We wished to see if Orthopaedic Surgeons are using the current evidence with regard to the use of drains in knee arthroplasty. A questionnaire was faxed to UK members of BASK.

We had a 71. 7% response rate (160 responses out of 223). For primary TKR, 89. 5% always use a drain. 42. 1% removed their drains at between 24 and 48 hours. The commonest reason for using drains was to prevent haematoma or haemarthrosis development.

The study suggests that the majority of BASK members do not practice evidence based medicine with regard to the use of knee drains.

This study investigates the role of pre-operative mental health on outcome following Total Knee Replacement.

Patients were recruited as part of a prospective, observational study of the outcomes of primary total knee replacement for osteothritis in centres in the United Kingdom (6 centres), United States (4 centres) and Australia (2 centres). Independent, research assistants recruited eligible patients, collecting clinical history and examination data pre-operatively, 3 and 12 month post surgery. The SF-36, WOMAC, patient satisfaction and demographic data were obtained by self-administered questionnaires.

We recruited 862 eligible patients and have completed 12-month data on 742 patients (86%). Mean age was 70 years (SD 10), 59% were female, 50% were from the UK, 30% from the USA and 20% from Australia. In linear regression models, the significant correlates of preoperative mental health (in decreasing order of significance) were: low preoperative WOMAC function (Std B 8, 2; p< 0. 0001), self reported depression (Std 8 7. 6; p< 0, 0001), female gender (Std 13 2. 9 p=0, 004), older age (Std 13 2, 9; p=0. 004), other comorbid conditions (Std 3 2. 8; p=0, 005) and low income (Std B 23; p-0, 03). 12 months following surgery, low pre-operative mental health was a significance predictor of worse WOMAC pain and function (p< 0. 0001). The linear regression models adjusted for preoperative pain and function, age, sex, comorbid conditions, country and centre within country. With the exception of the pre-operative WOMAC pain and function score, low pre-operative mental health was the strongest of worse outcome 12 months after TKR.

Low pre-operative mental health is a highly significant predictor of worse outcome one year after Total Knee Replacement. It may be possible to identify patients with poor mental health before surgery using the SF36 mental health score as well as self-reported depression. This may allow for effective treatment of their mental health problems prior to TKR and/or highlight the need for extra rehabilitation input to improve outcome following surgery.

We wished to determine the most accurate and reliable technique for insertion of tibial prostheses, with tibial resection guided by either intramedullary (IM) or extramedullary (EM) alignment jigs.

135 consecutive AGC cemented total knee replacements in 126 patients in a single unit were performed by, or directly supervised by, four consultant surgeons. Ethical approval and patient consent was obtained. Intramedullary alignment was used for the femoral cuts and patients were randomised at the time of operation to have either IM or EM guides for resection of the proximal tibia, cut with a zero degree posterior slope in both. The protocol only entered patients into the trial if their knees were suitable for use with both IM and EM tibial alignment although, in the event, no patients were excluded. Long leg radiographs (standing hip to ankle) were taken by a standardised method three months after the surgery. A blinded assessor, unaware of the alignment method used, evaluated acceptable films and measured tibial component alignment. The proportion of tibial prostheses aligned within two degrees of 90 was the endpoint of the study.

Of the 135 knees 100 suitable x-rays were assessed. Correct tibial alignment was more likely in the IM group (85%) than the EM group (65%), p=0. 019. Though mean alignment was similar, variation (standard deviation) was less in the IM group (2. 0 vv 2. 2).

In the AGC knee, intramedullary alignment guides are superior to extramedullary guides for alignment of the tibial prosthesis. We recommend the routine use of intramedullary tibial alignment.

The management of disabling osteoarthritis of the knee following ipsilateral femoral fracture malunion can be difficult. This study presents the results of seven such patients treated by femoral shaft osteotomy in the fracture region and with locked intramedullary nail fixation.

Seven patients with malunited femoral shaft fractures presenting with knee symptoms between 1992 and 1999 were treated by femoral shaft osteotomy. The presenting knee symptoms and function were graded from 0–4. All patients underwent open femoral shaft osteotomy at the apex of the deformity and fixation was by locked intramedullary nailing. The patients were followed up until osteotomy union and reviewed clinically and radiologically with particular emphasis on knee symptoms and function.

There were six males and one female. The mean age at presentation was 48 years and the mean time from fracture 28 years. (Range 13–37 years). The mean knee alignment angle preoperatively was 5 degrees varus (range 0–12). The mean time to osteotomy union was 28 months. The mean knee alignment angle postoperatively was 2 degrees valgus. (range 5 degrees varus-5 degrees valgus). Five of the seven patients reported excellent pain relief and functional improvement. One patient had serious vascular complication and now has a stiff but pain free knee. One patient who presented with very advanced OA has since undergone an uncomplicated total knee arthroplasty after osteotomy union and nail removal.

These patients presenting with severe disability at an age that would be too young for total knee replacement are difficult to manage. Five out seven patients in these series are symptomatically improved to return to their old occupation. The knee replacement has been delayed in these by a mean of five years. Their eventual knee replacement is likely to have been made less difficult as a result of alignment correction.

About one third of patients who require one knee replacement have significant bilateral symptoms and will require surgery on both knees before achieving their full functional potential. The options for these patients are either to have one-stage bilateral knee replacements or two-stage knee replacements. Our aim was to compare the relative local and systematic morbidity of patients who had one-stage bilateral knee arthroplasty with those of patients who had unilateral total knee arthroplasty in a retrospective, consecutive cohort of patients to evaluate the safety of one-stage bilateral total knee arthroplasty. Seventy-two patients treated with one-stage bilateral knee replacements were matched for age, gender and year of surgery with 144 patients who underwent unilateral knee arthroplasty. We found one-stage bilateral arthroplasty was associated with significantly increased risks of wound infection, deep infection, cardiac complications and respiratory complications compared to unilateral knee arthroplasty.

No increased risk of thromboembolic complications or mortality was found.

We conclude that one-stage bilateral total knee arthroplasty is associated with increased risk of both systematic and local complications compared with unilateral knee replacement and therefore should be performed on only selective cases.

Numerous procedures have been described for degenerative arthritis of the carpometacarpal joint of the thumb. The sling procedure is technically demanding and involves sacrificing part of a healthy tendon. Silicon arthroplasty is associated with stem fracture and synovitis. We have successfully used external fixation for distraction and correction of adduction deformity following trapeziectomy with S-Quattro (Stockport Serpentine Spring System). Following trapeziectomy specially designed pins are inserted into the base of the 1^st metacarpal and radial styloid and distracted with 2 serpentine springs. The fixator is removed at six weeks and removable thermoplastic splint applied for further 6 weeks.

We reviewed the results of 39 trapeziectomy performed in 32 patients (3 male) with an average follow up of 53 months. ROM, power, pinch, pain score and patient satisfaction were reviewed by an independent hand therapist.

Average functional score was 28. 9 post-op (maximum 30) compared to 20. 7 pre operatively. Mean thumb abduction was 48. 9 and extension 49. 2 degrees which increased from 42. 9 and 43. 8 pre-operatively. Span was 19 centimetres and opposition 9. 26 on the Kapandji scale. Average grip strength was 40 lbs, pinch strength of 6 lbs and key lateral of 9. 5 lbs. Pain score improved from 7. 9 pre-op to 0. 9. There was statistically significant improvement of all functions except span. Long term follow up radiograph showed good maintenance of gap between base of 1^st metacarpal and scaphoid. Three cases had deep penetration of the pins, which required early removal. We now insert padding between the fixator and the spring to avoid deep penetration. One patient had mild RSD and another patient had pain in the distribution of the radial nerve, both of which improved following pin removal.

Application of S-Quattro following trapeziectomy is a simple and quick procedure. It is reasonably well tolerated by patients. Long-term follow-up showed improvement in hand function and good maintenance of gap between base of 1^st metacarpal and scaphoid.

The aim of the study was to evaluate changes in clinical results after extracorporeal shock wave therapy (ESWT) on calcified lesions of the shoulder.

963 patients with calcifying tendinitis were treated with high energy shock waves. The mean energy flux density was 0. 28 mJ/mm2. To evaluate the effect we used the visual analogue scale (VAS) and the Roles-Maudsley-score to analyse the effect on activity of daily living, and pain perception. ESWT was indicated after non operative treatment failed.

At 12 months after ESWT, 73. 6% of patients reported excellent and good results, 26% scored satisfactory and poor, using the Roles-Maudsley-Score. The positive effect of the ESWT on pain perception after 12 months was statistically significant (p< 0. 001). The difference between pain perception before and after ESWT persisted in the follow up interval. No decrease was shown after 2 years. In all cases no severe side effects were observed except small petechial haemorrhages.

High energy shock wave therapy is indicated to treat calcifying tendinitis which is resistant to any other non-operative treatment. The decrease in pain perception persists over a period of more than two years. Absence of side effects and its effectiveness suggest that ESWT is indicated prior to surgical intervention.

The purpose of this study is to ascertain the efficacy of ultrasound in determining pathology prior to surgical intervention for rotator cuff tears, 88 patients were referred for surgery on clinical grounds.

One Radiologist who is widely experienced in shoulder ultrasound scanned these patients within one month prior to their operation using up to date equipment. The patients were categorised into 2 groups: those with or those without a full thickness rotator cuff tear. The results were then verified using surgery as the ‘gold standard’. This enabled the researcher to calculate the diagnostic accuracy of the procedure.

The findings show that in this Trust, ultrasound has a sensitivity of 95% in the detection of full thickness rotator cuff tears. The specificity is 87%, positive predictive value 87% and negative predictive value 95%.

Knowledge of the cuff status prior to surgery aids in pre-operative patient counselling in terms of surgical procedure (arthroscopic or open surgery), rehabilitation and prognosis. This study demonstrates that expert practitioners can produce reliable results using ultrasound, which can then be used as the primary investigation for the detection of full thickness rotator cuff tears. More expensive procedures such as Magnetic Resonance imaging are now limited to those patients with equivocal ultrasound findings.

68 patients underwent arthroscopic subacromial decompression for shoulder impingement syndrome. Patients were evaluated preoperatively, at 3 weeks and 3 months post operatively using the Constant score. Mean preoperative Constant score was 46. 5 (34–67), at 3 weeks 65. 8 (40–86), and at 3 months 82. 4 (50–99). There was no correlation between the impingement grade, presence of a cuff tear or acromioclavicular joint involvement, and a significant poorer outcome. Arthroscopic subacromial decompression is a reliable method of improving the functional ability of patients with subacromial impingement syndrome, with a 20 point increase in the Constant score at 3 weeks post surgery, rising to a 40 point increase at 3 months. Patients can therefore be counselled that they will make a significant functional improvement in a short time after surgery.

The purpose of this study was to identify aetiological that may determine prognosis in ulnar nerve lesions and to evaluate the role of non-operative treatment. 148 consecutive patients (100 male) with 170 electrophysiologically proven (by nerve conduction and electromyography) ulnar nerve lesions were identified from the departmental records. Patient details, symptoms, known aetiology and treatment profile were recorded. Each patient was then contacted by telephone and/or questionnaire 1–6 (median 3. 8) years following electrodiagnosis to determine clinical progress and outcome. In patients with sensory symptoms alone or non-progressive painless motor symptoms, non-operative treatment was commenced. This involved advice on activity modifications and protection with a tubipad bandage or night spin.

12. 9% and 8. 8% of lesions were due to injury and intra-operative pressure respectively. Other causes included deformity and/or synovitis from arthritis of the elbow, repeated pressure, medial epicondylitis and benign space occupying lesions. 58. 2% were idiopathic with no clinical aetiological factor. 22 patients had expected bilateral lesions whereas 15 had contralateral lesions that were not symptomatic. 89. 4% and 4. 7% of lesions occurred at the elbow and wrist respectively. 83% of patients received non-operative first line treatment. 21% of these required operative intervention following further clinical and electrophysiological assessment. Partial or complete recovery occurred in 80%, 67% and 52% of the intra-operative, idiopathic and injury cases respectively (P< 0. 05).

We conclude lesions of the ulnar nerve predominate in males and can be treated non-operatively providing clinical and electrophysiological monitoring is possible. Bilaterality is not uncommon and should be excluded. Lesions due to injury have a worse prognosis than those caused by direct continuous or repeated pressure or where no aetiological factor exists.

The aim of this study was to examine causes of the failed knee arthroplasty.

Since 1980 the Bristol Knee Replacement Registry has prospectively recorded data on 3024 patients. Complete original and 5 year follow up data was available on 999 knees.

The surgery was judged a failure if there was no improvement in the American Knee Society score at 5 years or if there had been a revision within that time.

The prosthesis used was Kinematic in 471 knees, the Medial Unicompartmental Sled in 258 knees, the Kinemax Plus in 134 knees and a variety of other designs.

At 5 years, 79 (7. 9%) either showed no improvement in the American Knee Society score or had been revised. The failure rate was 7% for the Kinematic, 7% for the medial Sled and 5% for the Kinemax Plus. 20% of the less frequently used designs failed.

Five (0. 5%) knee replacements failed because of infection. 22 knees (2. 2%) had significant comorbidity that precluded a satisfactory functional outcome. For 7 knees (0. 7%), the patient exhibited patterns of abnormal illness behaviour that were thought to explain the poor outcome. A further 27 knees (2. 7%) failed because of technical errors either at the time of surgery (13 cases, 1. 3%), or in selecting a prosthesis which failed prematurely (14 cases 1. 4%). No cause for failure could be identified in 12 cases (1. 2%).

The high failure rate amongst infrequently used prosthesis emphasises the need to use established designs. No cause for failure could be identified in 12 cases and 5 were due to infection; such cases are hard to avoid. This study shows the importance of assessing both the overall physical and psychological state of the patient if disappointing results are to be avoided. The most frequent cause of an unsatisfactory outcome was a technical one, which should be avoidable.

We report on our results of a pilot study in the use of extra-corporeal shock waves in the treatment of chronic calcific tendonitis of the shoulder. Twenty patients were randomised as part of a prospective controlled trial. 45% had subjective improvement with an increase of 11% in their constant score. This has statistical significance when compared with the control group. We found that ESWT is effective however patients found the treatment painful and we did not achieve the levels of success that had previously been reported in European studies.

Between June 1988 and December 1997, 332 babies with 546 dysplastic hips were treated in the Pavlik harness for primary Developmental Dysplasia (DDH) as a product of the Southampton selective screening program. Each was managed by a strict protocol including ultrasonic monitoring of treatment within the harness. The group was prospectively studied over a mean duration of 6. 5 years (SD=2. 7y) with 89. 1% follow-up. The Acetabular Index (AI) and Centre-Edge angle of Wiberg (CEA) were measured on annual radiographs to determine the natural history of hip development following treatment in the Pavilik harness. These were compared to published normal values.

We observed a failed reduction rate of 15. 2% of all complete hip dislocations; these required alternative surgical treatment. The development of those hips of infants successfully treated in the harness showed no significant difference from the normal values of Acetabular Index for female left hips, after eighteen months of age. Of those dysplastic hips that were successfully reduced in the harness; 2. 4% exhibited persisting significant late dysplasia (CEA< 20°) and 0.2% demonstrated persistent severe late dysplasia (CEA< 15 °) All such cases could be identified at sixty months. Dysplasia was clinically deemed sufficient to merit innominate osteotomy in 0. 9% dysplastic hips treated. Avascular necrosis was noted in 1% of hips treated in the harness.

We conclude that using our protocol, successful initial treatment of DDH with the Pavlik harness appears to revert the natural history of hip development to that of the normal population. We recommend that regular radiographic surveillance up to 60 months of age constitutes safe and effective practice.

37 patients (38 hips) underwent sub-capital osteotomy for slipped upper femoral epiphysis (SUFE) between 1980 and 1999. All slips were severe, and 28 (74%) were unstable. Patients were followed-up at a mean 6. 9 years (range 2. 2–20 years) to identify the relationship between the timing of surgery and complications.

Stable slips underwent urgent elective operations. Unstable slips, admitted as emergencies, were operated upon following two different protocols. 17 cases underwent the Dunn procedure on the next available list at a mean 1. 7 days after admission. 21 cases underwent the Fish procedure after a mean 22. 2 days of bedrest on “slings and springs”.

Of 23 patients (24 hips) who suffered no complications and for whom on Iowa Flip Score was available, the means score was 96. 5 (range 91–100). There were 6 cases of Avascular Nervosis (AVN) (16%), all occurring after unstable slips, and 4 cases of chondrolysis (10%).

Amongst unstable slips, shorter periods of pre-operative bedrest were associated with a higher incidence of avascular necrosis (AVN) (p< 0. 025). Direct comparison of the two surgical procedures showed no statistically significance difference in the incidence of AVN.

Sub-capital osteotomy is valid treatment for severe SUFE. More than 20 days of pre-operative bedrest decreased the incidence of AVN in unstable SUFE

To ascertain the optimum number, thickness and configuration of K-wires needed to prevent displacement of distal radial fractures.

Synthetic and cadaver bones were used. A transverse osteotomy was performed 1. 5 cm proximal to the articular surface of the distal radius. Different numbers and configurations of 1. 1mm or 1. 6mm K-wires were used to hold the bone reduced. Dorsoradial and distraction forces were applied using a tensiometer. The endpoint was a displacement of 3mm at the osteotomy site.

We demonstrated a statistically significant increase in the force required to displace the osteotomy site a) when using thicker wires and b) when using three crossed wires compared with two wires either crossed or parallel.

When balancing ease of insertion with maximum stability, we would recommend two parallel 1. 6mm wires inserted through the radial styloid process, with 1 wire inserted from the dorsoulnar corner of the radius crossing at approximately 90 degrees. All wires should pass into the opposite cortex. This configuration resisted forces of over 300 Newtons and there was little benefit in using additional wires.

The vertical configuration open MRI Scanner (Signa SPIO, General Electric) has been used to assess the place of interventional MR in the management of developmental dysplasia of the hip over the last four years. Twenty-six patients have been studied. In static mode, coronal and axial T1 – weighted spin echo images are initially obtained to assess the anatomy of the hip, followed by dynamic imaging in near-real time.

In all cases, dynamic imaging was very good for assessing and demonstrating stability. The best position for containment can be assessed and a hip spica applied. Scanning in two planes gives more information and allows more accurate positioning than an arthrogram. Confirmation of location of the hip after application of the spica can be easily demonstrated. Adductor tenotomies have been performed within the imaging volume, and in two cases, this enabled planning of femoral osteotomies. All patients have had a satisfactory outcome, but five have required open reduction and a Salter innominate osteotomy.

In ten cases, the opportunity has also arisen to alternative perform an arthrogram, either because of the complexity of the cases, or at a later date as an alternative to a repeat MRI, or because of difficulty with access to the machine.

The place of interventional MRI in DDH is not yet defined. As machines get better and the definition improves, the amount of information about the nature of dislocation, the relative size of the acetabulum to the femoral head, the state of the limbus, the best position for containment and stability, and the potential for growth of the acetabulum, particularly posteriorly will be increased.

It follows that the potential for more accurate definition of each hip and the outcome is better – and safer – than by arthrography, which remains the ‘gold standard’ but involves radiation and is only one-dimensional.

Clinical screening aims to identify and treat infants with neonatal hip instability in order to reduce the risk of subsequent hip displacement but risks failures of diagnosis and treatment (abduction splinting) and potential iatrogenic effects. The Hip Trial aims to assess the clinical effectiveness of ultrasound (US) imaging compared to clinical assessment alone to guide the further management of infants with clinical hip instability.

Infants with clinical hip instability confirmed by a second senior doctor were recruited from 33 UK centres and randomised to standardised US hip examination at age 2–8 weeks [US group: n=314] or clinical assessment alone [no ultrasound (NU) group: n=315. ] Primary outcomes by two years were hip X-ray appearances, operative treatment, abduction, splinting and walking. Analysis was ‘intention to treat’.

Key prognostic factors were similar between the randomised groups. Protocol compliance was high (90% US; 92% NU). X-ray information was available for 91% by 12–14 months and 85% by two years. Fewer children in the US group had abduction splinting in the first two years (RR 0. 78; 95% CI 0. 65–0. 94; p=0. 01). Operative treatment was required by 21 US (6. 7%) and 25 NU (7. 9%) infants (RR 0. 84; 95% CI 0. 48–1. 47. ) By two years, subluxation, dislocation, acetabular dysplasia or avascular necrosis were identified on X-ray on one or both hips of 21 US and 21 NU children (RR 1. 00; 95% CI 0. 56 – 1. 80. ) One US and 4 NU children were not walking by two years (RR 0. 25; exact 95% CI 0. 03–2. 53; p=0. 37)

The use of US imaging in infants with screen-detected clinical hip instability allows abduction splinting rates to be reduced, and is not associated with an increase in abnormal hip development or higher rates of operative treatment by two years of age.

The aim of this study was to assess patient-based outcome two years following non-operative management of displaced Colles fractures.

100 patients were evaluated at a minimum of two years after displaced Colles fracture. Fractures were reduced under regional anaesthesia and immobilised in a Colles-type cast for five weeks. The fractures were assessed radiographically by measurement of radial angle, dorsal tilt, radial shortening and carpal malalignment at the time of injury, post-manipulation, and after one and five weeks. The fractures were classified according to Frykman classification. A validated patient-based outcome questionnaire, using a visual analogue score, was used to assess outcome at the end of two years.

7 patients had died, 8 patients were unable to complete the questionnaire because of confusion and 5 were lost to follow-up. Complete outcome data were available on 80 patients.

The median age was 61 years. The median pain score was 5 (25%-2 and 75%-12, range 0–100). There was loss of reduction, with more than 5° dorsal angulation and/or 5mm radial shortening in 70% cases. We found that age had no effect on patient outcome except that patients over 50 years complained of more finger stiffness The Frykman classification was an important prognostic factor and a higher grade resulted in worse outcome in a number of areas. Dorsal angulation had no significant effect and carpal malalignment correlated with poor visual appearance. Radial angle and radial shortening were both associated with increased complaints of wrist pain and stiffness

This prospective patient based outcome study has demonstrated that patients make a good functional recovery following nonoperative management of Colles fracture. 70% of our patients had a poor radiological outcome but few reported problems with pain and function at 2 years. Extra-articular malunion due to radial angulation and shortening was common and correlated with wrist pain and stiffness at two years. Frykman classification correlated with pain and functional outcome.

This study seeks to determine the additional cost involved in the management of patients requiring operative fixation of their fractured ankle but whose operation is delayed more than 24 hours.

87 consecutive patients presenting acutely with a fractured ankle that required an operation during a single year were included in the study. All patients with ankle fractures referred from other centres, open fractures and ankle fractures whose non-operative management had failed were excluded from the study. 79 patients presented within 24 hours of their injury and so were eligible for early operative intervention. Of these, 74 presented within 6 hours of injury. Only 47 (60%) of the patients were operated on within 24 hours of their injury. Similarly, 11 (61%) of the 18 patients with trimalleolar fractures were operated on within 24 hours. Patients whose operations were delayed spent an average 4. 4 days more as an inpatient. This was statistically significant (p< 0. 0001, Wilcoxon signed rank test). The postoperative stay of patients having delayed operations was also statistically more than those undergoing early operation, (p< 0. 0001). The cost of the additional stay was calculated at £225/day/patient and equalled £39, 600 for the 40 patients whose operations were delayed.

We believe that the operative management of ankle fractures should be given special consideration. These injuries are such that they offer an initial limited window of opportunity for operative intervention (within 24 hours of injury). If this opportunity is missed, then the patient’s operation may have to be delayed for clinical reasons. In our study, only 60% of patients underwent early operative fixation of their fracture; a figure that can surely be improved upon. Therefore, we conclude that significant savings could be accrued by hospitals adopting protocols to fast-track pre-operative interventions to achieve early operation (within 24 hours) unless contraindicated.

We review the early results of 13 patients who underwent hip arthroplasty as the initial treatment following acetabular fracture. The indications for performing THA over open reduction and internal fixation included fractures of poor prognosis, dome comminution, femoral head damage and comorbidity. Fractures were fixed in a limited fashion and an uncemented Harris-Galante cup was inserted with bone grafting. All femoral components were cemented Exeters.

There were two deaths. The first in the immediate post-operative period due to massive pulmonary embolism and the second in the early rehabilitation period due to pre-existing respiratory problems.

The remaining 11 patients were assessed at an average of 37 months (13–68). The mean Charnley hip score was 15 (8–18) and the mean Harris hip score 82 (33–100). One acetabular cup had loosened accounting for the lowest scores and awaits revision. All fractures united by 6 months and all other components appeared stable at radiological review. Technical difficulties of this procedure will be discussed.

Stabilization and bone grafting are the basic principles in the treatment of fracture non-union, however, infection is always a concern. Percutaneous bone marrow grafting has been suggested as an alternative, which provides a source of osteogenic cells with osteoinductive effect.

This prospective study evaluates the efficacy of percutanous bone marrow grafting in patients with tibial non-union while on the waiting list for open surgical procedures. 21 adult patients with established tibial non-union were recruited. The average age of fracture non-union was 12 months (range 6–36). Infected cases, deformed non-unions and gap non-unions were excluded. Eleven were hypertrophic and ten atrophic type of non-union.

Under local anaesthesia, bone marrow was aspirated from the iliac crests using a 16 G sternal puncture needle. 3–5ml marrow was aspirated and injected immediately into and about the non-union site. Subsequent aspirations were performed 1 cm posterior to the previous site until a maximum of 15 ml marrow was injected. Patients were immobilised in a plaster cast. Radiographs were repeated at 6 weeks interval. A second injection was repeated at 6 weeks if there was no evidence of callus formation.

The procedure was considered a failure, if there was no union at six weeks following the third injection. Bone marrow could not be aspirated in one patient. 19 patients were followed up clinically and radiologically until there was definite bone union or failure.

Bone union was achieved in 15 patients out of 20 (75%), with an average time to union following the first injection 14 weeks (range 6–22 ). Two of the patients needed only one injection, nine needed two injections, and four patients needed three injections to unite. 4 patients (20%) showed no evidence of union.

There were no complications at the donor or recipient site.

We conclude that percutanous bone marrow grafting is a safe, simple, and reliable method of treating tibial non-union with minimal deformity.

34 adult patients were assessed at an average of 15 years (13–20) after stable internal fixation with early active mobilisation of a distal humeral fracture. 23 were Müller type C, (5 open), 9 type B and 2 type A.

Using the Mayo Score, 94% had an excellent/good result and 6% fair. None had a poor outcome. This study is the first to demonstrate that early stable internal fixation of distal humeral fractures by an experienced surgeon, gives excellent long term results with few complications, together with high rates of patient satisfaction and little functional morbidity.

In 1996 the quality of the early management of 100 consecutive patients referred to a regional pelvic and acetabular unit between 1989 and 1992 was studied. The management of these patients was assessed in four specific areas, and guidelines were laid down. It was found that in 56% of patients the early management did not meet these suggested standards, with 34% having deficiencies in more than one area. These results were presented, published and circulated to referring hospitals.

Five years later, the early management of a further 100 consecutive referrals was assessed using these same guidelines. The treatment of 57% of patients still did not reach the guideline standards, but the number with problems in more than one area fell to 20%.

There has been some improvement in the early management of pelvic and acetabular injuries. The use of external fixators to control severe haemorrhage increased, but frames were often poorly applied. Wider access to CT scanners has reduced delays in definitive imaging.

Associated injuries are still regularly overlooked, and occasionally treatment of ipsilateral hip or femur fractures compromises pelvic surgery. Early communication with the specialist centre is encouraged but unfortunately delays in referral are still common.

Generally ankle fractures in the very elderly are treated by non-operative methods but some fractures can be highly unstable and are difficult to treat in a plaster.

During a 10-year period, 74 patients over the age of 70 years were retrospectively studied to identify the early complications, length of stay, return to pre-injury mobility and residential status. There were 58 females and 16 males with an average age of 76 years (70–91years). 57(77%) fractures were at the level of the syndesmosis (Type B) and 17(33%) were above the level of the syndesmosis (Type C). All but one injury was due to a simple fall. All patients had initial manipulation and plaster immobilisation. They underwent ORIF after the reduction in the plaster was lost. Plate and screws were used in 53 patients (72%), rush pins in 12 patients (16%) and external fixation was used in 2 patients. All patients were immobilised in a below knee plaster after surgery for 6–8 weeks.

Following surgery, 1% deep infection, 9% delayed wound healing, 5% malunion, and 3% mortality were recorded. In 12% of patients, soft bone and communition precluded fixation of one malleolus. The average length of stay for patients who walked with a Zimmer frame before injury was significantly longer than for those who walked independently or with sticks. However, the majority (85%) of patients regained their pre-injury mobility and residential status.

