Currently, the cement being used for hemiarthroplasties and total hip replacements by the authors and many other surgeons in the UK is Palacos® (containing 0.5g Gentamicin). Similar cement, Copal® (containing 1g Gentamicin and 1g Clindamycin) has been used in revision arthroplasties, and has shown to be better at inhibiting bacterial growth and biofilm formation. We aim to investigate the effect on SSI rates of doubling the gentamicin dose and adding a second antibiotic (clindamycin) to the bone cement in hip hemiarthroplasty.

We randomised 848 consecutive patients undergoing cemented hip hemiarthroplasty for fractured NOF at one NHS trust (two sites) into two groups: Group I, 464 patients, received standard cement (Palacos®) and Group II, 384 patients, received high dose, double antibiotic-impregnated cement (Copal®). We calculated the SSI rate for each group at 30 days post-surgery. The patients, reviewers and statistician were blinded as to treatment group.

The demographics and co-morbid conditions (known to increase risk of infection) were statistically similar between the groups. The combined superficial and deep SSI rates were 5 % (20/394) and 1.7% (6/344) for groups I and II respectively (p=0.01). Group I had a deep infection rate 3.3 %(13/394) compared to 1.16% (4/344) in group II (p=0.082). Group I had a superficial infection rate 1.7 % (7/394) compared to 0.58% (2/344) in group II (p=0.1861). 33(4%) patients were lost to follow up, and 77 (9%) patients were deceased at the 30 day end point. There was no statistical difference in the 30 day mortality, C. difficile infection, or the renal failure rates between the two groups.

Using high dose double antibiotic-impregnated cement rather than standard low dose antibiotic-impregnated cement significantly reduced the SSI rate (1.7% vs 5%; p=0.01) after hip hemiarthroplasty for fractured neck of femur in this prospective randomised controlled trial.

Despite the generally inferior clinical performance of acetabular prostheses as compared to the femoral implants, the causes of acetabular component loosening and the extent to which mechanical factors play a role in the failure mechanism are not clearly understood yet. The study was aimed at investigating the load transfer and bone remodelling around the uncemented acetabular prosthesis.

The 3-D FE model of a natural right hemi-pelvis was developed using CT-scan data. The same bone was implanted with two uncemented hemispherical acetabular components, one metallic (CoCrMo alloy) and the other ceramic (Biolox delta), with 54 mm outer diameter and 48 mm bearing diameter. The FE models of the implanted pelvis (containing ∼116000 quadratic tetrahedrals) were generated using a submodelling approach, which were based on an overall full model of implanted pelvis (containing ∼217600 quadratic tetrahedrals) acted upon by hip joint force and twenty one muscle forces. The apparent density (ρ in g cm⁻³) of each cancellous bone element was calculated using linear calibration of CT numbers of bone, from which the Young's modulus (E in MPa) was determined using the relationship, E = 2017.3 ρ^2.46 [1]. Implant-bone interface conditions, fully bonded and debonded with friction coefficient μ = 0.5, were simulated using contact elements. Applied loading conditions consist of two load cases during a gait cycle, corresponding to 13% and 52% of the walking cycle. Fixed constraints were prescribed at the pubis and at the sacroiliac joint. The bone remodelling algorithm was based on strain energy based site-specific formulation [2]. The FE analysis, in combination with the bone remodelling simulation, was performed using ANSYS FE software.

The predicted changes in peri-prosthetic bone density were similar for the metallic and the ceramic implant. For debonded implant-bone interface, stress shielding led to ∼20% reductions in bone density at supero-anterior, infero-anterior and posterior part of the acetabulum (Fig. 1). However, bone apposition was observed at the supero-posterior part of the acetabulum, where implantation led to ∼60% increase in bone density (Fig. 1). The effect of bone resorption was higher for the fully bonded implant-bone interface, wherein bone density reductions of 20–50% were observed in the cancellous bone underlying the implant (Fig. 1), which is indicative of implant loosening over time. However, implantation led to an increase in bone density around the acetabular rim for both the interface conditions (Fig. 1). These results are well corroborated by the earlier studies [3, 4]. Implantation with a ceramic component resulted in 2–7% increase in bone density at supero-posterior part of the acetabulum as compared to the metallic component, for the debonded interface condition. Considering better wear resistant properties and absence of metal ion release, results of this study suggest that the ceramic component might be a viable alternative to the metallic prosthesis.

