Periprosthetic femoral fractures are increasingly seen in recent years, adding considerable burden to the National Health Service. These require complex revision or fixation and prolonged post-operative care, with significant morbidity with associated costs. The purpose of this study was to assess whether the size of femoral cement mantle is associated with periprosthetic femoral fractures (PPF).

This retrospective study was carried out on a cohort of 49 patients (Fracture Group - FG) who previously had a revision procedure following a proximal PPF between 2010 and 2021. Inclusion criteria – all primary cemented total hip replacements (THR). Exclusion criteria – complex primary THR, any implant malposition that required early revision surgery or any pre-fracture stem loosening. The antero-posterior (AP) radiographs from this cohort of patients were assessed and compared to an age, sex, time since THR-matched control group of 49 patients without PPF (Control Group - CG). Distal cement mantle area (DCMA) was calculated on an AP radiograph of hip; the position of the femoral stem tip prior to fracture was also recorded: valgus, varus or central. Limitations: AP radiographs only. Statistical analyses were performed using Microsoft® Excel.

Chi-square test demonstrated statistically significant difference in DCMA between FG and CG. DCMA of 700 to 900 mm² appeared to be protective when compared to DCMA of 0 to 300 mm². Also, a valgus position observed in 23% in FG Vs 4 % in CG increased the risk, with a smaller area of DCMA.

This study demonstrates and recommends that a size of 700 – 900 mm² of the DCMA is protective against periprosthetic fractures, which are further influenced by the positioning of the distal stem tip. This could be due to the gradual decrease in the stiffness gradient from proximal to distal around the stem tip than steep changes, thereby decreasing possibility of a stress riser just distal to the cement mantle or restrictor. Further biomechanical research specific to this finding may be helpful to validate the observation, progressing to suggest a safe standardised surgical technique.

Clinical commissioning groups (CCG) have been replaced with ICBs that will bring together NHS and social care for the local population. ICBs are allocating contracts for long waiters for total hip replacements (THR) to hospitals that have achieved pre-covid volumes of THR, THR volumes undertaken by hospitals in 2022 should be at 2019 levels or more.

Purpose of this study was to identify whether NHS hospitals in England are at a disadvantage in procuring ICB contracts for THR.

THR volumes for NHS and independent sector (IND) hospitals from January 2012 to November 2022 were identified via National Joint Registry. Regional and national trend for THR volumes were identified for both NHS and IND hospitals using linear regression analysis.

Trends of THR for NHS hospitals showed either stagnation or reduction in volume from 2014–2019. In 2022, nationally THR volume of NHS was 70% of 2019 (Figure 1). Trend of THR volume for IND hospitals nationally was a strong uptrend from 2012 to 2022 with a break only in 2020 due to COVID pandemic (Figure 2). Since the pandemic IND have overtaken NHS hospitals in volumes of THR undertaken. Similar picture of trends evolves when THR trends were assessed on a region by region basis.

With NHS hospitals not back to pre-pandemic THR volumes, IND hospitals have a distinct advantage in securing more contracts via ICB. This in turn puts NHS hospitals at risk of taking on more complex and medically unwell patients potentially worsening NJR outcomes for NHS hospitals.

The reasons for the lag in NHS hospitals’ THR volumes are multifactorial, not limited to continued bed pressures, increased emergency and unplanned admissions, staff shortages and sickness, pension taxations preventing doctors from undertaking more THR. However, lack of access to contracts from ICB will put NHS hospitals at huge financial and existential risk for elective care.

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Introduction: Correct alignment in both coronal and sagittal planes has been shown to be associated with longevity of total knee arthroplasty. The majority of procedures are performed using an intramedullary rod with a femoral cutting jig, with a 5°–7° offset depending upon the anatomical and mechanical axes. The cutting jig rotates around the rod and therefore the rotational alignment of the jig will also affect the cut and final component position (in addition to the rod entry point). It is interesting that rotational alignment of the femoral component is often assessed after the distal resection has been made. The distal resection plane determines the final position of the femoral component, influences patellar tracking and medial/lateral, flexion/extension balancing. This study measures the resultant effect on the distal femoral resection when entry point and jig rotation are varied.

