In a cross sectional cohort study three different metal on metal total hip systems were assessed. Two monoblock acetabular designs; the Durom socket (Zimmer, Warsaw, In) and the Birmingham socket (Smith and Nephew, Memphis, TN), and one modular metal on metal total hip system (Pinnacle, Depuy Orthopaedics, Warsaw, In) in patients who have received these implants in the our region. 56 patients were recruited in total. All patients were assessed clinically, radiologically and biochemically. Whole blood Cobalt, Chromium and titanium levels were tested.

The median head size used in the Birmingham group was 52mm (Range 44mm to 56mm), and in the Durom group, 48mm (Range 42 to 54mm). The median head size used in the modular Pinnacle group was 40mm (Range 36–44mm).

The blood metal ions levels in the larger non modular acetabular sockets were significantly raised compared to the Pinnacle group. For Co 1.95 µg/l and 2.70 µg/l in the Durom and Birmingham groups respectively compared to only 0.52 µg/l in the Pinnacle group (P< 0.001). Mean Cr levels were the same for the two monoblock systems, 1.9 µg/l compared to the Pinnacle sockets 1.2 µg/l (P< 0.001).

Our study clearly demonstrates that there is a significant difference in metal ion levels in patients following a monobloc large head arthroplasty system compared to a smaller modular metal on metal hip arthroplasty. The smaller head size appears to produce less metal ions whilst at the same time a 36mm–44mm head size is large enough to increase hip stability and range of movement as well as decreasing the risk of impingement. In our practice we are no longer using this design and the safest strategy, when considering metal on metal bearings, is to use a modular, smaller head system such as the Pinnacle.

Introduction

We discuss the use of the SMILES (Stanmore Modular Individualised Lower Extremity System) in salvage revision knee surgery and review the medium-long term results of 42 cases.

Recent interest has focused on minimally invasive hip surgery, with less attention being directed to maximising the potential benefits of this type of surgery. We have developed a new multidisciplinary programme for patients undergoing total hip replacement in order to facilitate an overnight hip replacement service.

The programme involves a pre-operative regimen of education and physiotherapy, a modified anaesthetic technique, a minimally invasive surgical approach and a portable local anaesthetic pump infusion for post-operative pain control. Strict inclusion and exclusion criteria were developed based on age, medical status and social circumstances. Patients were mobilised on the day of their operation and discharged home with an ‘outreach team’ support network. No patient complained that their discharge was early. Independent evaluation was performed using the Oxford Hip Questionnaire, the Merle d'Aubigné clinical rating system and Visual Analogue Pain Scores. Thirty seven patients underwent total hip replacement using the new protocol.

The average length of stay was 1.2 days. The mean pain score on discharge was 1.3/10. The Oxford Hip Questionnaire and Merle d'Aubigné scores were comparable to patients who underwent surgery prior to the introduction of the new protocol. Minimising in-patient stay for total hip replacement benefits the patient by reducing exposure to nosocomial infection and expediting the return to a normal environment for faster rehabilitation. This new programme allows patients undergoing total hip replacement to be discharged after 1 night post-operatively without compromising safety or quality of care.

Minimally invasive surgery with a suitable infrastructure can be used to dramatically reduce the length of stay in suitable patients. This can be achieved reliably, safely and with high patient satisfaction. In order to gain the benefit of Minimally Invasive Surgery we recommend introducing this type of comprehensive programme.

Aim: To assess the impact of a proforma pathway on the care of patients following fractured neck of femur at Maidstone General Hospital compared to the gold standard set out in the British Orthopaedic Association and British Geriatric Society Blue Book – The Care of Patients with a Fragility Fracture.

Objectives: Initial audit of care prior to the introduction of the Proforma

Development of a multidisciplinary care pathway and proforma following BOA Standards for Trauma (BOAST) and National Hip Fracture Database (NHFD) guidelines

Background: The recent publication of the BOA and BGS Blue Book guidelines for care of patients with fragility fractures has defined a gold standard for the care of these patients. This has highlighted the areas of care that are commonly suboptimal and defined the requirements of a department providing ideal care. Both this, and the introduction of the NHFD and the resultant requirements for data collection and monitoring led us to develop a proforma for management and data collection.