The effects of metal ion release and wear particle debris in metal-on-metal articulation warrants an investigation of alternative material, like ceramics, as a low-wear bearing couple [1]. Short-stem resurfacing femoral implant, with a stem-tip located at the centre of the femoral head, appears to provide a better physiological load transfer within the femoral head and therefore seems to be a promising alternative to the long-stem design [2]. The objective of this study was to investigate the effect of evolutionary bone adaptation on load transfer and interfacial failure in cemented metallic and ceramic resurfacing implant.

Bone geometry and material properties of 3D finite element (FE) models (intact, short-stem metallic and ceramic resurfaced femurs of 44 mm head diameter) were derived from the CT scan data. The FE models consisted of 170352 quadratic tetrahedral elements and 238111 nodes with frictional contact at the implant-cement (μ = 0.3) and stem-bone interfaces (μ = 0.4) and fully bonded cement-bone interface. Normal walking and stair climbing were considered as two different loading conditions. A time-dependant “site specific” bone remodelling simulation was based on the strain energy density and internal free surface area of bone [3]. The variable time-step was determined after each remodelling iteration. The Hoffman failure criterion was used to assess cement-bone interfacial failure.

Predicted change in bone density due to bone remodelling was very much similar in both the metallic and ceramic resurfaced femurs (Fig. 1). Both the metallic and ceramic implant resulted in strain reduction in the proximal regions (Region of interest, ROI 2 and 4) and subsequent bone resorption, average bone density reduction by 72% (Fig. 1). Higher strains were generated in ROI 5 and 7, which caused bone apposition, an average increase in bone density of 145% (Fig. 1). The tensile stresses in the resurfacing implants increased with change in bone density; a maximum stress of 83 MPa and 63 MPa were observed in the ceramic and the metallic implants, respectively. The tensile stress in the cement mantle also increased with bone remodelling. Although the cement-bone interface was secure against interface debonding in the post-operative situation, calculations of Hoffman number indicated that risk of cement-bone interfacial failure was increased with peri-prosthetic bone adaptation.

During the remodelling simulation, maximum tensile stress in the implant and the cement was far below its strength. However, with bone adaptation greater volume of cement mantle was exposed to higher stresses which, in-turn, resulted in greater risk of interfacial failure around the periphery of the cement mantle. Both the short-stem ceramic and metallic resurfacing component, under debonded stem-bone interface, resulted in more physiological stress distribution across the femoral head. Based on these results, short-stem ceramic resurfacing component appears to be a viable alternative to the metallic design.

Infection rates following arthroplasty surgery are between 1–4%, with higher rates in revision surgery. The associated costs of treating infected arthroplasty cases are considerable, with significantly worse functional outcomes reported. New methods of infection prevention are required. HINS-light is a novel blue light inactivation technology which kills bacteria through a photodynamic process. The aim of this study was to investigate the efficacy of HINS-light for the inactivation of bacteria isolated from infected arthoplasty cases.

Specimens from hip and knee arthroplasty infections are routinely collected to identify causative organisms. This study tested a range of these isolates for sensitivity to HINS-light. During testing, bacterial suspensions were exposed to increasing doses of HINS-light of (123mW/cm2 irradiance). Non-light exposed control samples were also set-up. Bacterial samples were then plated onto agar plates and incubated at 37°C for 24 hours before enumeration.

Complete inactivation was achieved for all Gram positive and negative microorganisms More than a 4-log reduction in Staphylococcus epidermidis and Staphylococcus aureus populations were achieved after exposure to HINS-light for doses of 48 and 55 J/cm2, respectively. Current investigations using Escherichia coli and Klebsiella pneumoniae show that gram-negative organisms are also susceptible, though higher doses are required.

