Over the initial eight month period, 335 trainees in Trauma and Orthopaedic posts responded. There was considerable variation in the proportion of responses from different deaneries, and it was felt this reflected differences in the use of the two logbooks available (FHI or ISCP).

Respondents were FTSTAs (50%), ST1s (11%) and ST2s (29%). The respondents reported their operative experience was poor with low numbers of index procedures – the median values being 2 DHS, 1 Hemiarthroplasty and 0 for Ankle ORIFs performed as the lead surgeon in the first 4 months, rising to 3, 1 and 1 respectively in the second. As an assistant the numbers were 3, 4 and 3. FTSTAs had done more procedures as lead surgeon. It is not clear whether this reflects motivation, or whether they are trainees who were unable to secure training posts due to seniority and were already more experienced. Many posts were entirely ward based.

Improvements in meetings with Assigned Educational Supervisors were noted, as was the use of the learning agreements, and with registration rates with the ISCP. There was considerable variation between posts, hospitals and deaneries, and a tool was developed to summarise this data to be post-, trainee-, and duration-specific. Summaries of each post were distributed to Training Program Directors, Heads of School, and the SAC. Although some improvement has occurred, further rounds of the survey are necessary to ensure that this continues. The next round will commence in September 2008 to complete twelve months of data.

Background: Although needle tip position has been correlated with outcome with respect to pain relief, and to complication rate, to our knowledge, no previous study assesses the location of the needle tip with respect to its ability to isolate injectate around the exiting nerve root without blocking the traversing nerve root to the next caudal level.

Aim: To study the location of injectate when diagnostic selective nerve root blockade is performed.

Method: 87 consecutive selective nerve root blocks performed by a single surgeon were assessed. A consistent surgical technique was utilised. Antero-Posterior fluoroscopy films were analysed to determine the location of injectate in relation to the foraminal and pedicle anatomy. A pro-forma operation note ensured all necessary data was collected prospectively.

Results: Of needle tips positioned lateral to the middle third of the superior pedicle on the AP view, 45 of 51 flowed into the nerve sheath alone, and 6 flowed into both the nerve sheath, and spinal canal. Of these 6, 2 were due to a larger volume of contrast injected, and 2 were due to abnormal anatomy from marked lumbar degenerative scoliosis. Of tips located below the middle third of the pedicle, 2 of 29 flowed into the nerve sheath alone, 2 flowed into the canal alone, and 27 flowed into both. Of those placed medial to zone below the middle third of the pedicle, all seven flowed into the canal only. Analysis using Fisher’s Exact test yielded an extremely statistically significant result, with p < 0.001 comparing needle tip positions in the lateral position with the mid-zone and medial tip positions, and their relationship with injectate reaching the traversing nerve root.

Discussion: For a nerve root block to be truly selective, no injectate must flow past the exiting root to the traversing root. Low volumes of injectate must be placed predictably and accurately. This paper demonstrates the importance of needle tip location in preventing flow beyond the foramen. It is also recommended that contrast be used when significant deformity is present. In cases where there is a therapeutic rather than diagnostic intention, such accuracy is unnecessary. This study does not address the efficacy of the selective nerve root block as a non-operative intervention, nor does it assess the ability of the block to predict operative benefit. It does, however, provide a benchmark for accuracy achievable in patients without significant spinal deformity.

Conclusion: Care must be taken to ensure that the needle tip is positioned lateral to the zone below the middle third of the pedicle if a selective nerve root block is to be used for diagnostic purposes, particularly if there is significant deformity or no contrast is used. In the absence of deformity, however, selective nerve root block may be performed reliably, with a location accuracy of 96%.

Aim: Subtle intra-articular screw penetration of the distal radius during fracture fixation is difficult to determine using standard PA and lateral radiographs. The purpose of our study was to determine which radiographs most reliably identify penetration into the joint.

Methods: A distal volar locking plate was applied to an isolated cadaveric radius bone and a series of plain radiographs taken. The radius, fixed along its long axis, was allowed to rotate through 180 degrees and inclined, in increments, to 40 degrees. In the control group the distal screws did not breach the articular surface. In the study group the screws penetrated the articular surface by 1mm. In each group 65 plain radiographs were taken and the presence or absence of screw penetration scored by two blinded observers.

Results: Using Weighted Kappa analysis the overall inter-observer agreement for all views was 0.5 (CI 0.39 –0.63). However in 7 radiographs there was complete inter-observer agreement correctly identifying screw penetration of the articular surface. The articular surface was correctly identified as intact in 13 views. Only a 75 degrees pronated view, without inclination, was 100% sensitive and specific for identifying the absence or presence of screw penetration through the articular surface.

Conclusion: The intra-operative use of a 75 degrees pronated view may reduce the need for repeated use of the image intensifier and excessive irradiation during plate fixation of distal radius fractures.

Introduction: Avascular necrosis of the femoral head may play a role in failure of the femoral component in metal on metal hip resurfacing arthroplasty. The purpose of our study was to determine, prospectively, femoral head perfusion during hip resurfacing arthroplasty in the posterior and anterolateral approaches.

Methods: 20 hip resurfacing arthroplasties were performed in 19 patients between September 2005 and March 2006 by two different surgeons; one using the extended posterior approach and the other an anterolateral approach. There were an equal number of procedures for each approach. 1.5 gms of intravenous cefuroxime was administered following caspsulectomy and relocation of the femoral head. After 5 minutes the femoral head was dislocated and prepared as routine for the operation. Bone from the top of the femoral head and reamings were sent for assay to determine the concentration of cefuroxime. The average time taken to prepare the femur and take samples was 8.5 minutes.