Methods: An initial audit of care was performed. Notes were reviewed retrospectively for 62 patients and results were compared to the gold standard.

In June 2008 the proforma was implemented and data collected for reaudit (n=48). Direct comparison and statistical analysis was performed for the two groups of patients

Results: Comparison of the two audit groups shows dramatic and highly statistically significant differences in a number of areas of patient care, notably: mortality rates; appropriate A& E investigation and treatment; documentation of correct diagnosis and social history; mental test scoring; time to ward admission; time to surgery and osteoporosis treatment.

Discussion: The lack of a ring fenced, dedicated trauma ward leads to patients being admitted to outlying wards following fractured neck of femur. These wards are less likely to be as well equipped to deal with the unique requirements of these patients, which may explain the consistent problems with pressure area care and delay in discharge.

A strong recommendation for gold standard care is the provision of an orthogeriatric service with regular medical review both pre- and post-operatively. Currently no such dedicated service exists at Maidstone and this affects both the treatment of acute medical problems and the provision of falls investigation and treatment.

The introduction of the pathway has clearly benefitted the management of this difficult problem. With the support of the Rapid Improvement Program, further beneficial changes can be made to the care of patients following fractured NOF.

Introduction: We report our experience with use of the SMILES prosthesis in primary knee arthroplasty.

Methods: The Stanmore Modular Individualised Lower Extremity System (SMILES prosthesis) has been shown to be effective in complex revision knee surgery. It incorporates a rotating hinge platform knee joint and can overcome the major problems of bone loss and ligamentous laxity.

38 patients (41 knees) who received a primary SMILES knee prosthesis by one of the senior authors between 1990 and 2006 were retrospectively studied. Knee function was assessed pre and post-operatively using the Oxford knee score (0–48 scoring system) and the Knee Society Score. Patients receiving surgery for tumours were excluded. The main indications for primary SMILES were bone loss and ligamentous laxity.

Results: The minimum follow-up was 18 months with a mean of 5 years (1–17). The mean age of the patients was 57.7 years (23–86); 15 of the patients were male. The indications for surgery were trauma (12), osteoarthritis with deficient medial collateral ligament (8), polio (7), rheumatoid arthritis (5), epiphyseal dysplasia (4), achondroplasia (2), avascular necrosis (1), osteogenesis imperfecta (1) and ankylosing spondylitis (1).

2 patients died and 5 were lost to follow-up. 2 patients required revision surgery (one for infection and one for re-bushing). Post-operative complications included peroneal nerve palsy (1) and DVT (1). The mean Oxford knee score improved from 9 pre-op to 44 post-op, and the mean knee society score improved from 24 pre-op to 71 post-op. The average range of motion was 57 degrees pre-op and 88 degrees post-op.

Conclusion: We conclude that the SMILES prosthesis offers significant improvement in clinician and patient assessed outcome scores in complex primary knee arthroplasty. The cost compares favourably with other designs and its use is well established.

Introduction: Recently there has been much interest in minimally invasive hip surgery, with less attention being directed to maximising the potential benefits of this type of surgery. We have developed a new multidisciplinary program for patients undergoing total hip replacement in order to facilitate an overnight hip replacement service.

Methods: The program involves a pre-operative regimen of education and physiotherapy, a modified anaesthetic technique, a minimally invasive surgical approach and a portable local anaesthetic pump infusion for post-operative pain control. Strict inclusion and exclusion criteria were developed based on age, medical status and social circumstances. Patients were mobilised on the day of their operation and discharged home with an ‘outreach team’ support network. No patient complained that their discharge was too early. Independent evaluation was performed using the Oxford Hip Questionnaire, the Merle d’Aubigne clinical rating system and Visual Analogue Pain Scores.

Results: Thirty seven patients underwent total hip replacement using the new protocol.