We conclude that ORIF of ankle fractures in the elderly carries a significant risk of wound edge necrosis with delayed wound healing but the incidence of deep infection is relatively low. ORIF should be reserved for patients where non-operative management has failed. Poor bone quality presents technical difficulties but the majority of patients can expect a good outcome.

To demonstrate the potential clinical benefits and safety of recombinant human bone morphogenetic protein-2 (rhBMP-2)/Absorbable Collagen Sponge (ACS) in the treatment of open tibial shaft fractures, as measured by the reduction of secondary interventions to promote fracture healing. In this prospective, controlled, multinational trial, patients were randomized to standard care (intramedullary nail and soft tissue management) or to standard care and rhBMP-2/ACS (0. 75mg/ml, 1. 5 mg/ml) implanted at definitive wound closure. 450 patients were enrolled at 49 centres. RhBMP-2 dose-dependently decreased the risk of secondary intervention for delayed union (p=0. 0004). Safety was similar among treatment groups.

The purpose of this retrospective study was to analyze the indications for spinal instrumentation, report the clinical features, operative details and outcome in 16 patients with active pyogenic spinal infection.

Between January 1991 to October 1999, 81 patients with spontaneous pyogenic spinal infection were treated at the authors’ institution. Surgery (other than biopsy) was indicated in 24 patients for neurological deterioration, deformity or instability. Sixteen of these patients were treated with instrumentation in the presence of active spinal infection. Six patients underwent combined anterior and posterior procedures. 10 had a posterior procedure only. Outcomes assessed were control of infection, neurology, fusion, back pain and complications.

At a mean follow up period of 26. 9 months, all surviving patients were free of clinical infection. None of the patients had neurological deterioration. All patients who had neurological deficit preoperatively improved by at least one Frankel grade. A solid fusion was achieved in 15 patients. 12/15 patients remained asymptomatic or had very little pain. The remaining 3 patients had mild to moderate back pain. The mean correction of the kyphotic deformity was 18. 92 degrees. Postoperative complications included bronchopneumonia, nonfatal pulmonary embolism and seizures in 3 patients. One patient developed progressive kyphosis despite instrumentation but eventually fused in kyphus.

Given early recognition of pyogenic spinal infection, most cases can be managed non-operatively. Our results support that instrumented fusion with or without decompression may be used safely when indicated without the risk of recurrence of infection. Instrumentation facilitates nursing care and allows early mobilisation. For biomechanical reasons, a combined procedure is probably indicated for lesions above the conus. For lesions below the conus, we were able to achieve successful results with posterior approach only.

In a prospective non-randomised study, 28 patients underwent laparoscopic assisted transperitoneal anterior interbody fusion at the lumbosacral junction with the BAK cage over a 3-year period. In laparoscopic group, there were significantly lower blood losses (P< 0. 005), operating times [P< 0. 05], analgesic requirements [P< 0. 05] and postoperative rehabilitation [P< 0. 05). 8 patients developed post-operative nerve root pain, 5 of which settled with nerve root blocks, and there was 1 case of donor site infection. Intraoperative complications included 1 CIA tear, 2 CIV tears and 3 open conversions [11%]. 6 cases [24%] required further surgery at a mean of 14 months [range 4–29 months]. 20 laparoscopic cases completed a subjective self-assessment score with 4 [20%] excellent results, 5 [25%] good, 2 [10%] fair, 8 [40%] same and 1 [5%] worse.

The preoperative Visual Analogue Pain Score [VAPS] and Oswestry Disability Index [ODI] were set at 100 for the purposes of analysing the results [n=number in brackets]:

Results show an improvement in the overall pain and disability. However, at two years patients still continued with some 65% of symptoms.

Laparoscopic assisted anterior spinal fusion with the BAK device is safe and reliable with advantages that include reduced operating time, blood loss, post-operative analgesia requirements and hospitalisation. However, the clinical outcome does not appear to give superior results to other implants and we question whether it use as a stand-alone device is sufficient and would recommend posterior stabilisation to confer improved mechanical stability.

This prospective clinical study investigates the relationship between intra-compartmental pressure and soft tissue oxygenation (StO2) measured non-invasively by near-infrared spectroscopy (NIRS) in patients at risk of acute compartment syndrome.

Patients (over 13 years) with fractures of the tibial diaphysis or high-energy fractures of the forearm or distal radius, or patients with soft tissue injury were recruited. Non-invasive and invasive monitoring was carried out pre and post operatively. The ‘Delta P’ value (DP) was calculated as the compartment pressure subtracted from the diastolic blood pressure. The threshold for fasciotomy was a DP < 30mmHg. Non-invasive tissue saturation measurements and pressure measurements were taken from the same compartment (anterior tibial or volar forearm). StO2 values were simultaneously recorded from the contralateral (uninjured) limb at the same anatomical site. All patients had the difference between the StO2 value on the injured and uninjured sides calculated (‘StO2 difference’).

42 patients with tibial diaphyseal fractures, 2 patients with forearm fractures and one case with thigh swelling were recruited to the study. The mean age was 40 years (SD 17 years). 11 patients underwent a four-compartment lower leg fasciotomy determined by a DP < 30mmHg. Patients who required a fasciotomy had an ‘StO2 difference’ that was 20% lower (p = 0. 002) compared to those who did not develop acute compartment syndrome. This suggests that patients who require a fasciotomy have reduced StO2 values on their injured legs compared to the contralateral (uninjured) side.

We have observed that non-invasive StO2 measurements for patients over 13 years at risk of acute compartment syndrome, correlates with the requirement for a fasciotomy as defined by P < 30mmHg. We are optimistic that near-infrared spectroscopy (NIRS) will be a reliable new non-invasive technique for detection of an acute compartment syndrome.

Twenty-one patients with rigid kyphosis treated by single stage vertebral column resection were evaluated retrospectively. The average age was 12 years and kyphosis was 75 degrees. Thirteen cases were due to tuberculosis while 8 had a congenital anomaly, 5 cases had neurologic deficit. Radiographs, CT and MRI scans were used for preoperative evaluation. The survey included transpedicular vertebral decancellisation, spinal column shortening, interbody fusion and segmental spinal instrumentation. At 36 months [36–60] follow up, the average correction was 61% and all cases adequately fused. Complications included one case with postoperative neurological deterioration and one patient with decompensated lordosis.

To evaluate and compare the stability of an anterior cement construct following total spondylectomy for meta-static disease against alternative stabilization techniques.

After intact analysis of ten cadaveric spines (T9–L3), a T12 spondylectomy was performed. Three reconstruction techniques were tested for their ability to restore stiffness to the specimen using non-destructive tests:

1) multilevel posterior pedicle screw instrumentation (PPSI) from T10–L2 {MPI}, 2) anterior instrumentation from T11–L1 with PPSI {AMPI}, and 3) anterior cement and pins construct (T12) with PPSI {CMPI}.

Circumferential stabilization {AMPI, CMPI} restored stiffness to a level of the intact spine. CMPI provided more stability to the specimen than AMPI. MPI alone did not restore stiffness to the intact level.

Circumferential reconstruction using an anterior cement construct following total spondylectomy is biomechanically superior to posterior stabilisation alone.

This prospective study was carried out to correlate findings of magnetic resonance imaging (MRI) and discography. Fifty-five consecutive patients with degenerative disc disease not responding to non-operative treatment were included in the study. There were 19 men and 36 women and the mean age was 45 years. Discography was carried out on 131 disc levels. The discograms were classified using modified Adams’s classification and pain recorded into three grades. MRI scans were graded using a new classification system based on parasagittal and axial images by two independent observers blinded to discography findings. There was good intraobserver (kappa 0. 74) and interobserver (kappa 0. 70) agreement for the classification system. There was a significant correlation in the morphology of discs as determined by discograms and MRI classification (p< 0. 001).

Each disc was graded on MRI scan as painful or painless on basis of defined criteria. Concordant discography pain was considered as the gold standard. The sensitivity and specificity of MRI in predicting symptomatic disc using defined criteria was 94% and 77%. The sensitivities and specificity of high intensity zones was 27% and 87% and for end plate changes was 32% and 98% respectively. In 14 patients (25%) the findings of MRI and discography did not correlate.

In conclusion though MRI is an excellent investigation for assessing disc morphology it should be interpreted along with discography findings before planning fusion surgery. The proposed MRI classification is a useful aid in predicting painful degenerative disc. The utility of high intensity zones and end plate changes is limited due to low sensitivity.

14 systems for anterior cervical stabilisation were evaluate under flexion-compression bending using test procedures conforming to Static and Fatigue Test Methods for Spinal Implant Assemblies using Corpectomy Models Part 2a [ISO/TC 150/SC5 N127C]

Plates of standardised active length were tested in an in-vitro model of a single corpectomy of the lower cervical spine using composite test blocks manufactured by Sawbones to have physical properties similar to cervical vertebrae.

Results reveal a wide range in final yield strengths with bi-cortical systems significantly stronger than uni-cortical ones. There was a fourfold difference in ultimate load between the stronger and weakest systems.

We found that mode of failure was influenced by plate thickness, screw length and screw placement.

It is recognised that those patients who present sciatica and significant preceding back pain will be disappointed, following discectomy, with the relief of the sciatica alone, as considerable degenerate disc will remain.

Though a bilateral fenestration exposure as much disc possible was removed right down to the back of the anterior longitudinal ligament. Intervertebral fusion was not used.

Of 25 patients, with a mean follow up of 20 months, 59% reported a significant improvement in pain (p< 0. 05) and function (p< 0. 05) following surgery. Post-operative radiography did not reveal malalignment or instability.

Prolo D et al. Toward uniformity results of lumbar spine operation. A paradigm applied to posterior lumbar interbody fusions. Spine, 1986: 11:601–6.

Cauda equina syndrome (CES) due to central disc prolapse produces acute neurological deficit. We investigated long-term urological disability after surgery for CES and the impact of emergency versus next day surgery.

20 CES patients (M=F), were assessed using a validated quality of life questionnaire; comparison was made with a matched group undergoing simple lumbar disc surgery. Median length of history before presentation was seven days. Nine were operated on within 4. 5 hours, the remainder all within 24 hours after neurosurgical admission. While the patients’ perception was of good general health (no different from controls), urological symptoms adversely affected their lives (P=0. 02). Only two patients had no urological symptoms. Emergency surgery (within 4. 5 hours of presentation) was not associated with reduced disability.

The passage of bacteria through surgical drapes is a potential cause of wound infection. Previous studies have shown that liquids and human albumin penetrate certain types of drapes¹². We studied the passage of bacteria through seven different types of surgical drape and an operating tray. We also studied the effect of different wetting agents on the passage of bacteria through wet reusable woven drapes. Bacteria were grown on an overfilled whole horse blood agar plate. The plate was covered with the drape to be tested and a second agar plate was inverted and placed on the drape. After 30 minutes the second agar plate was removed, incubated and inspected for bacterial growth. The experiment was repeated removing the second plate at 60 minutes and then again at 90 minutes. The entire experiment was repeated for each drape and then for each wetting agent.

Bacteria easily penetrated all the woven reusable fabrics within 30 minutes. The disposable non-woven drapes proved to be impermeable up to 90 minutes, as did the operating tray.

Chlorhexidine and Povidone-Iodine were demonstrated to slow, but not stop the passage of bacteria through reusable woven drapes. Normal saline and human blood accelerated the passage of bacteria through reusable woven drapes. We recommend the use of non-woven disposable drapes or woven drapes with an impermeable operating tray, in all surgical cases.

We analysed the functional outcome (Oswestry Disability Index) after technically and radiologically successful lumbar fusion in 39 non-compensation seeking patients with chronic low back pain, who had a High Intensity Zone (HIZ) – positive MRI and subsequently underwent discography. The average follow-up was 33 months. The HIZ-positive, discogrampositive group was the only one with statistically significant improvement. The HIZ-positive, discogram-negative group had the worst outcome. Relying only on the HIZ fails to identify the group of patients who would have had negative discography at the same levels. Therefore the presence of HIZ alone should not dictate treatment plan without discography confirmation.

Whiplash is a contentious issue in the medico-legal field; opposing views are held about persisting symptoms.

The exact pathology is not known; but it is generally accepted to be ‘soft tissue injury’. The same clinical syndrome can occur without a road accident.

No one doubts the reality of the condition in the early stages when the symptoms and signs (of a ‘mechanical derangement’) are clear cut.

As with other soft tissue injuries, most ‘heal’ within a usual time span; some take longer to heal; and some have persisting problems giving rise to chronic pain, restricted movements & /or a feeling of ‘instability’. In this latter group the physical signs are less obvious but are still present, if sought. Imaging is rarely relevant.

The psychological reaction to any injury or illness will vary from individual to individual (the previous personality); or from time to time in the same individual. People with chronic pain may become depressed and may develop ‘excessive’ psychological reactions – often referred to as ‘chronic pain syndrome’ and, by some, as ‘abnormal illness behaviour’; this is exacerbated when litigation is involved with its attendant adversarial, confrontational approach which questions the ‘genuineness’ of both the patient and their symptoms and disability.

Where symptom persist beyond the ‘usual’ time for healing, and are consistent with the (albeit subtle) physical signs found, there can be no grounds for arguing that they are nor related to the accident.

The EMG activities of the gastrocnemius and soleus muscle of five normal subjects were measured during non-weight bearing, heel and normal walking either with or without using a walking boot. The boot was set to plantigrade initially, then equinus by either adding a wedge inside or by adjusting the hinge. Results showed that heel walking has significantly lower EMG activities than normal walking while non-weight-bearing walking has the lowest activity. The wedge has no effect on decreasing the calf muscle EMG activity. Locking the boot into equinus produced a paradoxically higher EMG activity and a rather awkward gait.

The role of MRI or CT in the management of patients with LBP, for whom there is no clear clinical indication for the use of sophisticated imaging, is uncertain. The aim of The Scottish Back Trial was to determine whether early use of MRI or CT influences clinical management and outcome of patients with LBP and whether it is cost-effective.

Elective patients were new referrals to orthopaedic or neurosurgeons with symptomatic lumbar spine disorders (without ‘red flags’). After obtaining informed consent, patients were randomised to ‘early imaging’ (imaging as soon as practicable) or ‘delayed, selective imaging’ (imaging only if an imperative clinical indication developed). Principal outcomes measures were the SF-36, questionnaire, the Aberdeen LBP Scale and the EQ-5D. Patients completed questionnaires at trial entry and after 8 and 24 months.

From 15 hospitals, 2657 patients were assessed and 783 were recruited and randomised. Eight months and twenty-four months after trial entry, comparison of data abstracted from case notes indicated that, apart from the use of imaging, both groups had received similar clinical management. At follow-up, an improvement in health status, as measured by the SF-36 and Aberdeen LBP Scale, was reported by both groups. At 24 months, there was a statistically significant but small difference in favour of the ‘early imaging’ group (p=0. 002) as measured by the Aberdeen LBP Scale but no difference in the SF-36 except a marginal improvement in the bodily pain subscale.

The use of MRI or CT imaging for this group of LBP patients did not significantly affect their management. The clinical significance of the marginal improvement in health status in the ‘early imaging’ group is uncertain. The results of the cost-effectiveness analysis may clarify whether a policy of ‘early imaging’ would be a cost effective use of resources.

The NASCIS studies reported improved long-term neurological recovery when high dose methylprednisolone was administered following spinal cord injury.

To determine if there is correct implementation of the NASCIS protocols. Prospective observational study. The admission Frankel grade and ASIA neurological classification were recorded.

100 patients with complete or incomplete spinal cord injuries were studied during a 24 month period.

Outcome Measures: Correct administration of methyprednisolone.

The mean ASIA score was 192 and median Frankel grade was C. Only 25% of the patients received methyl-prednisolone according to the NASCIS regime.

“Evidence Based Medicine” is not being adopted.

Total knee arthroplasty (TKA) is a common, effective operation but postoperative infection has devastating consequences. Several papers have associated perioperative autologous transfusion with reduced infection rates. Salvaged blood may augment the inflammatory response and central within it is polymorphonuclear leukocyte (PMN). Our hypothesis was that autologous transfusion enhances PMN activity by: increased PMN transmigration to potential infection site, enhanced phagocytosis, augmented respiratory burst activity.

Our randomised controlled prospective study showed a significant increase in superoxide production by PMN of patients who received unwashed autologous transfusion supporting the clinical studies where infection rates following autologous transfusion were reduced.

Patient warming systems are used routinely to prevent hypothermia under anaesthetic, the benefits of which have been clearly shown in the anaesthetic literature. We were concerned that since these systems take ‘dirty’ air from floor level and distribute it over the patient, bacterial counts could be increased. Also, airflow under the blanket itself could disturb the patients’ own skin cells and thereby influence bacterial counts.

With slit air sampling we analysed air quality at the simulated operative site by passing a known volume of air over an agar plate (tryptone glucose yeast). Using probability curves we were able to calculate the volume of air required to detect 1 colony forming unit (CFU) per m³ with 97% confidence. All tests were performed in an ultra clean air laminar flow theatre.

We assessed the effect of varying degrees of skin shedding under the warming blanket using volunteer patients with Psoriasis. We also simulated activity outside the lamina flow to determine whether counts on the table were influenced.

No colonies were grown in any of the study groups. Plates exposed outside the laminar flow area at floor level showed a relatively high level of contamination. We therefore conclude that the WarmTouch warming system does not influence bacterial counts at the operative site in ultraclean air ventilated theatres.

The Mayo Conservative uncemented stem (Zimmer, Warsaw, USA) is designed to conserve proximal bone stock by virtue of a minimal neck resection and to maintain proximal femoral stress transfer, thereby reducing problems associated with stress shielding.

This study was performed to evaluate proximal femoral strain after implantation of the Mayo stem, in cadaveric femora.

Eight fresh-frozen cadaveric femora (each selected at random from within a pair) of known bone mineral density were prepared and coated with photoelastic materials (Measurements Group, Raleigh NC). Strain patterns of the intact bone were determined using a reflection polariscope, and recorded photographically, while under load. Quantitative measurements were taken from set points of the proximal femur. The femoral head was then replaced using a Mayo femoral prosthesis. Under the same loading conditions strain patterns were re-examined and measurements taken from the same set points.

The strain patterns following insertion of the Mayo stem closely matched those seen in intact femora except in two areas. Strain was reduced in the region of the lesser trochanter (53% of normal), although more proximal than this strain in the neck was closer to intact values (78% of normal). Previous studies have found that implantation of diaphyseal press fit stems in particular have led to significant reductions in shear strain values in the calcar region and distally along the medial border of the femur.

This study documents the strain pattern in the proximal femur after implantation with a new “conservative” short stem cementless prosthesis. The hypothesis that the Mayo femoral stem maintains proximal femoral stress transfer and may thus prevent stress shielding in vivo remains to be proven, but is supported by the results of this study.

Heterotopic Ossification (HO) is a common finding in the radiographs of patients who have had total hip replacement surgery (42–57%). HO is responsible for pain and limitation of postoperative motion in 3–10% of these patients. This study was initiated to find out if pulsed lavage affected the incidence of HO.

A prospective randomised double-blind trial was initiated consisting of 115 primary total hip arthroplasties. Intra-operative irrigation was provided by a 50 ml syringe and limited to 500 ml of room-temperature normal saline or pulsed lavage with three litres of room-temperature normal saline. The grade of HO at one year was classified according to Brooker et al. Statistical analysis of the results was made using the chi-squared test and the Kruskal-Wallis test.

The incidence of HO in this group of primary total hip arthroplasties was 57. 4%. The majority of cases with HO were graded 1 or 2 (42. 6%). No statistical significance was found to exist between the two methods of irrigation in relation to HO (chi-squared p value = 0. 456). From an analysis of the known risk factors for HO, only the type of osteoarthritis was shown to statistically influence the incidence of HO.

The process of HO is thought to be as a result of the differentiation of mesenchymal cells into osteoprogenitor cells. Theories have proposed that the inducing agent and/or the mesenchymal cells arise from bone at the time of the operation, although systemic agents have also been proposed. If the inducing agent or precursor cells were released from the bone intraoperatively, thorough irrigation could be expected to have an association with a lower incidence of HO. The lack of correlation between irrigation and incidence of HO indicates this is unlikely to be the mechanism.

Partial weight bearing is commonly taught by physiotherapists for orthopaedic patients who require protective weight bearing. Present methods for acquiring this skill have been shown to be inaccurate and unreliable. The authors have developed an insole which incorporates pressure sensors and an alarm. The results show that subjects who are able to partially weight bear learn the skill very quickly with minimal supervision. This device provides a simple and reliable means for patients to learn partial weight bearing.

To determine the effect of normal human ageing on neutrophil function and to assess the contribution that any decline may play in the increased susceptibility of elderly patients to bacterial infections following minor trauma. Furthermore, to determine any contribution, of trauma, to further neutrophil decline in these elderly patients.

Phagocytic index, CD16 (FcγRIIIB) and CD11b (CR3) expression were determined in neutrophils isolated from the peripheral blood of 15 healthy young (average age 26. 5 yrs, range 23–35 yrs; 8 male, 7 female) and elderly (average age 72. 9 yrs, range 65–71 yrs; 8 male, 7 female) volunteers. CD11b levels were unaltered, but phagocytic index and CD16 expression were both significantly reduced (p< 0. 05 and p< 0. 001 respectively) in the elderly group. CD16 levels were monitored in a large volunteer group and were found to correlate with phagocytic index. To determine whether trauma produces additional compromise to neutrophil function in the elderly, peripheral blood neutrophils from individuals (average age 82. 5 yrs, range 65–96 yrs; 7 male, 21 female) during neutrophilia, post-trauma, due to fracture of the femur, were analysed as described above. Patients with chronic inflammatory disease, diabetes or kidney disease, or who were receiving steroid medication, were excluded. The data showed that neutrophil CD16 expression was significantly reduced in the elderly group (p< 0. 05), furthermore following fracture of the neck of femur superoxide generation is significantly reduced. Patient follow up revealed that 17 (60. 8 %) of these patients subsequently acquired bacterial infections (including wound), within 4 weeks of trauma.

Normal human ageing was accompanied by a decline in neutrophil phagocytic ability and this may be in part due to reduced levels of the Fcγ receptor CD16. The reduced neutrophil CD16 expression accompanied by reduced superoxide generation in the elderly trauma patients may significantly undermine their ability to combat bacterial infections and contribute to increased incidence of post-traumatic infections in the elderly.

The purpose of this study was to determine if routine x-ray exposure produced any chemical oxidation of Ultra High Molecular Weight Polyethylene (UHMWPE), used for joint arthroplasty.

Three different polyethylene polymers were obtained from Biomet, Depuys and Howmedica. These samples had undergone sterilisation and packaging methods. Rectangular shapes of polymer were cut according to the standards specified by the ASTM (American Society For Testing and Materials). Eight samples of each polymer were obtained and divided randomly in to test and control subgroups. The test samples were exposed to ten x-rays with the standard dose used for the hip joint.

Polyethylene oxidation was measured using Fourier transform infrared spectroscopy. This technique can assess the incorporation of oxygen within the carbonyl region. Radiated and non-irradiated samples were compared in each polymer group.

Oxidation from the Fourier transform infrared spectroscopy was quantified by calculating the area under a signature absorption peak for UHMWPE (methylene band at 1370 cm-1) and an oxidation absorption peak (carbonyl band at 1720 cm-1). The ratio of the area of the oxidation peak to the area of the signature peak yields the carbonyl content, or oxidation, relative to the amount of polyethylene. There was no significant difference in oxidation after exposure to x-rays between test and control UHMWPE samples.

Although numerous studies have looked in to the effects of high dose radiation exposure on polyethylene, effects of routine x-rays have not been studied before. It is common practice to follow-up patients with joint replacements over a long period with xrays at each visit. Present study examined the effects of routine x-rays on oxidation of polyethylene. However there was no detectable oxidation after exposure to x-rays. This study paves way for further research in this direction.

To determine whether elderly patients presenting with a fracture of the proximal femur have an underlying vitamin D deficiency.

We identified 59 consecutive cases of a fracture of the proximal femur over a 10-week period. 16 patients were excluded as they had a secondary underlying cause of bone loss which included chronic renal disease, rheumatoid arthritis, thyroid/parathyroid disorders, long term steroid usage and malignancy.

Of the 43 that were eligible for the study, 7 were men and the average age was 81 years. 9 had sustained previous osteoporotic fractures. The majority mobilised independently or with 1 stick prior to the fall and the mechanism in all cases was a low velocity injury from standing height or less.

The mean vitamin D3 level in these cases was 28. 3 nmol/ l. 28 of the 43 had a pathologically low level of vitamin D3 as defined as < 30nmol/l.

The mean PTH level was 53. 7 nmol/ l. 15 of the 43 had an elevated PTH and all 15 were also deficient in vitamin D.

The mean Albumin, an indicator of nutritional status, was 29 g/l.

This study highlights that 65% of the patients who present with a fracture of the proximal femur are depleted in vitamin D. The ageing process is associated with a reduction in the intake of vitamin D, gut absorption and its sunlight activation. Repletion of vitamin D and suppression of parathyroid hormone, both prophylactically or at the time of injury, may reduce future fracture risk and assist in fracture repair.

The proportion of very elderly people within the general population is steadily increasing.

These people, who often have coexisting medical problems and a limited life expectancy, may pose a dilemma for Orthopaedic Surgeons when referred for elective Orthopaedic procedures. The purpose of this study is to review the outcome of primary hip and knee arthroplasty in patients aged 90, and over, who are registered with the Trent Regional Arthroplasty Database.

Between 1990 and 2000, prospective data was collected on patients aged 90, and over, undergoing primary total hip and knee arthroplasty. Data collection was carried out on behalf of the Trent Regional Arthroplasty Audit Group. The present living status of these patients was confirmed using patient administrations systems of the hospitals involved.

Missing data was obtained from the Office for National Statistics. Those patients alive at one year were sent a simple satisfaction questionnaire regarding their operation.

144 patients underwent 149 hip or knee arthroplasty procedures over this eleven year period. The group comprised 122 (85%) females and 27 (15%) males. There were 93 (62%) total hip replacements and 56 (38%) total knee replacements. Ostcoarthritis was the predominant reason for surgery. There was only one intra-operative complication, comprising a fractured femur during a total hip replacement. 78 patients have died since their surgery. The crude mortality rate at one year was 11. 5%. The median survival was 34 months. 51% of the patients returned satisfaction questionnaires one year after the operation. From this group the satisfaction rates for hip and knee arthroplasty were 93. 6% and 92. 6% retrospectively.

With suitable pre-operative assessment, primary total hip and knee arthroplasty can be a successful operation with a high satisfaction rate. This is an age group with a high mortality regardless of surgery, and age alone should not be a determining factor in deciding whether a patient will benefit from primary hip or knee arthroplasty.

It is well known that the integrity of the bone cement interface is crucial for the long-term survival of a primary total hip arthroplasty (THR). Revision THR with impaction bone grafting has recently offered a solution to gross bone loss due to osteolysis. As graft becomes incorporated, clearly the bone graft/cement interface is as crucial as the equivalent interface in primary THR.

The aim of this study was to examine factors that influence this interface. The effects of bone particle size, cement mixing time, and impaction force were examined.

The study was designed to mimic clinical practice. Fresh femoral heads were harvested from primary THR. These were morcelised into large and small particles. The bone was impacted into a purpose built jig with measured force. Cement was pressurised onto the dried surface of the impacted bone after measured mixing times. Cement pressurisation was measured. The cement/graft specimen was extracted and transected with a band saw. Cement penetration was measured with digital image analysis.

Large fragment size was 29 mm², and small was 7. 1mm². Light impaction was 2. 2 Atm. Medium and heavy were 2. 6 Atm. and 3. 2 Atm. respectively. Cement penetration was inversely proportional to impaction force. Cement mixing time also significantly affected cement penetration. Particle size had no effect.

Allograft should be adequately but not excessively impacted, to allow good cement incursion. Cement should be introduced and pressurised perhaps as early as two minutes. Fragment size does not affect cement penetration.

Although pathological fractures in the aged are usually due to metastasis, solitary lesions with undetected primary should be treated with caution. Assumption of such lesions as metastatic and their subsequent internal fixation could lead to completely inappropriate treatment if the lesion turns out to be a primary sarcoma of bone.

Referrals to our bone tumour service over a four year period were analysed. There were 62 pathological fractures of which 11(17. 8%) were primary sarcomas that were treated as a metastasis. The limb salvage was compromised and survival rates poor in these group.

Although it is believed that primary sarcomas are rare in the aged, our database confirms that 14% of primary sarcomas affect this age group. The survival figures of primary sarcomas in the aged (> 60 years) treated at our centre was a mean of 43 months with a 5-year survival of 22%. The presence of a pathological fracture did not significantly alter the long-term survival of these patients. On the other hand, metastasis had a poor survival with a mean of 19 months and a 5-year survival of 4% showing a significant difference. In addition, these patients underwent major inappropriate surgeries, which rendered limb-salvage difficult, worsened the morbidity and caused mental distress to patients.