This study has demonstrated that HINS-light successfully inactivated all clinical isolates from infected arthroplasty cases. As HINS-light utilises visible-light wavelengths it can be safely used in the presence of patients and staff. This unique feature could lead to possible applications such as use as an infection prevention tool during surgery and post-operative dressing changes.

Introduction

Infection rates following arthroplasty surgery are reported between 1–4%, with considerably higher rates in revision surgery. The associated costs of treating infected arthroplasty cases are over 4 times the cost of primary arthroplasties, with significantly worse functional and satisfaction outcomes. In addition, multiple antibiotic resistant bacteria are developing, so to reduce the infection rates and costs associated with arthroplasty surgery, new preventative methods are required. HINS-light is a novel blue light inactivation technology which kills bacteria through a photodynamic process, and is proven to have bactericidal activity against a wide range of species. The aim of this study was to investigate the efficacy of HINS-light for the inactivation of bacteria isolated from infected arthoplasty cases.

Raised blood pressures (BP) are associated with increased cardiovascular risks such as myocardial infarction, stroke and arteriosclerosis. During surgery the haemodynamic effects of stress are closely monitored and stabilised by the anaesthetist. Although there have been many studies assessing the effects of intraoperative stress on the patient, little is known about the impact on the surgeon.

A prospective cohort study was carried out using an ambulatory blood pressure monitor to measure the BP and heart rates (HR) of three consultants and their respective trainees during hallux valgus, hip and knee arthroplasty surgery. Our principle aim was to assess the physiological effects of performing routine operations on the surgeon. We noted if there were any differences in the stress response of the lead surgeon, in comparison to when the same individual was assisting. In addition, we recorded the trainee's BP and HR when they were operating independently.

All of the surgeons had higher BP and HR readings on operating days compared to baseline. When the trainer was leading the operation, their BP gradually increased until implant placement, while their trainees remained stable. On the other hand, when the trainee was operating and the trainer assisting, the trainer's BP peaked at the beginning of the procedure, and slowly declined as it progressed. The trainee's BP remained elevated throughout. The highest peaks for trainees were noted during independent operating.

We conclude that all surgery is stressful, and that trainees are more likely to be killing themselves than their trainers.

Cardiovascular disease is now the leading cause of morbidity and mortality worldwide. Raised blood pressures (BP) are associated with increased cardiovascular risks such as myocardial infarction, stroke and arteriosclerosis. During surgery the haemodynamic effects of stress are closely monitored and stabilised by the anaesthetist. Although there have been many studies assessing the effects of intraoperative stress on the patient, little is known about the impact on the surgeon.

A prospective cohort study was carried out using an ambulatory blood pressure monitor to measure the BP and heart rates (HR) of three consultants and their respective trainees during hallux valgus, hip and knee arthroplasty surgery. Our principle aim was to assess the physiological effects of performing routine operations on the surgeon. We noted if there were any differences in the stress response of the lead surgeon, in comparison to when the same individual was assisting. In addition, we recorded the trainee's BP and HR when they were operating independently. The intraoperative measurements were compared with their baseline readings and their stress response, assessed using the Bruce protocol.

Many trends were noted in this pilot study. All of the surgeons had higher BP and HR readings on operating days compared to baseline. The physiological parameters normalised by one hour post-theatre list in all subjects. When the trainer was leading the operation, their BP gradually increased until implant placement, while their trainees remained stable. On the other hand, when the trainee was operating and the trainer assisting, the trainer's BP peaked at the beginning of the procedure, and slowly declined as it progressed. The trainee's BP remained elevated throughout. The highest peaks for trainees were noted during independent operating.

We conclude that all surgery is stressful, and that trainees are more likely to be killing themselves than their trainers.

Anterior knee pain following primary total knee replacement (TKR) is a common problem with average reported rates in the literature of approximately 10%. Symptoms are frequently attributed to the patellofemoral joint, and the treatment of the patella during total knee replacement is controversial.

