Purpose: To eliminate iatrogenic Ulnar Nerve injury.

Methods: We prospectively reviewed 25 consecutive paediatric gartland’s type 3 supracondylar fractures with a minimum follow-up of 1 yr operated by our novel technique. Good reduction was achieved with closed reduction in 20 and 5 cases warranted an open reduction. Our technique involved passage of two percutaneous 1.6 mm smooth K-wires supero-medially from lateral condyle across the fracture site to obtain a purchase in upper medial cortex of proximal fragment. A third K-wire was passed percutaneously from lateral supracondylar pillar proximal to the fracture site in infero-medial direction to gain purchase in distal fragment’s subchondral bone of medial condyle thus creating a cross construct. Care was taken not to breach the subchondral bone so as to avoid ulnar nerve injury. All patients were operated in supine position under general anaesthesia and lateral collateral approach was used with same K-wire construct in cases that needed open reduction. Stability was checked post-operatively by rotation under real time imaging. The mean age of patients was 6.8 yrs. The mean time from sustaining the fracture to operative pinning was 24 hrs. An above elbow immobilisation backslab was applied for 3 weeks. The K-wires were removed at 3 and 4 weeks in cases that had closed and open reduction respectively and active assisted movements were initiated. All patients were followed up at 1/52, 3/52, 6/52, 3/12, 6/12 and 1 year post-operatively.

Results: Flynn’s criterion was used for post-op functional evaluation. 20 cases had excellent and 5 had good outcome at end of 1 year. There was no case of nerve palsy (superficial radian or ulnar N), pin-tract infection, loss of reduction or late cubitus varus/valgus or hyper-extension deformities.

Conclusion: Our innovative technique is an excellent alternative option without compromising on fracture stability in the treatment of these fractures.

Aim: To review the outcomes for avulsion fractures of the tibial spine in children managed by arthroscopic internal fixation using a canulated screw.

Materials & Methods: A retrospective review was performed of 8 tibial spine avulsion fractures in children managed operatively by arthroscopic canulated screw fixation over a 4 year period. All fractures were graded grade III or IV (Meyer and McKeevers) in severity. Notes and radiographs were reviewed and Lysholm scores were obtained. The average age of our patients was 10.6 years and the average duration of follow up was 23.6 months (Range: 3–52 months). The average Lysholm score achieved was 88.9 (median 94.5, range 61–100) with the score demonstrably improving after the first year from injury. Bony healing was seen in all cases. One patient needed manipulation under anaesthesia to realize full movement.

Conclusions: On the basis of these results, we recommend arthroscopic canulated screw fixation as the treatment of choice for tibial spine avulsions. It takes over a year, however, to achieve optimal results. This series represents the largest collection of these uncommon injuries hitherto reported from the UK.

Spiral fractures are one of the most common fractures seen in non-accidental injury. In such cases, with radiographic evidence for the mechanism of injury, the physician is more capable of identifying any inconsistencies in the offered explanatory history.

The objectives of the study were to detail and differentiate the fracture patterns created by rotation forces in different directions and to determine the reliability of that recognition method applied to standard radiographs.

Twenty rabbit femurs were fractured using a torque transducer and imaged using standard anterior-posterior and lateral radiographs. The radiographic interpretation skills of paediatric, radiology, orthopaedic and emergency room doctors were assessed before and after being given the findings of this study.

The radiographic propagation of the spiral fractures was consistent and followed six simple principles. There was a statistically significant difference in the numbers of correctly diagnosed radiographs, before and after the explanation of our findings, by these doctors (chi-squared=14.06, df=1, p=0.002).

The direction of the torsional force producing spiral fractures can be determined from characteristic features on routine radiographs but does not seem to be intuitive. These derived six principles will be a useful aid to physicians who manage paediatric spiral fractures where non-accidental injury is being considered.

The purpose of the study was to establish an algorithm for the treatment of pathological fractures in children.

Pathological fractures can compromise radiographic and histological diagnosis. The need for histological diagnosis and indications for surgical treatment are not clearly defined.

We reviewed our Centre’s Tumour Registry records of children who presented over the past 7 years with a fracture as the first manifestation of primary bone pathology. There were 23 patients (average age 12 years and 2 months).

There were 9 fractures through simple bone cysts, all treated conservatively initially. All patients were subsequently treated with needle biopsy and bone marrow injection. Three patients suffered refracture and underwent flexible intramedullary nail fixation.

There were 5 cases of fibrous dysplasia. Histological diagnosis was obtained in all cases, followed by prophylactic intramedullary nailing in 3 patients.

There were 2 patients with giant cell tumour, 3 with aneurysmal bone cyst and one with chondroblastoma. Histological diagnosis preceded curettage and grafting in all cases.

Finally, there were 3 patients with Ewing’s sarcoma of the femur. One underwent palliative intramedullary nailing for extensive local disease. The second patient was treated conservatively initially. She subsequently underwent segmental resection and vascularised fibular graft. The third patient underwent internal fixation in another unit for what was considered to be a benign lesion. The histological diagnosis of Ewing’s sarcoma was based on intra-operative specimens. Definitive surgery required wide resection and prosthetic replacement.

We recommend that primary fixation of pathological fractures should be avoided until histological diagnosis is obtained. All lesions should be appropriately imaged and biopsied if aggressive characteristics are present. However, if radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed. Definitive treatment of benign lesions with protective intramedullary nailing or curettage and grafting can follow frozen section under the same anaesthetic.