Any pathological fracture in the aged presenting as a solitary osseous lesion with an undetected primary or even remote primary should be treated with caution. Their diagnosis needs to be established by biopsy whatever the age of the patient before any form of internal fixation is undertaken. The temptation to carry out biopsy and internal fixation at the same sitting or even a prophylactic fixation should be avoided when the diagnosis is not clear. Standard principles of musculoskeletal oncology need to be followed.

The aim of this meta-analysis was to determine based on evidence from all randomised controlled trials whether closed suction drainage is preferable to no drainage for all types of Orthopaedic surgery. Trials were identified by a search strategy developed by the Cochrane Collaborative involving hand searching of major journals and computer aided searching of other databases.

Twenty-nine studies were identified but nine were excluded owing to problems with study design or under-reporting of outcomes. Twenty studies involving 2749 patients with 2946 wounds were included in our analysis. These studies included 566 THRs, 860 TKRs, 333 proximal femoral fractures, 287 non-emergency fractures and 900 other procedures.

Two reviewers independently extracted data from the papers. Methodology of the studies was assessed using a nine point scoring system. Generally the studies scored poorly, possibly owing to under-reporting of outcomes.

No study clearly differentiated against deep and superficial wound infections therefore all wound infections were considered together. No differences between the drained and the undrained groups was noted for wound infection overall or in any of the operative sub-groups. Similarly no difference was found for the outcomes of wound haematomas, infection, wound dehiscence, transfusion requirements, limb swelling, venous thrombosis, mortality or hospital stay.

There was a tendency to a higher re-operation rate for wound healing complications and significantly more patients required transfusion in the drained group. The only benefit that was shown in favour of the use of drains was that significantly more patients in the undrained group required dressing reinforcement.

Based on the randomised, controlled trials to date, the routine use of closed suction drainage in Orthopaedic surgery is questionable.

It has been recently suggested that hyponatraemia may be a cause of significant iatrogenic harm in orthopaedic patients. In an attempt to test this theory, this observational study was done to establish the incidence of post-operative hyponatraemia following hip fracture and evaluate its correlation with outcome.

An observational study was carried out on 213 consecutive hip fracture patients. 201 patients completed the requirements of the study (Male-45, Female-156). Mean age was 80 years. Serum sodium concentrations were recorded during the first week of admission. Hyponatraemia defined as significant (Na < 130mmol/L) was identified in 9% at admission and 18% during first week of stay. Incidence of severe hyponatraemia was 3%. There were no acute complications of hyponatraemia in these patients. 78% of hyponatraemia patients had received 5% Dextrose infusion during the postoperative period as their main intravenous fluid. All hyponatraemic patients had their sodium levels restored to normal during their stay.

Long term outcome measures used were mortality, change in residential status, walking ability and use of walking aids at 4 months following fracture. There was 20% mortality at 4 months in the hyponatraemic group and it was 30% in the normal serum sodium group. However this difference was not statistically significant. Hyponatraemia did not significantly influence deterioration in residential status (p< 0. 05), walking independence (p< 0. 05) or increase of walking aids (p< 0. 05).

In hip fracture patients, hyponatraemia whilst common was not associated with a poor outcome and at the same time we did not find any evidence of lapse in the recognition and treatment of hyponatraemia in a general orthopaedic ward. However emphasis should be made to junior medical staff to avoid iatrogenic hyponatraemia by following a proper postoperative fluid regime.

A prospective study was undertaken of wound healing in HIV positive patients undergoing orthopaedic implant surgery. 175 implant operations were assessed. 40 operations (23%) were in HIV positive individuals. Wounds were scored using the Asepsis scoring system.

Closed fractures in HIV positive patients had 1 (3. 5%) major infection. No correlation was seen between CD4 count and risk of wound infection.

With regards to early wound sepsis, implant surgery can be undertaken safely in HIV positive individuals with closed injuries regardless of CD4 count. The risk of wound sepsis rises dramatically in implant surgery for HIV positive patients with open fractures.

In the period 1991 to 1993, twenty-five patients had Tonnis Triple Pelvis Osteotomy (TPO) performed. The presenting condition was primary or residual acetabular dysplasia. The age range was 24 to 54. Fifteen operations were on the left and two patients had bilateral operations at intervals of more than one year.

The anterior approach (Salter incision) was limited to an internal dissection, with the most limited possible abductor elevation of 2cm at the level of the iliac osteotomy. An Orthofix leg-lengthener was used intraoperatively to manoeuvre the central acetabular fragment, to accurately correct the presenting deformity as determined by CT scans. Two or three 6. 5mm screws were used to fix the osteotomy. No immobilisation was used. Mean blood loss was 580mis (range 375–1050mis).

All patients presented with pain, and only two patients had (mild) pain at review. The adult acetabular index was corrected from mean 31 deg to mean 4deg (max 1 Odeg). The CEA was corrected from mean 8 deg to 20–35 (mean 29) degrees. There was one temporary sciatic neuropraxia in the first patient. One patient has been converted to a resurfacing. Harris Hip Scores (HHS) have been measured yearly from three years post-op. Presenting HHS was mean 58 (range 44–72). At most recent follow-up it was mean 91 (range 79–1 00). Only two patients had HHS < 85. These patients had only 50% joint space at presentation. There was no reduction in HHS with longer follow-up. The operation shows durable and promising results in the medium-term, consistent with other series reported in Europe. The authors recommend that this type of operation be performed before any joint space narrowing develops, so that irretrievable deterioration occurs

The best management of displaced intracapsular femoral neck fractures in the elderly remains undecided. Most are treated by hemiarthroplasty. The aim of this study was to establish whether the advantages of cement outweigh the disadvantages.

All patients with displaced intracapsular femoral neck fractures treated with herniarthroplasty between January 1997 and May 1998, in 2 hospitals within the same Deanery, were reviewed. The same prosthesis was used, but in hospital A they were uncemented, and in B cemented. There were 122 patients in hospital A and 123 in B. We conducted a detailed retrospective analysis of hospital notes. All surviving patients (50 and 56 respectively) were interviewed to obtain pre-fracture and current scores of pain, walking ability, use of walking aids, activities of daily living (ADL) and accommodation status, using validated scoring systems. The relative deterioration over the follow-up period (32–36 months) was determined and the groups compared.

Patient demographics confirmed comparability of groups. There was no greater incidence of intra-operative fall in diastolic blood pressure, or oxygen saturation in the cemented group. Cemented procedures were on average 15 minutes longer. Median in-patient stay was the same. Significantly fewer of the cemented group had been revised or were awaiting revision (p=0. 036). There was no difference in mortality rates at any point between surgery and follow-up. Prospective assessment of surviving patients revealed highly statistically significant greater deterioration in pain (p=0. 003), walking ability (p=0. 002), use of walking aids (p=0. 003) and ADL (p=0. 009) in the uncemented group. The trend for more dependent accommodation in the uncemented group failed to reach statistical significance (p=0. 14).

In conclusion, the cemented group faired significantly better than the uncemented group. Our findings suggest the advantages of cement outweigh the disadvantages, and we support the use of cemented hemiarthroplasty for the displaced intracapsular femoral neck fracture in the elderly patient.

38 patients were taken from the arthroscopic washout waiting list and randomised after informed consent to receive either a course of sodium hyaluronate injections or an arthroscopic washout. Those patients who had previously had an arthroscopic washout, an intraarticular injection in the last 6 months, mechanical symptoms or hypersensitivity to avian proteins were excluded. The injections were given using an aseptic technique after first aspirating the knee to dryness. An injection was given each week for 5 weeks. The washouts were performed using 0. 9% saline and debridement was undertaken as necessary. The outcome measures used were a visual analogue pain score (VAS), Knee Society function score (FS) and Lequesne index (LI).

19 people were randomised into each group. The groups were similar in terms of age, sex and analgesics used. 2 patients in the arthroscopy group declined arthroscopy after randomisation as their symptoms had improved. There was no significant difference in the pre-intervention VAS or LI. The FS was worse in the arthroscopy group (p< 0. 01). After treatment, 2 patients in each group moved from the area and were lost to follow up.

During the year, 5 patients from the sodium hyaluronate group underwent arthroscopy. 3 patients failed to improve and were listed for total knee replacement. The others had improved at 3 months.

At 1 year, the VAS (NS), FS (p< 0. 02) and LI (p< 0. 04) were all better in the sodium hyaluronate group.

Intra-articular sodium hyaluronate injections should be considered for use in selected patients with knee osteoarthritis without mechanical problems. Further study is required to confirm these findings and improve patient selection.

Between 1993 and 1998, 16 consecutive hips in 12 patients (3M, 9F) with a mean age of 22 yrs (14–38 yrs), and mean time of symptom onset from surgery of 35 mths (9–60 mths) underwent Z-plasty of the iliotibial band for snapping hip. At mean follow-up of 36 mths (15–60 mths), all 16 hips (12 patients) were free of snapping whilst 14 hips (11 patients) experienced complete relief of symptoms. All patients considered the procedure successful and worthwhile, and there were no complications. We conclude that, in select patients who experience painful snapping of the hip because of a tense iliotibial band that has failed non-operative measures, iliotibial band lengthening by Z-plasty has been successful at improving or completely abolishing hip pain and snapping.

Deep venous thrombosis (DVT) and clinical outcome measurements in a series of 610 patients who did not receive routine chemical thromboprophylaxis for lower limb arthroplasty were studied. Patients who had undergone primary total hip or knee replacement under the care of two orthopaedic consultants were identified from the Trent Arthroplasty Database. Surgery was performed between 1992 and 1999 in one hospital only. Venography was undertaken on the seventh to tenth postoperative day. Patients with proximal thrombosis were anti-coagulated with warfarin as per protocol. Venogram reports were available for 81% of cases.

One year following surgery a standard postal questionnaire was sent to all patients. A response rate of 88% was achieved. Data was captured with respect to residual pain, ability to walk and the overall satisfaction with joint replacement.

DVT following total hip (THR) or knee replacement (TKR) in patients who did not receive routine chemical thromboprophylaxis was common (46. 4%) in line with other studies.

Knee surgery was associated with a high prevalence of thrombosis (57. 6%) compared to hip replacement although only one fifth of DVTs were found to extend into a proximal vein. Approximately half (44. 2%) of all THR associated thrombus was above knee DVT. Questionnaire responses evaluating clinical outcome and satisfaction were correlated to venographic results and analysed using an SPSS statistical package. Using Chi-squared analysis no statistically significant differences were found between deep venous thrombosis and patient-perceived pain (p=0. 12), mobility (p=0. 07) or overall satisfaction (p=0. 23). It is generally assumed that chemical thromboprophylaxis will diminish DVT related complications such as post-phlebitic limb syndrome. Despite a high prevalence of thrombosis in patients who did not receive pharmacological agents for prophylaxis, this study did not demonstrate an adverse outcome on pain, function or patient satisfaction. Morbidity as a result of DVT needs to be studied further before the role of chemical thromboprophylaxis can be determined.

To establish the incidence of early dislocation following primary total hip arthroplasty performed through a direct lateral approach when no post-operative restrictions on patient positioning or mobilization were imposed.

499 primary total hip arthroplasties performed in 483 patients between October 1997 and July 2000 were studied prospectively. Surgery was performed through a direct lateral (Hardinge) approach with the patient in a supine or lateral position according to surgeon preference. An Exeter femoral stem with a 26mm head (Howmedica) and an Ogee socket (Depuy) were both cemented. Post-operatively abduction pillows were not used. Patients were specifically advised both pre- and post-operatively by their surgeon, nurses and physiotherapist that no restrictions were placed on their mobilization. They were encouraged to move in any way that they found comfortable and adopt any position they chose. They were allowed to sleep in their usual position and bathe or shower normally.

Mean patient age was 72 (range 35–95). 304 patients (61%) were female. The grade of operating surgeon was consultant in 326 (65%) cases, staff grade in 122 (25%) and specialist registrar in 51 (10%). 284 (57%) operations were performed with the patient placed in the lateral position.

No patients were lost to follow-up. There were three dislocations within six weeks of surgery (defined as ‘early’), a rate of 0. 6%. All were reduced closed and managed conservatively. One hip dislocated for a second time eleven days later but every patient subsequently achieved stability without further intervention. There were no late dislocations.

Our results suggest that a very low early dislocation rate can be achieved when performing primary hip arthroplasty through a direct lateral approach without the need to impose restrictions on post-operative mobilization which patients often find intrusive.

Although drains date back to the Hippocratic era, their routine use remains controversial in total hip arthroplasty. The literature suggests that they can provide a retrograde route for infection as well as decreasing the organism count required to develop an infection. The use of drains has not decreased the size of wound haematomas at day five on ultrasound or the incidence of massive wound haematomas. Neither have they been shown to significantly decrease wound infections. This consecutive prospective randomised study was designed to evaluate what role drains have in the management of patients undergoing hip arthroplasty.

A total of 577 patients undergoing unilateral or bilateral hip arthroplasty were evaluated in a randomised prospective trial of drain versus no drain, between September 1997 and December 2000. All patients had a standardised pre, inter and post operative regime and were independently assessed using the Harris hip score and SF36 pre-operatively, at discharge and at six months post surgery.

The superficial and deep infection rate of 6. 4% and 0. 4% was seen in those drained and 7. 1% and 0. 7% in the non-drained group. Only one patient sustained a clinical haematoma that did not requiring drainage or transfusion in the non-drain group. The transfusion rate in those drained was 33. 0% compared to 26. 4% in those not drained. There was no statistical advantage in using a drain P> 0. 05 regarding these variables or in the length of stay, SF36 or Harris hip scores at pre-op and six months. Using a drain did significantly increase the likelihood of requiring a transfusion P< 0. 05.

In conclusion drains provide no statistical advantage whilst represent an additional cost and expose hip arthroplasty patients to an unacceptable risk of infection and transfusion.

Differentiating cases of aseptic loosening of total hip arthroplasty (THA) from loosening due to low-grade infection can often be difficult. It is possible that some cases of ‘aseptic’ loosening may be related to unidentified bacterial infection.

Using Polymerase Chain Reaction (PCR), this study attempted to identify the frequency with which bacterial DNA could be observed at revision arthroplasty for what was considered ‘aseptic’ loosening.

All revision cases had to fulfil strict criteria to be considered aseptically loose In all cases operative specimens from the synovial fluid, synovium, femoral and acetabular membranes where possible were sent for analysis by histology, bacteriology and by PCR to identify the presence of the 16S bacterial ribosomal fraction, an indicator of bacterial DNA. Ten bacteria per millilitre of tissue/fluid were the threshold for detection. As a control for environmental contamination, specimens from primary THA were also sent for analysis in the same manner as revisions.

The identification of bacterial DNA in at least one sample from a patient was considered a positive case result.

45 revision THA were identified over a 3-year period (1998–2001). From those 45 revision cases, 163 specimens were sent for analysis by PCR. These specimens were compared to the control group of 34 primary THA from which 91 specimens were sent for analysis by PCR. When analysed by specimens positive by PCR, bacterial DNA was identified in 55 of 163 specimens sent from the 45 revision THA. This compared with 21 of 91 specimens positive by PCR sent from the 34 primary THA (p=0. 07).

When analysed by cases positive by PCR, bacterial DNA was identified in 29 of 45 revision THA and in 8 of 34 primary THA (p< 0. 001).

PCR is a sensitive test for detecting infection in revision THA. Results from the primary THA cases would suggest there is at least a 23% false positive rate even with negative bacterial culture. The increased frequency with which bacterial DNA has been identified in ‘aseptically’ loose revision THAs, however, is unlikely to be due solely to environmental contamination. These results may have relevance for our interpretation and understanding of aseptic loosening as well for the diagnosis of prosthetic infection.

Surgibone (Unilab R) is a dry bone graft substitute prepared from Canadian bovine bone. It contains hydroxyapatite and 20–29% protein. The manufacturer claims that it is biocompatible; does not lead to foreign body reaction and does not produce pyrogenic effects.

We have used Surgibone routinely in revision joint replacement surgery over a 6-year period, to augment autograft in filling osseous defects in the acetabulum and proximal femur. 27 patients who received Surgibone have been reviewed to assess the degree of graft incorporation, any evidence of graft rejection or immunogenic reaction. One patient died and 2 were excluded from the study for early fixation failure. The remaining 24 were studied 6 months to 5 years post surgery.

In 17 patients (71%) there was radiological appearance of complete incorporation of the bone graft within 6 months. In 3 of these patients the graft incorporated as early as 3 months. There were 7 failures (29%). 3 patients have no radiological evidence of graft incorporation up to 3 years post surgery, although 2 have a satisfactory clinical result. Another 3 patients appeared to have graft rejection, and at revision were found to have sterile pus around the graft. These patients had negative responses to skin patch test for allergy to Surgibone. The seventh patient suffered an MRSA deep infection of the prosthesis that resulted in removal of the implants 4 weeks post operatively.

We conclude that the use of xenograft Surgibone in revision hip surgery leads to unacceptable incidence of failure. Although in the majority of cases good incorporation of the graft was observed, there has been a substantial incidence of graft rejection.

Deep prosthetic infections are a significant cause of failure after arthroplastic surgery. Superficial wound infections are a risk factor for deep infections. We aimed to quantify the risk of deep infection after superficial wound infections, and analyse the microbiology of organisms grown.

We defused Superficial Infection according to the definition used by the Centre for Disease Control, and Deep Infection according to the Swedish Hip Register. We retrospectively analysed the results of 6782 THR and TKRs performed consecutively from 1988–1998. We analysed patient records, radiology and microbiological data. The latter collected prospectively by our infection control team.

We identified 81 (1. 2%) superficial wound infections, however we had to exclude 3 due to poor follow-up. Of the 78 patients studied, mean age was 71 (23–89), 50 were female, 28 male, 41 THR, 37 TKR and follow-up was a mean 49 months (12–130). The majority (81%) of organisms grown in the superficial wound infections were gram positive Staphylococci. These organisms were most frequently sensitive to Erythromycin or Flucloxacillin. All the superficial infections were treated with antibiotics, 66% settled with less than 6 weeks therapy. Deep prosthetic infections occurred in 10% of superficial infections in both THR and TKR. In 80% of cases the organism in the superficial infection caused the deep infection. Wound dehiscence, haematoma, post-op pyrexia and patient risk factors had no affect on onset of deep infection. However patients who had a wound discharge with positive microbiology and those patients in whom there was clinical doubt about the diagnosis of deep infection and thus had antibiotic therapy for more than six weeks had increased risk of deep sepsis.

Fatal pulmonary embolism (PE) after total hip replacement (THR) is a major concern to all orthopaedic surgeons. Our intention was to ascertain death rates and deaths due to PE following total hip replacement where chemical thromboprophylaxis was not used routinely.

We determined retrospectively, the postoperative mortality and fatal pulmonary embolism rates in 1671 consecutive primary total hop replacements in 1547 patients performed as staged procedures between January 1997 and April 2000 at an orthopaedic hospital. The minimum follow-up period was six weeks period after surgery at an orthopaedic hospital. Patients were traced by questionnaires, outpatient appointments and by telephone. Post-mortem records were used to verify cause of death. Follow-up was 100%. The death rate from PE was 0. 12% (CI 0. 03% – 0. 44%) and the all-cause mortality rate was 0. 36% (CI 0. 16% – 0. 78%). All deaths were within the first 10 days during the initial hospital stay. The patient mortality was compared with the population mortality for England and Wales, using standardised mortality ratios (SMRs). The SMR for both sexes combined was 0. 81. We observed a lower mortality in females (SMR=0. 43) but a higher mortality in males (SMR=1. 44) during the first 42 postoperative days compared to the general population.

Fatal PE after THR without routine chemical thromboprophylaxis is very uncommon. The death rate in patients undergoing THR appears to be lower than that in the general population.

We sought to determine the effect, if any, the presence of an untreated articular cartilage defect observed during ACL reconstruction would have on the results following surgery.

From 1987 to 1997, 34 of 2264 ACL reconstructions were found to have an isolated articular cartilage defect of the femoral condyles that were Fairbanks grade 3 or 4. This study group (DEF group) comprised 28 men and 6 women with a mean age of 28. 3 + 10. 1 years. These patients were matched for sex, age at time of surgery, injury type and sport played at time of injury from our prospective ACL database. None of the control group (CONT group) had any associated meniscus or chondral damage and had a mean age of 27. 3 + 8. 8 years. Routine subjective, objective and radiological prospective follow-up was undertaken.

The mean subjective follow up was 7. 2 + 3. 3 years and 7. 1 + 2. 9 in the DEF and CONT groups respectively with objective follow up similarly being 5. 4 + 3. 3 years and 5. 4 + 2. 5 years respectively. The annual mean subjective scores for the two groups were the same (all above 90) each year after surgery up to 12 years. 96% in the DEF group and 100% of patients in the CONT group returned to their same sports. The IKDC radiographic rating had 31 patients in the DEF group and 32 in the CONT group with normal or nearly normal knees.

Radiographic arthritic progression was seen in 6 patients in each group. Stability, range of motion and strength were similar in the two groups during follow-up. We found no significant difference between the two groups in any variable studied.

This study show that patients with chondral defects do not differ subjectively, objectively or radiographically from a matched control group for up to 12 years after surgery.

To assess the use of autogenous osteochondral graft fixation (mosaicplasty) in unstable osteochondritis dissecans (OCD) lesions (Clanton type 2 and 3) of the knee.

Eleven patients with x-ray and N4R1 confirmed OCD lesion in their femoral condyle, that had remained symptomatic despite adequate conservative treatment, underwent arthroscopic mosaicplasty plug fixation of the lesion. The OCD lesions were all loose at operation and were all fixed rigidly in situ. using a number of autogenous 4. 5min osteochondral plugs harvested from the edge of the trochlear groove. The patients were prospectively assessed both clinically and by MRI scan at 3, 6 and 12 months and then six monthly. Average follow up was 2. 7 years (2 – 4. 1).

Prior to operation all patients had joint effusions and were experiencing pain limiting their activities. By 6 months post-operation the IKDC score had returned to normal in all cases and none of the patients had joint effusions or pain. Serial NHU scans documented healing of the osteochondral plugs and a continuous articular cartilage surface layer in all cases by 9 months.

Using mosaicplasty plug fixation we were able to obtain healing in all 1 1 unstable OCD lesions. The benefits of this technique are the ability to obtain rigid stabilization of the fragment using multiple plugs, stimulation of the subchondral blood supply and autogenous cancellous bone grafting. We conclude that mosaic-plasty plug fixation of unstable OCD lesions in the knee is a good technique and recommend its use.

Eleven patients with an unstable osteochondritis dissecans lesion (OCD) in their femoral condyle underwent in situ arthroscopic osteochondral graft fixation (mosaicplasty) of the lesion using a number of 4. 5min plugs harvested from the trochlear groove. By 6 months follow-up all of the patients were pain free with no joint effusion and by 9 months all had NW evidence of plug healing and continuous articular cartilage coverage. The benefits of this technique are the ability to obtain rigid stabilization, stimulation of the subchondral blood supply and cancellous bone grafting. We conclude that mosaic-plasty fixation of OCD lesions is a useful technique.

We have performed a study comparing the radiological results of Total hip replacements performed by a single, experienced specialist hip surgeon with those reported from the Trent Regional Arthroplasty Study (TRAS) [presented at BOA congress 2000]. Results from TRAS have revealed that inadequate cementation grades and a cement mantle width of < 2mm were the most significant associations predicting early aseptic loosening. Interestingly, their respective incidences were as large as 20% and 50% in a random sample of THRs from the TRAS register.

Data is lacking as to whether poorer radiographic cementation grades have a trend towards individual surgeons or whether they are more evenly distributed amongst the surgical population including those adhering to modem techniques.

Therefore, we have undertaken an independent review of A-P and lateral radiographs of 33 consecutive Charnley THRs performed by a specialist hip surgeon using carefully controlled modem cementing techniques and compared the results with the same random cohort of THRs from the TRAS.

Our results show that the specialist surgeon achieved a significantly higher proportion (82%) of complete cement mantles (> 2mm in all zones) than those achieved by TRAS (50%) [Chi²=7. 79, p=0. 0052]. This suggests that improved cement mantles can be achieved by the adoption of carefully controlled modem cementing techniques. However, use of the Barrack system of grading was unable to detect differences in cementation quality between specialist (88%) and TRAS group (81%) [Chi²=0. 235; p=0. 631 suggesting less sensitivity in this technique for assessing cementation quality. These results are important for the following reasons. Achievement of adequate mantle (> 2mm) can be improved upon by adoption of carefully controlled modem cementing technique. However, regardless of the method of assessment of cementation quality, approximately 18% will appear ‘inadequate’ despite modern techniques suggesting that factors outside the surgeon’s control are involved in determining cementation grade. This has important medico-legal implication in the current climate in which surgeons are being criticised, in negligence cases arising out of the 3M Capital Hip experience, for achieving ‘inadequate’ cementation.

Certain cases of patello-femoral maltracking can lead to articular surface wear. Though most can be treated non-operatively, where there is increasing wear surgical intervention may be necessary. Patellar tracking is difficult to assess and though several different types of maltracking or loading have been described, each case warrants precise assessment of the wear patterns. Without this knowledge a logical approach to realignment surgery is impossible.

60 consecutive cases (age range 18–50 years) presenting with anterior knee pain were arthroscoped over a 4 year period. These patients all had been selected with either patellar instability or surface wear indicated either clinically, a positive radiograph, bone scan or MRI.

All patients were arthroscoped through standard anterolateral and antero-medial portals and also a superolateral and occasionally a supero-medial approach. The areas of articular damage were mapped on diagrams and recorded photographically. Patella views were taken in flexion and extension, and on passively stretching the patella medially and laterally.

We found 6 distinct patterns of wear which appear to indicate 6 different maltracking abnormalities. The largest group, 46 patients, consisted of lateral trackers, with 21 patients demonstrating medial facet and lateral femoral condylar wear.

Assessment of the articular surface of the patello-femoral groove from inferior portals is highly misleading and superior portals are needed for proper assessment. Medial facet wear can occur in lateral instability or medial compression. Lateral maltracking at engagement or distally are the commonest patterns.

Mosaicplasty¹ and Autologous Chondrocyte Implantation² (ACI) are both modern cartilage repair techniques used to repair symptomatic articular cartilage defects in the knee, based on small osteochondral grafts and cultured chondrocytes respectively. The aim is the restoration of articular cartilage, but until now there is no data comparing the two methods.

100 consecutive patients aged 15–45 with a symptomatic articular cartilage lesion in the knee suitable for cartilage repair were randomised at arthroscopic assessment to undergo either mosaicplasty or ACI. 42 patients underwent mosaicplasty, 58 had ACI. Mean age at time of surgery was 31 years and the average defect size 4. 66 cm².

46% of the defects were post-traumatic, 19% had osteochondritis dissecans, 14% had chondromalacia patella and 16% had lesions of unknown aetiology. 53% had a medial femoral condyle lesion, 25% patella, 18% lateral femoral condyle, 3% trochlea and there was one defect of the lateral tibial plateau.

The mean duration of symptoms was 7. 2 years and the average number of previous operations (excluding arthroscopies) was 1. 5. Only 6 patients had no prior surgical interventions to the affected knee. The mean follow-up was 1. 7 years.

Patients were evaluated using Modified Cincinnati and Stanmore Functional rating systems, visual analogue scores and clinical assessment. Arthroscopy and biopsy was performed at one year and repair assessed with the International Cartilage Repair Society grading system.

Clinical results at one year showed 70% of mosaic-plasty patients and 87% of ACI patients had a good or excellent result. Arthroscopy at one year demonstrated more complete healing in ACI patients. Eleven (26%) of the mosaicplasty group subsequently failed clinically and arthroscopically, with peak failure at 2 years.

At one year follow-up, both techniques of articular cartilage repair can be useful in selected patients. ACI is preferred for lesions of the patella. Long-term follow-up is needed to assess the durability of articular cartilage repair using these methods, in particular mosaicplasty which showed signs of progressive failure over 2 years.

Autologous Chondrocyte Implantation’ (ACI) is a cartilage repair technique that involves implantation of cultured chondrocytes beneath a membrane of autologous periosteum. In this study a porcine biodegradable membrane was also used to assess its effectiveness. The aim is to restore articular cartilage to symptomatic defects, rather than initiating a fibrocartilagenous repair.

We undertook a prospective study of 125 consecutive patients who underwent ACI. Average age at the time of surgery was 30. 9 years (range 14 – 49), 55% of patients were male. The average size of the defect was 4. 35 cm².