There is no article in the literature that the authors know of that has specifically evaluated the effect of patella rim cautery on TKR outcome. This is a denervation technique that has historically been employed, with no evidence base. A prospective comparative cohort study was performed to compare the outcome scores of patients who underwent circumferential patella rim cautery, with those who did not.

Patients who had undergone a primary TKR were identified from the unit's arthroplasty database. Two cohorts, who were age and gender matched, were established. None of the patients had their patella resurfaced, but all had a patellaplasty. The Low Contact Stress TKR (Depuy International) was used in all cases.

The effect of circumferential patella rim cautery on the Oxford Knee Score (OKS) and the more anterior knee pain specific Patellar Score (PS) a minimum of 2 years post surgery was evaluated. Previous reports have suggested that a change of 5 points in the OKS represents a clinical difference. A sample size calculation based on an effect size of 5 points with 80% power and a p-value of 0.05 would require a minimum of 76 patients in each group.

There were 94 patients who had undergone patellaplasty only, and 98 patients who had supplementary circumferential patella rim cautery during their primary TKR. The mean OKS were 34.61 and 33.29 respectively (p=0.41), while the PS scores were 21.03 and 20.87 (p=0.87).

No statistically significant differences were noted between the groups for either outcome score. Patella rim cauterisation is unnecessary in primary TKR.

To evaluate the current biomechanical and clinical evidence available on the use and effectiveness of lumbar interspinous devices

Literature review

A PubMed search was done using the following key words: interspinous implants, interspinous devices, interspinous spacers, dynamic stabilization, X-stop, Coflex, Wallis, DIAM. The abstracts of all the articles were reviewed. Further critical analysis was done of the relevant articles. Special emphasis was given to those articles pertaining to biomechanical and clinical results.

A total of 50 articles were found, 18 of them also related to the effect of spacers on the biomechanics of the spine. 25 articles were on the X-stop device. However, level I evidence is lacking. Only two prospective randomized controlled trials have been done and these were on the X-Stop device.

Analysis of current evidence suggests a potential beneficial effect of lumbar interspinous spacers in select group of patients. However, further level I evidence is required to justify their widespread use for all the proposed indications. The results of the ongoing trials are keenly awaited.

Aim

Grade is the most important predictor of the biological behaviour of soft tissue sarcomas. Assigning a pathologic grade is always a difficult task as discordance rate is 30-40% even among experienced sarcoma pathologists. Many of these tumours are heterogeneously large and only small fractions are sampled for biopsy. This emphasizes the need for an objective and accurate assessment of histology. Our aim is to evaluate the role of Choline as a tumour marker in (i) differentiating benign from malignant soft tissue tumour, (ii) to distinguish recurrent/residual tumours using in-vivo MR spectroscopy.

Aim

Grade is the most important predictor of the biological behaviour of soft tissue sarcomas. Assigning a pathologic grade is always a difficult task as discordance rate is 30-40% even among experienced sarcoma pathologists. Many of these tumours are heterogeneously large and only small fractions are sampled for biopsy. This emphasizes the need for an objective and accurate assessment of histology. Our aim is to evaluate the role of Choline as a tumour marker in (i) differentiating benign from malignant soft tissue tumour, (ii) to distinguish recurrent/residual tumours using in-vivo MR spectroscopy.

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.

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, 24hr on call then off next working day, or shifts including nights).

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.

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: Many types of prosthesis are currently used for total knee arthroplasty. Controversy exists as to whether mobile-bearing or fixed-bearing implants make any difference in achieving earlier or better movement, resulting in earlier patient discharge.

Aim: The purpose of our study was to compare the post-operative recovery and early results of 4 different mobile- and fixed-bearing knee implants.

Method: Between 19/7/05 and 15/6/07 202 knees were implanted into 190 patients. Patients were randomly selected for 1 of 4 implants (2 mobile-bearing, 2 fixed-bearing). Outcomes were assessed using the American Knee Society Score (AKSS) and range-of-movement, both pre-operatively and at 1 year post-operatively. Range-of-movement was also recorded on discharge.