Results: The concentration of cefuroxime in bone was significantly greater when using the anterolateral approach (mean 15.7mg/kg; CI 12.3 – 19.1) compared to the posterior approach (mean 5.6mg/kg; CI 3.5 – 7.8; p< 0.001). In one patient, who had the operation through a posterior approach, cefuroxime was undetectable.

Discussion: The posterior approach is associated with a significant reduction in the blood supply to the femoral head during hip resurfacing arthroplasty. This may be a cause for avascular necrosis and potential failure of the femoral component in this procedure.

Aim: To study the location of injectate when diagnostic selective nerve root blockade is performed.

Method: 87 consecutive selective nerve root blocks performed by a single surgeon were assessed. A consistent surgical technique was utilised for all patients. Antero-Posterior fluoroscopy films were analysed to determine the location of injectate in relation to the foraminal and pedicle anatomy.

Results: Of needle tips positioned lateral to the middle third of the superior pedicle on the AP view, 45 of 51 flowed into the nerve sheath alone, and 6 flowed into both the nerve sheath, and spinal canal. Of these 6, 2 were due to a larger volume of contrast injected, and 2 were due to abnormal anatomy from marked lumbar degenerative scoliosis. Of needle tips located below the middle third of the pedicle, 2 of 29 flowed into the nerve sheath alone, 2 flowed into the canal alone, and 27 flowed into both. Of those placed medial to zone below the middle third of the pedicle, all seven flowed into the canal only.

Conclusion: Care must be taken to ensure that the needle tip is positioned lateral to the zone below the middle third of the pedicle if a selective nerve root block is to be used for diagnostic purposes, particularly if there is significant deformity or no contrast is used. In the absence of deformity, however, selective nerve root block may be performed reliably, with a location accuracy of 96% providing the tip of the needle lies in the lateral position described.

There are no long-term published results on the survival of a third-generation cemented total shoulder replacement. We describe a clinical and radiological study of the Aequalis total shoulder replacement for a minimum of ten years. Between September 1996 and May 1998, 39 consecutive patients underwent a primary cemented total shoulder replacement using this prosthesis. Data were collected prospectively on all patients each year, for a minimum of ten years, or until death or failure of the prosthesis. At a follow-up of at least ten years, 12 patients had died with the prosthesis intact and two had emigrated, leaving 25 available for clinical review. Of these, 13 had rheumatoid arthritis and 12 osteoarthritis. One refused radiological review leaving 24 with fresh radiographs.

Survivorship at ten years was 100% for the humeral component and 92% for the glenoid component. The incidence of lucent lines was low. No humeral component was thought to be at risk and only two glenoid components. The osteoarthritic group gained a mean 65° in forward flexion and their Constant score improved by a mean 41.4 points (13 to 55). The rheumatoid group gained a mean of 24° in flexion and their Constant score improved by 29.4 points. This difference may have been due to failure of the rotator cuff in 75% of the patients with rheumatoid arthritis.

Thus a third-generation total shoulder replacement gives an excellent result in patients with osteoarthritis and an intact rotator cuff. Patients with rheumatoid arthritis have a 75% risk of failure of the rotator cuff at ten years.

Aim: Subtle intra-articular screw penetration of the distal radius during fracture fixation is difficult to determine using standard PA and lateral radiographs. The purpose of our study was to determine which radiographs most reliably identify penetration into the joint.

Methods: A distal volar locking plate was applied to an isolated radius bone and a series of plain radiographs taken. The radius, fixed along its long axis, was allowed to rotate through 180 degrees and inclined, in increments, to 40 degrees. In the control group the distal screws did not breach the articular surface. In the study group the screws penetrated the articular surface by 2mm. In each group 65 plain radiographs were taken and the presence or absence of screw penetration scored by two blinded observers.

Results: Using Weighted Kappa analysis the overall inter-observer agreement for all views was 0.5 (CI 0.39–0.63). However in 7 radiographs there was complete inter-observer agreement correctly identifying screw penetration of the articular surface. The articular surface was correctly identified as intact in 13 views. Only a 75 degrees pronated view, without inclination, was 100 % sensitive and specific for identifying the absence or presence of screw penetration through the articular surface.

Conclusion: The intra-operative use of a 75 degrees pronated view may reduce the need for repeated use of the image intensifier and excessive irradiation during plate fixation of distal radius fractures.

Introduction: Dividing the short external rotators 2 cm from their insertion into the femur should preserve the deep branch of the medial femoral circumflex artery. Our aim was to determine, prospectively, femoral head perfusion during hip resurfacing arthroplasty comparing two posterior approaches.

Methods: 20 hip resurfacing arthroplasties were performed in 20 patients by two different surgeons between September 2005 and November 2006. Patients were divided into two equal groups according to approach. One surgeon used the extended posterior approach and the other a modified posterior approach. Intravenous cefuroxime was administered in every case following capsulectomy and relocation of the femoral head. After 5 minutes the femoral head was dislocated and prepared as routine for the operation. Bone from the top of the femoral head and reamings were sent for assay to determine the concentration of cefuroxime.

Results: There was no statistical difference between the concentration of cefuroxime in bone when using the modified posterior approach (mean 5.6mg/kg; CI 3.6 – 7.8) compared to the extended posterior approach (mean 5.6; CI 3.5 – 7.8; p=0.95). In one patient, who had the operation through the posterior approach, cefuroxime was undetectable.

Discussion: The similarity in femoral head perfusion between approaches suggests the blood supply is further impaired by capsulectomy rather than by damaging the MFCA alone.

Aim: We present a new trunk asymmetry index for topographic measurement of patients with thoracolumbar scoliosis, which does not require full 3-dimensional reconstruction of the back shape and can be performed with a digital camera and a laptop.

