Aims

To determine the likelihood of achieving a successful closed reduction (CR) of a dislocated hip in developmental dysplasia of the hip (DDH) after failed Pavlik harness treatment We report the rate of avascular necrosis (AVN) and the need for further surgical procedures.

Background

Thrust plate prosthesis (TPP) is a bone conserving prosthesis in use for over thirty years. TPP is a stemless and uncemented femoral prosthesis fixed at the lateral femoral cortex with a bolt, plate and screw. This has a metal-on-metal articulation with a 28mm Metasul head and Allofit press fit acetabular cup. Our study aimed to assess the functional outcome of this prosthesis.

Background

Autologous Chondrocyte Implantation (ACI) is a procedure which is gaining acceptance for the treatment of cartilage defects in the knee with good results and a long term durable outcome. Its use in other joints has been limited, mainly to the ankle. We aimed to assess the outcome of ACI in the treatment of chondral and osteochondral defects in the hip.

Thrust plate prosthesis (TPP) is a bone conserving prosthesis in use for over thirty years. TPP is a stemless and uncemented femoral prosthesis fixed at the lateral femoral cortex with a bolt, plate and screw. This has a metal-on-metal articulation with a 28mm Metasul head and Allofit press fit acetabular cup. Our study aimed to assess the survival of this prosthesis. At Oswestry 234 TTP's were implanted between 1995 and 2005. All patients completed a self-assessed questionnaire of Harris Hip Score pre-operatively and post-operatively at 2 months, 1 year, and then yearly. Only those who had a follow up was within the last two years were included in the analysis. 76 patients who had failed to satisfy the criteria were excluded. Of the 158 hips in the study 75 hips were in male patients and 83 were in female patients. The median age of patients was 52 years (range 15 to 82). 75 hips were on the right side and 83 on the left. All patients were operated by the senior author or a senior trainee under his supervision (seven hips). Revision of the implant or decision to revise was taken as the end point of our study. The median time to follow up was 7 years (range 1 to 15). The median pre-operative hip score was 43 (range 3 to 77) which rose to 83 points (range 11 to 100) at the latest follow up. Median hip score in females improved from 39 to 82 points and in males from 52 to 85 points. Twelve patients (5.1%) underwent revision surgery either for infection or aseptic loosening. The Thrust Plate Prosthesis had a good outcome with an increase in hip score of 40 points and 94.9 % survival at a median of 7 years.

We aimed to assess the long term results of patients who underwent Autologous Chondrocyte Implantation (ACI) for osteochondral lesions of the talus. Between 1998 and 2006, 28 patients underwent ACI for osteochondral lesions of the talus. All these patients were prospectively reviewed and assessed for long term results. Outcomes were assessed using satisfaction scores, Mazur ankle score and the AOFAS score, and Lysholm knee score for donor site morbidity.

The 28 patients who underwent the procedure included 18 males and 10 females. Follow up ranged from 1–9 years. In all patients, there was an improvement in the Mazur and AOFAS ankle scores and the Lysholm scores showed minimal donor site morbidity. Improvement in ankle score was independent of age and gender. The better the pre-op score the less the difference in post-op ankle scores. Patients were unlikely to benefit with pre-op ankle scores over 75.

The mid to long term results of ACIs in the treatment of localised, contained cartilage defects of the talus are encouraging and prove that it is a satisfactory treatment modality for symptomatic osteochondral lesions of the talus. Complications are limited. However, in view of limited number of patients, a multi-centre randomised controlled study is required for further assessment.

Introduction: Hip resurfacing is a renaissance of metal on metal hip arthroplasty. It preserves bone stock and a large head allows greater range of motion. This new technique is gaining popularity among patients and surgeons alike. We present a nine year follow up in the context of survival, function and complications.

Methods: We analysed follow up data of 4778 patients who have had hip resurfacing using Birmingham Hip resurfacing (Smith & Nephew, UK) in 37 countries. Patients were followed up annually using Oswestry hip score and any revisions were updated on the database at the Oswestry Outcome Centre. Function was analysed using multilevel modelling and Kaplan-Meier method used for survival analysis.