Purpose: To determine if oral midazolam reduces the anxiety of children undergoing removal of percutaneous Kirschner wires (K-wires) from the distal humerus in the Orthopaedic Outpatient Department.

Methods: This was a prospective double blind, randomised controlled trial. 46 children aged between 3 and 12 years who had supracondylar fractures of the distal humerus internally fixed with K-wires were randomised into 2 groups. 0.2mg/kg oral midazolam (active group) or the same volume of an oral placebo (control group) was administered 30 minutes prior to removal of K-wires.

Venham Situational Anxiety Score was performed before and immediately after removal of K-wires. University College London Hospital sedation score was recorded every 20 minutes.

Results: 42 children with an average age of 7.1 years (range 3.6–12.3 years) had complete documentation for analysis. The two groups had similar demographics. All wires were removed in the clinic with or without midazolam.

There was no significant difference in anxiety scores between the groups either before or after wire removal. The change in scores was not significantly different between the 2 groups. However, 45% of children in the active group had reduced anxiety levels in the active group compared to 18% of children given placebo but this difference was not significant (p=0.102). No child was excessively sedated but one in the active group became agitated and restless.

Conclusions: The anxiety scores before and after wire removal in the active group were not significantly different from the placebo group scores. We do not recommend the routine administration of midazolam (0.2 mg/kg) to all children requiring k-wire removal in the outpatient department.

Purpose: In neuromuscular conditions, ankle foot orthoses (AFO) prevent deformity and improve functional balance by increasing the base of support, stabilizing the ankle joint and influencing the kinematics of more proximal joints; this study was designed to evaluate the role of fixed AFOs on balance in spastic diplegic children.

Methods: 12 children (age 7–15yrs) with spastic diplegia were recruited. All were community ambulators (GMFCS II/III). All had used AFOs for 12 months. Each child walked along the GAITRite electronic walkway at their preferred speed: barefoot, in shoes, and in AFOs with shoes. The order of the walks was randomized limiting the effects of fatigue and confidence. Normalized velocity, cadence, stride length and percentage of gait cycle in single leg support were selected as surrogate measures of stability. The child’s balance during other functional activities was assessed with the paediatric balance scale (PBS).

A two-way analysis of variance (ANOVA) explored differences in gait between the various walks. Fried-man’s test tested for differences in PBS scores between subjects and conditions.

Results: Significant improvements were seen in mean values for normalized velocity (p=0.02), stride length (p< 0.01) and percentage of gait cycle in single leg support (p< 0.01) in footwear-AFO compared to barefoot. Whilst there were also improvements in mean values for these parameters in shoes alone compared to barefoot, only the difference in stride length reached statistical significance (p< 0.01). There were no significant differences in PBS scores in shoes alone or with AFOs compared with walking barefoot.

Conclusions: AFOs improved balance during gait but had no effect on balance during other activities. Whilst shoes alone had a positive impact on gait, the most significant effects were seen in the AFO-footwear combination.

Significance: Advice regarding AFO use and footwear choice should consider the effects on gait as well as prevention of deformity.

Purpose: The aim of this research was to characterize the correlation of magnetic resonance image (MRI) measurements of femoral anteversion and tibial torsion with transverse plane kinematics from the gait analysis of ten healthy and nine cerebral palsy (CP) children.

Methods: The bone morphologies of nine spastic diplegic CP and ten healthy children were obtained by analysis of 3D MRIs. Location of anatomical landmarks along the femur and tibia were detected using medical imaging software. Each point was then defined with respect to bone-embedded femoral and tibial Cartesian coordinates, allowing 3D reorientation of the bone independent of the patient position within the scanner. Femoral anteversion was defined as the angle between the femoral neck and the transcondylar plane. Tibial torsion was defined as the angle between the transcondylar axis of the proximal tibia and the bi-malleolar axis.

Three-dimensional motion of the lower limbs was measured using gait analysis. Transverse plane kinematics, including hip rotation and foot progression angles were recorded.

Results: A moderate correlation was found between femoral anteversion, and maximum and average hip rotation in CP children (0.64 and 0.65). A high correlation was also seen between tibial torsion and maximum and average values of hip rotation for CP children (0.71 and 0.74). In healthy children, the only correlation observed was between femoral anteversion and average foot progression in stance (0.75).

Discussion: In healthy children, femoral anteversion appears to influence foot progression angle, implying that this can lead to an internally rotated gait. In CP children, the correlation between femoral anteversion and hip rotation is only moderate. The interaction between different joints is more complex and the rotation of joints is determined by multiple factors. This study showed that tibial torsion also plays a role in determining hip rotation during gait.

Aim: To assess the risk of iatrogenic ulnar nerve injury using the mini medial incision to reduce and stabilise displaced supracondylar fractures of the humerus in children with crossed K-wires.

Methods: We performed a retrospective evaluation of 26 children with closed Wilkins type IIB and III supracondylar fractures of the humerus, without vascular deficit, between January 1999 and April 2007. Mean age was 5.5 years (2.5–11 years). All were treated with open reduction and crossed K-wire fixation using a mini medial incision (5cm). Our modification is that we do not expose the fracture site or the ulnar nerve. It is a “feel” rather than “see” approach. The medial K-wire is placed under direct vision. All patients had early and late (4 months) post-operative ulnar nerve assessment. Patient outcome was assessed clinically using Flynn’s classification and radiologically using the metaphyseal-diaphyseal and humerocapitellar angles. Mean length of follow-up was 5 months (4–8 months).