Material and methods: To date, 27 patients were assessed preoperatively, and 14 of these also had post operative assessments. The midline was identified between the two lateral edges of the trunk visible on a digital photograph. This was compared with a straight line. We derived an asymmetry index for each image and compared this with the cobb angle on x-rays pre- and postoperatively.

Results: The new asymmetry index correlated well with the cobb angle up to about 50°. Curves beyond this tended to have compensatory curves. This made interpretation more complex, however, if the compensatory cobb angle was subtracted from the major cobb angle, the asymmetry index fell at the expected points. It clearly distinguishes pre-operative and post-operative images. With POTSI, (posterior trunk symmetry index) there is a significant difference between the pre- and post-operative groups and significant overlap of the two distributions.

Conclusions: Surface topography of scoliotic patients is a useful tool to assess the progression of scoliosis without X-rays, reducing radiation exposure. The proposed new index is a promising measurement for monitoring the progress of a thoracolumbar curve with much better sensitivity and specificity than existing topographic indices, without requiring the capital outlay for surface topography equipment as it can be obtained from a simple digtal photograph and laptop.

Aim: Avascular necrosis of the femoral head is believed to play a role in failure of the femoral component in metal on metal hip resurfacing arthroplasty. The purpose of our study was to determine, prospectively, femoral head perfusion during hip resurfacing arthroplasty in the posterior and anterolateral approaches.

Methods: 20 hip resurfacing arthroplasties were performed in 19 patients between September 2005 and April 2006. Patients were divided into two groups according to approach. An equal number of operations were performed by two different surgeons; one using the extended posterior approach and the other an anterolateral approach. Intravenous cefuroxime was administered in every case following capsulectomy and relocation of the femoral head. After 5 minutes the femoral head was dislocated and prepared as routine for the operation. Bone from the top of the femoral head and reamings were sent for assay to determine the concentration of cefuroxime.

Results: The concentration of cefuroxime in bone was significantly greater when using the anterolateral approach (mean 15.7mg/kg; CI 12.3 to 19.1) compared to the posterior approach (mean 5.6mg/kg, CI 3.5 to 7.8; p< 0.001). In one patient, who had the operation through a posterior approach, cefuroxime was undetectable.

Conclusion: The posterior approach is associated with a significant reduction in the blood supply to the femoral head during hip resurfacing arthroplasty. This may be a cause for avascular necrosis and potential failure of the femoral component in this procedure.

This is a prospective study to determine if we could identify patients who may benefit from preoperative catheterisation in lower limb arthroplasty.

211 consecutive patients undergoing total hip and knee arthroplasty were recruited. There were 131 female (62%) and 80 male (32%), the mean age (+−1 S.D.) was 68+−12 years old. Patients’ demographic details and pre-operative urinary symptoms were recorded. Previous urological surgery and past history of urinary catherisation were also documented. The anaesthetist who was blinded from the study selected the type of anaesthesia and the post-operative analgesia regime. All patients were required to produce mid-stream urine sample before surgery and at post-operation. Urine tract infection was confirmed on a positive microbiological culture. Regression analysis was used to assess various co-variables to identify the high-risk groups.

35 female (56%) and 27 male (44%) were catheterised, the mean age (+−1 S.D.) was 72+/−14 years old. The frequency of catheterisation was unrelated to the surgical procedure, the type of anaesthesia or the postoperative pain control regime. Age over 65 years old and nocturia were significant indicators for urinary catheterisation (p< 0.05). Patients with urinary incontinence and nocturia were strong determinant for urinary catheterisation (p< 0.03). Males over the age 65 years with a past history of urinary catheterisation (p=0.037) were more likely to be catheterised than females of the same group (p=0.947). This has become more evidential if patients have coexisting urinary incontinence and nocturia (p=0.005). Females over the age of 65 years with urinary incontinence were also significant (p=0.013).

The sensitivity for urinary catheterisation in patients over the age of 65 years with previous history of catheterisation, urinary incontinence or nocturia was 89.7%. This group of patients would benefit from pre-operative urinary catheterisation.

While the early period of distraction osteogenesis has been extensively investigated, there are very few data describing the long-term morphology of the regenerate. We performed magnetic resonance scans in ten adults (men age 35+− 11 yr), seven of whom had bone transport for an iatrogenic osseous defect while further three had tibial lengthening for limb length discrepancy. Follow-up ranged between 14 and 43 months (mean : 28 + − 10 months) following the removal of the external fixator. The perimeter, cross- sectional area, volume and the mean signal intensity was calculated from the obtained T1 weighted axial images. Values were compared with the contralateral tibia that acted as control. All cases that had bone transport increased the volume of the tibia from 15.3% up to 50.8%. The regenerated segment was noted to have expanded significantly (p< 0.0001) in all cases. Mean signal intensity in the regenerate decreased in seven cases significantly (p< 0.0001) suggesting increase content of unhydrated tissue such as bone and collagen. The cross-sectional surface of the transported segment was increased in all cases (p< 0.008). Finally in cases that underwent bone transport, the docking site was noted to be obstructed by unhydrated tissue. Contrary to previous claims, the post-distraction osteogenesis tibia is far from normal, consisting of areas with potentially different biomechanical properties. Recognition of these changes is essential not only for appropriate pre-operative counselling but also for considering treatment modalities in case of a fracture.

We present our technique for arthrodesis of the failed Keller’s excisional arthroplasty and the results of postoperative follow-up in a series of eight patients [nine feet].

Arthrodesis of the first metatarsophalangeal joint was performed with a tricortical interposition bone graft stabilised between the first metatarsal and proximal phalanx with a mini dental plate. In all cases the indication for the procedure was for chronic pain at the first meta-tarsophalangeal joint and transfer metatarsalgia of the lateral rays. Post-operative follow-up ranged from 13– 70 months and patients were evaluated using a custom-made satisfaction questionnaire, clinical examination and evaluation of pre-and post-operative x-rays.