Materials and Methods: The distal femoral resection was carried out in sawbones with three different entry points (central, inferior and superolateral) in neutral alignment and rotations of 10° (internal and external) about the transepicondylar axis. The resulting plane of the cut was assessed by a graphical method measuring the changes in orientation of the alignment rod in space before and after the distal cut. A computer navigation system was used to measure the varus/valgus and flexion/extension angles of the distal cut. This experiment was done thrice, in a total of 27 sawbones and the average values were recorded.

Results: The results varied considerably in the sagittal plane with central and inferior entry points. Internal rotation of the jig around a central entry point produced hyperextension (mean 3.3°) and external rotation caused flexion (mean 1.8°). Using an inferior entry point, flexion of the distal plane improved from an average 3° in neutral rotation to 1.6° on internal rotation; external rotation worsened flexion to an average of 4.3°. The angles digressed in both sagittal and coronal planes with a superolateral entry point; rotations of the distal cutting jig caused hyperextension (maximum of 7.5°). Coronal alignment ranged from 4.5° of varus to 5° of valgus in neutral alignment and rotations around a superolateral entry point.

Conclusion: The study demonstrates that there is a possibility of a compound error from misplaced entry point and that malrotation prior to distal resection is real. This error would invariably be extrapolated in the subsequent steps of conventional knee arthroplasty. Computer assisted arthroplasty may have a role in avoiding this surgical error.

Introduction: Sarcomas are best treated in designated treatment centres. A previous study identified the delays in referral patterns for the years 1999–2000 in Northern and Yorkshire region. The aim of this study was to identify the changes in referral pathways of all non-gynaecological sarcoma patients in view of the NICE guidelines.

Methods: Anonymous data for all non-gynaecological sarcoma patients from year 2000 – 2004 was obtained from the Northern & Yorkshire Cancer Registry.

Results: 1180 of 1430 cases registered in three cancer networks, were selected. The Northern Cancer Network catered to 532 patients. 86.2% of all patients were treated in a designated sarcoma centre compared to 59.8% in the previous study. Of the 504 patients whose dates of first report are available, 39 patients were referred within 2 weeks. 626 of 1180 (53%) patients were diagnosed within two weeks of attending the first hospital. Of the 948 referred to the second hospital, 195 (20.5%) were seen within two weeks of attendance at the first hospital, with an average 56 and median of 38 days. The median age for those referred and otherwise was 55. Of the 631 referred to a third hospital, 187 (29.6%) were seen within two weeks, (average 45 days). The number of patients (Range 1 – 307) seen in each specialty and time taken for referral (range 14 to 127 days) were tallied to denote their efficiencies.

Conclusions: There was a statistically significant increase in referral rates to specialist centres. Age had no influence in referrals, contrary to the previous study. Time delays within specialties show an unchanged trend, with a few exceptions. Further studies into the actual events are needed to unmask the deficient areas.

Purpose of Study: This study was done to assess the efficacy of EQ5D (EuroQol), a simple quality of life (QOL) score. The study was designed to test the feasibility and reliability of using this simple QOL score alongside Constant score following arthroscopic shoulder surgery. Though Constant score gives a shoulder related outcome it does not provide a patient perspective of outcome in relation to their quality of life.

Methodology: A prospective cohort study of 100 consecutive patients listed for arthroscopic shoulder surgery between May and December 2005 were recruited. Assessments were undertaken both preoperatively and at 6 months post operatively. EuroQol is a simple 5 question self administered questionnaire and the Constant score was recorded by the treating physician who was blinded to the result of the EuroQol. Data was assessed for normality and non parametric tests were used. Statistical significance was assumed at the p< 0.05 level.

Results: The median age of 54 years (32 to 79). 60% were male. The median pre operative EuroQol score was 0.26 with a median post operative score of 0.71. Preoperatively, the median constant score was 31.0 with a postoperative score of 72.0 The difference between pre and post operative scores in both the EuroQol and Constant scores was shown to be statistically significant (p< 0.0001 in each group). In the 200 paired observations the two scores were also shown to be closely correlated RS statistic 0.71 (p< 0.0001).

Conclusion: EQ5D is easily completed by the patient by a self administered questionnaire and reflects the quality of life improvement attained after shoulder surgery. It is very easy to use compared to other available QOL scores like SF12, SF36. We recommend its routine usage along with Constant Shoulder score as there is a strong positive correlation.