Results: There was no post-operative ulnar nerve injury. Clinically and radiologically there were 23 excellent and 3 good results.

Conclusions: The mini medial incision is simple. It provides an excellent view for correct medial pin entry; hence it reduces the risk of iatrogenic ulnar nerve injury. Crossed K-wires provide a stable and reliable fixation.

Purpose: To investigate the mode of presentation, management and outcome of ischaemic contracture following a supracondylar fracture with a pink, pulseless hand.

Methods: We reviewed the database at our tertiary referral unit to identify cases over a 20 year period who had been referred for complications of a supracondylar fracture and/or a Volkmann’s ischaemic contracture.

Results: We identified 20 children with Volkmann’s ischaemic contracture following a supracondylar fracture. Of these, 4 patients (mean age 5, range 2–11) were referred to us with evidence of an ischaemic contracture but they had always had a pink albeit pulseless hand. Two of these 4 had undergone vascular exploration at 48 hours and at 72 hours but despite this developed an ischaemic contracture.

The 2 patients with the most severe contractures have undergone surgical intervention for their contracture, and 2 were managed conservatively with splinting. All 4 cases have residual problems with hand function (mean follow-up 5.5 years, range 2–11).

Conclusions: Volkmann’s ischaemic contracture should be a preventable condition. The pink albeit pulseless hand is at increased risk of ischaemic muscle and nerve damage and should not be ignored as the consequences are potentially devastating.

Significance: Clinicians must consider whether they feel that their management protocols for the pink, pulseless hand are robust and defensible.

Purpose: Some patients with Cerebral Palsy who had a de-rotation osteotomy performed for correction of excessive anteversion had persistence of internal foot progression even after the surgery. The aim of this study was to see if there is any relationship between significant abductor weakness [less than Grade III: MRC] and persistence of internal foot progression.

Methods: We included all ambulatory patients with cerebral palsy who had had a de-rotation osteotomy between the periods of 2000 – 2005, who had also had a pre and post operative gait analysis, assessment of ante-version, muscle charting and hip range of movements.

There were 12 patients [17 hips, 5 bilateral] 5 male 7 female with an average age of 13. Seven were diplegic, two hemiplegic and three had asymmetric diplegia. Data was assessed using SPSS 13.0. As the data was found to be normally distributed the Fisher exact test and the Spearman’s Co-relation Coefficient was used.

Results: Of the 17 limbs operated, preoperative femoral anteversion was 20–60 degrees [mean: 45] and post op femoral anteversion was 0–35[mean: 15]. Of these 7 hips had persistent internal rotation gait on gait analysis. None of these patients with persistent internal rotation had any hip capsular contractures, and there was no significant change in abductor power after surgery.

On testing the hypothesis it was found that there is no relationship between weak hip abductors and persistent internal rotation. [Fisher exact test: p value: 0.8, r = -0.07]

Conclusion: Weak abductors may not be a cause of persistent internal rotation following de-rotation osteotomy. Weak abductor power is not a contraindication to de-rotation osteotomies and do not affect outcome of surgery.

The purpose of the study was to assess the usefulness of this combination of operations in this challenging patient group.

18 patients (19 hips) with cerebral palsy and painful subluxed or dislocated hips underwent hip resurfacing with shortening and rotation osteotomy of the femur between 1999 and 2005. The mean age was 25 (range 14–59) and follow-up averaged 47 months. Eleven patients were quadriplegic, five were diplegic and two were hemiplegic.

There were no infections. There were two plate cut-outs and two dislocations. All stabilised following necessary treatment. Four plates were removed after about one year. All quadriplegic and four of the diplegic patients were chair-bound pre-operatively. Their carers all felt that their comfort sitting had improved. Seventeen patients (eighteen hips) were pain-free at latest follow-up. One patient, whose plate had not been removed had some lateral tenderness on transferring, but no apparent pain on sitting. Three of the previously chairbound diplegic patients were able to stand and one was able to walk.

As all eighteen of the carers were very satisfied with the outcome, this approach to the treatment of these challenging patients has proved promising

The aims of this study were to compare the outcome of epiphysiodesis in patients with limb length discrepancy (LLD) as a result of cerebral palsy with those as a result of other causes in order to test our hypothesis that the hemiplegic / monoplegic limb may respond differently to epiphysiodesis, to evaluate the accuracy of the Moseley method and evaluate whether there is any difference between the outcomes of left or right hemiplegic limbs with LLD bearing in mind that the left hand is used for bone age calculations.

We reviewed the case notes and radiographs of 34 children who had undergone epiphysiodesis for the management of LLD by the same surgeon, using the Moseley method between February 1999 and May 2005 to final follow up at skeletal maturity. Of the 34 patients, 9 had a LLD as a result of cerebral palsy (4-Left, 5-Right) and 25 as a result of other causes. In the cerebral palsy group the mean residual LLD was 0.59cm and in the other group it was 1.18cm. Both groups were similar in terms of age and sex distribution. There was no demonstrable statistically significant difference in outcome between the 2 groups (unpaired T test, P=0.734). The Moseley method appeared accurate and there was no difference demonstrated in the outcome between left and right hemiplegic LLD.

We conclude that the Moseley method is reliable. We have not found any evidence that the hemiplegic limb behaves any differently. We have not demonstrated any difference in the outcome of left or right hemiplegic limbs.

Aim: Assess healing pattern of Achilles tendons across gap created by percutaneous tenotomy and maintained by cast in club feet.