44% of defects were attributable to known traumatic incidents, 2 1 % had osteochondritis dessicans, 18% chondromalacia patella, 12% had defects of unknown aetiology and 5% other.

The average duration of symptoms prior to this surgery was 7. 16 years. The mean number of previous operations (excluding arthroscopies) was 1. 6. Only 9 patients had no previous major surgery to the affected knee. 44% had defects of the medial femoral condyle, 31% patella, 20% lateral femoral condyle and 5% had a trochlea lesion. 26% of the defects were covered with periosteum and 74% with a porcine collagen membrane (chondrogide)

Minimum follow-up was six months, 70 patients had minimum follow-up of one year. Mean follow-up 18 months.

Patients were assessed using Modified Cincinnati and Stanmore Functional rating systems, visual analogue scores and clinical evaluation.

Arthroscopy and biopsy was performed at one year and the repair assessed using the International Cartilage Research Society grading system.

At one year follow-up overall 41 % patients had an excellent result, 48% good, 8% fair and 3% poor. For defects of the medial femoral condyle, 88% had a good or excellent result, 85% for the lateral femoral condyle and 80% for the patella.

61 patients were arthroscopically assessed at one year. 50/61 (82%) demonstrated ICRS grade 1 or 2 repair. Healing of the defect occurred with either a periosteum or chondrogide defect cover.

Results at one year suggest that ACI is a successful articular cartilage repair technique in selected patients. Long-term follow-up is required to assess the durability of the repair.

Anterior cruciate ligament reconstruction has been traditionally performed as an inpatient due to post-operative analgesic requirements.

Increased patient demands and pressures of bed shortages have led to the development of day case surgery.

Day case anterior cruciate ligament (ACL) reconstruction surgery using an analgesic pump was assessed.

24 consecutive ACL reconstructions using arthroscopic hamstring technique were performed as day case procedures.

All received a standard anaesthetic of propofol, fentanyl, tenoxicam, and morphine. And an intra-articular administration of 10mls 0. 75% Ropivicaine Hydrochloride at the end of surgery.

0. 2% Ropivicaine at a rate of 2mls/hr was infused over 48hrs using a compression spring infusion pump (Pain Control Infusion Pump – Sgarlato Labs) via an intraarticular catheter.

Post operative pain was assessed by a Visual Analogue Score (VAS) recorded by the patient onto an unmarked 1 Ocin line (0 – no pain ; 1 0 – maximum pain)

For the 48hrs the pump was infusing the average VAS was 2. 7 with minimal additional analgesia required.

Following pump removal by a District Nurse, the average VAS score was 1. 9 with similar analgesia requirements

All patients were satisfied with their care; none had problems related to the use of or removal of the pump; none required re-admission or review from their GP; or suffered post-operative complications.

The cost for day case surgery was 260 (including theatre time; pump and drug costs; District Nurse costs) compared to 1072 for an average in-patient stay of 4 days (both exclude ACL specific implants, surgeon and anaesthetist costs).

The intra-articular infusion of local anaesthetic has been shown to be well received by patients with no additional risks.

It is an effective and cost-effective means of providing post-operative analgesia allowing day case ACL Reconstruction surgery to be performed.

This study has demonstrated that there are no requirements for additional resources from primary care.

To determine the long term outcome and complications associated with arthroscopic synovectomy in 22 knees with rheumatoid arthritis.

A consecutive series of 22 knees in 18 patients with seropositive RA underwent arthroscopic synovectomy for painful and swollen knees unresponsive to medical treatment. All operations were performed by the senior author. The mean age at operation was 44 years (22–64). All pre-operative Xrays showed Larsen grade 2 or less and no knees demonstrated marked joint laxity. Knee Society scores were recorded pre-operatively and at review, with a mean follow-up of 8 years(6–16).

Two out of 22 knees (9%) have undergone TKR at 1 and 2 years post synovectomy. Two patients underwent further synovectomy for persistent symptoms but have since remained well. No per-operative complications were recorded but one large haemarthrosis and one stiff knee requiring manipulation were seen. The mean clinical and function scores increased by 22 and 15 points respectively at follow-up. The mean length of stay was 3 days and radiographs of the 20 knees not undergoing prosthetic replacement have all shown a small progression of degenerative radiological change.

This long-term study shows that arthroscopic synovectomy in appropriately selected patients with RA is a safe and reliable procedure with a low complication rate. The surgery is technically demanding but involves a shorter in-patient stay than with open synovectomy. The development of radiological degenerative changes were seen with all patients at review.

Arthroscopic lavage is commonly used in the management of mild to moderate arthritis of the knee. In the last few years the use of Hyaluronic Acid and its derivatives has become popular in the management of this same group of patients. The study was set up to establish whether Synvisc (HylanGF-20) produced equivalent or improved symptomatic relief when compared to arthroscopic lavage.

A prospective randomised trial. Fifty patients with knee OA were randomly allocated to either the arthroscopic lavage or Synvisc group. All patients were assessed prior to treatment using the WOMAC knee evaluation questionnaire, and further assessments were made at 6 weeks, 3 months, 6 months and one year post treatment.

The Synvisc group showed greater and more consistent improvement in WOMAC scores than the lavage group at all assessments post treatment. The difference between the treatment groups was statistically significant at 6 months (p< 0. 05) and at 1 Year (p=0. 0018).

We conclude that a course of Synvisc injections can be administered on an out-patient basis and is a safer, more cost-effective and more reliable treatment for Knee OA compared to arthroscopic lavage.

The value of arthroscopic partial meniscectomy in the severely arthritic knee has been questioned. Some authors suggest that it may result in progression of osteoarthritis precipitating the need for joint replacement and that symptomatic improvement may occur from lavage alone.

126 patients with a torn meniscus and Outerbridge grade IV changes in the same compartment underwent arthroscopic partial meniscectomy and limited debridement of unstable articular cartilage. The indication for surgery was a symptomatic meniscal tear not osteoarthritis. A control group consisted of 13 patients with grade IV changes and intact but frayed menisci who underwent washout alone. Mean age and follow up were similar in the two groups.

Initially meniscectomy improved symptoms in 82 cases (65%). Symptoms were unchanged in 26 cases (21%) and were made worse in 18 cases (14%). At a mean follow up of 55 months, 50 patients (40%) felt their knees were better than they were preoperatively. Their mean Lysholm score was 75. 5. 35 knees (28%) were not improved (mean Lysholm socre 59). 41 patients (32%) had undergone further surgery: 39 total knee replacements, 1 unicompartmental knee replacement and 1 tibial osteotomy. Older patients, those with varus/ valgus malalignment, and those with exposed bone on both articular surfaces fared worse.

Outcome following meniscectomy was better than outcome following washout alone: more patients reported an improvement after meniscectomy and fewer had undergone further surgery on their knees (p=0. 04). The median time between arthroscopy and the decisions for joint replacement was the same in both groups (8 months in the meniscectomy group and 7. 5 months in the washout group) indicating meniscectomy did not precipitate joint replacement.

These results suggest that arthroscopic partial men-iscectomy in the presence of Outerbridge grade IV changes can result in satisfactory long term outcomes for many patients, is more effective than washout alone and does not precipitate the need for joint replacement.

There is a recognised incidence of anterior knee pain following Anterior Cruciate Ligament (ACL) reconstruction using a patella tendon autograft.

This study examined two group of patients both pre ACL ligament reconstruction and post ACL reconstruction using patella tendon grafts to define if anterior knee pain is a result of patella tendon harvest or a primary consequence of an ACL injury.

The two groups of patients were best matched for age, sex and physical activity.

The pre-operative group of twenty-five patients had a confirmed ACL rupture and exhibited symptoms of instability requiring an ACL reconstruction.

The operative group of twenty-five patients were a minimum of a year post operation.

The graft was harvested by an open procedure and the graft bone blocks were secured with interference screws.

The patients’ anterior knee pain score was assessed using the Shelbourne scoring system that evaluates knee function in relation to anterior knee pain using five parameters. The maximum score is 100.

The scores were compared using the unpaired student test.

There was no significant age difference between the two groups, preoperative group age 32. 2 years (range 22 to 46) and postoperative age 34. 8years (range 19 to 48).

The mean anterior knee pain score for the preoperative group was 71. 6 (49 to 100), the postoperative group was 77. 7 (45 to 100), this was not significantly different.

We found no significant difference in knee function due to anterior knee pain between the two groups. Studies have shown significant anterior knee pain following hamstring reconstruction (Spicer).

This study shows anterior knee pain in the ACL deficient knee is present prior to surgery.

We conclude that patella tendon autografts produce no significant incidence of anterior knee pain post surgery.

This study was designed to determine the outcome following carpal tunnel decompression in relation to patient age. The outcome measure used was a previously published self-administered validated questionnaire which measured symptom severity and functional status in a prospective study of 91 patients undergoing carpal tunnel release. Diagnosis was made on clinical grounds and pre-operative electrophysiology tests. Patients with inflammatory disease, metabolic disorders, pregnancy and carpal tunnel syndrome secondary to trauma were excluded.

Each patient completed the questionnaire and underwent nerve conduction studies prior to surgery, and both were repeated 6 months after surgery. The change in symptom-severity and functional status scores were calculated. Four patients failed to attend review, leaving 87 patients in the study. There were 50 women and 37 men, with a mean age of 59. 8 years (range 31–91).

Ninety percent of patients improved on symptom score and 82% on function score. There was a negative correlation between symptom improvement and age (p=0. 003), and functional status and age (p=0. 046). The greatest difference in outcome was between those patients over 60 years and those 60 or under (p=0. 001 for symptoms and p=0. 034 for function). Both age groups, however, improved significantly in symptom and function scores following surgery (p< 0. 001 for both groups). There was no age group which did not show a significant improvement in outcome, including the very elderly.

Improvement in nerve conduction tests also declined over 60 years of age (p=0. 027).

However, there was no correlation between pre-operative questionnaire scores and nerve tests.

There was also no correlation between outcome and patient sex or symptom duration.

Ten patients expressed dissatisfaction with surgery (7 over 60 years), and a further 10 patients scored their surgery as neutral (7 over 60). These results show that patients over 60 show lower improvement in symptoms and function following carpal tunnel release than younger patients, and 1:3 fail to express satisfaction with the outcome of surgery.

The aim of this retrospective study was to investigate in patients with carpal tunnel syndrome the relationship between pre-operative symptoms, electrophysiological testing and outcome after surgery.

62 patients who had undergone carpal tunnel surgery were assessed in clinic, their case notes were reviewed and the electrophysiological results were analysed and graded according to severity.

The median duration of symptoms was 2 years. No relationship was found between the duration of pre-operative symptoms and the severity of electrophysio-logical impairment.

Furthermore, no relationship could be identified between electrophysiological impairment and either successful outcome after surgery (defined as complete symptom resolution) or time to resolution of symptoms after surgery

Autologous Chondrocyte Implantation (ACI) is a technique for repair of isolated symptomatic articular cartilage defects in the young adult knee. The knee is arthroscopically assessed and a sample of cartilage is harvested from the margin of the joint, this is digested and the liberated chondrocytes expanded in culture. At subsequent arthrotomy, the articular cartilage lesion is debrided and the cells injected behind a sutured flap. A concern regarding ACI is the iatrogenic insult to non-injured healthy cartilage adjacent to that harvested for culture.

Damaged cartilage around the lesion is routinely debrided and discarded at the second stage operation. The purpose of this study was to determine whether this damaged debrided cartilage could yield an adequate number of equivalent chondrocytes for ACL.

Cells from 11 patients were analysed. The debrided “waste” from around the lesion was collected, enzymatically digested and the liberated chondrocytes cultured in monolayer.

The cells were recovered and placed in a 3D-pellet culture in a defined medium.

Chondrocytes obtained from the routine harvest of healthy cartilage were placed in a similar culture system. The two groups were compared using DNA and GAG assays, histological and immunohistochemical techniques.

Chondrocytes obtained from the debrided cartilage lesion were equivalent to those obtained from the harvested healthy cartilage. Sufficient cell numbers for implantation were achieved for all patients, however cells cultured from the debrided defect in patients who had a large degenerate lesion required significantly longer in culture to attain the required number of cells.

For many patients undergoing ACI, the potential iatrogenic insult to the joint cartilage of the harvesting procedure could be avoided by harvesting the damaged tissue from around the defect itself.

We aimed to prospectively assess the familial incidence of Carpal tunnel syndrome (CTS)

151 patients undergoing elective carpal tunnel surgery at a district general hospital were given a written questionnaire on the day of surgery. Patients were asked to give details of all adult family members and to identify relatives that had been diagnosed with CTS by a doctor or had undergone CTS surgery. CTS is commonly associated with pregnancy, trauma, hypothyroidism, diabetes, gout and rheumatoid arthritis. We asked if the patients had any of these conditions. All patients were contacted by telephone within one month of surgery to validate the data collected.

The average age was 58. 4 (Range 28 – 84). The female / male ratio of patients undergoing surgery was 4A. Overall 26% of patients had a relative with CTS. 7. 8% of children (aged > 20), 2. 4% of parents and 4. 2% of siblings were affected.

A study of 44, 233 US workers reported a prevalence of 1. 55%. The child of a person with CTS is therefore 5 times more at risk of developing CTS than the normal population. Many parents were deceased resulting in a lower recorded prevalence for this group. Familial CTS was more common than any of the conditions traditionally associated with CTS (Except pregnancy).

Familial Carpal Tunnel Syndrome is common. Family history should be enquired about in occupations at risk of developing carpal tunnel syndrome.

A prospective assessment of the cause and results of surgery for recurrent carpal tunnel syndrome.

All patients undergoing revision carpal tunnel surgery over a five year period in a specialist hand surgery unit were reviewed. The physical signs, symptoms, ENIG, operative findings and operative outcome were recorded prospectively.

The selection criteria for surgery included an appropriate history, positive neurophysiology and one or more positive physical signs (Tinel’s, Phalen’s or pressure signs). Patients with normal neurophysiology results only underwent open release if the signs and symptoms were clear-cut, typically with at least 2 out of 3 positive signs.

Twenty-two patients (twenty-four wrists, mean age 55, range 33 to 91) underwent revision surgery. The mean time to re-operation was 7 years. 20 wrists had a positive Tinel’s test, 18 had a positive Phalen’s test, 19 had a positive pressure test and 18 had positive neurophysiology.

At operation, 20 wrists were noted to have compression proximally, 3 mid-retinacular and 3 distally. The proximal end of the primary wound scar was 1 cm or more from the distal wrist crease in 9 patients.

All patients reported some benefit. Significant or complete relief of symptoms were reported in 19 wrists. Better results were achieved in patients who had noted some improvement after primary surgery that had lasted for at least 4 months before relapse.

Most papers report inadequate distal release as the most common cause of re-operation but this study found inadequate proximal release to be more common. Less experienced surgeons may be apprehensive about performing an adequate closed proximal release but should be encouraged to take the scar to the distal wrist crease and if in doubt, incise across it in a standard manner.

To compare the results of standard open carpal tunnel release against minimal access release using the ‘Stryker Knifelight’ in the same patients.

A prospective, randomised trial was carried out recruiting all patients with bilateral carpal tunnel syndrome. There were 26 patients (18 females and 8 males), with a mean age of 48 years. The patients were randomised to having the ‘Knifelight’ on one side and therefore acted as their own controls. They were assessed preoperatively, and at 2 and 6 weeks postop by questionnaire, and grip strength measurements.

All sides were improved following release but those done by the open method were more likely to have complete resolution at 6 weeks. In contrast, the ‘Knife-light’ sides had better grip strength and allowed earlier return to work. In terms of preference, the patients were split equally between the 2 techniques. 2 patients had minor complications following minimal access release including one with numbness over the thenar eminence for 6 weeks.

This study shows that open carpal tunnel release remains the ‘gold standard’ but the minimal access technique offers some advantages in terms of quicker recovery.

Open reduction and internal fixation of comminuted, displaced intra-articular or potentially unstable fractures of the distal radius with plate and screws has increasingly become a favoured treatment. Intra-operative assessment of fixation with the help of an image intensifier has always been difficult because of the anatomy of the distal radius which has an average ulnar inclination of 22 degrees and an average volar tilt of 14 degrees. These inclination and tilt produce superimposition of images and imaging of the implants placed as distal as possible to achieve satisfactory fixation often shows the screws to be penetrating the joint.

We describe two new radiographic views of the distal radius, which we used intra-operatively in ten patients undergoing open reduction and internal fixation of distal radius fractures. These are the tangential views of the articular surface of the distal radius taken by elevating the wrist so that the forearm makes an angle to the operating table to negate the effects of natural inclination and tilt in antero-posterior and lateral views. The images were compared with the images of standard antero-posterior and standard lateral views. Screws were thought to have been penetrating the joint in the standard lateral views of all of them and in the standard antero-posterior views of eight of them. However, no screw was seen penetrating the joint in these new views.

The tangential views showed correct relation of the screws with the articular surface and a more distal placement of the plate was possible. This enabled the screws to engage the sub-chondral bone and obtain bi-cortical purchase in presence of dorsal comminution. We recommend use of these views in open reduction and internal fixation of distal radius fractures.

25 cases of closed fractures around the distal femoral growth plate were analysed prospectively over a one-year period. There were 22 males and 3 females. Mean age was 16 years (range 7 to 22).

According to the classification of Salter and Harris there were 6 cases (24%) of type 1 fracture, 12 (48%) type 2 fractures, 3 (12%) type 3, and 4 (16%) type 4. Mechanism of injury was football in 13 (59%), simple fall in 4 (18%), crush in 2 (9%), RTA in 2 (9%), and fall from height in 1 (5%); in 3, the mechanism was not recorded. The average time from injury to hospital admission was 5 days (range 0 to 17 days).

Management was conservative in 4 and operative in 21. The medial parapatellar approach was used in 16. Post-surgically plaster cylinders were used for a mean of 3 weeks (range 0 to 6 weeks). No patient received physiotherapy.

In the operative cases, sepsis was observed in 1 case (5%). This was a crash injury with a skin ulcer that became septic postoperatively and later required knee fusion.

Of the remaining 20 operative cases, 17 cases were reviewed, 4 to one year, 9 to six months, and 4 to three months. There were no cases of deformity, nor wound complications. Those reviewed at one year had an excellent range of movement averaging 0 to 117 degrees (range 0–100 to 0–140). At six months the average range of movement was 1–98 degrees (range 5–70 to 0–140) and at three months 2–62 degrees (range 10–50 to 0–95).

In conclusion, we believe that these difficult fractures should usually be managed operatively where expertise allows. Preliminary results suggest that the medial parapatellar approach provides excellent access but may inhibit initial rehabilitation.

This paper presents the results of forearm fractures in twenty children treated with flexible intramedullary nailing, over a period of 3 yrs.

Forearm fractures in children are an extremely common injury and excellent results are obtained in the majority of cases by closed reduction and plaster immobilisation. If adequate reduction cannot be achieved or maintained by conservative means or if it fails, some form of internal fixation will be required. Flexible nails are an extremely effective way for addressing this problem.

Twenty children had flexible intramedullary nailing done following forearm fractures over a 3-year period from 1997–2000 [failed reduction (10), unstable post MUA(3), slipped in plaster(6) and open fractures(1)]. There were 15 male and 5 female patients, the mean age being 10. 9. The nature of the injury were radial neck (3); proximal radius (1), galeazzi (1) and both bone fractures (15). Nine patients had closed nailing, while 11 required a mini open approach of which, 5 needed exposure only on one side. Patients were protected post surgery until signs of union were seen. The patients had regular clinical and radiological assessment and nails were removed on an average of 6–8 months, though in patients with radial neck fractures it was removed much earlier [4–5 weeks].

All patients went on to full bony union in excellent position, the average time to union being 5. 8 weeks. All but one patient regained full prono-supination, elbow and wrist motion, though none had any functional disability. There were a few minor complications especially following implant removal, including superficial wound infections (3), transient hypoasthesia in the distribution of the superficial radial nerve (2) and one patient in whom one nail had to be left behind as it could not be removed. There were no long-term sequelae.

Several methods of internal fixation are available, and the very diversity of choice demonstrates the lack of an ideal solution. K-wires are not applicable at all levels and plates have the disadvantage that they require extensive exposure of the fracture site. Removal of the plates is just as, if not more, fraught with complications.

Flexible nails can often be inserted closed, leave cosmetically more acceptable scars, provide excellent alignment of the fracture and can be removed easily without requiring any postoperative immobilisation. In our opinion it should be considered as the method of choice in treating forearm fractures in children, when some form of internal fixation is required.

Ten patients, who underwent treatment for complex fracture-dislocation of the proximal interphalangeal joint of finger and one patient for that of the interphalangeal joint of thumb with a modified pins and rubbers traction system, were reviewed to evaluate the clinical and functional results. Two patients had open fracture-dislocation, 5 had pilon fractures and 4 had fracture-dislocations. The system was modified to avoid rotation of the pins in the bone during joint mobilization, thus minimizing the risk of osteolysis due to friction of pins over the bone.

Michigan hand scoring system was used for subjective assessment and range of motion at proximal and distal interphalangeal joints and grip strength for objective assessment. Average follow-up was 18 months (range 3 months to 28 months). The average normalised Michigan hand score was 86. Based on Michigan scores, overall hand function was rated excellent in 8 patients, good in 2 and poor in 1. Eight patients have returned to their original jobs. The average arc of flexion in the proximal interphalangeal joint was 85 degrees and in the distal interphalangeal joint it was 47 degrees. The average grip strength was 95 percent of the uninvolved side. Two patients developed minor pin site infection, which did not necessitate pin removal or any alteration in the treatment regime. There have been no cases of osteolysis, osteitis or osteomyelitis. This modification of pins and rubbers traction system has given very acceptable results with a low complication rate. It is light, cheap, effective and easy to apply.

Displaced spiral and oblique fractures of the proximal phalanx are unstable and non-operative treatment frequently results in malunion. Such fractures are therefore treated operatively. No previous study has compared the two common techniques used.

Patients with an isolated spiral or oblique fracture of the proximal phalanx were prospectively randomised into two groups. One was treated by closed reduction and Kirschner wire fixation and the second treated by open reduction and lag screw fixation. An independent observer assessed function, pain, movement, grip strength and intrinsic muscle function. X-rays were assessed for malunion.

32 patients entered the study. At follow-up (mean 40 months) there were 15 in the Kirschner wire and 13 in the lag screw group. All returned to their normal employment and 18 described a full functional recovery. There was no significant difference in the functional recovery rates (Fischer exact test p=0. 3) or in pain scores for the two groups (median 0 for both). Radiographs showed similar rates of malunion and there was no statistically significant difference in range of movement or grip strengths.

This prospective randomised study has shown no significant difference in outcome for the two techniques. We would recommend that surgeons should choose the method with which they are most familiar and competent, or the technique that utilises the least health care resources.

Between 1982 and 1997, twenty-six children between the age of 2 and 15 (mean age 10. 6 years) underwent proximal femoral replacement. Twenty have survived and all but three have reached skeletal maturity.

Sequential radiographs have been reviewed with particular reference to acetabular development and fixation of the prostheses. Initially a cemented acetabular component was inserted, but recently uncemented implants and unipolar femoral heads that exactly fit the acetabulum have been used.

In older children the acetabulum develops normally and the components remain well fixed. One of nine children over thirteen years with a cemented acetabulum needed revision for loosening and one suffered recurrent dislocations.

In younger children the acetabulum continues to develop at the triradiate cartilage, so a cemented acetabulum grows away from the ischiopubic bar. As the component is fixed proximally, it becomes increasingly vertical and will almost inevitably loosen. In our study six of eight children under 13 years of age with a cemented acetabulum needed revision for loosening.

Unipolar replacements in younger children tend to erode the superior acetabular margin. Femoral head cover is difficult to maintain, and of four unipolar implants in children under thirteen, two required acetabular augmentation.

Cemented cups may be unsuitable for children under thirteen years but our results are not statistically significant. In this age group, unipolar implants may be more appropriate but they have serious potential complications. In children over thirteen, cemented implants survive longer. The number of uncemented implants in our study is too small to comment on long-term survival.

Accepted treatment for acute septic arthritis in children involves drainage of the pus and systematic antibiotics. Review of published studies show that there is a tendency for paediatricians and physicians to drain pus by aspiration and for surgeons to drain the pus by arthrotomy and surgical lavage. There is however no published prospective study comparing the two methods of drainage.

201 consecutive children under 13 (134 boys and 67 girls) presenting to our hospital with acute septic arthritis were entered into a prospective study and randomised to either aspiration of the joint with a 14g needle or arthrotomy and lavage. Both groups had systematic antibiotics for six weeks. All patients were followed up with clinical examination and x-rays at 2, 6, 12, 24 and 52 weeks.

There were 102 patients in the aspiration group and 99 in the lavage group. Both groups were similar in respect to mean age (2 yrs 5m and 2 yrs 10m respectively) and both groups had had symptoms for a mean of 6. 5 days. The commonest joint involved in both groups was the knee, followed by the shoulder, and the commonest organism involved was salmonella, followed by staphylococcus aureus.

Aspiration failed in 9/102 patients who then underwent arthrotomy. Aspirated cases were discharged at a mean of 7. 9 days compared to 9. 8 days in the lavage group. There is no published method of measuring clinical improvement in septic arthritis so we devised the Blantyre septic joint score (BSJS) which measures pain, swelling, range of motion and function. Using the BSJS we found significant difference in scores between the aspirated and the lavage groups at any stage of follow up.

We could not demonstrate any difference in clinical outcome between aspiration and arthrotomy with lavage in the treatment of septic arthritis.

The use of targeted ultrasound screening for ‘at risk’ hips in order to reduce the rate of surgery in developmental dysplasia of the hip (DDH) is unproven. A prospective trial was undertaken in an attempt to clarify this matter.

Over an 8-year period, there were 28, 676 live births. Unstable and ‘at risk’ hips were routinely targeted for ultrasound examination. One thousand eight hundred and six infants were ultrasounded, 6. 3% of the birth population.

Twenty-six children (19 dislocations and 7 dysplasia) required surgical intervention (0. 91 per 1000 births for DDH/0. 66 per 1000 births for dislocation)

Targeted ultrasound screening does not reduce the overall rate of surgery compared with the best conventional clinical screening programmes. The development of a national targeted ultrasound screening programme for ‘at risk’ hips cannot be justified on a cost or result basis.

To determine the usefulness of isotope bone scintigraphy in investigating skeletal pain in children, we reviewed the bone scans, plain radiographs and clinical notes of consecutive children under 16 years of age presenting to children’s orthopaedic surgeons at two teaching hospitals in one city.

There were 229 patients, of which 87 were boys and 142 girls. They had an average age of 11 years. 139 were investigated for back pain and 90 for skeletal pain in the appendicular skeleton. They were investigated for a variety of conditions including idiopathic back and skeletal pain, scoliosis, Scheuermann’s disease, spondylolysis, osteomyelitis and postoperative pain.

There were positive scans in 4 out of 78 patients with idiopathic back pain, and 13 out of 64 with idiopathic skeletal pain.

Overall the positive scan rate for all conditions was 10% for back conditions and 22% for pain in the appendicular skeleton.

Of all patients with back pain the management was altered in only 3 children. Of all those investigated for appendicular skeletal pain, the management was altered in 6 children. Isotope bone scanning is a low yield and non-specific investigation that imparts a significant dose of radiation to the patient.

It should not be used as a first line investigation for idiopathic back or skeletal pain in children. Other tools such as MRI should be considered initially.

It still has a role in the investigation of children with obvious abnormality on radiographs, with spondylolysis and probably where there are worrying clinical features to the pain such as night pain and recent onset.

The role of bone scanning in the investigation of skeletal pain should be re-evaluated in the investigation of skeletal pain.

This is a retrospective study describing four patients who developed symptomatic subluxation of the hip after stabilisation to the pelvis for myopathic scoliosis in Duchenne Muscular Dystrophy (DMD).

Fusion to the pelvis is recommended for treatment of scoliosis in DMD. Non-spinal extra-pulmonary complications following this have not been described.

4 patients (average age: 14 years) out of a cohort of patients who have undergone spinal stabilisation for DMD between 1991 and 1998 developed symptomatic subluxation of the hip at an average of three months after fusion from the upper thoracic spine to the pelvis. All four had pain and three noticed clicking in the hip.

X-rays revealed subluxation of the hip in all patients, and conservative treatment by adjustment of seating position in the wheelchair was successful in reducing the symptoms in all patients.

Flexion-abduction contractures of the hip, which are a feature of DMD, are known to cause uncovering of the contralateral hip. We postulate that the spine compensates for this uncovering to a large degree, and that spinopelvic fusion for scoliosis in patients with pre-existent abduction contractures negates the capacity of the spine to provide compensation. This leads to uncovering of the hip with the lesser degree of contracture, and the resultant symptoms.