Surgical options in the treatment of acute acromio-clavicular joint (Rockwood Type III and IV) dislocations are many and controversial. We evaluated our technique using TIGHTROPE connecting the base of the coracoid to the proximal fragment of the clavicle. Between March 2006 and December 2006, ten young and active adult patients with acute ACJ dislocations were treated with arthroscopically assisted ARTHREX TIGHTROPE fixation. The dislocation was reduced with traction and manual reduction with the patient in beach-chair position. The base of the coracoid was identified and isolated using a radiofrequency ablator placed through the anterior portal while visualizing through the lateral portal. An ACL guide was placed percutaneously supero-medial to the coracoid over the distal with the inferior end of the ACL guide placed through a posterior portal, approximated against the prepared base of the coracoid. The Arthrex Tightrope braided fibre-wire was introduced through the pre-drilled distal clavicle passed to the base of the coracoid and manually tensioned to achieve stable reduction. Standard rehabilitation protocol was utilised as for internal fixation of distal clavicular fractures. Patients were evaluated clinically using Constant Score, which ranged from 75 to 83 and radiologically at 6 weeks and 3 months. We present the functional results and the technical difficulties faced highlighting on the probable reasons for failure of fixation in two of our early patients who had revision fixations. We also describe the additional intra-operative techniques used in the last few patients to prevent such complications and achieve a secure reduction. We conclude that Arthroscopic Reconstruction of dislocated Acromio-Clavicular joint using TIGHTROPE may require additional repair of the ligaments in carefully selected patients to prevent failure of fixation.

To evaluate the long term functional and the oncological outcomes of patients who underwent scapulectomy as a limb saving procedure for various tumours of the scapula.

A retrospective study was done in twenty-five patients who underwent scapulectomy for various tumours between 1989 and 2005. We describe twenty-three patients of scapular tumours who were followed up for a minimum of two years after surgery. Nineteen patients had malignant neoplasms of which chondrosarcoma was commonest, followed by Ewing’s sarcoma. Surgical staging was done using Enneking’s system; with stage II B being the commonest. Eight patients underwent subtotal scapulectomy of Malawer Type IIA and fifteen patients underwent total scapulectomy (Type III A). All patients with Ewing’s and Osteosarcoma received neoadjuvant chemotherapy.

With a follow-up ranging from 25–202 months, functional prognosis and oncological outcomes were evaluated for all patients. Two patients had superficial wound infections requiring antibiotics and one had skin necrosis requiring skin cover. Three patients died of pulmonary metastasis and the fourth patient died of local recurrence complicated by multiple metastasis. Functional results were analysed using Musculoskeletal Tumour Society scoring system. The Kaplan Meier 5-year survival computed in 19 patients with malignant tumours was 75.9%.

Scapulectomy is a more realistic option for bone and soft tissue tumours around shoulder girdle. It permits a curative, non-ablative, alternative to forequarter amputation in carefully selected patients.

Purpose Of The Study: To find the functional and oncological outcome of patients who underwent limb salvage surgery and custom mega prosthesis for Malignant Fibrous Histiocytoma of bone.

Methods And Results: Twenty patients with histologically diagnosed Malignant Fibrous Histiocytoma of bone were treated by resection and reconstruction with custom mega prosthesis between May 1991 and December 2002. The average age was 42 and two-thirds of the patients were males. Majority of the tumours were located around the knee and were in Stage II disease of the Enneking system. Wide margins of resection were achieved in 18 patients and reconstruction was done with total knee prosthesis in patients with distal femoral and proximal tibial tumours. The proximal humeral and proximal femoral sites were reconstructed with their respective prosthesis. Fourteen patients treated after 1996 received chemotherapy. With an average follow-up of 57.7 months, 4 patients had amputation for local recurrence and five patients died of disease. Two patients had fracture of prosthesis necessitating revision of prosthesis in one. Functional result was excellent in 5 patients and good in 9 patients. The Kaplan-Meier 5-year survival rates of the patients treated without chemotherapy and with chemotherapy were 50% and 75.8% respectively.

Conclusion: MFH is an aggressive malignant tumour with a poor prognosis. A combined approach using neoadjuvant chemotherapy together with adequate surgical margins improves survival.