To test the knowledge of clinicians in Orthopaedic clinics and Emergency departments of the surface anatomical landmarks that should be examined during assessment of foot and ankle injuries. Specifically trained assessors observed 109 clinicians examining 6 anatomical landmarks on uninjured subjects. Each landmark was chosen for their relevance in assessment of foot and ankle injuries. The landmarks were the medial malleolus, lateral malleolus, fibula head, navicular, base of the 5th metatarsal and the anterior talo-fibular ligament (ATFL).

Two participants failed to identify a single landmark. Of 109 assessed, 27% correctly identified all 6 landmarks. The average correctly identified by each clinician was 4.1 with a standard deviation of 1.5 and range of 0–6. One hundred and seven clinicians correctly identified the lateral malleolus, the most consistently identified. The most poorly identified landmark was the ATFL, by 45%.

The knowledge of surface anatomy overall by junior Orthopaedic and Emergency clinicians was found to be poor and only seems to significantly improve once higher specialty training is reached. Despite the potential for subjectivity and bias the authors believe the methodology is sufficient to demonstrate a lacking in anatomical knowledge amongst clinicians. Poor anatomical knowledge leads to inaccurate examination. This can lead to incorrect diagnoses or even mal-treatment of patients. Clinicians are becoming more reliant on potentially unnecessary and expensive imaging investigations. They have neglected the basic art of physical examination based on sound knowledge of human anatomy. At present, the authors believe that the anatomical teaching in undergraduate medicine is inadequate.

Aim: To test the knowledge of clinicians in orthopaedic clinics and emergency departments of the surface anatomical landmarks, that should be examined during assessment of foot and ankle injuries.

Methods: Specifically trained assessors observed 109 clinicians examining 6 anatomical landmarks on uninjured subjects. Each landmark was chosen for its relevance to assessment of foot and ankle injuries. The landmarks were the medial malleolus, lateral malleolus, fibula head, navicular, base of the 5th metatarsal and the anterior talofibular ligament (ATFL).

Results: 2 participants failed to identify a single landmark. Of 109 assessed, 27% correctly identified all 6 landmarks. The average correctly identified by each clinician was 4.1 (sd: 1.5 and range: 0–6). 107 correctly identified the lateral malleolus, the most consistently identified. The most poorly identified landmark was the ATFL, by 44%.

Discussion: The knowledge of surface anatomy of junior orthopaedic and emergency clinicians was found to be poor and only seems to significantly improve once higher specialty training is reached. Despite the potential for subjectivity and bias the authors believe the methodology is sufficient to demonstrate a lack of anatomical knowledge amongst clinicians. Poor anatomical knowledge leads to inaccurate examination. This can lead to incorrect diagnoses or even maltreatment of patients. Clinicians are becoming more reliant on unnecessary and expensive imaging investigations. They have neglected the basic art of physical examination based on sound knowledge of human anatomy. At present, the authors believe that the anatomical teaching in undergraduate medicine is inadequate.

Aim: A prospective study to quantify the functional outcome of the Aequalis Shoulder Arthroplasty in our local population.

Method: 110 Aequalis shoulder arthroplasties have been performed in 99 patients by a single surgeon in a district general hospital. Rheumatoid arthritis was the indication in 61 shoulders, Osteoarthritis in 26 and 23 for other indications. There were 78 females and 32 males.

Patients were assessed using the Constant-Murley (CM) Score, the corrected Constant-Murley (CM) Score and the American Shoulder and Elbow Society (ASES) function score pre and post-operatively. Pain was measured on a reverse Visual Analogue Scale (VAS) and a range of movement was clinically assessed. All these parameters including standard radiographs were regularly assessed during the follow up period.

Results: Mean length of follow up is 2.29 years (range 6 months to 8 years). 27/110 (24.55%) had a Glenoid replacement.

There have been steady and significant improvements in all parameters over the follow up period. Improvements have been sustained and continue to increase the longer the prosthesis has been in situ. The pain score is measured on a reverse analogue score, which accounts for the increasing scores. There have been 2 cases complicated by deep infection requiring revision and 2 cases of peri-prosthetic fracture.

Conclusion: The Aequalis shoulder prosthesis gives good, reliable results which are reproducable outside specialised centres.