We recommend screening for, and treatment of, flexion-abduction contractures of the hip in all patients undergoing spinal fusion for DMD, to avoid the possibility of development of symptomatic subluxation of the hip.

Treatment for developmental dysplasia and dislocation of the hip (DDH) presenting after one year of age is controversial. There are advocates of both open and non-operative reduction. Surgeons advocating open reduction believe in excising the obstructing soft tissues for all such cases. Others reducing non-operatively suggest that pressure from a reduced femoral head provides gradual concentric reduction with remodelling of the restraints. MR images of hips in a group of patients treated non-operatively were examined to determine the long-term development of the soft tissue around the hip.

We have been treating late presented DDH by graduated traction and gentle manipulation under general anaesthetic since 1975. 10 (12 hips) of these patients were consented to have an MRI Scan of their hips. Mean age of presentation was 17 months (13–36 months). Mean follow up was 16 years (7–26 years). Mean duration of traction was 31 days (16–45 days). None of the hips had an open reduction. Subsequently 3 hips had a femoral osteotomy at a mean age of 5. 9 years (4. 1–7. 8) and 3 hips underwent a Salter-type osteotomy at a mean age of 4. 3 years (3. 7–5. 4).

According to the grading of Barrett et al, 9 hips were graded clinically excellent, 2 were good and 1 hip was fair. The latest radiological result was graded according to Severin. There were 9 grade 1 hips, 2 grade II hips and 1 grade III.

All the patients had coronal, sagittal and transverse scans of both their hips. All the MRI Scans showed a good coverage of the femoral head. Anterior and posterior acetabular cover was adequate in all the hips. Osseo-cartilaginous extension beyond the acetabular margin was constantly found in all the hips. Even in the hip with a Severin score of III, the cartilaginous acetabular extension produced a concentric hip joint. The anterior and the posterior labrum were found to be well developed in all the hips. None of the hips showed any evidence of inverted limbus. 3 hips showed mild evidence of avascular necrosis but there was no evidence of collapse or flattening. Thinning of the articular cartilage was seen in 3 hips but no mechanical changes observed. Capsule and ligamentum teres were found to be well developed and non-obstructive.

Long-term results of non-operative treatment of late presented DDH have been found to be satisfactory. The MRI scans have shown an excellent soft tissue remodelling around the hip. Soft tissue restraints preventing initial reduction in late-presented DDH are therefore not an absolute indication for open exploration. MRI scans were found to be an excellent tool to study the effect of soft tissue remodeling in such cases.

To assess the performance and success of joint sparing limb salvage surgery in high grade malignancy, in terms of function, complications, recurrence and survival, as compared to joint resection.

We report a ten-year experience of twenty patients with high grade malignancies of bone which did not cross the epiphyseal plate. They underwent not only limb salvage surgery but also joint preservation. The aim of this is to preserve function in the joint and to prevent the inevitable wear of prosthetic joints requiring revision surgery. The age range was 4 - 25 years (mean 13. 5). The Diagnoses were 14 Osteosarcomas and 6 Ewings sarcomas. Mean follow up was 49 months. There were 13 femoral & 7 tibial malignancies. 12 underwent complex biological fixation with a combination of reimplanted autoclaved or irradiated bone; vascularised fibular graft; femoral or humeral allograft. In 8 cases custom made hydroxyapatite coated prostheses were used to replace the resected bone. This surgery must clearly be evaluated in the context of recurrence, particularly as this is associated with an increased risk of metastases and death. Analysis of our results to date has not shown a greater rate of complications. We experienced one recurrence, and one death. The custom prostheses group had fewer complications and operations. Functionally these patients report near normal limbs and joints and do not report any limitation of activities.

Joint sparing limb salvage surgery is extremely worthwhile as it produces a significantly better functioning limb and lower morbidity, with less likelihood of revision surgery. We have not found a higher risk of post-operative complications, recurrence or death. Furthermore massive prosthetic replacement is quicker, osseointegrates reliably and is associated with a lower complication and further operation rate.

A vertical scapular osteotomy was first described by Wilkinson in 1980.

We report six children with a mean age of 9 years 6 months at operation (range 4–16). Mean abduction pre-operatively was 77 degrees (range 70–160 degrees). Cosmetically all were Cavendish grade three except one grade four. Five of the six had associated abnormalities of the cervical spine (three Klippel-Feil and one hemivertebra) and four had omovertebral bars. One boy had a full range of movement pre-op and had a cosmetic correction. One girl had a preceding Erbs palsy which had resolved completely prior to surgery.

Mean follow-up is five years (range 1–12 years). All patients have an excellent cosmetic result, four graded Cavendish one, two graded two, and one grade three. Mean abduction improved to 148 degrees and mean improvement was 77 degrees.

Sprengel’s deformity presents significant cosmetic and functional deficits. We have found the vertical scapular osteotomy as described by Wilkinson a simple and reliable procedure with predictably good results. With regards to the omovertebral bone, we concur that its presence has no influence on functional outcome. Cosmetically, when clothed, the result is excellent, with the shoulders level. Undressed, however, asymmetry is still obvious with a truncated shoulder girdle and persistence of some webbing or fullness in the base of the neck. This appears more marked when an omovertebral bone was present.

We conclude that a vertical scapular osteotomy is a reliable operation for improving shoulder girdle function, but that cosmetic objectives must be reliable.

Amputation vs. limb salvage in FH has been based on fibular presence or absence and a ‘good’ or ‘bad’ foot. None of the current FH classification systems address ankle joint, hindfoot and forefoot morphology. We present a new, comprehensive FH classification which delineates leg, ankle and foot morphology. Three major groups are proposed: I-mild fibular shortening; II small or miniature fibula; III-absent fibula. Ankle mortise morphology is defined as H=horizontal, S=spherical, V=valgus. A small ‘c’ denotes a tarsal coalition. Numerals 1–5 reflect the number of forefoot rays present. For example, a patient with a miniature fibula, valgus ankle, tarsal coalition and 4 rays would be classified as II Vc4.

We present a reproducible classification which reflects the spectrum of ankle and foot involvement seen in review of 31 FH cases. Early amputation is recommended for limbs with fewer than 3 rays. Twenty-seven patients underwent limb reconstruction and 4 had ankle disarticulation and required adjunctive bony and soft tissue procedures. Extension of the circular fixation to the foot should be done during tibial lengthening in FH.

Thirty-two limbs in 31 FH patients were assessed by teleoroentgenograms and weightbearing ankle and foot radiographs. All had shortened femurs, the amount of which did not correlate with fibular type. Type III fibulae were highly associated with valgus ankles (56%), decreased number of rays (46–100%), and tarsal coalition (69%). Coalition was found in all ray categories but diminished number of rays (42–100%) with associated valgus ankles (68%) correlated strongly with a coalition. In patients with type III fibulae, one third had horizontal ankles, 53% had 4 or 5 rayed feet and 30% had no coalition. Fibular absence did not correlate with percent tibial shortening or ankle valgus.

The use of botulinum is established in the management of spasticity in cerebral palsy; most series concentrate on its injection into the Gastrocnemeii and hamstrings. During the swing phase, the rectus femoris acts concentrically at the hip, and eccentrically at the knee, to accelerate the thigh while controlling the rate of knee flexion. In spasticity there is prolonged activity with some of the rectus firing concentrically, resulting in a decreased rate of knee flexion, decreased peak flexion and a delay to its occurrence. These factors contribute to poor foot clearance.

Our aim was to establish whether the temporary paralysis of the rectus femoris by botulinum injection can improve knee kinematics.

Patients included were ambulant diplegics with clinical and kinematic evidence of rectus femoris spasticity. Independent clinical assessment was combined with 3D gait analysis pre and post injection. Kinematic Data for sagittal plane knee flexion/extension allowed us to calculate changes in the rate of flexion, the degree of peak flexion and time to its occurrence. Clinical evidence of spasticity was detected using the fast Duncan Ely test. There were 7 patients who underwent 15 injections into Rectus Femoris. Age range: 8–25 years (mean, 14–4 years). From the sagittal plane knee flexion graphs 10/15 had improvement in the rate of knee flexion, 9/15 had improvement in the peak flexion and 8/15 in the time to peak flexion. The mean increase in the fast Duncan Ely was 20. 5 degrees.

Using 3 Dimensional gait analysis we observed an improvement in the kinematic data following injection of the rectus femoris with botulinum.

This was accompanied by a clinical reduction of spasticity as measured by the Duncan Ely test. As with other muscle groups, botulinum injection of the rectus femoris has the potential to be both therapeutic and diagnostic.

We conducted a retrospective analysis of all elective Paediatric Orthopaedics referrals during the period 1998–1999 made by general practitioners to one of the two Paediatric Orthopaedic consultants in a moderate sized district general hospital serving a population of approximately 300, 000 with a delivery rate of approximately 3000 live births per year. This study was taken with a view to assess the spectrum of elective Paediatric Orthopaedic referral quality of work generated and to find out the final outcome and hence try to improve resource utilisation. We found out that majority of cases (85%) needed simple assurances or supportive measures, a task that can be easily shared by a trained clinical assistant along with the consultant and routine clinical cases are not adequately covered in Paediatric Orthopaedics courses for trainees.

During 1999, a total of 120 new elective Paediatric Orthopaedic referrals from GPs were seen in 600 bedded district general hospital by one of the Paediatric Orthopaedics consultants out of the 2 in the hospital. Case notes were analysed for age of patient, sex, joint affected, reason for referral, diagnosis made and the outcome following consultation. The outcome was measured in the form of whether the patient had an operation, was referred to Physiotherapy, orthotics, kept under observation (include masterly inactivity), referred to other subspecialty or reassured and discharged. Mean age of presentation was 7. 8 years and there was near equal presentation of boys and girls. Maximum cases were referred for knee problems 32 (26. 67%), hip 28 (23. 33%), foot 18 (15%), general 18(15%).

Majority of patients referred need simple assurance to parents and majority of patients seen in Clinics need no operation (85%), indicating that Orthopaedic Surgeons need to spend more time on reassuring parents than on operation, a task that can be easily shared by a trained Clinical Assistant.

Inadvertent excision of lumps which turn out to be soft tissue sarcomas is still unfortunately quite common. It is known as the “whoops” procedure. Determining whether there is residual disease is key to deciding subsequent management. The value of MRI has been assessed.

All new patients referred to our unit with a potential diagnosis of a “whoops” lesion were routinely reassessed with MR1 6 weeks after the initial operation.

Notwithstanding the result of the scan all patients underwent a further wide excision of the involved area shortly after the MRI. The scans of these patients have been reviewed and classified into positive, equivocal or negative. These results have been compared with the histological assessment of the re- excision specimen to determine the accuracy of MR1 in predicting the presence of residual tumour.

Of 887 patients with newly diagnosed soft tissue sarcomas seen in an 8 year period, 140 (11 %) had previously had a ‘whoops” procedure. Of these 111 had re-evaluation MR1 scans and had also undergone a further re-excision. There was residual tumour in 63 (57%) patients, whilst 48 (43%) had no residual tumour.

The sensitivity of MRI in predicting tumour was 64% but specificity 93%. Positive predictive value was 93% and negative predictive value 67%. Overall accuracy was 77%.

MRI is useful in identifying residual tumour after a whoops procedure but a negative result by no means excludes it. Re-excision remains essential despite the MRI results in most cases to ensure tumour clearance. Preventing the “whoops” procedure is clearly the best option of all!

To determine if rates of local recurrence and metastasis differ in upper versus lower extremity sarcomas.

Prospectively collected data relating to patients undergoing limb-sparing surgery for extremity soft tissue sarcoma between January 1986 and April 1997 were analysed. Local recurrence-free and metastasis-free rates were calculated using the method of Kaplan and Meier. Univariate and multivariate analyses of potential predictive factors were evaluated with the log-rank test and the Cox proportional hazards model.

Of 480 eligible patients, 48 (10. 0%) had a local recurrence and 131 (27. 3%) developed metastases. Median follow-up of survivors was 4. 8 years (0. 1 to 12. 9). There were 139 upper and 341 lower extremity tumours. Upper extremity tumours were more often treated by unplanned excision before referral (89 vs 160, p< 0. 001) and were smaller (6. 0cm vs 9. 3cm, p< 0. 000). Lower extremity tumours were more often deep to or involving the investing fascia (280 vs. 97, p< 0. 003). The distribution of histological types differed in each extremity. Fewer upper extremity tumours were treated with adjuvant radiotherapy (98 vs. 289, p< 0. 000).

The 5-year local recurrence-free rate was 82% in the upper and 93% in the lower extremity (p< 0. 002). Local recurrence was predicted by surgical margin status (hazard ratio 3. 16, p< 0. 000) but not extremity (p=0. 127) or unplanned excision before referral (p=0. 868).

The 5-year metastasis-free rate was 82% in the upper and 69% in the lower extremity (p< 0. 013). Metastasis was predicted by high histological grade (hazard ratio 17. 28, p< 0. 000), tumour size in cm (hazard ratio 1. 05, p< 0. 001) and deep location (hazard ratio 1. 93, p< 0. 028) but not by extremity (p=0. 211).

Local recurrence is more frequent after treatment for upper compared with lower extremity sarcomas. Variation in the use of radiotherapy and differences in histological type may be contributory. Metastasis is more frequent after treatment for lower extremity sarcomas because tumours tend to be large and deep.

The purpose of this retrospective study was to analyze the risk factors, causes, bacteriology of deep infection following extensible endoprosthetic replacement for bone tumours in children and to review our experience in the treatment of 20 patients with infected prostheses.

123 patients with extensible endoprostheses were treated between 1983 and 1998. Three types of prostheses, which differed in the lengthening mechanism used, were implanted. 20 of these were diagnosed to have deep infection. Patients were divided into 3 groups: group I 5 patients were treated with a single stage revision, group 11– 13 patients were treated with a two stage revision procedure, group Ill- 2 patients had a primary amputation. Control of infection was assessed clinically and with inflammatory markers. Function was assessed using the MSTS score.

The overall incidence of infection was 16%. The incidence of infection at the proximal tibia and distal femur was 27% and 14% respectively. Staphylococcus epidermidis was the most common organism. The most common clinical features were pain and swelling around the prostheses. Infection in most cases was immediately preceded by an operative procedure or by distant a focus of infection. The number of operative procedures and the site of the prosthesis were significant risk factors. The success rate was 20% in Group 1 and 84% in Group II. Amputation was the salvage procedure of choice for failed revision procedures. The mean MSTS functional score was 83% in patients in whom the infection was controlled.

The incidence of deep infection is high following extensible endoprostheses. The site of the prosthesis and the number of operative procedures are significant risk factors. The type of prosthesis used is not a risk factor. Two-stage revision is successful in controlling infection in a majority of these cases.

To determine whether the Dynamic Condylar Screw, DCS, is suitable in treating pathological subtrochanteric fractures of the femur and the incidence of failure with this device.

Nineteen sequential and unselected patients with twenty femurs with pathological subtrochanteric fractures, or impending fractures, were identified, which had been treated with DCS. Mean age was seventy. Follow up was until functional union (minimum follow up 18 months) or until death. Primary tumour was identified in seventeen of the nineteen cases.

Grade of surgeon was recorded as was the use of adjunctive measures at the time of surgery (PMMA). Subsequent failure, cause and need for revision was noted.

Operative morbidity was low and initial pain relief good in all cases. Two fractures went on to unite. Eight original implants survived until the patient died (mean survival time 24 days). Ten implants failed (50%). Failure resulted from fracture through the DCS plate in eight cases and cut out of the screw in the other two. Of these, five patients (6 femurs) went on to further operative procedures. The others were either deemed unfit (3 cases) or refused further surgery (1 case).

In the light of newer intramedullary techniques we feel the DCS should be used with caution in this type of fracture. DCS in this fracture is associated with a high degree of failure.

To assess the efficacy of the current surveillance programme for patients with sarcoma we undertook a prospective analysis of all patients with sarcoma treated between 1990 and 1995. The patients routinely enter a surveillance programme which consists of regular clinical evaluation, CXR and radiological imaging.

We reviewed 643 cases of sarcoma with mean follow up 8. 4 years (range 6. 2–11. 3). Local recurrence occurred in 14% of cases and 34% developed metastases. The cumulative survival at 10 years was 59%. 46% of the deaths were directly attributable to metastases.

For the soft tissue sarcomas 15% of the local recurrences were picked up at surveillance appointment and 70% were picked up early by the patient. For the sarcomas of bony origin 36% were picked up at surveillance and 57% were picked up early by the patient.

Pulmonary metastasis was by far the common metastasis with 82% developing these. 78% were identified by surveillance CXR of which 83% were asymptomatic and 34% went on to thoracotomy and metastectomy. Of the other metastases a third were picked up during surveillance and all were symptomatic.

Surveillance programmes have a role in the management of patients with sarcoma, allowing the earlier identification of local recurrence and metastasis. Clinical evaluation and CXR were found to be, in particular, valuable tools, but patient education and open access to clinics is also important.

812 consecutive patients with soft tissue sarcoma of the extremity were studied to compare the characteristics and outcome of patients who had primary amputations and limb preserving surgery.

Patients with primary amputations were more likely to have metastases at presentation, high-grade tumours, larger tumours and were older.

The most frequent indications for primary amputation were tumour excision which would result in inadequate function and large extracompartmental tumours with composite tissue involvement including major vessels, nerves and bone.

The requirement for primary amputation was a poor prognostic factor independent of tumour grade, tumour size and patients’ age.

We present the management and outcome of patients who presented following internal fixation of primary malignant tumours of the femur.

This is a retrospective study of eleven patients. All underwent internal fixation of pathological or impending fractures of the femur in the assumption of metastatic disease, or prior to diagnosis of primary malignancy. Data was collected from database records and case notes.

The mean age was 47 years (range 13 – 73). Six patients were male and five female. Tumour type was osteosarcoma (3), MFH (3), chondrosarcoma (2), Ewing’s sarcoma (1), fibrosarcoma (1) and liposarcoma (1). The site of the lesion was proximal in six cases and distal in five. Nine patients presented initially with pathological fractures and two with lytic lesions. The mode of fixation was DHS (3), AO screws (1), antegrade IM nailing (2), retrograde IM nailing (3), Blade plate (1) and DCS fixation (1). No patients underwent biopsy prior to fixation. Surgical treatment at the Bone Tumour Unit was excision and segmental endoprosthetic replacement (5), total femoral replacement (2), hip disarticulation (2), above knee amputation (1) with one patient dying prior to surgery. Eight patients also received chemotherapy and three radiotherapy. Four patients had local recurrences, three presented with metastatic disease and five more went on to develop metastases. Two patients died within one year of initial surgery, three more within two years and none have so far survived five years. Three patients are still alive.

We believe that internal fixation of primary malignant tumours has a detrimental effect on limb salvage and survival, emphasising the absolute necessity of pre-operative investigation of solitary bone lesions.

This is a retrospective study of 70 patients with chondroblastoma treated between 1973 to 2000. Of these 70 patients, 53 had their primary procedure performed at our unit in the form of an intralesional curettage. The purpose of this study was to determine the rates of recurrence and the functional outcomes following this technique. Factors associated with aggressive tumour behaviour were also analysed. The patients were followed up for at least 22 months, up to a maximum of 27 years. 6 out of these 53 cases (11. 3%) had a histologically proven local recurrence. Three patients underwent a second intralesional curettage procedure and had no further recurrences. Two patients had endoprosthetic replacement of the proximal humerus and one patient underwent a below knee amputation following aggressive local recurrences. One patient had the rare malignant metastatic chondroblastoma and died eventually. The mean MSTS score was 94. 1%. We conclude that meticulous primary intralesional curettage without any additional procedure can achieve low rates of local recurrence and excellent long-term functional results.

To assess whether primary spindle cell sarcomas of bone behave like other primary bone sarcomas.

185 patients with primary spindle cell sarcomas of bone, that is non-osteosarcoma, non-chondrosarcoma and non-Ewings sarcoma of bone, were identified from the patient database of the Orthopaedic Oncology Service in Birmingham, UK. This database contains information on over 10, 000 patients treated in Birmingham since 1970 and collected prospectively since 1986.

Spindle cell sarcomas of bone are primary bone tumours which share the histological spindle shaped cells. They are a heterogeneous group including the cytological diagnoses of malignant fibrous histiocytoma (MFH), spindle cell sarcoma, leiomyosarcoma, fibrosarcoma, angiosarcoma and secondary sarcoma.

119 (64%) of the patients were male. The mean age was 47 years with 116 (63%) older than 40 years. Only 6 patients were low grade and 34 had metastases at presentation. 12 patients developed tumours secondarily to other pathology such as Pagets or radiotherapy. The patient’s limb was affected in 155 (84%) of cases with the distal femur being the most common site.

Treatment was with chemotherapy and surgery where indicated. Chemotherapy was with adriamycin and cis-platin most commonly and was neoadjuvant in 75% of those who had it. Of the 150 patients who had surgery, 113 (75%) had limb salvage.

Overall five year survival was 52 %. Survival in patients who had high grade limb tumours, with no metastases at presentation and which weren’t secondary tumours had a five year survival of 60 %. These results are comparable to previous studies looking at similar tumour groups. Good prognostic factors included treatment since 1980, good response (> 90% necrosis) to neo-adjuvant chemotherapy, limb tumours, age < 40 and local control. 73% of patients with local recurrence died with a mean survival of 11 months. There was no difference in outcome or behaviour between the different diagnoses although prognosis was slightly better than those of aged matched patients with osteosarcoma.

Spindle cell sarcomas of bone respond in a similar way to, if not better than, osteosarcoma when treated in the same way with chemotherapy and surgery. Consequently this should be the preferred method of management.

Current survival rates for cancer in the UK are perceived to be worse than those in mainland Europe. In order to asses this we investigated the prognostic value of patient and treatment parameters in the management of osteosarcoma, and whether these parameters are equally important across international boundaries.

Retrospective, cross-sectional study of patients (n=428) diagnosed with non metastatic distal femur or proximal tibia osteosarcoma, between 1990–1997 at two specialist orthopaedic oncology centres; Birmingham, UK and Bologna, Italy. Disease free survival (DFS) and overall survival (OS) were assessed by Kaplan-Meier, Fisher’s PLSD and Cox proportional hazard regression. Results : DFS and OS were 43% and 60% at 5 years in Centre 1 and 56% and 73% at Centre 2 respectively. Median survival was 108 weeks at Centre 1 and 136 weeks at Centre 2. A significant difference in DFS and OS was demonstrated between the centres (p=0. 0019 and p=0. 0280 respectively). The most important prognosticators were raised alkaline phosphatase (p=0. 002 and p=0. 0019), degree of chemotherapy induced necrosis (p=0. 0001 and p=0. 0002) and tumour volume > 150cm³ (p=0. 0037 and p=0. 0057).

The most significant combination of prognosticators was alkaline phosphatase and tumour necrosis. 75% of patients in centre 2 had a good chemotherapy response (> 90% necrosis) compared to only 29% in Centre 1. The other prognostic indicators were evenly matched. Chemotherapy regime was found to have significantly different outcome in DFS and OS.

This is a retrospective study designed to explore possible reasons for differences in survival between two international centres. It would appear that all known patient factors were matched between the centres but that the main difference was in the effectiveness of chemotherapy. Further international prospective studies are needed to confirm these findings.

Reconstruction of the shoulder joint following resection of the proximal humerus for bone tumours remains controversial. We report the long term functional results of the simplest form of reconstruction – an endoprosthesis.

One hundred patients underwent endoprosthetic replacement of the proximal humerus between 1976 and 1998. Thirty eight had osteosarcoma, 17 had chondrosarcoma, 16 had metastases and 9 had Ewing’s sarcoma. Mean age was 36 years (range 10 to 80 yrs). Survivorship of patients and prostheses were calculated. Function was assessed using the Musculoskeletal tumour society (MSTS) and Toronto extremity salvage (TESS) scoring systems. Thirty patients could come to the clinics for MSTS scoring and 38 out of 49 alive patients replied to the TESS questionnaires sent out to them.

The overall survival of the patients was 42% at 10 years. Local recurrence (LR) arose in 16 patients, being most common in chondrosarcoma (26%) and osteosarcoma (22%) and arose in 50% of patients with these tumours who had marginal excisions. Of these 16 patients, 8 had forequarter amputations whilst the remainder had excisions and radiotherapy. Mean time to LR was 12 months and all but two of these 16 patients subsequently died within a mean of 18 months.

The prostheses proved reliable and dependable. Only 9 required further surgery of any sort, 2 needing minor surgery to correct subluxation and 7 needing revisions, one for infection after radiotherapy and six for loosening – three after trauma. The survivorship of the prosthesis without any further surgery was 86. 5% at 20years. The survivorship of the limb without amputation was 93% at 20 years.

The functional outcome was very predictable. Most patients had only 45 degrees of abduction although three patients had normal movements. The mean MSTS functional score was 79% and the mean TESS score was also 79%. There was a high level of patient satisfaction but difficulty was encountered especially in lifting and in all activities above shoulder height. Endoprosthetic replacement of the proximal humerus is a predictable procedure providing reasonable function of the arm below shoulder height. The endoprostheses have proved highly dependable with a low re-operation rate. There is a high risk of local recurrence after inadequate surgery which should be avoided if possible.

Our centre has used a specially designed custom-made endoprostheses with curved stems to reconstruct femoral defects in patients with residual short proximal femur after excision of primary bone sarcoma over the last 18 years. Two designs of endoprostheses with curved intramedullary stems were used: the rhinohorn stem type and the bifid stem type. We report the safety, survival and functional outcome of this form of reconstruction.

Twenty six patients who had these special endoprosthesis reconstruction were studied. The median age was 16 years (range 7 to 60 years). Prostheses with rhino horn stems were used in 15 patients and bifid-stem in 1 1 patients. Twenty patients had the prostheses inserted as a primary procedure after excision of primary bone sarcoma, and in six patients the prostheses were inserted after revision surgery of failed distal femur endoprostheses. Seventeen patients (65%) were alive and free of disease at a median follow-up of 98 months (12 to 203 months) and nine patients had died of metastatic disease. Local recurrence developed in two patients (1 0%) out of the 20 patients. Surgical complications occurred in five patients (191/o). Deep infections occurred in two patients (8%) requiring revision surgery in one patient. Prosthetic failure, occurred in nine patients (35%). The cumulative survival of prostheses was 69% at five years and 43% at 10 years. Musculoskeletal Tumour Society mean functional score was 83% (53% to 97%).

In conclusion, preservation of a short segment of the proximal femur and the use of endoprostheses with curved stems for reconstruction of the femur is technically possible. There is an increased risk of fracture of the prostheses decreasing the survival rate. Functional outcome of patients with this form of reconstruction is not significantly different from the functional outcome of patients who have proximal femur or total femur endoprosthetic reconstruction. This operation is particularly desirable in skeletally immature patients and allows normal development of the acetabulum.

Endoprosthetic Replacements are one of the most commonly used types of limb salvage following surgical excision of bone tumours. The advantages of Endoprosthetic Replacements are their initial reliability and the rapid restoration of function along with their ready availability. The problems with Endoprosthetic Replacements are the long term problems of wear, loosening, infection and mechanical failure. Increasing and insolvable problems may lead to the necessity for amputation. This paper assesses the risk of amputation following Endoprosthetic Replacement.

A total of 1262 patients have undergone Endoprosthetic Replacement surgery at our centre in the past 34 years. They have a total of 6507 patient years of follow up. A total of 112 patients have had subsequent amputation (8. 9%). The reasons for amputation were local recurrence in 71(64. 4%), infection in 38(33. 9%), mechanical failure in 2(1. 8%) and continued pain in 1 case (0. 8%). The risk of amputation was greatest in the proximal tibia 15. 5% (n=38/246), followed by pelvis 10. 2%(5/49), and femur 7. 4% (n=58/784), whilst the risk of amputation was least in the humerus at 6. 4% (n= 1l/182). The time to amputation varied from 2 days to 16. 3 7 years, with a mean of 31 months. The risk of amputation decreased with time although 10% of the amputations took place more than 5 years after implantation.

The greatest risk of amputation is in the first 5 years and is due to local recurrence, whilst infection poses the next greatest threat. The risk decreases with time. Attempts to control both local recurrence and infection will decrease the need for amputation. Late failure of the endoprosthetic replacements, even in young patients does not seen to be a major cause of amputation thus far.

Between 1975 and 2000, we treated 404 patients with Ewings sarcoma; 350 had osseous and 54 had extraosseous forms. The 5 year survival for osseous was 65%, and for extraosseous, 63%. There was a statistically significant difference in the average age of the 2 groups. However, there was no difference in the prognosis with regard initial blood results, excision margin, response to chemotherapy, or the presence of metastases at diagnosis. The overall rate of metastases was the same in both groups. We would therefore suggest that both osseous and extraosseous Ewings sarcoma are manifestations of the same disease.