Results: No significant difference was shown between the individual implant groups and the actual mean pre-operative and 1 year post-operative AKSS knee or functional scores or the change in knee score. A difference was noted however in the change in functional score between the 2 mobile-bearing knees (p=0.03). No significant difference was found between the 4 individual implants or the type of bearing used (mobile- or fixed-bearing) with regards to gender, age, length of stay or range-of-movement.

Conclusion: The type of implant used does not affect the early or 12 month outcomes in relation to range-of-movement, length of stay or AKSS knee scores.

An audit of fractured neck of femur patients indicated that the delay in acquiring an echocardiogram was delaying surgery (time to echo 5.4 days ± 3.4SD (n=72), time to surgery 7.5 days ± 5.5SD (n=72)). This instigated a change in policy with the introduction of routine ‘targeted’ echocardiography performed by a cardiac technician at the patient’s bedside.

A re-audit has demonstrated an improvement in service (time to echo 1.0 days ± 0.7SD (n=96), time to surgery 2.9 days ± 1.9SD (n=118)). A targeted echocardiogram consists of an evaluation of left ventricular function expressed as normal, mild, moderate and severe (left ventricular ejection fraction > 50%, 40–50%, 30–40% and < 30%), the aortic valve (normal, non severe aortic stenosis, severe aortic stenosis, aortic regurgitation and aortic gradient). A targeted echo gives less information than a departmental echo where more parameters are measured, however the information provided is enough to guide the anaesthetists choice of anaesthesia and intraoperative anaesthetic management. Senior Echo technicians perform the investigation at the patients bedside on the trauma ward in the mornings of the working week using a portable machine. Each echocardiogram takes 2 to 5 minutes to perform. If obvious significant other pathology is seen, the patient is referred for a full departmental echocardiogram.

A total of 28.4 patient bed days per month were saved following this change in practice, assuming days waiting for echo preoperatively equate to extra days spent in hospital. The total cost saving per month was £4435, based on the cost of routine targeted echocardiography (£10), departmental echocardiography (£60) and bed cost (£155 per night).

Expedient surgery within this group of patients should not be compromised by delays in obtaining timely echocardiography. The cost of routine ‘targeted’ echocardiography is low and this change in practice can be justified in both clinical and economic terms.

Good medical practice predicates a contemporary knowledge of the literature to guide ones practice. The British edition of the Journal of Bone and Joint Surgery [JBJS (Br)] is considered one of the leading peer reviewed journals, guiding orthopaedic practice in the UK and abroad. Whilst seeking guidance on proposed changes to departmental policy, informal discussion with some high profile units raised concerns regarding the implementation of their published clinical recommendations. We intended to contact the publishing departments, to establish their routine practice with respect to the topic on which they have written in the literature.

We reviewed all articles published in JBJS (Br) over a 24 month period. Specifically we were seeking papers making recommendations for a change in practice. The originating department was contacted by telephone and communication sought from an individual not directly involved in the publication, but whom the change in practice stated in the literature would have direct impact.

Seventy-nine papers representing the work of 87 separate hospitals from 22 different countries were identified as making recommendations in any aspect of practice. We found that published articles were being followed in 56% of cases, 42% were not.

Our study demonstrates that a large proportion of institutions making clinical recommendations are not practicing them. Should the author’s own institution not follow their guidance, then how can the wider orthopaedic community be expected to follow? As such, have we exposed a fundamental flaw in the publication of clinical research?

In conclusion, we do practice what we preach… sometimes.

Introduction – Patients who have sustained a fracture of the hip should have their surgical treatment with 48 hours of admission to hospital. A delay results in increased morbidity and mortality.

This elderly cohort of patients often have confounding co-morbidities. A pre-operative echocardiographic assessment to guide the anaesthetic is frequently requested upon clinical grounds. A delay in acquiring the echocardiogram was observed thus delaying surgery. This instigated a change in policy within the department whereby all patients over 70 years old who sustained a hip fracture underwent echocardiographic assessment with 24 hours of admission.