The average length of stay was 1.2 days. The mean pain score on discharge was 1.3/10. The Oxford Hip Questionnaire and Merle d’Aubigne scores were comparable to patients who underwent surgery prior to the introduction of the new protocol. Minimising in-patient stay for total hip replacement benefits the patient by reducing exposure to nosocomial infection and expediting the return to a normal environment for faster rehabilitation. This new program allows patients undergoing total hip replacement to be discharged after 1 night post operatively without compromising safety or quality of care.

Conclusion: Minimally invasive surgery with a suitable infrastructure can be used to dramatically reduce the length of stay in suitable patients. This can be achieved reliably, safely and with high patient satisfaction. In order to gain the benefit of Minimally Invasive Surgery we recommend introducing this type of comprehensive program.

Introduction: High-frequency ultrasound is an effective mechanism for coagulating and cutting tissue. We report the first use of the ultrasonic scalpel in orthopaedic surgery, with the aim of minimising blood loss and tissue trauma in minimally invasive total hip replacement.

Methods: This is a prospective, single-blind, case-matched study to compare blood loss in minimally invasive total hip replacement using an ultrasonic scalpel versus electrodiathermy. Twenty cases have been performed via a minimally invasive posterior approach. The treatment was otherwise no different between the two groups. The groups were compared with regard to blood loss, post-operative pain and wound healing.

Results: The mean intra-operative blood loss in the ultrasonic scalpel group was 242mls compared with 319mls in the electrodiathermy group. This is statistically significant (p < 0.05). The percentage drop in Haemoglobin was also reduced in the ultrasonic scalpel group (18.9% compared with 26.4%), which is also statistically significant (P< 0.01). There was no significant difference in the operating time or post-operative pain scores and there were no wound complications in either group.

Discussion: The ultrasonic scalpel works by converting electrical energy into mechanical energy resulting in longitudinal oscillation of the blade at 55,500Hz. This achieves coagulation and tissue dissection at lower temperatures than standard diathermy. The potential advantages include less lateral tissue damage, minimal smoke and no electrical energy passed to or through the patient. With the development of minimally invasive hip replacement surgery this technique can be used to reduce tissue trauma. The initial results from this study suggest that the ultrasonic scalpel has a useful role in minimally invasive hip replacement surgery in terms of reducing blood loss and tissue trauma. This may help to facilitate early mobilisation and reduced hospital stay.

This prospective study analyses the histological results of autologous chondrocyte transplantation in patients with articular cartilage defects of the knee joint. Chondrocytes from a non-weight bearing area of the knee were harvested and then cultured in vitro.

Re-implantation involved injection of the chondrocytes into the defect, which was then sealed with a collagen membrane. One year post-op, patients were evaluated by clinical, arthroscopic and histological assessment. A biopsy of the transplanted region was examined by staining with Erlich’s H& E and Safranin 0, polarised light microscopy and by analysis with S100 and immunohistochemistry. Hyaline cartilage content was further assessed by examination of Type IIa & lIb collagen mRNA expression using in-situ hybridisation.

The median age was 31 years. 63 knees were treated. Solitary lesions were treated in 61 knees with two defects being treated in three knees (66 defects in total). The defects were located on the medial femoral condyle in 39 cases, lateral femoral condyle in 14, trochlea in 2 and patella in 11. The defect size ranged from 1–7 cm2 (mean area 3cm2 ). 40 patients had at least one-year follow-up. Using the Brittberg Rating, 11 had excellent results, with 15 good, 10 fair and 4 poor. The mean Lysholm and Gillquist scores improved from 44 pre-op to 77 one-year post-op. Biopsy at one year conftrmed the presence of hyaline cartilage in 22 out of 32 cases (69%). In-situ hybridisation confirmed the presence of Collagen type II in the deep zones of the biopsy with a fibrocartilaginous appearance superficially.

Conclusion: This technique can provide an effective treatment for cartilage defects. The histological results are encouraging and chondrocyte transplantation may be the only procedure to allow regeneration of hyaline like articular cartilage.