Results: There were 3193 males and 1585 females operated by 138 surgeons in 37 countries. The mean age was 52.8 years (13 – 87.8). Using hierarchical regression the annual hip scores were analysed. Overall function was significantly affected by pre op score and gender (p< 0.01). Age at operation had no effect on outcome score (p =.462).

We observed similar effect in individual domains of pain, mobility and range of motion. Survival of the implant at nine years with revision due to any reason was 93.5%. We observed a significant difference in survival of procedures done by pioneer surgeons and by non pioneering surgeons (p < 0.01) (log rank test). There were 119 complications of which there were 30 fractures, 21 occurring within the first six months of operation.

Conclusion: Nine year results of hip resurfacing arthroplasty look promising and are comparable to traditional hip arthroplasty. The difference between two surgeon groups could be due to a learning curve in the technique. Further follow up would be necessary to ascertain the long-term clinical effectiveness of this technique.

Introduction: Total hip replacement in one of the most commonly performed operation in orthopaedics in the UK with similar numbers being operated in other parts of the world (2). The main reasons for this magnitude are marked improvement in function and the quality of life. The hip prosthesis has evolved significantly over half a century and better prostheses are available today. These newer implants are required to have a survival of 90% for a minimum of 10 years. The improved survival of the implant tends to have effect on the quality of life as well as the life expectancy. There has been a continuous attempt to quantify this increased life expectancy and survival following total hip arthroplasty.

Materials and Methods: We compared the mortality figures of 3947 patients who had hip resurfacing arthroplasty with the national mortality figures of the UK. The cause of death was determined by telephone call to the next of kin and from the national death register.

Results: The average standardized mortality ratio of hip resurfacing patients compared to national figures over the nine year period was 0.524(99 percent C.I. 0.39 to 0.69). Individual SMR for each year is shown in Table. The number of observed deaths were 86 as compared to the expected deaths number 164. Out of the total 86 deaths over a nine year period, 36 deaths were due to cancer, 25 due to cardiovascular causes, eight due to respiratory conditions, four following accidents and 13 due to other causes such as suicide, old age. In the cancer group 7 patients died of lung cancer and 8 died of blood cell neoplasms. National figures for year 2007 were not yet compiled so SIR for cancer was not calculated.

Conclusion: The results of this study are comparable to other follow up studies on mortality following total hip replacement. This indicates that increased activity following hip resurfacing may help the patients maintain better fitness.

The incidence of cancer needs to be interpreted with caution and can only be ascertained by a prospective study.

Objective: Assessment of hip function is done by surgeon and few patient based tools. These patient assessed scores do not measure range of motion. The American Academy of Orthopaedic Surgeons has outlined pain, mobility and range of motion as three fundamental aspects of joint assessment. We aimed to validate Oswestry hip score which was developed as a patient-completed self-assessment to provide both Harris hip score and Merle d’Aubigne hip score with added content to estimate hip range of motion.

Methods: 144 patients completed the Oswestry hip score, WOMAC Index and the Oxford hip score at two different occasions. The patients were seen two weeks later and filled the Oswestry hip score and a surgeon filled the Harris hip score. The study included 80 females and 64 males with a mean age of 62 years range (32–91). We assessed the reliability, validity and responsiveness of this new tool by comparing the individual domains of the Oswestry hip score to similar domains of the WOMAC, Harris hip score and Oxford hip score.

Results: The reliability of this new score was established by the Intraclass Correlation Coefficient. Internal consistency was measured by Cronbach’s alpha. The Cronbach’s alpha was 0.7, which is considered a good measure of internal consistency. Content validity of the Oswestry hip score was established by the validated domains of pain, function and range of motion of the Harris hip score. Analysis of frequency of response distribution showed normal floor and ceiling effect for any of the domains of the Oswestry hip score. Multi-method multitrait matrix analysis was used to establish the construct validity of the Oswestry hip score. There was good correlation between pain and function domains (p< 0.001). Moderate correlation was found among clinical assessment of hip movement and movement domains of Oswestry hip score (Pearson’s r=0.55; p0.001). The responsiveness of the Oswestry hip score was measured with Cohen’s effect size. An effect size of > 0.8 is considered large. The mean effect size was 2.06 (1.36–2.97).