Aim: To describe and evaluate the use of the limited contact plate in complex humeral shaft fractures.

Certain sub-groups of humeral shaft fractures can be very difficult to treat. These ‘complex fractures’ include fractures in very osteoporotic bone, those associated with shoulder or elbow prosthesis, non-unions and those associated with intra articular extensions and dislocations.

The AO limited contact plate (LCP) is a new form of fixation whether the screw heads lock into the holes in the plate. The plate is not designed to cause compression and does not need to lie perfectly adjacent to the bone.

Methods: A prospective study of six consecutive complex humeral shaft fractures treated with LCP plate. Rate of union, complications, and subjective and objective outcome (DASH scores) are analyzed.

Results: Union occurred in 9/10 patients. The final patient is progressing to union. There were no serious complications. Good subjective and objective outcome in all patients.

Conclusion: This heterogeneous series of complex and complicated humeral shaft fractures all pose significant management problems. Treatment with the LCP plate demonstrated good results with no significant complications. This completely new rational for treatment seems particularly suitable for the treatment of complex or complicated humeral shaft fractures.

Aims: The purpose of this study was to quantify the functional outcome of the Aequalis shoulder system. Methods: Pre-operatively, 85 patients were scored using the constant scoring system to assess pain, activity, mobility and strength and adjusted (for age) and modified (excluding strength) scores were calculated. Range of movement (ROM) was assessed using a nominal scale. All patients were regularly followed up and were assessed functionally, using the constant scores and ROM, using a nominal scale Results: Pre-operatively, modified constant score range was 4 – 76 with mean 30.3. ROM was variable but poor overall. Abduction was < 600 in 69% and internal rotation was < ‘hand to buttock’ in 77%. At follow up (range 6 – 60 months, mean 24 months), modified constant score range was 29–126 with mean 74.6. Abduction was > 600 in 76% and internal rotation was > ‘hand to sacrum’ in 77%. No implant has been revised. There have been 2 periprosthetic fractures and 2 implants appear radiologically to be loose. Subjectively, only 6 patients are disappointed with the clinical outcome. Conclusion: The Aequalis shoulder system has been demonstrated to be a reliable implant with up to 5 year follow up. It has a good functional outcome with demonstrable improvement with pain, activity and mobility.

Tissue engineering in reconstructive surgery has many potential attractions, not the least to avoid donor site morbidity and reduce the potential need for allografts and prostheses. Currently there are only two products that have FDA approval in the United States, namely skin and cartilage. Other potential products being trialled are artificial blood vessels and heart valves. The common denominator of these is that they are essentially two dimensional and relatively avascular. Three dimensional tissue engineering has three essential components, (1) cells, (2) scaffold and (3) blood supply. Cells are most easily derived from an autologous source, by conventional tissue culture where they are expanded and implanted into the required site. They are committed cells and usually a large source of donor tissue is required to obtain an adequate source of cells for reconstruction. Stem cells have the potential to grow and differentiate, they may be embryonal which introduces ethical problems or adult stem cells. Cells can be genetically engineered to produce specific growth factors for the purpose of further cell proliferation, such as vascular endothelial growth factor for angiogenesis. The second essential is a scaffold for cells to adhere to and grow. This is particularly important for the development of the vascular network. Fibrin, PTFE (Dexon) Matrigel (a form of Laminen) or collagen are the most popular forms of matrix. The third and most essential component for three-dimensional tissue engineering is vascularization. To date, most tissue engineering research involves invitro studies of cell differentiation and growth but the invivo potential is limited because of inability to transfer a blood supply.

At the Bernard O’Brien Institute at St Vincent’s Hospital, Melbourne, we have developed a model of invivo tissue engineering which involves the initial creation of a vascular core inside a plastic chamber which can be moulded to any desired shape. This construct seems to be an ideal environment for seeding of cells, including stem cells which allows them to survive and differentiate into various mesenchymal tissues. To date we have been able to generate skin flaps, fat, tissue and skeletal muscle. Although our prime interest has not been bone or cartilage it is reasonable to assume that this can be relatively simply produced in the same model from either stem cell sources or by the use of differentiating factors.