All patients were female. The mean age of the patients was 53.2 years [range 32–69]. The post- operative questionnaire revealed that five patients [six cases] were highly satisfied with the surgery. However, we do report complications associated with the procedure including one case of deep infection and four cases in total of radiological non-union of the graft.

The majority of patients were highly satisfied with the surgery, but this technique for the revision of failed Keller’s procedures has a significant risk of complications, so patients should receive appropriate counselling pre-operatively. Although the mini dental plate was low profile, its decreased rigidity may have been responsible for the four cases of non-union.

We determined the effect of the surgical approach on perfusion of the femoral head during hip resurfacing arthroplasty by measuring the concentration of cefuroxime in bone samples from the femoral head. A total of 20 operations were performed through either a transgluteal or an extended posterolateral approach.

The concentration of cefuroxime in bone was significantly greater when using the transgluteal approach (mean 15.7 mg/kg; 95% confidence interval 12.3 to 19.1) compared with that using the posterolateral approach (mean 5.6 mg/kg; 95% confidence interval 3.5 to 7.8; p < 0.001). In one patient, who had the operation through a posterolateral approach, cefuroxime was undetectable.

Using cefuroxime as an indirect measure of blood flow, the posterolateral approach was found to be associated with a significant reduction in the blood supply to the femoral head during resurfacing arthroplasty compared with the transgluteal approach.

Introduction: The anterior drawer test for anterior cruciate ligament (ACL) deficiency, requires a subjective assessment of joint movement, as the tibia is pulled forward. The aim of this study was to objectively quantify this movement using a magnetic tracking device.

Materials and Methods: Ten patients aged 24 to 44 years were assessed as having unilateral ACL deficiency with conventional clinical tests. These patients were then re-assessed using a magnetic tracking device (Polhemus Fastrak). Patients had magnetic sensors attached around their femurs and tibias using elasticated Velcro straps. The Anterior Drawer test was then performed with the patient lying within range of the system’s magnetic source. The test was performed three times on the normal and injured knees of each patient, using a spring balance to apply a standard 20 lb (=89 N) force. During the tests, sensor position and orientation data was collected with an accuracy better than 1 mm and 1 degree, respectively. The data was sampled at 10Hz and stored on a computer for post-test analysis. This analysis deduced the tibial displacement resulting from each anterior drawer.

Results: During the anterior drawer test the supine patient’s knee is in 90 degrees flexion, with the foot planted on the examination couch. As the tibia is pulled anteriorly, it rotates upwards from the foot and the femur experiences a corresponding rotation from the hip. These complex coupled movements are best quantified in terms of absolute displacement of the tibia from the femur. In the normal knees, the mean displacement of the tibia from the femur was 4.2 mm (SD=1.6). In comparison the ACL deficient knees had a mean displacement of 6.3 mm (SD=2.9). This is 50 % more. A paired t test of this data showed a highly significant difference, with P = 0.005.

Conclusion: This study has quantified the movement produced during the Anterior Draw test for ACL deficiency. The tracker’s lightweight sensors caused minimal disturbance to the established clinical test. The system therefore provides objective measurement data to augment the clinicians subjective assessment.

Aim of study: To establish whether there was a correlation between the degree of bony spinal canal encroachment and initial neurological deficit and subsequent neurological recovery.

Methodology and Results: Twenty-six Patients with Thoraco-lumbar Burst fractures presenting with Frankel Grades C, D and E were studied retrospectively. All the Patients were admitted to the spinal injury centre within seven days of injury and were managed conservatively with bed rest for six weeks (mean) followed by brace or a POP jacket for a further period of approximately six weeks. Neurological progress was assessed by Frankel Grade and American Spinal Injury Association (ASIA) motor score.

The degree of spinal canal encroachment was determined from coronal sections of the CT scan by measuring the antero- posterior diameter (APD) and the surface area (Area). (APD 18.84% – 80.62%, Area 9.5% – 81.29%).

Average period of follow up was 24.8 months. All Frankel Group C improved to Frankel D and six out of the 13 Frankel D patients improved to Frankel E. The other seven Frankel D patients out of the 13 patients also had improvement in motor scores but did not change Frankel grade.

Conclusion: There appeared to be no statistically significant correlation between the degree of canal encroachment, the degree of initialneurological impairment or the degree of neurological recovery in patients who had motor sparing within one week of injury.

Purpose: To evaluate the clinical results after meniscal repair using Bionx arrows.

Methods: The study reports the clinical results of 50 patients who had meniscal repair.

The meniscal repairs were carried out by a single surgeon over a period of 4 years.

30 patients ( 1st set) had isolated meniscal repairs. 9 patients ( 2nd set) had meniscal repairs and ACL reconstruction at the same time. 11 patients (3rd set) had meniscal repair followed by ACL reconstruction few months later. The patients were seen in the clinic at 2, 6, 24 weeks post surgery and then kept under surveillance.

Results: In the 1st set , there were only 2 failures who needed partial menisectomy at 7 months and 2 years respectively after the initial repair. So, the failure rate is only 6.6%.

There was only 1 failure in the 2nd set who needed partial menisectomy 19 months post repair. This gives it a failure rate of 11.1%. In the 3rd set, there were 2 failures out of whom one needed partial menisectomy and other needed re-repair using the arrows at 3 and 7 months respectively post repair at the time of ACL reconstruction, a failure rate of 18.8%.

Repair of distal biceps tendon rupture is a subject that has received increasing attention in the past decade. In the active individual who desires as close to normal function as possible, repair of biceps tendon is recommended.

The author describes a tehnique with a single anterior incision and fixation with superanchors. This method was successfully used in 25 patients with excellent functional results. There were no failures and no complications of neurological injury. The single anterior incision approach in which superanchors are used is recommended as an alternative to the traditional two-incision method.