Conclusion: A positive construct validity and high correlation with WOMAC, Oxford Hip Score and Harris hip score shows that the Oswestry hip score can give an adequate measure of hip joint function. An effect size of 2.0 shows good responsiveness of the Oswestry hip score. The Oswestry hip score can be completed by patients themselves and is therefore ideal for long-term and large scale collection of clinical outcome data.

Objective: The aim of this study was to validate Oswestry hip score. This is a new score which was developed as a patient completed self-assessment to provide both Harris and Merle d’Aubigne hip score with added content to estimate hip range of motion.

Methods: 61 patients completed the Oswestry hip score, the WOMAC and the SF-36. Validity was tested by comparing the domains and items of the Oswestry hip score to WOMAC and SF-36. The new movement scale of Oswestry hip score was specifically validated against Merle d’ Aubinge, mobility scoring system. SPSS software was used for statistical analysis.

Results: Mean age was 56 years (range 18–83).Content validity of the Oswestry hip score was demonstrated by two main indicators for hip surgery, pain and function. Analysis of frequency of response distribution showed no floor or ceiling effect for any of the domains of the Oswestry hip score. Construct validity of the Oswestry hip score domains of pain and function showed good correlation with the correspondent domains of WOMAC and SF-36 (p< 0.001). Moderate correlation was found among clinical assessment of hip movement, Merle d’ Aubinge mobility score and movement domains of Oswestry hip score (Pearson’s r=0.55; p0.001). Correlation between Harris and Oswestry hip score was 0.63 to 0.91. Cronbach’s alpha was 0.7, showing good internal consistency.

Conclusion: A positive construct validity and high correlation with WOMAC and SF-36 shows that the Oswestry hip score is can give an adequate measure of hip joint function. The new questionnaire is brief and can be completed by patients themselves. It is therefore ideal for long-term and large-scale collection of data. Oswestry hip score does not intend to replace the clinical examination at the critical phases following hip surgery but can be a useful adjunct. We report the validity and reliability of this new tool.

Introduction: Lisfranc injuries account for 0.2% of all fractures. Around 20% of these injuries are missed or misdiagnosed leading to long term problems with the foot. Early recognition and treatment of these injuries are crucial in restoring the function of the foot.

Aim: To review the functional outcome of patients following surgery for lisfranc injuries.

Methodology: This is a retrospective review of patients treated surgically for lisfranc injury in our hospital between January 2000 and January 2007. There were 13 patients whose records were reviewed and data including age, mechanism of injury, associated injuries, surgery performed, and peri-operative complications were collected. A telephonic survey was conducted to find out the current functional and employment status. AOFAS mid-foot score was used to evaluate the outcome.

Results: 13 patients were included in the study. Mean age was 31 years at the time of injury. 5 patients were female and 8 male. 10 had injury on the left foot while 3 had on the right. 11 were closed lisfranc injury. 10 patients had isolated lisfranc injury. Seven patients had sustained lisfranc injury following a fall, while three had a road traffic accident. Six patients had a homo-lateral, four had isolated and two had divergent type. Nine patients had trans-articular fixation, seven of whom had open reduction and internal fixation while two had K-wire fixation. Extra-articular fixation was done in four patients. Average AOFAS mid foot scoring was 80 ranging from 47 to 100. Lower scores were related to pain. Nine patients were pain free at follow up and returned to work. Average follow-up period was 32.6 months (range5–77 months)

Conclusion: Two thirds of patients with a Lisfranc fracture dislocation return to work and extra-articular fixation may result in superior outcomes compared with the traditional methods.