Method: An audit was performed assessing delays in acquiring the echocardiograms and measuring the time taken to perform the operation.

Results: Period 1 – Selective Echo: Mean time to echo 5 days, mean time to theatre 7 days. Period 2 – Unselective Echo: Mean time to echo 1 day, mean time to theatre 2 days.

Conclusion: As a result of the unselective policy to perform echo cardiograms on all patients admitted with a fractured neck hip, the delay to perform surgery has been reduced significantly.

The management of the patella during total knee replacement is controversial. In some studies the absence of patellar resurfacing results in residual anterior knee pain in over 10% of patients. One form of treatment which may be used in an endeavour to reduce this is circumferential patellar rim electrocautery. This is believed to partially denervate the patella. However, there is no evidence of the efficacy of this procedure, nor do we know if it results in harm.

A retrospective comparative cohort study was performed of 192 patients who had undergone a primary total knee replacement with the porous coated Low Contact Stress rotating platform prosthesis without patellar resurfacing between 2003 and 2007. In 98 patients circumferential electrocautery of the patellar rim was performed and in 94 patients it was not. The two groups were matched for gender and age. The general Oxford Knee Score and the more specific patellar score for anterior knee pain were used to assess patient outcomes a minimum of two years post-operatively.

No statistically significant differences were noted between the groups for either scoring system (p = 0.41 and p = 0.87, respectively). Electrocautery of the patella rim did not improve the outcome scores after primary total knee replacement in our patients.

Introduction: Various techniques are being currently used for the internal fixation of scarf osteotomies. We conducted a prospective study on 23 consecutive cases of hallux valgus treated with scarf osteotomy, which was internally fixed with AO mini fragment screws. The aim of our study was to evaluate the clinical efficacy of the AO mini fragment screws in these cases.

Method: Sixteen women and one man (twenty three feet) were included in our study. Mean age was 46 years at the time of surgery. The mean follow-up time was 18 months. A single surgeon performed surgery. Patients were assessed by clinical and radiological evaluation. Preoperative and postoperative American Orthopaedic Foot and Ankle Society score was obtained.

Results: All the osteotomies united without any failure of fixation or hard ware problems. One patient developed superficial wound infection, which responded to antibiotics. At the time of follow-up all the patients were very satisfied. The mean AOFAS score improved significantly from 55 points pre-operatively to 91.95 at follow-up (p < 0.001). The intermetatarsal and hallux valgus angles improved from the mean pre-operative values of 15.86° and 31.18 degrees to 9.09° and 15.18°, respectively. These improvements were significant (p < 0.0001).

Conclusion: We report no failure of fixation in our series and conclude that this is a safe and simple technique. It is cost effective, provides stable fixation and maintains correction till the union of osteotomy.

A study of 50 consecutive osteoporotic pelvic rami fractures has been carried out to investigate the full extent of injury following low energy falls.

50 consecutive elderly patients with fresh fractures of the pelvis were each investigated with an MRI scan of the pelvis in order to assess the competency of the pelvic ring. The 50 patients consisted of 45 female and 5 males with a mean age of 77.7 years. 44 patients had unilateral pubic rami fractures. The mechanism of injury in all cases was a simple fall in the home environment. On admission 96% of the patients complained of sacral pain and were tender in the sacral or posterior pelvic region. On MRI, 90% of patients had a sacral fracture associated with the pubic rami fractures and in all but 4 of these the posterior pelvic pain was directly related to the sacral fracture site. At 6 month follow-up, 82% still complained of posterior pelvic tenderness. Areas of tenderness corresponded to the sites of the fractures. Before the injury, 38 of the final 44 reviewed were reasonably independently mobile, whilst at review 39 were significantly disabled.

Conclusion: The study shows that the apparently benign traumatic pelvic rami fracture in the elderly has a high association with sacral fractures. After discharge from hospital, attention should be paid to treatment of the on-going anterior and posterior pelvic pain.