The Biceps brachii is an important flexor of the elbow and is the main supinator of the forearm. Avulsion of its distal tendon insertion is rare injury that mostly affects middle-aged men. It represents only 3% of all biceps tendon ruptures. There is an average of 1.24 spontaneous complete distal biceps ruptures per 100,000 people per year.

The decline in the number of distal biceps tendon ruptures with increasing age correlates with a decrease in at-risk activities after the fourth decade of life. Decreased vascularity, tendon impingement, degenerative changes of the distal biceps tendon and the use of anabolic steroids have been postulated to predispose to tendon rupture.

Our study shows that repair of distal biceps tendon ruptures using superanchors is safe and gives clinically objective and functional results similar to bone tunnel fixation.

We had no major complications, no suture anchor failures and no occurrence of synostosis and neurological injuries. We recommend the use of superanchors for the treatment of distal biceps tendon ruptures.

Do patients’ recollections of disease severity following joint replacement surgery accurately reflect their pre-operative disability? Oxford Knee score questionnaires were sent to 100 patients who had undergone primary knee replacement surgery between January 1998 and July 2000.They were asked to complete these in a manner reflecting their pre-operative disability. The results were then compared with actual scores completed by the same group of patients prior to their surgery. The response rate was 78%.The mean pre-operative score was 45 compared to the recall score of 46.9. The difference was not significant (p=0.77).We believe that recall of disability using a simple knee score is a reliable method of assessing pre-operative disability.

There is a legal and ethical obligation to gain informed consent before treatment commences. A number of bodies have issued guidelines for obtaining consent and these include the Department of Health, the GMC, The Royal College Surgeons of England, and the B.O.A. For a patient to give their informed consent to surgery they must receive sufficient information about their illness, proposed treatment and its prognosis. There are no specific guidelines regarding joint replacement. With this in mind a retrospective case note study was undertaken involving 100 patients who had undergone a hip replacement. Noting the documented discussion at all stages of patient contact.Fifty percent of patients had been seen and listed in the Outpatients by a Consultant, 25% were discussed with the Consultant responsible and the remainder were listed without Consultant input. In only 33 % of cases were any specific risks recorded. This had fallen to 4% on their visit to pre operative assessment clinic. All the consent forms were completed at the time of admission for surgery. Forty percent of these on the day of surgery. The majority were completed by SHOs (58%), while only 4% were completed by consultants. None of the forms noted the lead surgeon. All the consent forms noted some frequently occurring risks. However there was a large variance in the details recorded. The study highlights that the majority of complications are only documented on the consent form, with little note of the dialogue leading up to it. It is also apparent that there is no agreement as to what represents a significant or frequent complication.

This review raises a number of important issues. There needs to be a national standardisation of the process of consent. We propose the introduction of a specific consent form for hip replacements that provide improved documentation of the standardised risks involved. This should also include guidelines regarding prosthesis choice, surgical approach and the extent of trainee involvement. In addition we would also suggest there is a need to improve sequential documented discussion up to the point of surgery and introduce specific training for juniors carrying out consent.

Introduction and aims: Numerous questionnaires are available to assess outcome of hip arthroplasty, but as yet there is no consensus as to which are the most appropriate to use following acetabular osteotomy. We have prospectively evaluated a quality of life measure validated for patients from the United Kingdom and self-administered disease and hip specific questionnaires in patients undergoing Bernese periacetabular osteotomy and compared these to outcome as measured by the Harris hip and Merle d’Aubigne and Postel hip scores.

Method: Since 1997, 24 Bernese periacetabular osteotomies have been performed at our institution. Only patients with a primary diagnosis of development dysplasia of the acetabulum, no evidence of degenerative disease and a minimum of 24 months of follow-up were included in this study. Any non life-threatening co-morbid conditions were documented and recorded. Harris hip (HHS), Merle d’Aubigne and Postel (MDP), Nottingham Health Profile (NHP) and Oxford Hip scores (OHS) were calculated pre-operatively and post-operatively at 6 weeks, 12 weeks, 6 months, one year and then yearly.

Results: Patients have been followed up for an average of 3.2 years (range: 1–5.5 years). The male: female ratio was 1: 8.5. The average age at time of operation was 32.3 years (range 18 – 48). No patient required further surgery or conversion to total hip arthroplasty. Mean postoperative HHS was 89.9. MDP 16.4 and OHS 16.3. All dimensions of the NHP demonstrated improvement of greater than 50 %. The MDP and OHS were most sensitive to time of assessment in the post-operative period. There was no significant difference in the order of magnitude of improvement between any of the scores.

Conclusion: This study has demonstrated that the Bernese periacetabular osteotomy, in a carefully selected group of patients, has a reproducibly good outcome as measured by a variety of scoring methods dependent upon both clinician and patient derived assessment.

We explored the association of post-operative pyrexia following hip arthroplasty and the development of deep infection Method: The postoperative temperature records of 80 patient’s following primary hip replacement were retrospectively analysed. Thirty-one patients had revision surgery at a mean time interval of 37.2 months (range 5–74 months) for confirmed deep prosthetic infection. The control group of patients were asymptomatic at a mean follow-up of 31.5 months. There were 28 patients with an uneventful clinical outcome following surgery and 21 patients who had developed a systemic infection during their stay in hospital. The maximum daily temperature of each patient was recorded. Results: The mean peak temperature of patients with deep prosthetic infection was significantly lower then patients with a systemic infection or a normal clinical recovery following surgery (p=0.01). The difference between the peak post-operative temperature and the preoperative temperature was also significantly lower in patients who subsequently required revision surgery for prosthetic infection (p=0.007). Conclusion: Patients with deep prosthetic infection have a lower pyrexia response then patients with either an uneventful clinical recovery or the development of a systemic infection following total hip replacement. Pyrexia is part of the acute phase response following surgery is mediated by cytokines including IL-1 and IL-6, which are also involved in activation of the patients cellular and humoral immune response. A low pyrexia response following surgery may therefore also be suggestive of reduced acute phase response to the potential wound contamination produced during surgery with a consequence of subsequent prosthetic infection.