A dorsal incision is made over the metatarso-phalangeal joint (MTPJ) extending 2cm proximally and distally from the joint line. A routine cheilectomy of the MTPJ is performed. The Extensor digitorum longus (EDL) tendon is identified and divided through a separate incision 5 cm proximal to the MTPJ at the mid-foot level. A 3/0 vicryl stay suture is placed in the divided tendon. The tendon is retrieved from the distal wound and mobilised along with the extensor expansion and the dorsal capsule to expose the proximal half of the proximal phalanx. The transverse fibres of the extensor expansion and the MTPJ capsule are divided medially and laterally with preservation of the collateral ligaments. Extensor digitorum brevis is identified and protected. A groove is created on the dorsum of the proximal phalanx at the centre of the articular surface to stabilise the EDL tendon in its final position. A 3.2mm tunnel is then created at a 45 degree angle through the metatarsal neck beginning dorsally 2.5cm from the metatarsal articular surface and exiting just proximal to the plantar plate. The mobilised EDL tendon, expansion and capsule are then passed down through the MTPJ via a perforation in the plantar plate. The EDL tendon is then passed through the tunnel from plantar to dorsal where it is sutured to the periosteum of the metatarsal using a 3/0 vicryl suture. Hence the EDL tendon, expansion and dorsal capsule form an interposition arthroplasty.

Eleven patients with an average age of 37 years underwent the above procedure for Freiberg’s Disease or osteoarthritis of the second or third MTPJ. There were no intra-operative complications and at an average 31 month follow up 70% were pain free. We recommend the Cobb II procedure as a primary management option for MTPJ Freiberg’s Disease/osteoarthritis.

Purpose of the study: to demonstrate a mechanism of loosening of the Souter-Strathclyde Total Elbow Replacement (TER) using evidence from revision surgery.

Methods: nine Souter-Strathclyde humeral and ulnar components retrieved from revision surgery for aseptic loosening were examined macroscopically and then microscopically under low power magnification. The wear patterns were compared and photographed.

Results and conclusion: inspection of the retrieved cobalt chrome steel humeral components revealed no evidence of surface wear. However on examination of the polyethylene ulnar components six of the nine exhibited macroscopic wear taking the form of deep linear grooves on either the medial or lateral articulating surface. Microscopic examination revealed wear exhibited as complete disruption of the polyethylene machining lines on the medial and lateral articular surfaces, but almost complete preservation on the central gliding ridge. The findings are best explained in the context of normal elbow kinematics and congruence of the Souter-Strathclyde components. The normal elbow joint is not a simple hinge joint. In addition to flexion/extension, axial rotation and abduction/adduction motion patterns occur. However articulating surfaces of the Souter-Strathclyde components are highly congruent and thus resist the elbow’s normal translational and rotational movements. Our wear patterns are the result of humeral component rocking during flexion and extension as a result of this resistance. The central gliding ridge is preserved because the humeral component is not always in contact with it as it rocks out of its articulation in the coronal plane. Furthermore as the humeral component rocks, the sharp edge of its articulating surface makes contact with the articulating surface of the ulna causing abrasion and in the extreme circumstance the deep linear grooves observed. The biomechanics eventually lead to component loosening.

Background and objective: in 2003 in its publication ‘Care of fragility fracture patients’ The British Orthopaedic Association highlighted the orthopaedic surgeon’s role in assessment and management of patients at high risk from osteoporosis. In general such secondary prevention of osteoporosis is carried out poorly by orthopaedic surgeons. This audit aimed to determine if software which identifies patients at high risk from osteoporosis from clinic letters, improves orthopaedic surgeons’ referral rates for DEXA.

Methods: two audit cycles were carried out using local guidelines. The audits concerned patients over 50 years having sustained a fragility fracture of the distal radius. According to local guidelines all such patients should undergo DEXA. Patients were identified from hospital records and the number referred for DEXA determined. Those who had undergone DEXA in the year prior to fracture were excluded. The baseline audit was from April to June 2004 inclusive followed by closure of the loop between October and December 2004 following reinforcement of guidelines. Following continued poor referral rates at this point the software programme was introduced. It identifies patient age and key words in dictated clinic letters when they are being printed, for example distal radial fracture. Appropriate patients have computer generated osteoporosis advice included at the bottom of the general practitioner letter along with a DEXA referral form which General Practitioners complete. A further audit using similar methods was carried out 3 months after the software introduction (January 2006).