Malignant peripheral nerve sheath tumours (MPNSTs) constitute 10% of soft tissue sarcomas. A significant proportion arise in neurofibromatosis type 1 (NF1). Several publications have compared MPNST survival in sporadic and NF1 patients, without consensus on whether NF1 is an independent factor for poor prognosis.

Clinical and histological data from 135 proven MPNSTs were analysed from 2 national centres for soft tissue tumour surgery diagnosed from 1979 to 2000. 129 patients had follow-up data from 6 months to 21 years. 35 were from patients with NF1. Local treatment involved surgery in surgery in 95%, radiotherapy in 44% and chemotherapy in 21%.

NF1 patients were younger than those with sporadic tumours (median age 26 years vs 53 years, p< 0. 001). Overall MPNST survival was almost identical to that in soft tissue sarcomas as a whole, but was worse in NF1 than in sporadic tumours (33% vs 72% at 30 months [p< 0. 01], 17% vs 39% at 60 months, 6% vs 21% at 120 months). A trend towards shorter time to local recurrence was seen in NF1, but not time to metastasis. Superficial tumours gave improved prognosis. Tumour volume over 100ml was associated with worse survival (46% vs 91% at 30 months, p< 0. 02), as was histological grade (80% high grade vs 25% low grade at 60 months, p< 0. 01). In terms of location, a non-significant over-representation of NF1 MPNSTs in the sciatic and brachial plexii was identified.

NF1 and sporadic MPNSTs exhibited no difference in depth or tumour volume profile, although NF1 tended towards higher grade. Analysis of survival in only high grade tumours, however, still resulted in a significant survival disadvantage in NF1 (33% vs 70% at 30 months, p< 0. 01). Removal of brachial and sciatic plexus tumours from analysis did not affect survivorship profiles in NF1 and sporadic MPNSTs.

Grade, volume and tumour depth correlate with survival; only 7 of 45 patients with deep high grade tumours over 100ml volume were observed to survive beyond 2 years. MPNST survival is worse in NF1 than sporadic tumours. Grade, depth, site and volume differences could not explain this disadvantage.

To assess the results of this technique for stabilisation of severe spondylolisthesis, 12 patients with symptomatic severe spondylolisthesis underwent this procedure. The slipped L5 vertebra was stabilized using a hollow medullary screw through the posterior part of the body of S1 into the slipped L5 body, supplemented with pedicle screws into L5 and S1 with posterolateral fusion.

At one year follow-up, all but one patient had improved in leg pain. 2 patients were aware of the prominent pedicle screws. 360° fusion was achieved without any progression of spondylolisthesis. Thus 360° fusion for severe L5-S1 spondylo-listhesis can be achieved effectively using this technique.

This retrospective clinical study describes our experience of the use of growing endoprostheses in children with primary malignant tumours of the proximal femur and analyses the results.

Between 1983 and 1996 we treated nine children with primary bone tumors of the proximal femur by resection and proximal femoral extensible replacements. Outcomes measured were function of the limb using Musculoskeletal Tumor Society score, oncologic outcome, complications and equalization of limb length. Results: Four patients died as a result of pulmonary metastases. The remaining five patients were observed for an average follow-up period of 7. 6 years (range 11–12. 7 years). One patient had a hindquarter amputation for uncontrolled infection. In these five patients we performed an average of 10. 2 operative procedures per patient (range of 3–17 procedures) including 5 lengthening procedures (range of 1–8 procedures) and a mean total extension of 69. 7 mm per patient. Acetabular loosening and hip dislocations were the most frequent complications. Only two patients have not had a revision or a major complication. Despite this, 4 children are alive with a functioning lower limb and a mean Musculoskeletal Tumour Society functional score of 77. 6%. The limb length discrepancy was less than 1 0 mm in three of these patients. The remaining patient has a discrepancy of 50 mm and is awaiting further limb equalization procedures.

Extendible endoprostheses of the proximal femur in selected children is a viable reconstructive procedure. It allows for equalization of limb length and the ability to walk without the use of mobility aids.

34 two-stage revision procedures were carried out between 1989 and 1998 for controlling deep infection following resection of bone tumours and reconstruction with endoprostheses. In 4 cases the procedure failed with early recurrent infection. In six others infection reappeared after further operative procedures. Six of these ten patients required amputation. The success of the procedure in controlling infection was 75% at 5 years. Two stage revision procedures have proved effective in controlling infection in massive endoprostheses but the risk of re-infection appears to be much greater in patients requiring further surgery for any cause.

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.

A prospective study to evaluate the design, outcome and complications of the AcroFlex titanium/polyolefin artificial lumbar disc replacement.

11 subjects with single-level discographically proven discogenic pain of at least six months duration and refractory to conservative treatment underwent Total Disc Replacement (TDR) using the AcroFlex TDR. Surgery was performed by an anterior retroperitoneal approach. The following outcome measures were recorded pre-operatively, at 6 weeks and 3, 6, 12 and 24 months: Visual Analogue Score (VAS), Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), and SF-36. Physical examination and radiological assessment (plain radiographs, flexion/extension views, cine-radiography) were performed at the same time intervals. Complications and reoperations were recorded.

11 patients were enrolled since April 1998 (7 male / 4 female). The mean age was 41. 3 years. All patients have been followed for a minimum of two years.

Surgery averaged 136 minutes with 143 mls blood loss. There were no operative complications. The average length of stay was 6. 1 days. The mean VAS reduced from 8. 8 to 4. 4 at two years. ODI improved from 51. 3 (mean) to 20. 9 (mean) at 24 months. The mean LBOS of 18. 4 improved to 47. 3 at two years.

Patients showed improvement in all subsets of the SF-36. Radiological examination confirmed a mean flexion/extension arc of 6. 6 degrees with restoration of native disc height. Adverse events included one disc expulsion (under radiological observation), one autofusion (F/E views still confirm movement) and one catastrophic rubber failure requiring revision to combined anterior/posterior interbody fusion. As a result of this case all patients underwent ultra fine cut CT scans. An additional 4 cases showed small anterior tears in the rubber and are currently asymptomatic.

The two-year outcome of the AcroFlex TDR is reported in 11 patients. Improvements in VAS, ODI, LBOS and all domains of the SF-36 were reported by 10 of 11 patients. Radiological outcome confirmed preservation of movement and restoration of disc height. Adverse events including disc expulsion, autofusion and rubber failure demand continued vigilance.

Few studies of wound complications following limb salvage surgery for soft tissue sarcomas separate anatomical compartments. Forty-nine patients with adductor compartment sarcomas underwent limb salvage surgery, 43% developing significant wound complications, 25% requiring further surgery and 20% had delays in adjuvant radiotherapy as a result. Prior surgery by non tumour surgeons and previous radiotherapy led to an increased risk of wound healing problems. In this particular group of patients, special attention should be made to prevent wound healing complications, possibly involving plastic surgeons at an earlier stage of management.

The aim of surgery in the treatment of tumours of the distal radius is to achieve satisfactory clearance whilst best preserving function of the hand and wrist. Since 1992 a technique of distal radial tumour excision with reconstruction by autologous free fibula strut grafting has been employed in the treatment of thirteen patients at our unit. The procedure employs fixation of the non-vascularised fibula shaft to the proximal radius by step-cuts and a dynamic compression plate. The fibula head substitutes for the distal limit of the radius and articulates with the carpus.

We have treated 10 cases of primary or recurrent giant cell tumour and cases of osteosarcoma, chondrosarcoma and Ewings’ sarcoma by this technique. The patients were reviewed at a mean of 50 months post surgery, with assessment of their functional outcome and measurement of the range of wrist movement and grip strength.

The patient with Ewings tumour had died of meta-static disease 62 months post grafting. Three patients treated for giant cell tumour had required further surgery, two of these had forearm amputation for malignant transformation. In comparison to the unoperated wrist, range of movement was well preserved. The power of grip strength was 57% of the contralateral wrist and hand.

These results compare well with published rates of recurrence of benign giant cell tumour treated by other methods. This technique would seem to offer an acceptable functional result without compromise of the tumour prognosis.

Recent years have seen the popularization of minimally invasive approaches to the spine.

However, the use of the balloon assisted retroperitoneal approach has not been widely described, moreover there has been no direct comparison between this mini-ALIF (anterior lumbar interbody fusion) and the conventional open method in the literature.

Comparison of peri and intra-operative parameters between the rnini-ALIF (using the balloon assisted dissector and Synframe retractor system) and the open midline approach for single and double level anterior lumbar interbody fusions in order to assess the efficacy of this procedure.

An independent retrospective evaluation of 35 patients who underwent single or double level ALIF under the care of the senior author at the University Hospital, Nottingham during the period from 1997 to 2000. The patients were split between those undergoing a mini-ALIF (balloon assisted retroperitoneal dissection) or the conventional approach via a larger midline incision. The groups were matched for age, sex and number of levels. Data was collated from the medical notes with regards to intra-operative blood loss, operative time, intra-operative complications, PCA requirements, time to mobilisation and length of hospital stay.

A statistically significant (p=0. 01) reduction in time to mobilisation (mean 2. 1 days vs 3. 9 days) and operative time (mean 175mins vs 265mins) was found for the single level mini-ALIF. This reflects the greater number of L5/SI fusions in this group. The number of vascular injuries was also greater in the approach to L4/5.

No difference was found between the two groups for double level procedures.

The immediate advantages of a less invasive approach both to the patient and hospital do not appear to be borne out by this study. Cosmesis was not assessed and the long term functional outcome awaits later confirmation.

Pedicle screws allow for biomechanically secure fixation of the spine. However if they are misplaced they may effect the strength of the fixation, damage nerve roots or compromise the spinal cord. For these reasons image guidance systems have been developed to help with the accuracy of screw placement. The accuracy of pedicle screw placement outside the lumbar spine is not well published. To determine the accuracy of pedicle screw placement using CT scanning post operatively. Cortex perforations were graded in 2mm steps.

Prospective observational study. Plain x-rays are inaccurate for determining screw placement and therefore high definition CT scanning was used. The screw positioning on the post-operative CT scans was independently determined by a research registrar who was not present at the time of surgery. Screw position and clinical sequelae of any malposition.

Thirty patients (13 F:17 M) with segmental instability. Twelve were for metastatic disease, seven for trauma, seven for spondylolisthesis, three for atlanto-axial instability and one for a vertebral haemangioma. All patients were operated on by the senior author.

One hundred and seventy six pedicle screws were inserted in the thirty patients over the 20 month study period. Six screws violated the lateral cortex of the pedicle but none perforated the medial cortex. There were no adverse neurological sequelae.

The findings from this study will serve as a good comparison with future studies on pedicle screw placement, which may claim to improve accuracy and safety by the use of image guidance systems, electrical impedance or malleable endoscopes.

Limb Salvage surgery is the preferred treatment for malignant tumours of bone. This may require resection – arthrodesis, endoprosthetic replacement or allograft reconstruction.

We have re-implanted the patient’s bone for reconstruction of the defect after debulking the tumour and irradiation in ten patients. All had grade IIB sarcomas of the pelvis, humerus, tibia and metacarpal.

Median overall survival was 24 months (maximum 69 months). Four patients are alive at the most recent follow-up. One of them has metastatic disease and local recurrence while others remain free of disease. One patient has had pathological fracture through the irradiated bone that healed with conservative measures. One developed avascular necrosis of the femoral head and required resurfacing arthroplasty of the hip.

The pelvic sarcoma continues to be a challenge. Resection, extracorporal irradiation and re-implantation may offer some hope but remain experimental.

To quantify the expected shortage of Orthopaedic Specialist Registrars (SpRs) planning careers in Spinal Surgery with one third of Specialist Spinal Surgeons due to retire in the next 3 years and to provide the needed expansion of 25% in the existing number of 175 surgeons.

A postal survey of the 528 SpRs was performed with a response rate of 71%. The critical question was the post accreditation intention as either a Specialist Spinal Surgeon (greater than 70% of elective work), as a Surgeon with an Interest in Spinal Surgery (more than 30% of elective work), a surgeon doing occasional Spinal Surgery (less than 30% of elective work) or one who avoids all Spinal Surgery. This attitude could then be taken into account when analysing the training provided and the perceptions of Spinal Surgery to identify factors which could be discouraging an interest in Spinal Surgery.

Sixty nine percent indicated that they intended to avoid all Spinal Surgery. Thirty five (9%) intended becoming either Specialist Spinal Surgeons or Surgeons with a Spinal Interest but only 9 (2%) are in their final two years of training. The declared intention to avoid Spinal Surgery increases from 54% in the first 2 years of training, to 70% in the middle 2 years, and to 75% in the final 2 years and post CCST fellowships. Based on a projection of the 4. 3% response intending to become Specialist Spinal Surgeons there will be a shortfall of 34 Specialist Spinal Surgeons by 2005.

The features of Spinal Surgery which appear to have a negative affect and overwhelm the potentially attractive features are badly organised clinics; the perceived psychological complications of spinal patients; and a perceived inadequate exposure to spinal surgery during SpR training.

The modification of training programmes so that all SpRs are exposed to Spinal Surgery in the formative first three years; properly structured spinal clinics; and a need for Spinal Surgeons to be encouraging and enthusiastic about this field of surgery are essential.

A retrospective review, comparing outcome following circumferential versus anterior decompression and fusion for patients with cervical spondylotic myelopathy (CSM).

To assess the safety and efficacy of the circumferential operation for CSM.

Cervical spondylotic myelopathy has traditionally been managed by anterior or posterior decompression with/ without fusion. However, there is a considerable variation in neurological recovery and clinical outcome following these procedures. While circumferential decompression and fusion has been shown to provide superior neurological outcome in selected patients with cervical trauma and tumours, its role in the management of CSM has yet to be clearly defined.

Fifteen patients who underwent a 360° operation (Groupl) for CSM were matched (age, number of levels operated and follow-up duration) with patients (Group 2, n=15), that underwent anterior decompression and fusion for the same problem. All patients were operated by a single surgeon and reviewed independently. Charts, radiographs, patient interviews and MODEMS Cervical Spine Outcome questionnaires were the basis for assessment.

The operative time, blood loss, in-hospital stay and post-operative complications were higher in group l. The pseudoarthrosis rate was comparable though a trend towards increased graft and hardware problems was noted in group 2. Neurological improvement as measured by the mJOA Myelopathy Scale was significantly better (p = 0. 039) in group 1. 87% of those in group1 and 67% in group 2 showed improved function. Patients in group1 also performed better (p=0. 056) in the neurological domain and treatment expectation scales of the cervical spine questionnaire, though the incidence of post-op, neck pain was higher.

Single stage circumferential spinal decompression and fusion permits consistent neurological recovery in selected patients with cervical spondylotic myelopathy and it can be performed with limited morbidity.

To evaluate large/Jumbo acetabular cups in revision surgery, 52 cups in 48 patients were reviewed; mean age was 71. 6 years and mean follow up 6 years.

Average Harris Hip Score was 85. Excellent bony incorporation was seen in all but the failures, of which there were three, 1 due to infection and 2 due to aseptic loosening. Major complications included 2 intraoperative fractures.

Intermediate results of acetabular revisions, using large cups, without bone grafting are encouraging.

A province-wide study designed to use administrative data to determine the rate of post-operative complications, the survival duration and predictors of outcome among patients undergoing surgery for metastatic disease of the spine.

Surgery for patients with spinal metastasis is primarily palliative. It is often fraught with complications, which may in fact diminish quality of life. Quantification of survival rates and the risk of potential complications following surgery is important to the clinician and the patient’s families for decision making.

All patients that underwent surgery for spinal metastasis between 1991 and 1998 were identified using the Ontario health insurance database and a hospital discharge registry.

The mean age at surgery was 60. 3 years (range: 13–92 years). The mortality files identified patients who were dead by October 1999. Information about individual inpatient admissions including post-operative complications was then collected. The survival rates and complications following surgery were quantified and the effect of several variables on these two parameters was computed.

The median and mean survival was 227 days and 793. 4 days respectively. The 30-day and 3-month mortality were 9% and 29% respectively. Advanced age at surgery, male sex, presence of a pre-operative neurological deficit and primary cancers of lung, gastrointestinal tract & melanoma are predictive of poor survival. 39% patients had complications. Pre-operative neurological deficit was associated with a 71% higher risk of developing post-op. wound infection.

In the past, surgery has been recommended in patients with an anticipated survival of at least three to six months. The current study shows that even patients preselected on the basis of predictions of longer survival, there is a potential for early mortality and significant complications. Hence, a careful estimation of the benefits of surgery versus surgery related morbidity must be made prior to offering surgery for palliation.

The aim of this study was to determine the medium term survivorship and function of the cemented Exeter Universal Hip Replacement when used in younger patients.

Since 1988 The Exeter Hip Research Unit has prospectively gathered data on all patients who have had total hip replacements at the Princess Elizabeth Orthopaedic Hospital.

There were 88 Exeter Universal total hip replacements (THR) in 71 patients who were 50 years or younger at the time of surgery and whose surgery was performed at least 10 years before. 25 surgeons performed the surgery. Mean age at surgery was 43 years (range 24 to 50 years. ) 5 patients who had 7 THRs had died leaving 81 THRs for review. Patients were reviewed in clinic at an average of 11. 4 years (10 – 13 years). No patient was lost to follow up.

At review, 8 hips had been revised. 5 cases were for loose cemented metal backed acetabular prosthesis. Two femoral components were revised for infection and one for aseptic loosening. Radiographs showed that a further 10 (13%) acetabular prosthesis were loose and that 3 femurs showed significant osteolysis. Overall 10-year survivorship of stem and cup from all causes was 93%. The 10-year survivorship of stem only from all causes was 98% and from aseptic loosening was 99%.

The Exeter Universal Stem performs extremely well in the younger patient. However the high failure rate of the cemented metal backed Exeter acetabular component has compromised the overall results in this series.

Radio-pacifiers in bone cements are an accepted part of every-day practice. They have, however, been shown to be a potential cause of an increase in third body wear and to excite bone resorption in vitro and in vivo studies.

We reviewed the results of 228 consecutive Stanmore Total Hip Replacements performed between 1981 and 1985 in 211 patients. All were inserted with radiolucent bone cement. Information regarding whether the prosthesis had been revised was available for all patients. 73 patients (83 hips) were still alive and 41 patients (44 hips) were sufficiently healthy to attend clinic. Information regarding pain level was obtained from the remaining 32 patients. When revision of the implant was taken as the end-point, there was 95% ten-year survival, 91% fifteen-year survival and 75% eighteen-year survival. These long-term results of Stanmore THRs, performed in a district general hospital, with radiolucent bone cement, compare favourably with the other published series for this implant. We did not find the inability to see the bone cement a particular disadvantage when reviewing x-rays for signs of loosening.

We found the ABG cementless hip has excessive acetabular wear and premature failure due to osteolysis.

In 60 patients implanted at mean age 56 years, 66 hips (mean follow up 48 months), 7 were revised and 7 have severe acetabular osteolysis. In some this is entirely asymptomatic. There was significant association with osteolysis, length of follow up and wear but no correlation between wear and acetabular component position, age, liner thickness, and use of ceramic or CoCr heads.

We recommend regular lifelong radiological review of these hips and suspension of use of this prosthesis until a wider review is undertaken.

To compare hallux valgus surgery performed by orthopaedic surgeons and podiatrists within the same Health Authority, a consecutive series of 50 patients operated on within the orthopaedic department for hallux valgus was compared with a group operated on by the podiatry surgeons within the same time period.

This retrospective study was performed by analysis of the case notes and radiographs. Data was collected on patient age, sex, comorbidity, anaesthetic, surgery, surgeon grade, post-operative rehabilitation and complications. Pre and post operative hallux valgus and intermetatarsal angles were measured.

Patient demographics showed no significant difference between the 2 groups. All but one patient in the orthopaedic group had a general anaesthetic whilst regional anaesthesia (ankle block) performed by the operating surgeon was used in all cases in the podiatry group.

There were 4 different operations in the orthopaedic group (Mitchells, Chevron, bunionectomy, Wilsons) compared with 2 in the podiatry group (Scarf, Kellers). Pre-operative radiological measurements revealed comparable groups with the correction obtained better in the podiatry group (HV angle 15° vs 10°; IM angle 7° vs 4°).

There were 13 complications in the podiatry group compared with 8 in the orthopaedic group.

9 patients in the podiatry group underwent re-operation to remove metalwork whilst no patients in the orthopaedic group required further surgery.

Within our region, orthopaedic and podiatry surgeons operate on the same type of patients with hallux valgus in respect to age, sex, comorbidity and radiological abnormality. There is marked difference in the anaesthetic techniques used. Correction obtained in the podiatry group was slightly better but at the expense of a higher complication and re-operation rate.

It has been well documented that leg length discrepancy can be associated with back, knee and hip problems. Less is known about the effect on the foot. The effect of a simulated leg length discrepancy on foot loading patterns and gait cycle times in normal individuals was investigated.

Thirty feet of normal volunteers were evaluated using a ‘Musgrave Footprint Computerised Pedobarograph System’. Leg length discrepancy was simulated using flexible polyurethane soles of 1 to 5cm thickness, secured to the sole of a sandal worn on the opposite foot. Recordings of foot pressures and load were made barefoot (control) and then recordings were taken with simulated leg length discrepancies of 1 to 5cm. As leg length discrepancy increased, the total loading on the foot increased from 35. 31 to 37. 99 kg/cm²/sec, the forefoot loading increased from 15. 58 to 19 kg/cm²/sec, whereas hindfoot loading remained the same. Further analysis of forefoot loading revealed that all subjects except for female middle loaders demonstrated increased hallux loading as the leg length discrepancy increased (p< 0. 0001). Analysis of gait cycle time with increasing leg length discrepancy showed that the contact phase of gait decreased from a mean of 22% to 13% (p< 0. 0001), the midstance phase remained the same, whereas the propulsion phase increased from 44% to 50% (p< 0. 003).

This study demonstrates for the first time that leg length discrepancy has manifest changes in the foot. When prescribing orthotics to address leg length discrepancy, orthopaedic surgeons should consider attempts to relieve the increased pressure on the 2nd and 3d metatarsal heads, or incorporate a metatarsal bar to decrease the time of metatarsal loading.

The purpose of our study was to find out the midterm results of the Müller acetabular roof reinforcement ring in primary and revision total hip arthroplasty. From 1988 to 1998, 48 total hip arthroplasties using the acetabular roof reinforcement ring (39 patients) was performed by one surgeon (PDB).

We reviewed all patients who had a minimum of five year follow up. There were 37 hips (31 patients) with a mean follow up of 7 years (5 to 12 years). Acetabular deficiencies were classified according to the AAOS classification. Acetabular reconstruction was done using the Müller acetabular roof reinforcement ring with the polyethylene cup cemented to the ring, and morcellized cancellous bone graft. Müller straight stem femoral prosthesis was used in all cases for femoral reconstruction. All patients were followed up annually and outcome assessed using Harris hip score. There were 27 primary procedures and 10 revisions. 30 patients (81%) had cavitary, 2 (5%) had segmental and 5 (14%) had combined defects.

Survival analysis was done with failure defined as radiological evidence of loosening of the acetabular component. Statistical analysis was done using SPSS for Windows (SPSS Inc, Chicago, Illinois). 5 patients died due to unrelated causes and 2 patients were lost for follow up. The mean Harris hip score improved from 42 preoperatively to 82 postoperatively (p< 0. 001)(Wilcoxon Signed Rank test). Both mean pain and function score showed improvement from 12 to 39 postoperatively (p< 0. 001) and 12 to 32 (p< 0. 001) respectively. 5 patients had radiological loosening of the ring. The migration rate was 13%. The cumulative survival rate at 12 years, excluding all patients who died and were lost for follow up, was 79. 3% (95% confidence interval 71. 4 to 87. 2, standard error 4). There was no statistical difference in the failure rate between primary and revision procedures (chi-square test). This series show satisfactory medium term results with Müller roof reinforcement ring and cancellous bone graft in acetabular deficiencies with poor bone stock.

Thirty patients who had 34 Bio-Action Great Toe Implants (four bilateral replacements) for symptomatic advanced degenerative changes in the first metatarso-phalangeal joint (MTPJ) were followed prospectively for an average period of 20. 7 months (range 8–32 months).

The age range of patients was between 38 and 72 years with mean age 55. 8 years. Majority of patients had either a Hallux rigidus (19/34 replacements, 56%) or hallux valgus with severe degenerative changes in first MTP joint (9/34 replacements, 26%). The scoring system designed by Kitaoka et al for the American Foot and Ankle Society, was adopted to assess the functional results. Patient satisfaction, length of stay, time to return to routine activities, footwear problems, x-ray appearances and complications were all assessed.

There was a statistically significant improvement in the range of motion achieved and Hallux MTP scale after the operation. (Paired samples test was significant at 5 percent level). There was a positive correlation between the patients’ satisfaction and Hallux MTP scale. However, there was no correlation between patients’ age and patients’ satisfaction. Similarly, there was no correlation between patients’ age and post operative Hallux MTP scale score. (Pearson’s correlation coefficients). There is statistically significant improvement in life style, foot wear requirements and functional abilities after the operation. The complications includedmetatarsal fracture during operation (l/34 replacements) in one case, four cases of superficial infection which resolved completely with a course of antibiotic and one case of aseptic loosening of the implant which was revised to a cemented implant. Two out of 34 replacements reported sustained transference metatarsalgia beyond 6 months post operatively. 72% of patients (24/34 replacements) considered the result of the operation to be excellent or good. Overall, the early functional results of this total joint system appeared to be satisfactory.

The operation of Keller’s arthroplasty for hallux valgus associated with arthritis appears to have fallen from favour. It is pertinent therefore to review the long-term results in patients treated by one consultant orthopaedic surgeon using a standardised technique.

We were able to locate 30 patients (47 feet). Four were male and 26 female, and the age at surgery was 20–74 years (mean 65). Follow-up was from 7–22 years (mean 13). All patients were recalled for clinical evaluation, recording history of symptoms in the feet, need for further surgery, and presence of deformity. Clinical rating on the American Orthopaedic Foot and Ankle Society score for the hallux was determined. Pedobarographs (Musgrave) were recorded and radiographs taken of symptomatic feet.

27 patients (43 feet) were either very satisfied or satisfied with the outcome of surgery. The mean AOFAS score was 80 (range 49–100). Three patients (4 feet) were dissatisfied because of floppy toe (1), or elevated toe with metatarsalgia (2). Pedobarograph and radiographic findings will be presented.

We found Keller’s arthroplasty to be a reliable procedure in the management of hallux valgus associated with arthritis. Satisfactory results in the long term were obtained in 90% of patients. We believe attention to detail in the performance of the procedure to be important.

We would like to acknowledge that patients studied in this review were treated under the care of Mr GD Stainsby.

The SCARF osteotomy is a three dimentional osteotomy for hallux valgus. It combines a lateral release of the adductor hallucis with a lateral and plantar displacement of the first metatarsal. The osteotomy is ‘z’ shaped in the lateral view and displacement of the distal fragment is followed by internal fixation.

In this study we set out to determine whether the SCARF osteotomy was an effective method in the correction of moderate to severe hallux valgus deformity. A prospective radiographic study was performed on 22 cases of SCARF osteotomy with an average age of 52 years (range 25–78). Standardised weight bearing anterior-posterior radiographs were taken preoperatively and at six months post operatively.

The American Foot and Ankle Society guidelines were used for all measurements. Measurements were made using overlay acetate sheets to minimise inter and intra observer error.

These were compared to determine changes in the intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA) and joint congruency angle (JCA). Correction of sesamoid position and metatarsal length changes were also assessed.

The results showed a median reduction of IMA of 6 degrees, HVA of 16 degrees, DMAA of 6 degrees and an improvement in JCA of 11 degrees. Improvement of the lateral sesamoid displacement from beneath the first metatarsal head was seen postoperatively. Metatarsal length was assessed by comparing the ratio of the length of the first to second metatarsal pre and post operatively. No shortening was found. There was no incidence of avascular necrosis or non-union. This study indicates that the SCARF osteotomy produces effective radiological correction of hallux valgus where there is moderate to high degree of deformity. It also improves sesamoid displacement and avoids shortening of the first metatarsal.

To study the admissions to a busy trauma unit on a day by day basis over a one year period, and to look for any correlation with local weather variation or temporal factors (day of the week, week-ends/school holidays etc. )

Admissions data for the Trauma Unit at the Leicester Royal Infirmary was collected for the calendar year of 1998. On a day-by-day basis, admissions were split into four groups: all admissions, adult admissions, admissions for fractured neck of femur (NOF) and paediatric admissions. Weather information for the local area was obtained from the Met. Office.