Aims: To investigate whether blood transfusion practice in primary total knee replacement (TKR) was being managed appropriately, and to assess the cost effectiveness of pre-operative autologous donation (PAD). Methods: A retrospective survey of blood transfusion practice was conducted for all TKR. The unit has an established PAD service with over 60% uptake for suitable candidates. An analysis of all pre-operative and post-operative haemoglobin concentrations (Hb) was performed. Using Hb concentration of 8 g/dl or 9 g/dl as the transfusion criteria, the total units of blood used, saved or discarded was calculated. Results: 174 TKR were performed, 84 (48%) patients were transfused. 52 patients (117 units) received allogenic blood, 35 patients (61 units) received PAD blood, 8 patients received both. 60 units (50%) of PAD were discarded. Using a level of Hb of 8 g/dl, 46 patients (96 units) would have received allogenic blood, 30 patients (51 units) would have received PAD blood and 7 patients both. 70 units (58%) of PAD would have been discarded. Using a level of Hb of 9 g/dl, 35 patients (69 units) would have received allogenic blood, 22 patients (36 units) would have received PAD blood and 6 patients both. 85 units (70%) of PAD would have been discarded. If the transfusion threshold used were < 8 g/dl and < 9 g/dl, the potential saving was estimated at approximately £9578 and £6884 respectively. Conclusions: PAD service is considerably more expensive than allogenic blood. With high percentages of PAD being discarded, the service is not cost effective. Substantial saving can be achieved with a þrmer transfusion policy for post-operative patients.

The metabolic response of trauma may mimic infection and the reliability of serological parameters for diagnosing infection may be questionable. We prospectively assessed the changes in the acute inflammatory markers, febrile response and the immune profiles of 101 patients following primary hip arthroplasty and their association with infection. Method: The clinical outcome of 101 patients was monitored. Serological analysis was performed pre-operatively and on the second and 8th post-operative day as well as in an out patient clinic 6 weeks following surgery. The serological markers included total white blood cell count along with T and B lymphocyte function. Levels of CD4, CD8 and CD56 were analysed for T helper, T Cytotoxic cell and Natural Killer cell activity. Inflammatory makers included plasma viscosity and CRP. Serological titres of Staph. Aureus and Staph. Epidermis were performed preoperatively and on day 8 and week 6 following surgery. Results: post-operative complications included 19 UTI, 11 chest infections and three URTI and six a confirmed deep vein thrombosis. Twenty patients had elevated ASO titres and 19 patients had raised Staph. Epidermis titres. Statistical comparison of WBC, Plasma viscosity, temperature profiles and T helper, T cytotoxic cell and NK cell assays is not different between patients with and without systemic infection or raised titres of Staph. Aureus or Staph. Epidermis. Conclusion: The acute phase responses following surgery and metabolic response to trauma obscures the changes seen in infective complications up to six weeks post-operatively. Their use in diagnosing infection appears unjustified.

Aims: To report the outcome of secondary patellar resurfacing in patients with chronic anterior knee pain following primary total knee replacement. Methods: A total of twenty patients identified over a 10-year period from 623 patients managed without patellar replacement during primary knee arthroplasty were included and evaluated pre and postoperatively using the American Knee Society (AKS) score, as well as by radiological analysis. Results: The mean follow up was 36.1 months (range 12–104 months). The mean knee score improved from 46.7 to 62.2 points while the mean functional score increased from 44.7 to 52.2 points. Only 44.5% of the patients reported some improvement whereas the remaining reported no change or deterioration. Postoperative radiographic alignment of the primary knee arthroplasty did not influence outcome of secondary patellar resurfacing. Complications were noted in 6 of the 20 patients including patella fracture, patella instability and loss of a range of movement. Conclusions: Anterior knee pain following knee arthroplasty remains a difficult condition to manage and secondary resurfacing of the patella is clearly not to be advocated in all patients since it may well increase patient dissatisfaction and hasten revision.

Introduction: While the early period of distraction osteogenesis has been extensively investigated, there are no data describing the long-term morphology of the regenerate. Patients and Methods: We performed MRI scans to ten adults, seven of which had bone transport for an osseous defect while further three had lengthening for limb length discrepancy. Follow up ranged between 14 and 43 months (mean: 29 months) following the removal of the external fixator. The perimeter, cross sectional area, volume and the mean signal intensity was calculated from the obtained T1 weighted axial images. Values were compared with the contralateral tibia that acted as control. Results: All cases that had bone transport increased the volume of the tibia from 15.3% up to 50.8%. The regenerated segment was noted to have expanded significantly (p< 0.0001) in all cases. Mean signal intensity in the regenerate decreased in seven cases significantly (p< 0.0001) suggesting increase content of unhydrated tissue such as bone and collagen. The cross sectional surface of the transported segment was increased in all cases (p< 0.008), which associated increase in the signal intensity (p< 0.003). Finally in cases that underwent bone transport, the docking site was noted to be obstructed by unhydrated tissue. Conclusions: Contrary to previous claims, the post-distraction osteogenesis tibia is far from normal, consisting of areas with potentially different biomechanical properties. Recognition of these changes is essential not only for appropriate preoperative counselling but also for considering treatment modalities in case of a fracture.