Methods and Results: 21 tenotomies in 16 patients (Age range 12 weeks–36 months) were monitored with dynamic and static ultrasonographic studies. Ultrasounds performed before, immediately after and at approximately 3, 6, 12 weeks post tenotomy. Cast removal was done at 3 weeks. Two patients above age of two were casted for 6 weeks.

The healing pattern went through different phases although they were not distinctively exclusive from each other and did show considerable overlap. First phase showed formation of bulbous mass with some continuity of scar tissue across tendon gap. The transition zone between new fibre and the original tend quite distinct. However dynamic ultrasound showed the Achilles tendon moved as a single unit. Second phase showed fibres resembling normal tendon crossing the gap and reduction of bulbous mass. The transition zone was still discernible. Final stage demonstrated more homogenous fibres of Achilles tendon with an indistinct transition zone. Two older children showed a distinctly longer process of healing.

At 3 weeks there was no evidence of healing.

Conclusion: Young Child (< 1 Year): When cast immobilisation is discontinued, the tendon is in mid phase of healing. There may be a positive effect on continued improvement in dorsiflexion while using boots and bars.

Older Child-Safe to consider percutaneous tenotomy in children up to 3 years of ages provided the period of immobilisation is extended.

Although Bohler’s & Gissane’s angles are measured in adult calcaneal fractures, it is not known if such measurements are reliable in children nor how such measurements vary with the age of the child.

The Picture Archiving and Communications System (PACS) databases of 2 London Teaching Hospitals were searched and all children who had a lateral ankle xray taken as part of their attendance to the A& E department were identified. Films were excluded if there was a fracture of the calcaneus or if the film was oblique or of poor quality. Bohler’s and Gissane’s angles were measured using the image viewer software. All patients’ films were measured on two separate occasions and by two separate authors to allow calculation of inter- and intra-observer variation. Interclass Correlation Coefficients (ICC) were used to assess the reliability of the measurements.

347 children were identified and after exclusions, 218 films were used for the study. The overall ICC for Bohler’s angle inter-obsever error was 0.91 and for intra-observer error was 0.92, giving excellent correlation. This reliability was maintained across the age groups. Gissane’s angle inter-observer error was very poor and the intra-observer error poor across the age groups, although accuracy did improve as the patients approached maturity.

Further analysis of the Bohler’s angle showed a significant variation in the mean angle with age. Contrary to published opinion, the angle is not uniformly lower than that of adults but varies with age, peaking towards the end of the first decade before attaining adult values.

We feel that measurement of Gissane’s angle is unreliable in children but measurement of Bohler’s angle is accurate and reproducible. Bohler’s angle varies with age and knowledge of Bohler’s angle variation is important in the evaluation of os calcis fractures in children.

Introduction: Physical challenges and a long term treatment for Perthes disease can affect patients’ behaviour in their adolescence. We carried out a study to assess the long term psychosocial development of children treated non-operatively using abduction cast and brace.

Methodology: 104 patients treated for Perthes disease between 1992 and 2001 were recruited for a retrospective study. Besides clinical review, patients and their main carers were asked to fill in Strengths and Difficulties Questionnaires (SDQ). SDQ included scores for total difficulties, emotional symptoms, conduct problems, hyperactivity, peer problems, social behaviour and total impact. 70 controls, matched for age and sex, attending the clinics for other unrelated pathology were requested to fill in the same questionnaires along with their main carers.

Results: Data from 91 patients was available for assessment. Age at diagnosis was 1.9 to 7.3 years (median 3.9 years). Follow-up duration was 5.6 to 15.1 years (median 8.7 years). The age of subjects at final follow up was 8.9 to 20.4 years (median 15.3 years). The mean duration of treatment in abduction cast or brace was 2.4 years.

57 controls and 69 subjects were found to be low risk for emotional disorder (p> 0.05).

Similarly 58 control and 74 subjects were predicted to be low risk for behavioural disorder. 16 controls and 18 subjects had medium or high risk for hyperactivity or concentration disorder (p> 0.05; student t test). There was no significant difference between the self report and parent questionnaires for difficulties or their impact.

Conclusion: Perthes disease and the resultant restricted physical activities in early childhood does not affect the emotional and mental well being of patients in a long term.

Aim: To audit the impact of emergency hip ultrasound in the management of suspected hip septic arthritis.

Methods and Results: Case series – Review of 13 consecutive patients who presented with acute hip pain, where clinical examination and inflammatory markers, highly suspicious of Septic arthritis.

Emergency ultrasound was only available in 9 patients.

Septic arthritis group.

– Emergency ultrasound unavailable in 2 patents. They proceeded straight to arthrotomy yielding pus.

“Non Septic Arthritis of Hip” (8 patients).

– In 2 patients emergency ultrasound unavailable. They underwent emergency arthrotomy with negative findings of pus.

If ultrasound was available in all cases, then 8 (63%) patients would have avoided an unnecessary arthrotomy.

Out of hours urgent hip ultrasound may be difficult to request. However our recent experience leads us to propose that if available ultrasound should be performed in all suspected case of hip septic arthritis prior to surgical drainage.

Pathology in the vicinity of the hip can often masquerade convincingly as a septic hip joint.

Aim: To assess the outcome for Perthes disease in children over eight treated by observation, varus osteotomy, abduction plasters and acetabular augmentation.