Details of school holidays were obtained from the local Education Department.

A number of climatic and temporal variables were examined using Poisson regression analysis for their potential importance in explaining day-to-day variation in admission rates for the four groups.

For adult and NOF admissions, none of the weather factors appeared to explain variation in incidence. For total and paediatric admissions, a number of factors appear important, with the daily maximum temperature being the single most important using univariate analysis.

Total trauma admissions increase on hot days; this is mainly due to an increase in paediatric admissions. Interestingly, there are more adult admissions in the early part of the week than later in the week. The implication is that a hot Monday will be a very busy day. The reasons for this will be explored.

Os calcis fracture patterns in ten children (mean age 12. 8) with eleven fractures were classified using plain films and CT scans and found to be similar to those in adults.

All except two of the fractures (which were not significantly displaced) were treated with open reduction and internal fixation. In all cases it was possible to achieve anatomic reduction and rigid internal fixation. Eight patients had ‘excellent’ long-term clinical results.

One patient with a court case pending scored ‘good’, and one patient with an ipsilateral talar neck fracture scored ‘fair’. This patient had mildly limited ankle movement; all others had full ankle movement. Six had full subtalar movement, in 2 it was mildly limited and in three it was moderately limited (50–80%). There was no evidence of abnormality of the physes on follow up x-rays. We conclude that operative treatment of these fractures yields optimal results.

The aim of this study was to evaluate the early results and complications of internal fixation for displaced fractures of the talar neck.

A retrospective review was undertaken of displaced talar neck fractures. 35 patients had open reduction and lag screw fixation during a 16-year period. All patients were followed with serial radiographs for at least three years.

There were 25 males and 10 females with a mean age of 31 years (range 15–61 years). The most common mechanism of injury was fall from height (n=13) and motor vehicle accidents (n=l1). There was one bilateral fracture. Ipsilateral ankle fractures occurred in 5 patients (14%) and 8 patients (23%) had multiple injuries. There were 31 Hawkins’ type II fractures and 5 Hawkins’ type III fractures. 25 patients (71%) had no complications as a result of their injuries or surgery. All fractures united within 6 months. There was one deep infection (3%) in a IIIB open fracture that required early amputation. 8 patients developed avascular necrosis: 6 Hawkins’ type II fractures (19%) and 2 Hawkins’ type III fractures (40%). Avascular necrosis was more common if surgery was delayed beyond 24 hours but this may reflect the severity of injury rather than the timing of surgery. The outcome following avascular necrosis was poor in general and 5 patients (63%) required hindfoot fusion.

Talar neck fractures are rare. This is the first study from the UK to evaluate this injury and it is the first to look specifically at one method of operative treatment. In general, the early results were good with only 1 deep infection (3%) and all fractures united following lag screw fixation. Avascular necrosis remains the most common complication but, compared with other studies, we report low rates of this problem.

Good results can be obtained following lag screw fixation of displaced talar neck fractures. The complication rate is low but avascular necrosis remains a serious problem.

This paper describes the outcome of type III pilon fractures of the distal tibia treated primarily with an Ilizarov ring fixator.

Only patients with an intra-articular fracture of the tibial plafond on plainradiographs that corresponded to type III pattern with the system of Rfiedi andAllgower were included.

There were thirteen patients with a mean age of 45 (range 29–65), twelve males and one female. The mechanism of injury in all the patients was high-speed road traffic accident.

Operative fixation consisted of fracture reduction and stabilisation using the llizarov circular frame external fixator and olive tipped wires. Further insult to the already damaged soft tissues was avoided.

Bony union was achieved in all cases. Treatment in the frame lasted between 3 and 10 months (average 6. 3 months). Neither deep infection nor soft tissue complications occurred.

Outcome measurements included the Olerud ankle score, modified Ovadia and Beals radiological criteria, and the SF-36 Health Questionnaire.

Wound and deep infections were successfully avoided and bony union was achieved in all our patients. This compares well with other fixation techniques. The use of the llizarov circular frame external fixator without any additional internal reduction or fixation procedures is a definite option for the treatment of these high-energy injuries.

A 5 year review into the workload and subsequent financial implications of pelvic and acetabular reconstruction at a regional tertiary referral centre.

To ascertain the level and means of financial recompense for performing pelvic/acetabular reconstruction on patients from other healthcare trusts at a tertiary referral centre.

The records of all 120 patients who underwent either pelvic or acetabular reconstruction between 1995–2000 were examined. Epidemiological data and information on all possible costs of their stay was accumulated (itemised finance department figures were used).

The individual patient billing system of ECRs (Extra Contractual Referrals) was changed in 1998 and replaced by the OATs system (Out of Area Treatments) whereby an annual lump sum was received based on historic referral patterns. We investigated the financial effects that occurred.

60 out of 120 patients treated, were from other health-care trusts. From 1995–1998, 25 ECR patients were treated at an estimated cost of £480, 000. The trust received £280, 000, a net loss of £200, 000. From 1998–2000, 34 OATS patients were treated at an estimated cost of £650, 000, amounting to a net gain of £1. 15 million pounds.

‘Out of area’ referrals for pelvic and acetabular reconstruction have increased by 50 % in the last 2 years. However the new payment system i. e. OATS has resulted in the tertiary referral centre being generously rewarded, unlike prior to 1998 and the old ECR system. It is therefore recommended that annual review must be carried out to ensure that funding will meet the demand for specialist services in the future and prevent subsidisation of some centres by other trusts.

Proximal femoral fractures have always been in the centre of attention in terms of their demand on the manpower and resources of the NHS. With an ageing population, the number of these fractures will continue to be a big part of the workload of all the Orthopaedic and rehabilitation units. Hence it is important to be aware of any definite variation in the incidence of proximal femoral fractures for appropriate planning of the available resources.

We carried out a study to find out whether there is a definite variation in the incidence of these fractures. The number of operated proximal femoral fractures across 31 hospitals of North-west England and Scotland were collected on a monthly basis from 1994 to 1999. This database of 27, 000 operated proximal femoral fractures was assessed statistically.

Our analysis reveals that the incidence of these fractures during December is about 17% higher than the rest of the annual mean with a 2% standard error of the mean (SEM) and in January this increase is about 22% with an SEM of 1%. These trend and pattern were observed for both intra and extra capsular fractures of neck of femur and was consistent over the five years. There was no other significant change in the incidence pattern during other months of the year.

This study, one of the largest of its kind ever carried out in Britain, proves that there is an increase in the incidence of hip fractures in the months of December and January. There should be appropriate allocation of manpower and rehabilitation facilities along with a matching reduction in the elective Orthopaedic admissions during the months of December and January to tackle this seasonal variation.

Blood is a costly commodity with side-effects that can be avoided by eliminating unnecessary transfusion. The purpose of this study was to prospectively audit the amount of blood we were transfusing in elective joint surgery and to then institute a new, more scientifically based post-operative protocol to see if we could reduce our transfusion requirements.

We prospectively audited 79 patients undergoing primary knee or hip arthroplasty (38 knees and 41 hips) in our unit and found that 66% (58% of knees and 73% of hips) had at least one unit of blood transfused postoperatively, with a mean transfusion requirement of 1. 3 units per patient (1. 1 for knees, range 0–6; 1. 5 for hips, range 0–4).

We then devised a new protocol for post-operative blood transfusion. This new protocol requires the calculation of the volume of blood that each individual patient can safely lose (maximum allowable blood loss – MABL) based upon their weight and pre-operative haematological indices. Total blood loss up to this volume is replaced with colloid. In the first 24 hours, if a patient’s total blood loss reaches their MABL they have their haematocrit measured at the bedside using the Microspin™ system. If their haematocrit is low (< 0. 30 for males, < 0. 27 for females) they are transfused blood. We set our ‘transfusion trigger’ after the first 24 hours at 8. 5 g/dl. Blood is transfused if the formal haemoglobin check on days 1, 2 or 3 is less than this.

We conducted a further audit of 82 patients (35 knees, 47 hips) following the institution of this protocol. Under the new protocol only 24% of patients required blood (11 % of knees, 34% of hips) with a mean transfusion requirement of 0. 56 units per patient (0. 26 for knees, range 0–4; 0. 79 for hips, range 0–4).

The use of clinical audit and the institution of strict guidelines for transfusion can effectively change transfusion practice and result in the delivery of improved patient care. Our transfusion protocol is a simple and effective method of keeping blood transfusion to a minimum and is particularly useful in a unit that does not have the facility to use autologous blood or re-infusion drains for elective orthopaedic surgery.

The aim of this study was to assess the outcome of patients who underwent ElmslieTrillat antero-medial tibial tubercle transfer for treatment of persistent symptomatic anterior knee pain due to chondromalacia patellae.

We performed a prospective analysis of 23 patients who underwent Elmslie-Trillat antero-medial tibial tubercle transfers over a five year period for chronic anterior knee pain and an arthroscopic diagnosis of chondromalacia patellae. All patients who presented with anterior knee pain underwent an initial period of physiotherapy and all patients whose symptoms persisted following physiotherapy underwent arthroscopic assessment. Patients who continued to experience debilitating symptoms despite this initial treatment and who also had a diagnosis of chondromalacia patellae from arthroscopic assessment were listed for an Elmslie-Trillat tibial tubercle anteromedialisation. Patients who gave a history of instability or dislocation were excluded. The average age of patients undergoing surgery was 34 years (21–48 years) and the average time between arthroscopic diagnosis and surgery was 14 months. All patients who underwent surgery had pre and post operative KuJala patellofemoral scoring. The average pre-operative score was 54 (30–78) and post operative score 76 (46–100). The average post operative assessment was 25 months (6–62 months). Twenty one patients had improved post operative scores with one having a worse score and one score remaining unchanged following surgery. Nineteen patients felt that their symptoms had improved, three felt that there had been no change and one felt that they were worse after surgery. When asked if the improvement in symptoms had been worthwhile nineteen stated that they would undergo surgery again if in the same situation and four stated that they would not.

The treatment of symptomatic chondromalacia patellae remains a challenge. Although a more selective approach to individuals with anterior knee pain is widely advocated in the literature this study demonstrates that good results can still be achieved in patients treated empirically with a tibial tubercle anteromedialisation.

The clinical results of carbon matrix support prostheses for treatment of articular cartilage defects of the femoral condyle and patella were assessed in 97 patients (100 prostheses) between 1989–99. Patients were independently reviewed by subjective and objective criteria. Pre-operative and current visual analogue scores for pain (VAPS); Stanmore and modified Cincinnati functional rating scores were obtained. Forty-nine patients had lesions of the patella, forty-four patients of the medial femoral condyle and seven patients of the lateral femoral condyle.

Patella group – subjectively 49% reported they were improved, 8% unchanged and 43% worse. Stanmore score: 6 excellent and 17 good (47%), 5 fair and 21 were poor. The Cincinnati score increased from 26. 5 pre-operatively to 47. 5 currently (p< 0. 001). The mean VAPS decreased from 8. 1 to 5. 0 (p< 0. 001).

Medial femoral condyle group – subjectively 60% reported they were improved, 14% unchanged and 26% worse. Stanmore score: 8 excellent and 16 good (55%), 8 fair and 12 poor. The Cincinnati score increased from 22. 3 pre-operatively to 48. 5 currently (p< 0. 001). The mean VAPS decreased from 8. 6 to 5. 1 (p< 0. 001).

Lateral femoral condyle group – subjectively 42% reported they were improved, 29% unchanged and 29% worse.

Stanmore score: 2 excellent and 1 good (43%), 2 fair and 2 poor. The Cincinnati score increased from 35. 0 pre-operatively to 52. 0 currently (p< 0. 25). The mean VAPS decreased from 6. 5 to 4. 0 (p< 0. 25).

There were no statistical differences in outcome based upon gender, site, pre-operative functional rating score, diagnosis, or any correlation with age or length of follow up, or when comparing excellent/good with fair/ poor subgroups in patellae or femoral condyles in relation to these variables.

This study demonstrated that 49% improved in the patella group, 60% in the medial femoral condyle and 43% in the lateral femoral condyle groups. The use of these prostheses was effective on the medial femoral condyle for periods up to 10 years but the use in the patella and lateral femoral condyle was less successful.

This study aimed to evaluate the effect of using ICPs (Integrated Care Pathways) on the outcome of TKA.

Prospective data was collected from 429 patients (130 from 2 sites that use 1CPs and 299 from 4 sites that did not). Pre-operatively and at 12 months an independent researcher performed a clinical knee examination and patients completed WOMAC and SF-36 questionnaires. At 12 months patients answered additional questions on satisfaction with outcome. The follow-up rate was 86%.

The median length of stay (LOS) in the ICP group was 9 days compared with 12 in the non-ICP group (p < 0. 001). After adjusting for other significant variables, ICP site was shown to be the most significant factor in shorter LOS (p < 0. 001). Following discharge, 78% of the ICP group and 47% of the non-ICP group received outpatient physiotherapy (p < 0. 001). Logistic regression analysis showed that the ICP group were 4 times more likely to receive outpatient physiotherapy (odds ratio = 4. 35, p < 0. 001). After adjusting for other significant variables and baseline values, at 12 months the ICP group had significantly less pain (p = 0. 041) and significantly better function (p < 0. 00 1) than the non-ICP group. There was no difference in the number of postoperative orthopaedic complications (p = 0. 64). At 12 months, 83% of the ICP group were very satisfied with their surgery compared to 70% of the non-ICP group (p = 0. 009). Logistic regression showed that the ICP group were over twice as likely to be very satisfied with their outcome at 12 months (odds ratio = 2. 27, p = 0. 029).

These results indicate that ICPs can result in shorter LOS without compromising outcome although use of outpatient physiotherapy was increased. In addition ICPs appear to result in greater patient satisfaction.

In Ireland and the United Kingdom, there were 22 deaths as a direct result of blood transfusion during the period October 1996 to September 1998. Added to this there were 366 complications directly related to blood transfusion. With the introduction of a Haemovigilance Nurse and changing surgical personnel we were anxious to review transfusion rates in our Regional Orthopaedic Centre for the period January 1999 to July 2000.

All patients undergoing primary or revision arthroplasty in our Regional Orthopaedic Unit during the study period were reviewed. 459 primary or revision arthroplasties were performed in the study period.

Prior to the introduction of a Haemovigilance Nurse, transfusion rates for primary arthroplasties averaged 1. 41 units/patient, with 74% of patients being transfused. After the introduction, transfusion rates averaged 0. 51 units/patient, with 31% of patients being transfused.

Prior to the introduction of a Haemovigilance Nurse revision arthroplasties averaged 2. 5 units/patient, with 100% of patients being transfused. After the introduction transfusion rates averaged 1. 2 units/patient, with 62% of patients being transfused. There was a statistically significant difference between transfusion rates prior to and post the introduction of a Haemovigilance Nurse (p< 0. 005).

In the current climate post the Finlay Tribunal in Ire-land and the resultant increased public awareness, transfusing a patient without justifiable cause is no longer acceptable. Patients in this Unit are now transfused according to clinical needs and accurate measurement of intra-operative and post-operative blood loss, compared to their calculated maximum allowed blood loss (MABL). Our new transfusion protocol is working well without compromising patient care.

An audit of general practitioner (GP) Paediatric orthopaedic referrals to our hospital (1996) revealed that the average waiting time was 84 weeks for non-urgent simple conditions. A physiotherapy specialist clinic was set up to reduce waiting times for non-urgent, new general practitioner Paediatric Orthopaedic referrals.

To review the outcome at a minimum of 12 months of 1046 consecutive referrals to the Physiotherapy Specialist clinic and to analyse its effectiveness.

114 patients failed to attend the clinic. The remaining 932 patients form the basis of this study. Outcome measures included reduction in the waiting times, patient satisfaction, number of re-referrals to the clinic from the general practitioners and cost-effectiveness. 93% of these patients were managed without direct consultant intervention 71. 6% with advice and reassurance, 16. 9% by referral to the physiotherapy department and 4% with surgical appliances. Only 7% needed consultant evaluation. Waiting time for non-urgent conditions was reduced from 84 weeks in May 1996 to 5 weeks in May 1999. A majority of the parents were satisfied with the clinic. The clinic was found to be cost-effective.

The physiotherapy specialist clinic was effective in reducing waiting times for new non-urgent Paediatric Orthopaedic referrals. The success of the clinic was attributable to good co-operation between the consultant and physiotherapist and a well-defined protocol for assessment and management of patients.

The purpose of study was to investigate kneeling ability after total knee replacement.

100 patients who were at least one year following routine uncemented primary total knee replacement were identified.

32% of patients stated they were able to kneel without significant discomfort. 64 (64%) of patients were actually able to demonstrate kneeling ability without pain or discomfort or with mild discomfort only. 24 (24%) of patients were therefore unable to demonstrate the ability to kneel because of discomfort in the knee.

There was no difference in the “kneelers” and “non-kneelers” with regard to overall knee score, range of motion and the presence of patella resurfacing.

The purpose was to evaluate clinical and radiographical outcome of 1777 patella non-resurfacing in two major centres. Patella management in total knee arthroplasty (TKA) is of concern when resurfaced (multiple problems) or when non-resurfaced (pain). Reports in the literature are frequently non-specific regarding surgical approach, femoral rotation alignment, and femoral design.

1777 non-resurfaced patella TKAs from two large centres were evaluated with a 2 to 15 year follow-up, using similar selection criterion, operative techniques, and prostheses. Patient demographics included 70% females (mean age 68 years). Diagnoses included 8% rheumatoid. Radiologic skyline view assessment of 200 cases (100 from each centre) with longest (mean 9. 2 years) follow-up, formed a subset group. Clinical success rate was good/excellent in 94. 6%; scores improved from 59 to 87.

Patella-related anterior knee pain requiring re-operation was 1. 1% (19 patients), only 9 (0. 55%) of which had unequivocal improvement following re-surfacing. Twenty-one cases (1. 2%) underwent “incidental” patella resurfacing at revision for other reasons. There were no patella subluxations or dislocations. Two hundred cases with longest follow-up revealed perfect congruent contact in 97. 5% with no lateral deviation (mid-sulcus to patella crown) over 6 mm. Asymptomatic remodelling was noted in 8%, with relative sclerosis and height loss of the lateral facet in 2. 5%. No changes correlated with clinical symptoms.

These data support a success rate of over 98% with non-resurfaced patella in a mobile-bearing (LCS) TKA system that includes a patella friendly design, proper soft tissue management, and femoral component rotational alignment using the tibial shaft axis and balanced flexion tension gap method.

The purpose of this study was to assess whether there was significant variation in distal femoral morphology between individuals. In the first part of this study we analysed the distal femoral morphology of 100 consecutive patients undergoing routine total knee replacement for osteoarthritis. In the second part we reviewed the morphology of 50 cadaveric distal femoral specimens without osteoarthritis. There was considerable variability in distal femoral morphology.

Our findings suggest that: 1, use of the posterior condylar axis for femoral component alignment should be used cautiously; 2, problems in balancing flexion and extension gaps on both sides of the knee can be predicted; 3, a greater range of femoral component shapes should be available.

A knowledge of bacteriological profiles in previously treated cases is helpful as a guide to management of infected joint replacements, especially in those cases where bacteriology results are not available. The object of this study was to assess the changing trends of the bacteriology of infected total knee replacements (TKR) over 2 decades.

The records of 79 patients undergoing revision for infected TKR between 1979 and 1999 were reviewed. There were 30 males and 49 females, average age 63 years, range 36 – 82 years. The types and sensitivities of bacteria identified, and the use of prophylactic systematic and cement antibiotics, was recorded. The Chi-squared test was used to test statistical significance.

70 organisms were identified in 62 patients: 29 Staphylococcus aureus; 27 Coagulase Negative Staphylococci (CNS); 8 Streptococci; 6 Coliforms. In the 1980s S. aureus accounted for 55% of infections, CNS 25%. In the 1990s S. aureus 38%, CNS 41%. Following the use of systematic antibiotics (3 x cefuroxime) or antibiotic cement (bacitracin/erythromycin/colistin – BEC) at primary TKR, fewer CNS infections were seen (p< 0. 05). There was only 1 case of methicillin resistant S. aureus. Coagulase negative staphylococci had a 36% resistance to flucloxacillin. With BEC cement there was a tendency to increased erythromycin resistance in CNS, but this did not achieve statistical significance.

At revision for infected TKR, different bacterial profiles were observed depending on prophylactic antibiotic usage. As CNS now causes > 40% of infections, patients undergoing revision TKR should have antibiotics effective against CNS until definitive results are available.

There is little data on the long-term outcome of rotating hinge total knee arthroplasty. We provide a clinical and radiographic assessment of survivorship of the Kinematic rotating hinge total knee arthroplasty (How-medica, Rutherford, NJ), in a series of 72 implants, performed by a single surgeon in one unit, between 1983 and 1997. Survival analysis using known all cause revision revealed a 92% five-year implant survival, but worst-case scenario was 31% at five years.

In a subset of 27 patients we used the Nottingham Health Profile (NHP) to assess prospectively the changes in health-related quality of life following rotating hinge arthroplasty. In this salvage arthroplasty setting we demonstrate a significant improvement in two modalities of the NHP (pain and physical mobility).

To establish whether postoperative x-rays were of sufficient quality compared to those at the first outpatients’ appointment, uncomplicated primary total knee replacements performed by one surgeon were reviewed retrospectively. Measurements were made from these X-rays. Rotation was also assessed.

Forty-eight knee replacements were reviewed. Postoperative films showed the tibial tray to be tilted an average of 5. 04 degrees and a femoral valgus angle of 1. 56 degrees. First outpatients’ X-rays showed the tibial tray to be tilted an average of 1. 16 degrees and the femoral valgus angle to be an average 5. 16 degrees. 15 of 25 postoperative films were found to be rotated compared to 1 of 25 in the outpatients’ group.

Immediate postoperative films are of variable and often poor quality. Films at the first outpatients’ appointment were of superior quality.

Wound breakdown and implant exposure is the most serious complication of total knee arthroplasty. In some patients after removal of the implant, a soft tissue defect remains that is not amenable to closure in any conventional manner as patient co morbidity precludes further major surgery. In addition the risk factors for infection post surgery are the same as those leading to the failure of flap coverage. It is in this group of patients that we have employed the vacuum dressing.

In none of our patients so far has the prosthesis been felt to be amenable for salvage, therefore the first step was a radical debridement of the wound and removal of the prosthesis. Stability of the bone end was then obtained using a Charnley clamp or other external fixator. The vacuum dressing system was inserted and the wound left to heal by granulation. The dressing was changed every 24 to 48 hours depending on wound healing. This resulted in a large amount of healthy granulation tissue and the elimination of residual infection. The resulting wound was then closed either directly or using a split skin graft thereby negating the need for further major surgical interventions.

So far treatment of five patients has been completed. All our patients had significant co morbidity. The mean age was 74 years with a range of 68 to 86 years. These cases were all operated on within six months of their knee replacement. Limb salvage was successful in 4 out of the 5 patients who have completed treatment so far, and these patients have returned to the level of function they had prior to their total knee arthroplasty.

In conclusion, the technique of negative pressure wound dressing and subsequent wound coverage is an effective addition to management options in these difficult cases, and is certainly preferable to amputation.

A study was undertaken of externally fixed tibial fractures in which a fracture stiffness of greater than 15Nm/° was used to define when the frame was removed were included 37 patients were studied; 20 (54%) non-smokers and 17 (46%) smokers. The two groups were comparable (ANOVA p=0. 35) for other factors.

Mean healing times in the non-smokers was 15. 5 weeks and in smokers was 21. 2 weeks (t-test p=0. 05).

We encourage all patients with tibial fractures to stop smoking by quoting an increase of treatment time of six weeks.

To assess the prevalence of anterior knee pain more than 5 years after closed intramedullary nailing of the tibia and evaluate the long-term socioeconomic impact of this complication in terms of knee function and employment.

A retrospective, cohort study of 298 consecutive tibial intramedullary nailings in 295 patients. Minimum follow-up was 5 years and patients were assessed using a questionnaire and the Lysholm knee score. 26 patients are known to have died, 22 patients, greater than 60 years at the tune of their injury, were excluded, Thus, 251 knees in 248 patients were available for review.

The mean age at follow-up was 40. 8 years. The male to female ratio was SA:1 and mean follow-up was 7. 9 years. Anterior knee sensory disturbance was reported by 58% of patients. This interfered with activities of daily living (ADLs) in 29%, work in 25% and sport in 37%. Anterior knee pain was reported by 47% of patients. This interfered with ADLs in 37%, work in 36% and sport in 57%, Anterior knee pain was present all the time in 4%, often in 12%, sometimes in 27%, rarely in 21% and never in 37%, Pain on kneeling was rated on a visual analogue scale as mild in 54%, moderate in 34% and severe 12%. AKP improved with time in 73% patients and became worse in 4%. The Lysholm score rated 4 1 % knees as excellent, 19% as good, 26% as fair and 14% as poor. 86% of patients have been able to return to work, 9% are currently unemployed and 5% disabled. The presence of anterior knee pain was felt by the patient to prevent return to previous work in 10%.

Anterior knee pain persists in 47% of patients after intramedullary nailing of the tibia- There is some decrease in symptoms with time and the majority of patients are able to return to work and activities of daily living. However, anterior knee pain causes significant disability in a small number and all patients should be warned of this problem prior to surgery.

All known shoulder surgeons in Scotland have made a voluntary registration of shoulder replacements since 1996. Information regarding diagnostic and demographic characteristics of the patients, rotator cuff status and type of procedure performed were collated.

20 surgeons have contributed to the register, performing a varied number of shoulder arthroplasties (2 to 79). By five years the total number of shoulder replacements performed was 451. 23. 2 % of patients were male and 76. 8% female. 397 patients had a hemiarthroplasty and 54 (12 %) had a total shoulder replacement. 204/451 (45 %) humeral components used were cemented. In comparison 48/54 (89%) glenoid components used were cemented.

The most common condition requiring shoulder arthroplasty was inflammatory arthritis (184 cases), followed by trauma (128 cases), of which 60 % were for acute trauma and 40 % for old trauma. The remainder consisted of osteoarthritis (87 cases), avascular necrosis (27 cases), and others (25 cases). The consultant in 425 cases and the trainee in 26 cases performed the operation. In 85/451 (18. 9%) of the cases, associated procedures were performed which included cuff repair (26 cases), coracoacromial ligament excision (43 cases), coracoid osteotomy (14 cases) and acromioclavicular joint excision (2 cases). There were 24 intra-operative complications and 9 patients had a revision.

Comparison with figures from the Information and statistics division in Scotland however indicated that our register collected only 53 % of all the arthroplasties performed. In addition it was noted that 30 % of shoulder replacements were performed by surgeons who performed three or fewer shoulder replacements a year.

In an age of clinical governance we believe that a register can provide detailed and accurate information. It is useful for demonstrating current practice and can highlight future changes in practice.

This register supports the need for a national register and surveillance of shoulder replacements. However, in addition to the voluntary data registration, it is proposed that dedicated data collection staff are employed to coordinate the data collection process.

The purpose of the study was to ascertain whether there were benefits from surgical treatment of acetabular fractures within 3 days of injury, as opposed to within a 2–3 week time period as stated in the current literature.

This is a matched-pair, retrospective study, using prospectively entered data from 2 trauma units’ databases, of patients with acetabular fractures treated operatively between 1991 and 1996. Patients were matched for age, acetabular fracture pattern and associated injuries. One group of patients had surgery within 3 days of injury (median time to surgery 1. 5 days), the other group had surgery at 4 or more days post-injury (median 8 days, range 4–19 days). There were 128 patients, 64 per group.

The proportion of patients with complications was higher in the later surgery group (relative risk 2. 1, CI 0. 24–0. 87). Median lengths of stay were significantly shorter in the early surgery group, 11 days compared to 22 days (p< 0. 001 Mann-Whitney-U test). The rate of HO in the early surgery group was 2% compared with 14% in the later surgery group. The rate of good or excellent results was 81% in patients with earlier surgery, and 72% in the later surgery group, in those with median follow-up time of 24 months.

Surgery for acetabular fractures can and should be undertaken as soon as possible. In the setting of our Trauma Units, this seems to confer lower risks of early and late complications, shorter inpatient stay and may improve long-term outcome.

This is the largest detailed study of conservative management of Achilles tendon rupture in the literature to date.

We assessed 140 subjects who had a complete rupture of their Achilles tendon treated with our combined conservative and orthotic regime between 1992 and 1998. Subjects were assessed subjectively and objectively, including isokinetic measurements of ankle plantarflexion and dorsiflexion.

Overall 56% had excellent, 30% good, 12% fair and 2% poor results. The complication rate was 4%, with only 3 tendon reruptures.