Pyrexia in the post-operative setting has often been associated with a possible systemic or wound infection. We assessed whether there is any justification for our concern regarding post-operative pyrexia following hip arthroplasty and subsequent deep prosthetic infection.

We undertook an assessment of the clinical outcome of 97 sequential patients who underwent 103 primary hip arthroplasty for primary osteoarthritis replacements. Daily temperature and systemic complications in the post-operative period were recorded. Clinical outcome was measured using an Oxford hip questionnaire.

Patients had a mean follow-up of 5.2 years (range 3.5–7.2years)

We reviewed the postoperative temperature records of 80 patients who had undergone primary total hip replacement. Thirty-one patients had required revision surgery at a mean time interval of 37.2 months (range 5–74 months) for confirmed deep prosthetic infection. The remaining Forty-nine patients were asymptomatic at a mean follow-up of 31.5 months.

Study 1

Post-operative pyrexia of 38 degrees Celsius was present in 51% of patients undergoing primary hip replacement in the first post-operative week but in 21.1% no etiological cause could be identified. Clinical outcome measured by an Oxford hip questionnaire was not influenced by the post-operative temperature pattern.

Study 2

The mean peak temperature on the first post-operative day was significantly lower in patients with deep prosthetic infection then patients with a clinically normal outcome (p=0.01).

Post-operative pyrexia is clearly not uncommon following primary arthroplasty and its presence should not be regarded as detrimental. Pyrexia in the postoperative setting is a component of the acute phase response to trauma and study 2 demonstrates patients who develop a low-grade infection following arthroplasty may have a diminished febrile response to surgical trauma which may be an indirect representation of a diminished immune response to surgical trauma or infection

Fatal pulmonary embolism (PE) after total hip replacement (THR) is a major concern to all orthopaedic surgeons. Our intention was to ascertain death rates and deaths due to PE following total hip replacement where chemical thromboprophylaxis was not used routinely.

We determined retrospectively, the postoperative mortality and fatal pulmonary embolism rates in 1671 consecutive primary total hop replacements in 1547 patients performed as staged procedures between January 1997 and April 2000 at an orthopaedic hospital. The minimum follow-up period was six weeks period after surgery at an orthopaedic hospital. Patients were traced by questionnaires, outpatient appointments and by telephone. Post-mortem records were used to verify cause of death. Follow-up was 100%. The death rate from PE was 0. 12% (CI 0. 03% – 0. 44%) and the all-cause mortality rate was 0. 36% (CI 0. 16% – 0. 78%). All deaths were within the first 10 days during the initial hospital stay. The patient mortality was compared with the population mortality for England and Wales, using standardised mortality ratios (SMRs). The SMR for both sexes combined was 0. 81. We observed a lower mortality in females (SMR=0. 43) but a higher mortality in males (SMR=1. 44) during the first 42 postoperative days compared to the general population.

Fatal PE after THR without routine chemical thromboprophylaxis is very uncommon. The death rate in patients undergoing THR appears to be lower than that in the general population.

Cross match practice for patients with femoral neck fractures continue to cause concern due to a failure of compliance to the existing protocols. We addressed this issue by conducting a number of studies over three years and we report the summation of the studies and demonstrate the reasons for the poor compliance. We provide a simple and effective protocol that has helped reduce preoperative cross matching of femoral neck fractures from 71% to 16.7% two years after its introduction.

Study 1

Retrospective review of the cross-match practice for 240 femoral neck fractures and reviewed the changes in pre-operative and post-operative haemoglobin levels and association with surgical procedure.

Study 2.

Postal questionnaire of 129 anaesthetic and orthopaedic trainees assessing the perceived cross-match requirements of patients with femoral neck fractures based on preoperative haemoglobin values between 8–13g/dl. In addition reviewed the source of trainees perceptions and practice

Study 3

Review of the efficiency of the cross-match protocol two years after its introduction Results

Study 1

71% patients with femoral neck fractures were cross-matched at admission but only 29% of the patients were subsequently transfused. From the 384 units of blood ordered at admission 230 were returned unused. Inter-trochanteric fractures had a mean blood loss of 3.1g/dl (range 1.5–7.2g/dl) following surgery in comparison to a mean loss of 1.7g/dl (0.9–3.4g/dl) for patients with displaced subcapital fractures

Study 2

Orthopaedic trainees at all levels of training requested more blood then their anaesthetic counterparts for patients with femoral neck fractures. There was misconceptions regarding blood loss following surgery amongst all trainees and only 14.3% trainees used existing literature to guide their cross-match practice where as 53.4% devised protocols based on their own or colleagues’ experience.

Study 3

Cross-match protocol was working effectively. Only 16.7% of the patients with femoral neck fractures were cross-matched on admission.

Conclusion

Cross-match recommendations fail to influence trainees. In order to address this we produced a protocol that does not rely on orthopaedic trainees. The haematology MLSO provides the appropriate amount of preoperative blood for the patient based on our finding of blood loss of different fracture patterns and the patients’ preoperative haemoglobin level. Our results show our protocol is still effective two years following its introduction despite numerous changes in trainees during this period.

This study was performed to evaluate the pre-operative concerns of patients undergoing total knee or hip replacement surgery.

A cross-sectional study of 370 patients was performed. The patients completed a postal questionnaire on 29 concerns, each rated on a scale of 1 (not concerned) to 4 (very concerned). SF-12 and Oxford knee or hip scores were also calculated. Analysis was carried out using chi-squared test.

217 questionnaires were returned. The results showed that the greatest concern for patients was cancellation of their operation. This was followed by failure of the operation to reduce pain, loss of a limb and joint infection. Concerns regarding scar problems, nursing care and preoperative tests were the lowest.