Results: baseline audit identified forty-three patients (36 women and 7 men) with a mean age of 73 years, 3 were referred for DEXA (7%). Following reinforcement of guidelines fifty-two patients were identified (46 women and 6 men) with a mean age of 68 years, 16 (31%) were referred. At re-audit (following the introduction of the software programme) 45 patients were identified (38 women and 7 men) with an average age of 71 years. 30 (67%) were referred for DEXA. This is a significant improvement using a Chi squared analysis.

Conclusion: the software programme significantly improves orthopaedic surgeon identification of patients at high risk of osteoporosis and referral rates for DEXA.

Purpose: to quantify the cost of hospitalisation and theatre time in the treatment of infected primary total knee replacements.

Materials and Methods: hospital approval was obtained for the study. Inclusion criteria were defined as: patients requiring surgery for deep or superficial infection of a primary total knee replacement (TKR) with subsequent positive bacteriological cultures. Clinical coding provided a list of patients with the ICD 10 code T845 (infection or inflammatory reaction due to an internal joint replacement) over a 2 year period and notes of patients were obtained to confirm the inclusion criteria were met. The theatre procedures performed and numbers of days in hospital for all admissions related to joint infection were recorded. The cost of a day in hospital and the cost of each procedure by time in minutes were obtained from the hospital finance department hence the overall cost of hospitalisation and theatre per patient estimated.

Results: 15 patients were identified as having undergone surgery for an infected primary TKR. Prolonged hospital stay, predominantly for administration of antibiotics claimed the largest proportion of expenditure in our patient group. An average of 64 excess days per patient were spent in hospital (range 13 to 218). The cost of an overnight hospital stay is £180, therefore the cost per patient was £11544. Seven day procedures at a cost of £473 each were also carried out. Each patient underwent an average of 4.7 theatre procedures (range 1 to 12). The most common surgical procedures were joint washout / debridement for early infection, joint aspiration, first and second stage revision. The cost of a minute of theatre time is £12.97, hence the cost of theatre time per patient was £4959. The overall estimated cost per patient for treatment of an infected primary total knee replacement is £16503 (exclusive of implant and antibiotic costs).

Conclusion: the cost of an infected TKR is a substantial financial burden for trusts as well as a catastrophic complication for patients. Methods of reducing expenditure include reduction in hospital stay by administration of antibiotics by district nurses or trained family members, rapid management of early joint infection by washout and debridement with the possibility of avoiding revision surgery and explantation of components upon diagnosis of bone/cement interface infection hence avoiding futile operations.

Aim: to compare the reliability of pre-operative templating for total hip and knee arthroplasty using printed digital radiographs versus conventional radiographs.

Materials and Methods: a prospective continuous study commenced January 2005. The PACS digital imaging system was introduced in May 2005 and the radiology department adopted a policy of printing orthopaedic radiographs to ‘true size’. All consultants and their registrars undertaking primary total hip and knee arthroplasty were asked to participate in the study and agreed. The operating surgeon completed a proforma for each Total Hip Replacement (THR) performed noting the templated cup and stem size and offset. Following the surgery the actual sizes and offset of the components implanted were also recorded on the proforma. A similar procedure was followed for the femoral and tibial components of Total Knee Replacements (TKR).

Results: there were 254 completed proformae. 186 pro-formae for conventional radiographs and 68 proformae for printed digital radiographs. Templating was possible from all the conventional radiographs; however templating was only possible from 58 of 68 (85%) digital radiographs as the images were obviously not true size. The templated sizes of both hip and knee components from conventional radiographs were more predictive of the actual size implanted in all cases. Furthermore there were a greater number of predicted outlying sizes using printed digital radiographs.

Conclusion: digital radiographs, even those said to be true size are unreliable for the purposes of pre-operative planning.

Introduction: The Trent arthroplasty register reported that results of Hip arthroplasty in general setup were less than that reported from specialist centres by 5%. This independent prospective study tests the hypothesis that results of Birmingham Hip Resurfacing arthroplasty from specialist centres would not accurately represent the outcome of hip resurfacing when performed in general setup.