Methods and results: A retrospective case note review of prospectively collected data for 44 children (48) hips with Catterall grades 2, 3 or 4 Perthes’ disease with onset age eight or older and followed to maturity was performed. The groups were demographically similar. For all groups combined 60% had a satisfactory Stulberg grade I to III outcome. Poorer outcomes (as assessed by Stulberg, centre edge angle and Reimer’s migration index) were associated with increasing age, greater initial head deformity and greater head involvement. Initial head deformity did not remodel for any treatment group. Indeed, progressive head deformity occurred despite plaster treatment or varus osteotomy but not after acetabular augmentation. Hips managed by acetabular augmentation also had better outcomes than the other groups for Stulberg, Reimer’s index and centre-edge angle.

Conclusions: Whatever the treatment the outcome for Perthes’ disease in children over eight is poorer with increasing age. No treatment offers the prospect of a good result in the older child with significant head involvement or significant initial deformity but acetabular augmentation seems to improve Stulberg, Reimer’s migration and centre-edge angle outcomes and prevents progressive femoral head deformity compared with observation, varus osteotomy and plaster treatment.

The aim of the study is to highlight the skeletal changes that result from untreated DDH if it is decided to leave the hip unreduced, as may occur if a child presents at a late age. This is of interest today as the data with which we try to determine prognosis in such cases is very old and comprised of small patients numbers. The method used is the study of c.10,000 human skeletons excavated from the medieval cemetery of Spitalfields in London, dating from 1100–1530AD. Diagnosis was made by the presence of an abnormal true acetabulum incompatible with articulation with a femoral head in life, with an associated false acetabulum on the iliac wing. The results demonstrated a range of skeletal consequences in the 13 dislocated hips present. At the hip joint itself, degenerative change was only present in cases with a well developed, cup-shaped false acetabulum. Only 17% of cases had such a cup-shaped false acetabulum. Cases with no such false acetabular cup (83%), presumably with soft tissue articulation, showed no degenerative change. Hip adduction with valgus knee was common, as was femoral neck anteversion with compensatory tibial torsion. Scoliosis in unilateral cases caused lateral wedging of vertebral bodies and markedly asymmetric degenerative change in older individuals. We conclude that the presence or absence of a deep cup-shaped bony acetabulum at late presentation may have prognostic implications as to whether degenerative change in the hip, and so pain, may occur in adulthood. If confirmed by clinical studies, this may influence whether an attempt at reduction should be made. From the viewpoint of the spine, if a hip is reduced late, surgeons should be aware that the scoliosis may not correct as they would expect if the vertebrae are already laterally wedged by the time the child presents.

Purpose: Scarf osteotomies are commonly performed in adults with symptomatic bunions. We have reported the radiological and clinical outcome of this procedure in the treatment of moderate to severe hallux valgus among adolescent children.

Methods: Data was collected retrospectively from a tertiary referral children hospital between April 2001 and June 2006. The pre and postoperative intermetatarsal angle (IMA), hallux valgus angle (HVA) and distal metatarsal articular angle (DMAA) were determined. Patients were followed up for a mean of 8.6 months (3–18).

Results: 23 scarf osteotomies were performed in 16 patients with a mean age of 14.3 years (12–18). The mean pre operative IMA of 14.4 degrees was improved to a postoperative value of 9.3 degrees, p< 0.0001. The mean HVA angle was improved from 34.7 to 16.5 degrees, p< 0.0001. The DMAA was improved from 13.1 to 8 degrees, p< 0.0001. There were 2 cases of superficial wound infections successfully treated with oral antibiotics. One patient developed a complex regional pain syndrome that resolved with physiotherapy and analgesia.

Conclusion: We believe that scarf osteotomy is a safe and effective option for the management of the adolescent symptomatic bunions.

Significance: There are no published reports in the English literature of scarf osteotomy in the management of adolescent children with symptomatic hallux valgus. The aim of this paper is to report the radiological and clinical outcome of scarf osteotomy in the treatment of moderate to severe hallux valgus among adolescent children.

Introduction: Approximately 5% of grade III supracon-dylar fractures are associated with vascular compromise. Following closed reduction and K wire stabilisation 60% of childrens surgeons in UK would adopt a policy of observation providing the hand is well perfused. We have retrospectively compared 2 groups of patients to determine whether observation or exploration leads to the best outcome.

Materials and Methods: Over a 7 year period 18 patients were identified with pulseless pink hands. Management following reduction and K wire fixation was at the discretion of the admitting consultant. 10 Patients were managed expectantly and 8 patients had immediate exploration of the vessel.

Results: Of 10 patients managed by observation, 3 had secondary exploration of the vessel and one patient has developed forearm claudication. Although a palpable radial pulse was present in all cases by 3 months it had returned within 24hrs (suggesting spasm of the artery) in only 3 patients.

In 6 of 8 primarily explored brachial arteries the vessel was observed to be tethered to the fracture site.

Following release, in 6 of 8 cases the radial pulse had returned within 24hrs. Satisfactory radiological reduction of the fracture does not preclude vessel entrapment.

In 8 cases there was an associated median nerve palsy. All of these cases were found to have an anatomical obstruction to the brachial artery.

Conclusions: In the majority of cases absent pulse is due to vessel entrapment. Long term perfusion of the forearm is due to collateral circulation. Providing a near anatomical reduction is achieved observation for 24 hours would seem reasonable course of action. If the pulse has not then returned further imaging (arte-riograme/MRA) may be advisable. If there is associated nerve palsy immediate exploration is warranted

Introduction: We conducted a prospective study on 29 patients comparing the medium-term outcome between intramedullary nail fixation and plate fixation in paediatric forearm fractures.