Introduction Total hip replacement is the commonest arthroplasty procedure performed in the UK. The in-patient stay has gradually reduced and patients now typically spend five to seven days in hospital. We have developed a new multidisciplinary protocol for patients undergoing total hip replacement in order to facilitate early discharge.

The aims of this study were to prospectively assess whether this new protocol could be safely applied to patients undergoing total hip replacement and whether it reduced length of stay.

Methods The protocol involved a pre-operative program of education and physiotherapy, a modified anaesthetic regime, a minimally invasive surgical approach and a portable local anaesthetic pump infusion for post operative pain control. Strict inclusion and exclusion criteria were developed based on age, medical status and social circumstances. Patients were mobilised on the day of their operation and discharged to an outreach team support network. Independent evaluation was performed using the Oxford Hip Questionnaire, the Merle dAubigne clinical rating system and Visual Analogue Pain Scores.

Results Twenty-five patients underwent total hip replacement using the new protocol. All patients were discharged home within 48 hours of surgery. There were two unplanned reattendances neither of which required readmission. The mean pain score on discharge was 3/10. The Oxford Hip Questionnaire and Merle dAubigne scores were comparable to patients who underwent surgery prior to the introduction of the new protocol.

Discussion Minimising in-patient stay for total hip replacement benefits the patient by reducing exposure to nosocomial infection and expediting the return to a normal environment for rehabilitation. It may also help to improve efficiency and alleviate pressure on an overburdened health service. This new protocol allows patients undergoing total hip replacement to be discharged within 48 hours of undergoing surgery without compromising safety or quality of care.

Aim: This prospective study analyses the histological results of autologous chondrocyte transplantation in patients with articular cartilage defects of the knee joint.

Methods: This is a prospective, single centre, single surgeon study. Consecutive patients undergoing autologous chondrocyte transplantation were studied. Chondrocytes from a non-weight bearing area of the knee were harvested and then cultured in vitro. Re-implantation involved injection of the chondrocytes into the defect, which was then sealed with a collagen membrane. One year post-op, patients were evaluated by clinical, arthroscopic and histological assessment. A biopsy of the transplanted region was examined by staining with Erlich’s H& E and Safranin O, polarised light microscopy and by analysis with S100 and immunohistochemistry. Hyaline cartilage content was further assessed by examination of Type IIa & IIb collagen mRNA expression using in-situ hybridisation.

Results: The median age was 31 years. 63 knees were treated. Solitary lesions were treated in 61 knees with two defects being treated in three knees (66 defects in total). The defects were located on the medial femoral condyle in 39 cases, lateral femoral condyle in 14, trochlea in 2 and patella in 11. The defect size ranged from 1–7 cm2 (mean area 3cm2). 40 patients had at least two-year follow-up. Using the Brittberg Rating, 11 had excellent results, with 15 good, 10 fair and 4 poor. The mean Lysholm and Gillquist scores improved from 44 pre-op to 77 two-years post-op. Biopsy at one year confirmed the presence of hyaline cartilage in 22 out of 32 cases (69%). In-situ hybridisation confirmed the presence of Collagen type II in the deep zones of the biopsy with a fibrocartilaginous appearance superficially.

Conclusion This technique can provide an effective treatment for cartilage defects. The histological results are encouraging. Chondrocyte transplantation appears to regenerate tissue with the features of normal hyaline cartilage.

Introduction High-frequency ultrasound is an effective mechanism for coagulating and cutting tissue. We report the first use of the ultrasonic scalpel in orthopaedic surgery, with the aim of minimising blood loss and tissue trauma in minimally invasive total hip replacement.

Methods This is a prospective, single-blind, case-matched study to compare blood loss in minimally invasive total hip replacement using an ultrasonic scalpel versus electrodiathermy. Twenty cases have been performed via a minimally invasive posterior approach. The treatment was otherwise no different between the two groups. The groups were compared with regard to blood loss, postoperative pain and wound healing.