Material and Methods: All patients were prospectively followed for at least five years at Oswestry Hip outcome centre. The surgeons carrying out the operation prospectively provided surgical details and thereafter patients were followed using Oswestry hip questionnaire (OSHIP) at fixed intervals. Survival was assessed by Kaplan-Meier method. The results were compared to the published results of BHR from specialist centers

Results: There were 679 patients, and 58 surgeons in the study. Mean age at operation was 51 years and mean follow up was 5.63 years. The predominant preoperative diagnosis was osteoarthritis. The mean OSHIP score was 89.5. There were 29 (4.2%) failures mostly due to fracture neck of femur (62%); all of them were revised to conventional THR. The Kaplan-Meier survival at seven years is 95.354%.

Discussion: Compared to the published results, there were 2 to 19 times high failure rate which is significantly higher (p=0.001) than the published studies. Hence we prove our hypothesis, as the results of BHR from specialist centres do not accurately reflect on the outcome in general setup. The discrepancy in the results that we have identified would help to identify the weak areas in the general setup, where most of the patients get benefited from BHR arthroplasty.

The Trent arthroplasty register reported that results of Hip arthroplasty in general setup were less than that reported from specialist centres by 5%. This independent prospective study tests the hypothesis that results of Birmingham Hip Resurfacing (BHR) arthroplasty from pioneering centres would not accurately represent the outcome of hip resurfacing when performed in general setup.

All patients were prospectively followed for at least five years at Oswestry Hip outcome centre. The surgeons carrying out the operation prospectively provided surgical details and thereafter patients were followed using Oswestry hip questionnaire (OSHIP) at fixed intervals. Survival was assessed by Kaplan-Meier method. Results were compared to the published results of BHR from specialist centres.

There were 679 patients, and 58 surgeons in the study. Mean age at operation was 51 years and mean follow up was 5.63 years. The predominant preopera-tive diagnosis was Osteoarthritis. Mean OSHIP score was 89.5. There were 29 (4.2%) failures mostly due to fracture neck of femur (34%). Out of 14 failures in the first year, 9 (64%) were due to fracture neck of femur. The Kaplan-Meier survival up to eight years is 95.354% in the current study.

Compared to the published results, there were 2 to 19 times high failure rate which is significantly higher (p=0.001) than the published studies. Most of the early failures were due to fracture neck of femur in the first year. Hence we prove our hypothesis, as the results of BHR from specialist centres do not accurately reflect on the outcome in general setup. The discrepancy in the results is mostly due to fracture neck of femur in the early postoperative time. The results of this study will enhance awareness of the early trend in failures. Appropriate patient selection and meticulous surgical technique will help avoid this complication in the general setup, where most of the patients get benefited from BHR arthroplasty.

Background: Articular cartilage injuries are very common. Small defects don’t heal on their own and large defects can’t regenerate new cartilage. This would largely be due to the fact that chondrocytes are embedded in a firm and tough matrix and hence can’t migrate to the defect site to regenerate a new cartilage tissue. So ultimate fate is patient getting early osteoarthritis. Cartilage defects in the knee may be symptomatic and cause pain, swelling and catching. There are several different surgical procedures available to treat cartilage injuries, but no method has been judged superior. The ultimate aim of the treatment is restoration of normal knee function by regeneration of hyaline cartilage in the defect, and to achieve a complete integration to the surrounding cartilage and underlying bone. Arthroscopic debridement and lavage may give symptomatic relief for a limited time. Autologous Chondrocytes Implantation (ACI) was first described in 1994. Encouraging primary results were reported, and further research was promoted. Long-term results are encouraging. ACI is being done in Robert Jones & Agnes Hunt orthopaedic Hospital, Oswestry since last 8 years.