Materials and Methods: The criteria were patients who had a nail (10) or plate fixation (19) for a single or both bones forearm fracture between 2004 and 2006. All these patients were recalled following ethical approval for assessment of their grip strength using a hand dynamometer, forearm and elbow range of movements, scar assessment, POSNA outcome questionnaire and new radiographic views of the forearms.

Results: Mean age of 10.4 years for both groups (4–16), All fractures were caused by low velocity falls. Grip strength is reduced in 83% of patients, comparable in both groups. Elbow flexion is more reduced in the plating group but more reduction in extension in the nailing group. The reduction in forearm pronation (69% of patients) and supination (61%) were comparable in both groups. Using the ‘Manchester scar proforma’; the plating group scored worse with 14/21; nail 11/21. ‘POSNA outcome questionnaire’ score showed the nailing group had 90% excellent or good result and plating group 74%. The moderate and poor POSNA outcome (26% plate, 10% nail) were associated with pain, restricted rotation, bad scarring and difficulty lifting heavy objects. Nails were removed after bony healing but all plates were left in situ. Complete remodeling of forearm bones were seen in all radiographs in both groups. One case of non-iatrogenic ulnar nerve injury and two cases of wound infection were noted; all made full recovery.

Conclusion: The medium-term outcome at 2.5 years following either fixation method is generally comparable and good. The obvious differences were; a higher (better) POSNA score in the nailing group, larger scar formation in plating, elbow extension restriction in nailing and elbow flexion restriction in plating group. Factors that were comparable were grip strength, forearm rotation and radiographic remodeling and outcome.

Introduction: Forearm fractures are the most common long bone fracture in the paediatric population. Associated neurological injury is a well recognized complication of these injuries yet is generally considered to beuncommon. This study sought to evaluate the incidence of neurological impairment in children referred for manipulation by the orthopaedics team in this tertiary referral hospital.

Materials & Methods: A retrospective chart analysis was performed of the first 100 children to be referred for orthopaedic assessment. This represented 43% of the total number of children presenting to the emergency department in this time period. Inclusion criteria involved a fracture of any segment of the radius and/or ulna on radiological examination. Exclusion criteria included concomitant ipsilateral upper limb fracture, and compartment syndrome.

Results: A total of 96 cases met the inclusion criteria. The cohort had a mean age of 8.04. Males were more likely to be injured as was the left forearm. The distal metaphysis was the segment most likely to be fractured and compound injuries were uncommon. The incidence of associated neurological impairment was 15.6%. The median nerve was most commonly injured, comprising 60% of nerve injuries. Distal physeal fractures were the most common fracture pattern to be associated with neurological impairment, with a rate of 37%.

Conclusions: Forearm fractures requiring manipulation in the paediatric population are commonly associated with nerve injuries, with distal physeal fractures having a particularly strong correlation. Clinicians require a high index of suspicion for nerve injury when evaluating forearm fractures to avoid underdiagnosis. Failure to recognize neurological injury at the time of initial assessment has the potential to delay time to reduction due to the injury being misclassified as non-urgent. This delay has the potential to cause a prolonged or failed recovery of nerve function.

Background: Pediatric comminuted femoral shaft fractures are not frequent but difficult in treatment due to concomitant injuries and instability. Although orthopaedic literature is rich in reports on paediatric femoral shaft fractures only few focus on comminuted ones.

Purpose: The aim of the study is to present results and complications of surgical treatment in comminuted femoral shaft fractures during growing age.

Material and Methods: Between 2001–2006 twenty eight children presented with 29 wedge or complex femoral shaft fractures. All children underwent clinical and radiographic examination on follow up and their medical data was retrospectively reviewed. TEN scoring criteria, time to solid union, early and late complications were of the primary interest during follow up assessment.

Results: There were 18 boys (64,3%) and 10 (35,7%) girls. Their mean age during injury was 10,1 years and average follow up period was 35,7 months. In 15 children (53,6%) multiple injuries were present. Three fractures were treated conservatively, the remaining 26 underwent closed or open reduction with stabilization using EBI external fixation, intramedullary Rush or TEN rodding, multiple screws or plate osteosynthesis.

On follow up there were 12 (41,4%) excellent, 14 satisfactory (48,2%), 3 poor (10,4%) results. All fractures united and a mean time to achieve solid union was 20,7 weeks. Leg length discrepancy occurred in 20 children (71,4%), and in 10 (35,7%) was greater than 10 mm. Four children required in early secondary surgical procedures to achieve better alignment or fracture stabilization. One femoral osteomyelitis required in surgical drainage and prolonged intravenous antibiotic therapy.

Conclusions: Comminuted femoral shaft fractures in children heal well after surgical treatment although the risk of serious complications is high. Intramedullary rodding seems to be sufficient in most cases. Screw fixation alone should be avoided.

Purpose: To determine the effect of the ossific nucleus on avascular necrosis (AVN) of the hip in the treatment of hip dislocation.

Methods: A systematic review was performed in MED-LINE, EMBASE, DARE, and Cochrane Library. Two independent reviewers evaluated all articles. Interrater agreement was determined by the kappa statistic. Quality of evidence was evaluated by the GRADE statement. A meta-analysis was performed on the main outcome, AVN 2 years after reduction.