When compared with published results for operative repair, our combined conservative and orthotic treatment produces better results overall. Patients are subjectively happier, they have better strength results and have fewer complications.

Screw stripping in osteoporotic bone and bone of otherwise poor quality represents a common problem. Treatment alternatives, such as using a larger diameter screw or a longer plate, may add time, increase morbidity, be impractical, or simply be ineffective. Alternatively, the stripped screw can be augmented with a bone cement. A new injectable synthetic cortical bone void filler (Cor-toSSTM) is based on a resin system, resulting in a very strong, radiopaque, extensively crosslinked, biocompatible composite that does not resorb. We tested the safety and efficacy of the new bone cement in augmenting stripped screws until bone healing.

Of a total of 143 screws implanted in 24 patients with ankle fractures (average age 66. 8 years), 61 became stripped and were augmented. The primary efficacy endpoint was successful intraoperative screw augmentation. The secondary endpoint was whether screw fixation, determined radiologically, remained effective during the 3-month follow-up required for the fracture to heal.

All the stripped screws were successfully augmented. During follow-up at 24 hours, 7 days, and 1 month, none showed any movement relative to either the plate or the bone. At 3 months, one augmented screw in a patient with severe osteoporosis showed gross movement above the plate, which did not affect healing. Serial radiographic analysis did not show the development of any lucencies or cracks in the cement. All fractures healed within 3 months following surgery.

Screw augmentation allowed successful reduction and fixation of the fractures. No adverse events directly attributable to the device were observed. The new bone void filler represents a safe, simple, and reliable method by which to achieve stable internal fixation constructs in patients in whom bone screws fail to gain purchase due to poor bone quality or overtightening.

Twenty five femoral fractures in 23 patients with Paget’s disease had been treated since 1974 with a locking titanium Huckstep nail designed by the author in 1967 and used in the first seven patients in 1971. Paget’s disease is frequently complicated by delayed or non-union; Dove in 1980 (J. Bone Joint Surg (Br)1980;62:12–17), in an analysis of the literature, found an incidence of between 32%–35% reported non-unions after treatment in 182 femoral fractures in Paget’s disease.

Twenty-one femoral fractures in 19 patients in this series had been followed up since April 1974. Fifteen fractures had been united for over six months and eight for more than a year. Radiological union occurred in 12 fractures within six months and in a further five fractures within 12 months of operation. Three fractures took longer than 12 months to unite and one fracture remained ununited, an overall union rate of over 95%. Only three nails required removal after union, as stress shielding was not observed. This was presumably due to the low modulus of elasticity of the 12. 5 mm square section titanium alloy nail with multiple screw holes for the 4. 5 mm fine threaded titanium locking screws. Drilling for these multiple titanium screws used an accurate jig system which obviated the necessity for image intensifier control in most cases. Bowing due to Paget’s disease was improved apparently by the internal splinting effect of the nail. Difficulties of operation included increased vascularity and sclerosis of the Paget bone and associated hypercalcaemia. Bowing sometimes required a shorter nail inserted retrogradely at the fracture site. Advantages of the nail included a strength greater than the average femoral shaft which allowed for early postoperative weight-bearing in most cases. The operative and post-operative complication rate were relatively low.

To assess the indication and role of shoulder arthroscopy for the problem shoulder arthroplasty.

Between 1995–2000, 28 patients who had excessive pain or limitation of motion following a shoulder arthroplasty underwent arthroscopy. A pre-operative diagnosis was made in 13 out of the 28 patients.

Of the 13 patients who had a pre-operative diagnosis an impingement syndrome was confirmed and successfully treated by arthroscopic subacromial decompression in 10, a rotator cuff tear was confirmed and debrided in two and in one loose bodies removed. Of the 15 patients who did not have a pre-operative diagnosis a post-arthroplasty capsular fibrosis was found in seven, six undergoing a successful arthroscopic capsular release. Loose or worn components were found in four of the shoulders, a small cuff tear was identified in one, a florid synovitis was present in another, loose cement was found in a further patient and in one no abnormality could be found. During the procedures orientation within the joint was often hindered by the reflection from the prosthesis making it difficult to differentiate between the real and mirror images of both the tissues and arthroscopic instruments. Access was also often compromised.

Arthroscopy following shoulder arthroplasty is useful for the diagnosis and treatment of pain and loss of motion in selected patients, but can be technically demanding. Diagnostic arthroscopy following shoulder arthroplasty should be considered for patients suffering from pain in whom no cause can be found using less invasive investigations.

Distal humeral fractures are difficult fractures to treat. In the elderly population the problems are compounded by gross comminution and osteoporosis. Concurrent presence of rheumatoid arthritis makes the problem more difficult. Open reduction and internal fixation of such fractures have been shown to give poor results. Total elbow replacement has been recommended as an alternative solution to this difficult problem. We present the results of a retrospective review of a small group of elderly patients who underwent total elbow arthroplasty in our unit for comminuted fractures of the distal end of the humerus.

We have followed up seven patients (seven elbows) with a mean age of 81. 7 years (range 74. 1 to 87. 8) at the time of injury. The presence of rheumatoid arthritis in three of them influenced the choice of treatment. All replacements were performed using the semiconstrained Coonrad-Morrey elbow replacement prosthesis. The duration of follow up at present is between two and four years. None of the patients have been lost to follow up.

At the latest follow up the mean arc of flexion was 20 to 130 degrees. 6 of the patients had no pain while 1 complained of mild pain. All elbows were stable. The Mayo Elbow Performance Score (MEPS) for five elbows was excellent, two scored good. The mean MEPS for all the elbows was 92/100. There were 2 cases of superficial wound infection and no cases of deep infection, ulnar nerve neuritis or component failure.

These results suggest that a semiconstrained total elbow replacement has a role to play in the treatment of carefully selected distal humeral fractures, which cannot be treated by internal fixation due to extensive intraarticular comminution and gross osteopenia. Although these are short-term follow up results they are encouraging outcomes for treatment of one of the most challenging fractures.

To report the results of the vertical apical suture Bankart lesion repair.

Fifty-nine patients (52 men and 7 women) with a mean age of twenty-seven years (range, 16 to 53 years) were studied. The mean duration of instability was 4. 1 years and mean follow-up was 42 months (range 24 to 58 months).

A laterally based T-shape capsular incision was performed with the horizontal component directed towards the glenoid neck and into the Bankart lesion. A vertical apical suture through the superior and inferior flaps of the Bankart lesion, tightens the anterior structures to allow them to snug onto the convex decorticated surface of the anterior glenoid. The inferior flap of the capsule was then shifted superiorly and the superior flap shifted inferiorly to augment the anterior capsule, with the shoulder in 20 degrees of abduction and 30 degrees of external rotation.

At final review, according to the system of Rowe et al., 94. 9% (56 patients) had a rating of good or excellent. Three patients had a recurrent dislocation due to further trauma.

The mean loss of forward elevation was 1 degree, external rotation with the arm at the side was 2. 4 degrees and external rotation in 90 degrees abduction was 2. 2 degrees. Of forty-four patients participating in sport, thirty-five (79. 5%) returned to the same sport at the same level of activity, seven returned to the same sport at a reduced level of activity and two patients did not return to sport.

The vertical apical suture repair offers a 94. 9% stability rate, a maintained range of motion and a 79. 5% return to pre-injury level of sporting activity. It is technically less demanding than the Bankart procedure. All sutures used are absorbable. Complications related to non-absorbable implants and absorbable anchors and tacks are avoided.

This study assesses long term performance of the Souter-Strathclyde elbow arthroplasty. From 1984 to 1999, 68 Souter-Strathclyde prostheses were inserted in 53 patients; nine patients died, one was lost and 38 (88%) had full clinical examination.

Mean survival was 72 months (range 8 to 187), 25 elbows survived to 5-year follow up, with improvement in pain, motion, stability and function. Mayo score was satisfactory in 92% of all 68 elbows.

Complications occurred in 13 elbows (19%) and 14 elbows were revised for instability (six), fracture (three), loosening (three) and intraoperative problems (two). Survivorship at 10 years was 74% (95% Confidence Interval ± 7. 7).

Thirty-four patients with an average age of 64 years had forty consecutive total elbow replacements done using Souter-Strathclyde prostheses between 1991 & 1994. Six patients had died, however useful data was available in three that were included in the series, two patients failed to attend review clinic due to other medical problems and were excluded from this study. The results of thirty-five elbows were analysed and are presented in this paper. Mean follow up at the final evaluation was 79 months.

All patients were evaluated before and after the operation using Modified Mayo’s Performance index with maximum score of 100. An independent observer performed the latest clinical evaluation.

The average score before the operation was 51. 4, this improved to 82. 4 (p< 0. 001), pain score (maximum 50) improved from 23. 4 before the operation to 47. 1 (p< 0. 001) and the functional component of the score (maximum 30) also improved from 12. 5 to 18. 57 at the time of follow up. The range of motion score (maximum 20) showed least improvement with slight improvement in flexion from 127. 57 before the operation to 134. 34 (p=0. 387) at the time of last follow up.

Four elbows were removed, one due to early and three due to late onset deep infection; there has been no incidence of aseptic loosening requiring revision. Other complications were ulnar nerve dysthesia (two), minor intra-operative fracture (two), dislocation (one).

The Souter-Strathclyde elbow provides sustained pain relief, and functional improvement in the upper extremity. Motion remains unaffected, with some improvement in flexion. We believe that the Souter-Strathclyde elbow replacement can help patients with rheumatoid elbow disease, and we continue to evaluate prospectively a larger series of patients.

40 linked total elbow replacements were inserted into 35 patients over a 12-year period. The mean age was 67. 3 years, (range 48 to 87 years) and the mean follow up 50 months (range 8 to 134 months). Each patient had undergone at least 1 operation prior to the index arthroplasty (range 1 to 10). 27 elbows were flail and 13 unstable due to previous failed total elbow replacements in 23, gross bony erosion due to rheumatoid arthritis in 9, distal humeral non-union in 6 and Charcot joints due to syringomyelia in 2.

A Coonrad Morrey sloppy hinge prosthesis was implanted in 25 elbows and a snap-fit Souter Strath-clyde prosthesis in 15. The technique included preservation of the triceps mechanism and early mobilisation in most cases. At review 38 elbows had no or mild pain, 2 moderate, and no patient had severe pain. All patients achieved a functional range of movement. There was no linkage failure of any implant.

Complications included revision for aseptic loosening of one humeral and one ulnar component, debridement for infection in one and curettage and bone grafting of a cement granuloma in one. One patient with a Charcot joint developed a non-union after failure of plating and grafting of a periprosthetic fracture at the tip of the humeral component. In addition six had delayed wound healing, two ulnar nerve symptoms and two triceps weakness.

In conclusion, a linked elbow replacement can reliably provide stability, mobility and pain relief in a flail or unstable joint allowing the hand to be positioned in space and therefore the function of the limb is dramatically improved. This method is especially appropriate in elderly frail patients.

To assess the value of physiotherapy in the treatment of patients with subacromial impingement syndrome

Patients with subacromial impingement syndrome were identified. Those who had not previously had any physiotherapy and had failed to respond to non-surgical management were selected and placed on the waiting list for subacromial decompression.

Patients were randomised into two groups. One group was referred for physiotherapy while waiting for surgery. The control group had no intervention prior to surgery.

The patients in the physiotherapy arm underwent assessment and treatment by a single physiotherapist.

All patients were evaluated independently at 3 and 6 months. The Constant Score was used to assess all patients initially and at each visit.

Physiotherapy group: All patients (n=42) increased their Constant score. 11 of the 42 patients improved to an extent that surgery was no longer required (26%). In patients not requiring surgery, the mean improvement in Constant score was 25 (12–45) In patients requiring surgery (n=31), the mean improvement was 21 (3–34).

Patients not requiring surgery had a higher initial Constant score, 65 (30–84) than those requiring surgery 48 (17–59). Patients not requiring surgery also tended to be younger 52 (27–68) than those requiring surgery 59 (48–68).

Control group: All patients (n=23) went on to have surgery.

The mean improvement in Constant score was 2 (−16 to 12).

All patients with subacromial impingement syndrome improved with physiotherapy when compared to a control group that did not receive physiotherapy. Some patients in the physiotherapy group improved to the extent that surgery was no longer required (26%)

This study aimed to ascertain the effect of operative delay on mortality of patients with hip fractures excluding those delayed for medical reasons.

In our unit, patients with hip fractures (fractures of the femoral neck and trochanteric zone) have surgery on trauma operating lists shared with plastic surgery emergencies. They are not specifically prioritised and are operated on in order of admission. In a 6-month period, 221 consecutive patients over the age of 65 were planned for surgical treatment of their hip fracture in our unit. 16 patients had surgery delayed for medical reasons and were excluded from further analysis. In a further 9 patients it was not possible to confirm the exact delay to theatre from records and these were also excluded. This left 196 patients in whom it was possible to relate in-hospital and 90-day mortality to surgical delay.

These data demonstrate a significant trend towards increasing mortality with increasing delay (χ²-test for trend: p = 0. 0015 (in-hospital) and p = 0. 0021 (90-day)). Comparison of mortality between those delayed 2 days or less (164 patients) and those delayed more than 2 days (32 patients) was also highly significant (Fisher’s exact test: p = 0. 0008 (in-hospital) and p = 0. 0004 (90-day)).

We conclude that delays to surgery in patients with hip fractures, particularly beyond 2 calendar days, result in unacceptably high mortality. Practice should be modified to ensure these patients receive greater priority for theatre time.

Non-unions of the supracondylar area of the humerus are uncommon but they produce profound functional disability. We have successfully treated a series of these non-unions surgically using the Coventry hip screw. This is a large metaphyseal screw which is applied through both humeral condyles and then compressed on to a single 4. 5mm narrow tibial plate applied to the lateral aspect of the humeral shaft.

Between 1993 and 2000 we operated on thirteen consecutive patients aged 20 to 81 years (mean age 51 years). All the patients had a severe functional disability. The mean time to surgery was 23 months following their accidents. The average follow up was 16 months (range 8–18 months). All but two of the thirteen patients went on to bony union. The mean time to radiological union was six months (2 to 12 months). The mean arc of flexion doubled to 90 degrees.

Until now, the recommended operative technique for stabilisation of non-unions of the distal humerus is identical to that described for primary fracture repair, and involves fixation with two 3. 5 mm plates at 90 degrees. In our experience, this was the technique usually used at the initial operation/s, and is therefore likely to fail again. This correlates with the reported 6–12% non-union rate in the literature. In this series, stable fixation was achieved by using the Coventry hip screw.

Whiplash remains a challenging condition because the pathology is undefined. The purpose of this study was to evaluate the response of chronic neck, shoulder and arm pain to decompression of the median nerve at the wrist and pronator teres level.

In a prospective study of 150 cases following whiplash injury (108 carpal tunnel and 42 pronator teres syndrome) clinical symptoms were assessed by clinical, neurological, radiological and visual analogue scale. The pathophysiology of pain and effects of surgery have also been assessed by neuropeptide studies.

Clinical and neurological examination revealed signs and symptoms of carpal tunnel and pronator teres syndrome along with severe neck, shoulder and arm pain. Local anesthetic infiltration around the median nerve at the wrist and forearm abolished the chronic neck and shoulder pain within 10mins of injection. This demonstrated the site of pathology and temporarily relieved upper limb symptoms and trapezius muscle spasm as well. Neurophysiological studies were always normal.

Surgical intervention in successful cases cured chronic neck shoulder and arm pain with sensory and motor recovery. Also activities of daily life normalised permanently.

The main neurotransmitter peptides Substance P and Calcitonin gene related peptide levels returned to control levels six weeks after surgery in successful cases (p< 0. 005 and p< 0. 05 respectively). This is the biochemical evidence of effect of surgery in relieving pain and neuroinflammatory process.

Our study suggests that neck shoulder and arm pain following whiplash injury is caused by entrapment of the median nerve due to stretching. Surgical decompression of the carpal tunnel and pronator teres muscle yielded 93% and 80% good results respectively with the disappearance of chronic neck shoulder and arm pain. Consequently normalisation of daily activities were observed. Although mild hand symptoms caused by carpal tunnel syndrome have also been cured the primary aim of surgical intervention is to cure chronic neck shoulder and arm pain.

To study the outcome of stabilisation of humeral shaft fractures using an elastic retrograde humeral nail that is self-locking proximally and easily locked distally.

20 closed humeral shaft fractures were stabilised in 19 patients between 1996 and 1999.

There were three acute fractures, nine cases of failed non-operative treatment (three cases of loss of fracture position and six cases of non-union), five established pathological fractures and three impending pathological fractures. The average age of the patients in the acute/failed non-operative treatment group was 43. 6 years (range 18 to 83 years) and in the established/impending pathological fracture group was 73. 6 years (range 60 to 81 years).

Patients in the acute/failed non-operative treatment group were followed until fracture union. This occurred without further intervention in 83% of cases at a mean of 11. 8 weeks (range 10 to 16 weeks). Shoulder and elbow movement were rated by determining the percentage loss of movement compared to the other side. Almost all these patients regained a full range of elbow and shoulder movement without residual pain or disability. Two cases needed further surgery to achieve union and it was noted that nail removal in these patients was difficult. In one of these cases the original injury was a floating elbow. All of the pathological fractures were successfully stabilised with good pain relief. Four of the five patients with established fractures survived to fracture union. This occurred at a mean of 12. 5 weeks (range 10 to 16 weeks) without the need for further procedures. There were few complications.

We have obtained encouraging results with both pathological and non-pathological fractures using this nail with good preservation of both shoulder and elbow movement. We have continued to use the nail routinely.

Longer hip axis length (HAL) has been shown to be associated with the risk of hip fracture. We examined whether HAL is associated with hip fracture risk in elderly community dwelling women in England, unselected for osteoporosis.

We undertook a case-controlled study of women aged ≥ 75 years enrolled to a large, randomised controlled study looking at the effect of a bisphosphonate, clodronate, in the prevention of hip fractures. Cases comprised those women who sustained a radiologically verified hip fracture during follow-up (median 3. 1 years). Two age, height and weight-matched controls were selected for each case. Baseline total hip bone mineral density (BMD) was measured using a Hologic 4500 QDR and the HAL was measured using the densitometer’s automated software.

92 of 4347 women (2. 1%) sustained a hip fracture, but two women had not received a baseline BMD assessment and were excluded, leaving 90 women with hip fractures and 180 matched controls.

The mean age of the cases and controls was 81. 9 ± 4. 9 years. The mean hip BMD was significantly lower (0. 65 ± 0. 31 vs 0. 72 ± 0. 13, P< 0. 001) and the mean HAL was significantly longer in the hip fracture women than the controls (11. 1 ± 0. 6 vs 10. 9 ± 0. 6, P=0. 03).

The increase in the HAL was significantly associated with the risk of hip fracture (Odds Ratio (OR) per 1 standard deviation increase was 1. 33, 95% CI 1. 02–1. 72; p=0. 03) remaining significant after adjustment for hip BMD (OR 1. 32, 95% CI 1. 01–1. 71; p=0. 04).

An increase in hip axis length is associated with an increased risk of hip fracture in elderly English women independent of hip BMD, although the odds ratio appears somewhat lower than that reported in other studies.

Controversy exists regarding the use of closed suction drainage in Total hip and Total knee replacement. A retrospective study on hip and knee arthroplasties was carried out to assess the efficacy of postoperative wound drainage. Twenty-five consecutive hip replacements and twenty -five consecutive knee replacements had closed wound drainage for twenty-four to forty-eight hours after the surgery while twenty-five patients in each group did not.

All operations were carried out using similar operative technique under the care of a single surgical team. Perioperative protocol for thromboprophyaxis, antibiotics, dressing and postoperative mobilisation was similar in all the patients. Thromboprophylaxis consisted of 5000 units of Fragmin daily for five days and 75 mg of Aspirin for six weeks from the day of operation.

Antibiotic prophylaxis consisted of three doses of intravenous Cefuroxime perioperatively. The hospital records including the physiotherapy and nursing notes were used for data collection. Patients were evaluated for preoperative and postoperative haemoglobin levels, the amount of blood transfused, hospital stay, functional outcome in terms of range of motion and complications. The average period of follow -up was one year.

The study showed no difference in the drop in haemoglobin levels between the drained and the undrained hips. However, the drained knees had a greater fall in haemoglobin levels postoperatively compared to the undrained. In both hip and knee arthroplasties, a larger volume of blood had to be transfused in patients with drains than those without. There was no difference between the drained and undrained patients in both the hip and knee groups in terms of hospital stay, range of movements and incidence of complications. Our preliminary study suggests that Total hip and Total Knee replacement without the use of postoperative drainage is a safe procedure. The study has financial and clinical implications.

A postal questionnaire was sent to 225 GPs and 225 Orthopaedic Surgeons (Consultant and Specialist Registrars) in 20 hospitals in North West England. They were asked to give their routine clinical practice with regard to investigation of underlying osteoporosis in 3 clinical scenarios :

55 year old lady with a low trauma Colles fracture

The participants were asked whether patients over 50 years old with low trauma fractures required investigation for osteoporosis, and whether an osteoporosis Nurse Specialist would provide a beneficial service.

The response rate was 52% (n=l17) from Orthopaedic Surgeons and 49% (n=l11) from GPs. Both groups agreed that patients over 50 years old with low trauma fractures required investigation for osteoporosis (81 % surgeons and 96% GPs), and that Osteoporosis Nurse Specialists may provide a beneficial Service (81% Surgeons and 94% of GPs).

A majority of surgeons (56%) replied that they would routinely discharge the Colles fracture patient without requesting or initiating investigation for underlying osteoporosis. However, a majority of GPs (67%) would not investigate a similar patient for osteoporosis, unless prompted by the surgeon or patient.

A greater proportion of both surgeons (71%) and GPs (64%) would routinely initiate investigations or treatment for osteoporosis in the Vertebral Wedge fracture patient.

65% of surgeons would simply discharge a patient with a femoral neck fracture after orthopaedic treatment and 40% of GPs will simply file the hospital discharge letter.

Most Orthopaedic Surgeons and GPs are aware that low trauma fractures in patients over 50 years old require investigation for Osteoporosis, however, a large population of patients with Colles and Femoral Neck fractures are not being given the advantages of secondary prevention of Osteoporosis. This may lead to greater workload for Orthopaedic Surgeons in the future.

The aim of this study was to evaluate the peri-operative (30-day) mortality following hip fracture and look at the variables which influence early mortality after this injury. A prospective audit of all patients admitted with hip fracture was undertaken over an 18-month period. An independent research assistant collected data on a standardised questionnaire. Data included basic demographics, comorbidities, mental test score, mobility and social status, All patients received prophylactic antibiotics and thromboprophylaxis and surgery was undertaken on dedicated trauma and hip fracture operating lists.

There were 1072 patients admitted with hip fracture: 829 females (77%) and 240 males (23%) with a mean age of 80 years (range 24–103 years). The basic fracture types were intracapsular (n=616; 58%); extracapsular (n=414; 38%); subtrochanteric (n=29; 3%) and periprosthetic (n=12; 1%). 69 patients (7%) had acute medical problems which delayed anaesthesia. Delays to surgery, because of a lack of theatre resources, were common and only 314 patients (29%) had their hip fracture fixed on the day of admission or the following day. There were 9 deep infections (0. 8%) and 69 patients (6%) died within 30 days of surgery. Linear regression analysis showed that the 30-day mortality was not associated with pre-injury mobility or mental test score (p=0. 224). Any delay to surgery (2 days or more) resulted in a significant increase in mortality (p=0. 0042) and the risk of death increased 21% for every day surgery was delayed. Subgroup analysis showed that acute medical comorbidity was the most important factor influencing mortality with an odds ratio for death of 4. 9 (p=0, 0007). Delay to surgery in medically fit patients (n= 633) gave an odds ratio for death of 1. 6. In this group, the risk of death increased 16% for every day surgery was delayed with an 85% probability (p=O. 125) that this trend was significant.

The peri-operative mortality for hip fractures is now quite low (6%). Acute medical comorbidities are the most important cause of early post-operative death. Delay to surgery may be a factor in medically fit patients and our data suggests that the ideal time for surgery is the day after admission.

To evaluate the effects of smoking on fracture healing in a non-union population.

A consecutive cohort of 104 patients with 107 non-unions managed by external fixation was reviewed. 75% were regular smokers compared to the regional average of 3 0%. 5 8 male and 20 female smokers, matched with the non-smoking group. Patients’ records and x-rays were evaluated; where information was missing patients were contacted by phone/post. Scoring was recorded from our own prospective database.

The smokers underwent 2. 6 procedures per segment with a mean treatment time of 17. 43 months (4–64) compared to 1. 9 and 10. 9 (2. 5–24) respectively in non-smoking group. The total hospital stay was 66% greater in the smoking group (41. 12 vs 27. 4 days).

102 non-unions healed, including seven who required revision surgery, six of whom were smokers. In smoking group five went on to amputation and three had residual infection. The entire non-smoking group healed after primary surgery except a 70 years old lady who was converted to intramedullary nailing.

The final assessment of the bony and functional results was performed by the method described by Paley and Catagni (JBJS 77A 1995).

When considered in the context of regional statistics for smoking there was a trend towards non-union in smokers [P< 0. 05].

We conclude that smoking adversely affects both primary fracture healing and non-union treatment.

To promote cultural awareness and acceptance of clinical governance by developing a simple, reproducible model for reporting critical incidents and near misses within our department.

An A4 sized departmental proforma was developed to parallel the Trust’s official adverse incident register. Prospective reporting of adverse events using the proforma was encouraged between August 2000 and June 2001. Incidents were discussed in an anonymised and a blame-free setting, at the monthly multidisciplinary clinical governance meeting and appropriate action taken.

In the 6 months prior to commencing this study only 4 adverse events were reported with no discernible action taken. Following the introduction of the proforma 61 critical incidents and near misses were reported in the period August 2000 to June 2001. As a result of effective reporting of adverse events we have developed a number of protocols to improve patient care.

A simple model for reporting critical incidents and near misses has been established. This has fostered a cultural change within the department and all members of staff feel more comfortable with reporting such incidents. The process is seen as educational and an important part of continuing professional and departmental development. Protocols and changes in organisational practice have been developed to reduce and prevent the occurrence of adverse events and offer our patients continuous improvement in care.

Healthcare organisations are accountable for improving the quality of their services, safeguarding high standards of care and meeting shorter waiting time targets. This presents a challenge of how to achieve such targets with limited resources. This paper looks at the hypothesis that adequate and appropriate clinical governance can be undertaken while increasing orthopaedic spinal clinic throughput in order to decrease outpatient waiting times.

A spinal outpatient clinic was used as the test bed for the hypothesis of the project. The theoretical number of patients an individual consultant can see per session was calculated from recommended British Orthopaedic Association consultation times for new and follow-up cases. Patients were asked to complete the MODEMS (Musculoskeletal Outcomes Data Evaluation and Management System) questionnaire. A prospective randomised trial utilising a touch-screen computerised version of the questionnaire was also used. Time taken for outcome data management is included in the analysis. The time taken to see new and follow up patients was 31–42 and 24–35 minutes respectively. These times have implications in terms of waiting times and Director of Performance Management targets. The shortfall is calculated in terms of additional support necessary to reach these targets. Salary costs and infrastructural support costs are projected. The figure is likely to represent that required by any specialist clinic to realise the ideals of clinical governance and conservatively estimated to be £35, 000 per year.

Total clinical governance and patient outcomes are inextricably linked. This is true of orthopaedic spinal surgery in that important information about clinical practice can be obtained. The organizational infrastructure and methods to implement data collection is technically feasible however is not without cost. In terms of economic evaluation the correct price for a resource is its opportunity cost. ‘Don’t just buy more healthcare, invent new healthcare’ is as incongruous as total clinical governance and increased capacity without support.

In order for the variations in the treatment of whiplash injuries to be studied a short postal questionnaire was sent to every Accident and Emergency department in the U. K. A literature search was then performed in order to determine how much this treatment is evidence based.

We present data from 186 Accident and Emergency units. The use of cervical collars in whiplash treatment is widespread. In the literature no study has shown a therapeutic benefit from collars. The majority of studies comparing early mobilization with immobilization in a collar show a prolongation of symptoms, an increase in pain and, decrease in movement from treatment in collars.

Physiotherapy is also provided by a number of units. There is certainly evidence that early mobilization is better than rest but, no evidence that physiotherapy is superior than self-mobilization after advice and prescribed exercise programs. Non steroidal anti-inflammatory drugs are also widely prescribed. There is no evidence these are superior to simple analgesia and they have significantly increased side effects.

A large proportion of Accident and Emergency units are providing treatment that is at best ineffective and, in some cases, detrimental to patients. This is at significant cost to the NHS and we suggest that treatment protocols be reviewed.