Methods: We studied a cohort of first 118 patients who underwent ACI for knee joint in this institute, focussing on their mid-term results. Patients having chondral defects were offered ACI. They all were explained the procedure and informed written consent was obtained. Patients filled in a self-assessed Lysholm forms before the operation. They also underwent pre-operative MRI scan of knee joint. ACI procedure consisted of three stages— Stage I —Arthroscopic harvest biopsy of cartilage and chondrocytes culture in lab. Stage II—Arthrotomy of the knee. The defect edges were freshened, covered by periosteum or chondroguide, which was sutured to the cartilage with 6-0 vicryl. Chondrocytes were injected underneath this patch. Post-op CPM and Physiotherapy. Stage III—1-year arthroscopic surgery. Assessment was done with Lysholm score, MRI scan, histological and arthroscopic analysis. Patients were followed up clinically thereafter with yearly Lysholm scores.

Results: 118 patients with an average age of 35 years (15–59) underwent ACI for knee in last 8 years. 93 patients had single defect, 24 had multiple (> 1) chondral defects, with mean area 4.81 cm2. MRI showed a good integration of defect with surrounding cartilage with varied signal intensities. About 55–56% patients underwent some or other form of trimming, which improved immediate results. However only 50 % of these were symptomatic. Defects on MFC did well as compared to other sites, followed by on trochlea. Defects on patella showed poor results, though the number is less for comparison. Total 79 specimens of 1-year histology showed good healing with formation of fibrocartilage (40), mixed (20) and hyaline (8), fibrous tissue (6), bone in 1 case and inconclusive in 2 cases. Mean pre-op Lysholm score was 50.16. Average score at one year was found to be 69.52.

Conclusion: Results of ACI are encouraging. Patients continued to improve slowly over a period of time, achieving maximum function between one and 2 years post-surgery. Our study showed that there after their scores remained static.

Aim: to determine the proportion of patients with fragility fractures who underwent risk assessment for osteoporosis as a result of their fracture clinic attendance prior to and following reinforcement of guidelines

Methods: The inclusion criteria were defined as: new patients fifty years of age or over sustaining a fragility fracture of their distal radius presenting during two three month periods in 2004 (April to June and October to December). Guidelines for osteoporosis risk assessment (the Northumberland guidelines) were reinforced during the interim period. Patients were identified from hospital records and the notes obtained to confirm the fracture type as fragility. The number assessed during each period was determined from outpatient referral for DEXA records and compared. Patients who had undergone DEXA scanning in the year prior to their fracture clinic attendance were excluded from the analysis.

Results: from April to June there were forty-six patients (39 women and 7 men) with a mean age of 73 years while between October and December there were fifty-four patients (48 women and 6 men) with an average age of 68 years. In the April to June cohort 3 patients had already had a DEXA scan prior to fracture clinic attendance. Of the 43 remaining patients 3 were risk assessed for osteoporosis (7%). Within the October to December group two patients had previously undergone DEXA scanning and of the remaining 52 patients 16 (31%) underwent osteoporosis risk assessment.

Conclusion: Risk assessment for osteoporosis is still carried out ineffectively by orthopaedic surgeons even following enforcement of guidelines.

Aim: This retrospective study was undertaken to establish the accuracy of magnetic resonance imaging (MRI) in diagnosing medial meniscal, lateral meniscal and anterior cruciate ligament (ACL) tears.

Materials and methods: Sixty patients who had arthroscopic knee surgery following MRI scans were included in the study. MRI findings were then compared with the pathologies noted at subsequent arthroscopy.

Results: In this study, the sensitivity of MRI in diagnosing tears was 67% (ACL), 100% (medial meniscus) and 57% (lateral meniscus) whereas the specificity was 91%(ACL), 46 %(medial meniscus) and 77 % (lateral meniscus).The positive predictive values were 29% (ACL), 68% (medial meniscus) and 57% (lateral meniscus). The negative predictive values were 98% (ACL), 100% (medial meniscus) and 76% (lateral meniscus).

Conclusion: In contrast to some studies, these findings indicate a lower accuracy for MRI scanning in detecting tears of, in particular of the ACL and lateral meniscus. We suggest that where symptoms and clinical findings support one of these diagnoses and arthroscopic therapeutic intervention is contemplated, that MRI scanning is not beneficial. The additional expense and delay in management seems inappropriate given the findings we have demonstrated.