Women showed statistically significant greater concerns in 9 areas. Younger patients (age< 65) showed increased concerns in 8 areas. Patients who had previously undergone joint replacement were less concerned than those who had not had previous lower limb joint replacements for 6 responses. They showed increased concern in 2 areas, nursing care and hospital food. Those undergoing total hip replacement were more concerned about dislocation, dressing and returning to work (all p< 0.05). The mean Oxford Knee or Hip Score was 42.96 and 45.12 respectively (scale 12–60, 60 being most severe symptoms). The mean SF-12 scores were 41.14 for the mental component and 28.70 for the physical component score (scale 0–100, 100 representing greatest level of good health).

The mean level of concern is low at 1.9 (scale 1 to 4). It is encouraging that patients who have had a previous joint replacement are generally less concerned. Possible reasons for increased concerns amongst women and younger patients are discussed. SF-12 and Oxford Knee/Hip Scores are comparable with other studies.

In conclusion, this study provides useful information for the preoperative counselling of patients and the production of pre-operative literature.

This study was performed to evaluate the pre-operative concerns of patients undergoing total knee or hip replacement surgery.

A cross-sectional study of 370 patients was performed. The patients completed a postal questionnaire on 29 concerns, each rated on a scale of 1 (not concerned) to 4 (very concerned). SF-12 and Oxford knee or hip scores were also calculated. Analysis was carried out using chi-squared tests on SPSS.

217 questionnaires were returned. The results showed that the greatest concern for patients was cancellation of their operation. This was followed by failure of the operation to reduce pain, loss of a limb and joint infection. Concerns regarding scar problems, nursing care and preoperative tests were the lowest.

Women showed statistically significant greater concerns in 9 areas. Younger patients (age< 65) showed increased concerns in 8 areas. Patients who had previously undergone joint replacement were less concerned than those who had not had previous lower limb joint replacements for 6 responses. They showed increased concern in 2 areas, nursing care and hospital food. Those undergoing total hip replacement were more concerned about dislocation, dressing and returning to work (all p< 0.05). The mean Oxford Knee or Hip Score was 42.96 and 45.12 respectively (scale 12–60, 60 being most severe symptoms). The mean SF-12 scores were 41.14 for the mental component and 28.70 for the physical component score (scale 0–100, 100 representing greatest level of good health).

The mean level of concern is low at 1.9 (scale 1 to 4). It is encouraging that patients who have had a previous joint replacement are generally less concerned. Possible reasons for increased concerns amongst women and younger patients are discussed. SF-12 and Oxford Knee/Hip Scores are comparable with other studies.

In conclusion, this study provides useful information for the preoperative counselling of patients, production of preoperative literature and for improving the service we offer to our patients.

Background: While generally aware about other infectious diseases, few realize the threats posed by Hepatitis C. We assessed if the Orthopedic surgery residents have adequate knowledge and wheather they take necessary precautions when exposed clinically to Hepatitis C.

Methods: A pre coded structured questionnaire was administered to Orthopedic surgery residents from three provinces and seven cities of Pakistan, who were participating in the Annual Orthopedic Review Course at the Aga Khan University hospital. Unprompted questions, focused on key knowledge issues, while beliefs and practices were assessed through knowledge and attitude towards Hepatitis C infectivity, complications, therapeutic modalities, actual precautions taken by them while handling body secretions of the patients. and their reading habbits about the literature of this disease.

Results: The median number of surgeries participated in, by the forty-three residents was 150 in the last one year. Though 83% knew that there was no vaccine for HCV, majority (66%) was unaware that it is a sexually transmitted disease and 82% did not know about its possibility of being transmitted perinatally. Eighty-eight percent knew about its transmission through a needle prick injury but 71% of the residents were unaware of the fact that in the case of the needle prick, highest risk of acquisition is of HCV when compared to HBV and HIV. In practices, 74% were vaccinated for HBV. When handling a known case of HCV, 87% used an extra pair of gloves while only 50% took extra care with needles. Median number of needle pricks was one in last one year. Only 16% knew the serostatus of the patients they received injury from. Only 28% of the residents knew their own serostatus for HCV compared to 60% for HBV. 60% of these residents were in habit of handling needles with their hands. Knowledge of HCV did not diff

Conclusion: Changing the attitude of the health care workers towards HCV has become increasingly important. We suggest that all new residents should be given a pretest, a lecture, a demonstration of the standard precautions and infection control procedures with post test, in the beginning of their carriers.

Aim: To determine retrospectively the post-operative mortality and fatal pulmonary embolism (PE) rates in 936 consecutive primary total knee replacements (TKR) in the three month period after surgery where chemical thromboprophylaxis was not routinely used.

Methods: Operations were performed over a period of eleven years by eight different senior orthopaedic surgeons on 248 men and 525 women. One hundred and sixty three patients had bilateral TKRs and the mean age at the time of operation was similar (69.4 and 72.2 years respectively). Patients were traced by out-patient appointments, telephone and through their general practitioners (GPs). Post-mortem examinations were used to verify cause of death in all save three of the cases. All but one of the patients were followed up.

Results: There were no deaths from PE confirmed by post-mortem examinations. As three patients were certified dead without post-mortem examination and one patient could not be traced this meant that, at worst, our fatal PE rate was 0.43% (4/936; CI 0.14%–1.17%). The all-cause mortality rate was 0.64% (6/936; CI 0.26%–0.46%) (Table 1). The patient mortality was compared with the population mortality of England and Wales using standardised mortality ratios (SMRs). The SMR for both sexes combined was 0.74 (CI 0.29–1.52). We observed a lower mortality in females SMR = 0.67 and males SMR = 0.84 during the first three post-operative months than compared to the general population.

Conclusion: Fatal pulmonary embolism after total knee replacement without routine chemical thromboprophylaxis is uncommon. The overall death rate in this series of patients undergoing total knee replacement appears to be lower than that in the general population.