Results: 6 observational studies met the inclusion criteria. Inconsistency was found in that half of the studies reported a protective effect of the ossific nucleus, whereas half of the studies did not. A meta-analysis of all studies (415 patients) showed no statistical significant effect of the ossific nucleus on the development of AVN, with 42 (17%) cases of AVN in infants with the ossific nucleus present at reduction compared with 47 (28%) in the group without a ossific nucleus (RR 0.60, 95% CI 0.28 to 1.27). If only radiographic changes of grade ≥II were considered AVN, a significant difference in the prevalence of AVN was found, with 15 (6%) cases of AVN in infants with the ossific nucleus compared with 28 (20%) without the ossific nucleus (0.34, 0.17 to 0.67). Subgroup analysis showed that the presence of the ossific nucleus reduced the probability of AVN by 70% (0.30, 0.14 to 0.62) in case of a closed reduction, but no significant effect was found for open reduction (0.87, 0.50 to 1.54). All studies demonstrated methodological weaknesses compromising the quality of evidence.

Conclusion: We could not demonstrate a significant effect of the ossific nucleus on the development of AVN. The meta-analysis suggested that the ossific nucleus might have a protective effect against the development of more severe forms of AVN.

Introduction: Growing pains are a common complaint in school age children, but no definite organic causes have been identified. An association between musculoskeletal pain and joint laxity has been proposed. This study therefore investigates the relationship between growing pains and joint hypermobility in children.

Materials and Methods: Thirty three children with growing pains and thirty one controls of similar age and sex were recruited from outpatient clinics of a specialist paediatric hospital. Joint hypermobility was assessed in each group using the Beighton score. A Beighton score of greater than or equal to 4 out of 9 was considered hypermobile.

Results: The median Beighton scores were 6 for the study group and 0 for the control group. 93.3% of the study group had a Beighton score of equal to or greater than 4, compared to 22.6% of the control group. There was a highly significant difference in Beighton score between the two groups (P< 0.0001), with an estimated difference of 4 points 95% CI 4–6.

Discussion and Conclusion: A link between joint hyper-mobility and musculoskeletal symptoms has been demonstrated in adults. There is also some evidence that hypermobile children are more likely to experience musculoskeletal pain, particularly articular, but the extent to which joint hypermobility is related to growing pains specifically has been poorly defined. We have investigated a selective population of children with growing pains and have shown them to be significantly more hypermobile than the control children. The aetiology of growing pains remains unclear. While the growing pains will get better, in view of the possible association of joint hypermobility and other musculoskeletal complains, these children should be carefully assessed for joint laxity.

Background: Aim of the study was to evaluate the clinical results of Montgomery Hip Screw for fixation of proximal femoral osteotomies. There are a number of devices for proximal femoral fixation, including sliding hip screws. Rotational instability of the proximal femoral segment can be a problem. To overcome this, a hip screw has been introduced with two screws in the proximal segment.

Methods and Results: A prospective cohort undergoing osteotomy was followed up. Inclusion criteria included consecutive patients < 16 years of age, with an indication for elective proximal femoral osteotomy. All operations were performed by senior author or under his supervision using a standard postero-lateral approach. Further incisions for adductor/psoas release and pelvic osteotomy were added as indicated. In 23 cases MHS was used with a mean follow up of 10 months (6 to 24). In 9 patients there was an underlying neurological problem, one case of LCPD, and the rest had DDH. Previous surgery with a hip screw on the contralateral side had been undertaken in 5 cases. The mean age was 5 years (range 1 to 12) and mean time to union was 6.3 weeks. There were no occurrences of rotational instability or failure of fixation. No wound complication was encountered in the cohort.

Conclusions: Early results indicate that Montgomery Hip Screw is a safe device for fixation of proximal femoral osteotomy with the added advantage of rotational stability.

Introduction: A criticism of innominate osteotomy is that it causes relative acetabular retroversion, predisposing to osteoarthritis. This study was designed to address this hypothesis.

Materials and Methods: We had access to radiographs of 30 patients that had undergone open reduction and innominate osteotomy for late presenting developmental hip dislocation. The patients are now middle-aged and formed part of a previously reported study on the long term outcome of this protocol. Standardised, well-centered anteroposterior standing hip radiographs had been obtained. We used the validated method of Hefti (1995) to measure anterior and posterior acetabular coverage and contact area. All measurements were made by a single independent investigator.

Results: 10 operated hips had advanced osteoarthritis which made it impossible to identify acetabular landmarks. 26 hips were readable despite signs of mild to moderate osteoarthritis in some (Group A). 20 contra-lateral hips without DDH which appeared radiographically normal formed control group B.

Discussion: We were unable to assess operated hips which had gone on to replacement or severe osteoarthritis. This is a flaw as those hips with better radiographs have been selected out for study. Nonetheless this was a unique opportunity to assess the effect of innominate osteotomy on acetabular development in good numbers of hips with a variety of evolved outcomes.

Conclusion: Acetabular coverage and load area in hips with a good outcome after innominate osteotomy with open reduction were not different to a control group of radiographically normal hips without previous DDH. Innominate osteotomy before the age of 5 years has the potential to facilitate, or at least not prevent, normal acetabular development and version.

Introduction: Fibular hemimelia (FH) is a congenital limb reduction deficiency characterised by partial or complete absence of the fibula and a spectrum of associated anomalies. For children with a major anticipated limb length discrepancy and severe foot deformity, management (amputation or limb reconstruction) is controversial.

Materials and Methods: 8 children who are now adults (average age 28 years) underwent limb reconstruction as children in one of two UK centres for severe fibular hemimelia. All 8 participants were recalled to our institution for instrumented gait analysis. The SF-36 and lower limb domains of the Toronto Extremity Salvage Score (TESS) questionnaires were also administered.