Results The mean intraoperative blood loss in the ultrasonic scalpel group was 156mls compared with 295mls in the electrodiathermy group. This is highly statistically significant. The percentage drop in Haemoglobin was also reduced in the ultrasonic scalpel group (18.9% compared with 26.4%), which is also statistically significant. There was no significant difference in the operating time or post-operative pain scores and there were no wound complications in either group.

Discussion The ultrasonic scalpel works by converting electrical energy into mechanical energy resulting in longitudinal oscillation of the blade at 55,500Hz. This achieves coagulation and tissue dissection at lower temperatures than standard diathermy. The potential advantages include less lateral tissue damage, minimal smoke and no electrical energy passed to or through the patient. With the development of minimally invasive hip replacement surgery this technique can be used to reduce tissue trauma.

Conclusion The initial results from this study suggest that the ultrasonic scalpel has a useful role in minimally invasive hip replacement surgery in terms of reducing blood loss and tissue trauma. This may help to facilitate early mobilisation and reduced hospital stay.

Introduction: Malignant tumours of the fibula are rare and can be difficult to treat. We discuss the management and outcome of 52 patients who presented with malignant tumours of the fibula over a 15-year period between 1983 and 1998.

Methods: Data was collected prospectively and reviewed from the Bone Tumour database, medical records and by clinical review. Consecutive patients were studied and survival was calculated using the Kaplan-Meier curve.

Patients: The tumour type was Osteosarcoma (23 patients), Ewing’s sarcoma (16), Chondrosarcoma (11 – of which 10 low grade) and Malignant Fibrous Histiocytoma (2). We concentrate on the two most common frankly malignant groups: Osteosarcoma and Ewing’s. The male:female ratio of patients with Osteosarcoma was 11:12 and with Ewing’s Sarcoma was 11:5. Mean age for Osteosarcoma was 21.5 years and for Ewing’s Sarcoma was 14.2. The most common site of tumour was in the proximal fibula in both Osteosarcoma (19 / 23) and Ewing’s Sarcoma (10 / 16). The stage of disease at presentation was IIa or IIb in the majority of patients, with seven patients presenting with metastases.

Management: The current investigative procedures are Radiographs, Magnetic Resonance Imaging, Radioisotope Bone Scans, Computerised Tomography of the chest and needle biopsy whereas in the past CT of the lesion and open biopsy were common. Chemotherapy was administered as per protocol at the time of diagnosis and radiotherapy was given in selected cases. Surgery was performed on all but 3 patients, who were unfit and died. This consisted of local en bloc resection in 86.3% and above knee amputation in 6.8%.

Outcome: Whereas all the diaphyseal and distal lesions were completely excised, 9 out of 26 proximal lesions had a marginal excision, 4 of which had open biopsies. The common peroneal nerve was sacrificed in 50% of cases and this had no link to survival. The overall 5-year survival was 33% for Osteosarcoma and 40% for Ewing’s Sarcoma, with proximal lesions doing much worse than diaphyseal and distal lesions. Patients who had marginal excisions all died within 2.5 years.

Introduction: Total femoral endoprosthetic replacement can be an alternative to amputation following extensive tumour excision or in cases of severe bone loss. In skeletally immature patients the problem of leg length inequality may be overcome by the use of extendable prostheses. The aim of this study is to assess the functional outcome of patients following total femoral endoprosthetic replacement.

Methods: This is a retrospective, single centre study of 16 patients who underwent consecutive total femoral replacements between 1978 and 1999. Information was collected from the Bone Tumour database, medical records and clinical review. The prostheses were custom made by the Biomedical Engineering Department of University College London and Stanmore Implants Worldwide. The implants are composed of a Titanium alloy shaft with Cobalt-Chrome bearing surfaces, incorporating a SMILES (Stanmore Modular Individualised Lower Extremity System) knee joint. Outcome was assessed using the Musculoskeletal Tumour Society (MTS) rating score.

Sample: Eight patients were male and eight female. Mean age was 35 years (range 5–75 years). Ten patients underwent total femoral replacement as a primary procedure; nine for malignant tumour and one for hydatid disease. Of the patients with malignancy five had metastases at the time of presentation. The other indications were failed distal femoral replacement in four cases and periprosthetic fractures in the remaining two. Four children received extendable prostheses.

Results: Of the patients with malignant disease, all but one had complete tumour excision. Three patients developed local recurrence. Two patients died of metastases within one year of diagnosis and three more died within five years. Three required revision procedures. Two more dislocated at the hip joint. Other complications included infection and lymphoedema. In patients surviving longer than one year the average range of motion at the hip was 85 degrees and at the knee 80 degrees. Using the MTS rating score the mean functional outcome was 60% of normal (range 27–90%). Of the survivors one achieved an excellent result, five were good, four fair and one poor.

Conclusion: Total femoral endoprosthetic replacement can be effective in limb salvage and provide an alternative to amputation. Good functional results can often be achieved. However, the complication rate is high and the outcome extremely varied.

Introduction and Aim: This project reports on patients treated with malignant fibula pathology at the London Bone Tumor Service with the aim of reporting on the prognosis for such patients.

Method and Results: Over a 15-year period, The London Bone Tumor Service has treated 39 patients with malignant fibula pathology: Osteosarcoma (23), Ewing’s sarcoma (16). Proximal fibula pathology was more common (29), distal (five) and diaphyseal (five). Thirty-two patients were treated with wide local excision initially, one below knee amputation, three above knee amputations, two were not fit for surgery and two died while receiving chemotherapy. Two patients required subsequent above knee amputations and one patient a hip disarticulation. Relapse was very common in proximal fibula osteosarcoma. Only 7/23 patients avoided both metastasis and local recurrence.

The five-year survival rate of osteosarcoma of the proximal fibula is 33%, distal fibula 100% and diaphyseal 100%. Ewing’s sarcoma of the proximal fibula is 40%, diaphyseal 50% and distal fibula 100%.

Conclusion: Despite relatively early presentation of symptoms, the prognosis of proximal fibula osteosarcoma and Ewing’s remains poor. Unlike the prognosis of both distal and diaphyseal pathology, which remains excellent.

We discuss the management and outcome of 52 patients who presented with malignant tumours of the fibula over a 15-year period between1983 and 1998.

The tumour type was Osteosarcoma (23 patients), Ewing’s sarcoma (16), Chondrosarcoma (11 – of which 10 low grade) and Malignant Fibrous Histiocytoma (2). We concentrate on the two most common frankly malignant groups: Osteosarcoma and Ewing’s.

The male:female ratio of patients with Osteosarcoma was 11:12 and with Ewing’s Sarcoma was 11:5. Mean age for Osteosarcoma was 21. 5 years and for Ewing’s Sarcoma was 14. 2. The most common site of tumour was in the proximal fibula in both Osteosarcoma (19 / 23) and Ewing’s Sarcoma (10 / 16). The stage of disease at presentation was IIa or IIb in the majority of patients, with seven patients presenting with metastases.

The current investigative procedures are Radiographs, Magnetic Resonance Imaging, Radioisotope Bone Scans, Computerised Tomography of the chest and needle biopsy whereas in the past CT of the lesion and open biopsy were common. Chemotherapy was administered as per protocol at the time of diagnosis and radiotherapy was given in selected cases.

Surgery was performed on all but 3 patients, who were unfit and died. This consisted of local en bloc resection in 86. 3% and above knee amputation in 6. 8%. Whereas all the diaphyseal and distal lesions were completely excised, 9 out of 26 proximal lesions had a marginal excision, 4 of which had open biopsies. The common peroneal nerve was sacrificed in 50% of cases and this had no link to survival.

The overall 5-year survival was 33% for Osteosarcoma and 40% for Ewing’s Sarcoma, with proximal lesions doing much worse than diaphyseal and distal lesions. Patients who had marginal excisions all died within 2. 5 years.