Results: Partcipants scored well for general health but had functional limitations reflected in lower TESS scores. Kinematic analysis revealed decreased sagittal knee motion and valgus knee alignment. Also ubiquitous were anterior pelvic tilt and obliquity with incomplete hip extension and reduced range of hip abduction. Kinetic analysis showed reduced peak plantar flexion moment with reduced push-off power and an internal hip adduction moment in late stance. These parameters are compared to control data for below knee amputees.

Discussion and conclusions: Although the number of participants is small, this is the first study to use instrumented gait analysis for severe fibular hemimelia managed with limb reconstruction. The results add objective data to the debate over limb reconstruction or amputation in this group of children.

Introduction: Osteomyelitis remains a rare diagnosis and a difficult one to make. Acute osteomyelitis in the context of sickle cell disease remains the subject of some controversy, particularly with regard to aetiology. It is known that Salmonella species are more commonly the cause of acute bone infection in sickle cell patients than in patients with normal red blood cell morphology, but there has long been an argument as to whether Staphylococcus Aureus is in fact still the most common bacterial cause overall in this patient group, as it is in the population overall. We present a consecutive case series of 12 cases of acute osteomyelitis in paediatric patients in East London over the last twenty years.

Materials and Methods: Retrospective review of 12 consecutive cases. Medical Notes along with microbiology records and radiographic results were cross referenced with a paediatric sickle cell data base held by the haematology department.

Results: 10 of the 12cases had an organism isolated from either blood or bone culture(s). Salmonella spp in cases, S. Aureus in 2 cases and Pseudomonas in the remaining case

Discussion: The question of causative organism is complicated by the fact that most case series’ have bracketed adults and children together, and that conflicting conclusions have resulted from quite small, usually retrospective studies at different times and from different parts of the world – Nigeria, Saudi Arabia and the United States of America. It appears that endemicity is a result of many factors including age; race and socioeconomic factors all play a role.

Conclusion: These results reveal that in our paediatric sickle cell population, Salmonella infection occurs ore commonly than Staphylococcus.

Purpose: The main purpose of the study is to present our experience with the Ponseti casting followed by an Achilles tendon (AT) tenotomy in children with arthrogryposis multiplex congenita (AMC).

Methods: 7 children with 14 severe clubfeet were treated by us with a Ponseti manipulations and casting followed by AT tenotomy. 5 children (10 feet) were followed at least 24 months after the AT tenotomy and were selected for the final evaluation. Their mean age at follow up was 38,4 months and average follow up period was 35,8 months. The treatment was begun within first month of life, the AT tenotomy to correct rigid equinus was performed at 14,4 weeks of life on average, after 7–10 cast changes (mean 8,4). Niki H. et al. clinical criteria and standard standing AP and lateral radiographs were analyzed for final evaluation.

Results: There were 7 feet with clinically satisfactory results. Among 3 unsatisfactory feet there were two (1 child) with rocker-bottom pseudocorrections after repeated bilateral AT tenotomies and one recurrent clubfoot (1 child). Six feet required in soft tissue releases in 3, 12 and 21 months after the AT tenotomy due moderate equinus and adductus. 3 feet underwent repeated AT tenotomies in 6 and 15 months after the primary procedure. The mean interval between initial AT tenotomies and redo surgical procedures was 10,5 months (range 3–21 months). Two feet (20%) remain without significant deformity after AT tenotomies.

Conclusion: Clubfeet in AMC respond initially to the Ponseti method of casting and the deformity may be corrected or diminished. In some children wide surgical treatment can be avoided, in other delayed. Despite necessity for additional surgical intervention, the Ponseti method of casting and Achilles tenotomy does seem to be an alternative for initial treatment in children with AMC.

Introduction: Shoulder relocation is commonly performed for the subluxating or dislocated shoulder secondary to Obstetric Brachial Plexus Palsy (OBPP). We have observed that even when relocation is performed at a young age, remodelling of the immature, dysplastic glenoid is often unreliable, resulting in recurrent incongruity and requiring treatment of the glenoid dysplasia.

Methods and results: In a series of 19 patients, we used a posterior bone block to buttress the deficient glenoid at the time of shoulder relocation. At a mean follow up of 28 months (6–73 months), we describe failure in at least 50% with erosion of the bone block, progressive subluxation and resultant pain.

A different technique of glenoplasty is now used. An osteotomy of the glenoid is performed postero-inferiorly, elevating the glenoid forward to decrease its volume. Bone graft, often taken from an enlarged and resected coracoid is then packed into the osteotomy and the whole assembly is held with a plate. In a series of 11 patients with a mean age of 6.7 years (1–18 years) we describe good results at short term followup, suggesting that this is a technique warranting further investigation.

Conclusion: We believe that where a deficient glenoid is found at surgery for relocation of the shoulder in OBPP, a glenoplasty should be performed at the same time whatever the age of the patient, as glenoid remodelling will not reliably occur. We no longer advocate posterior bone block in these cases as it has a significant failure rate.

Purpose of study: To compare our practice of paediatric foot and ankle surgery with other hospitals in the UK and to assess the safety and patient satisfaction of day-case procedures on an afternoon list.

Methods and Results: A postal questionnaire was sent to 135 consultant members of BSCOS to identify which foot and ankle operations were being performed as inpatients (“Major surgery”) and day-cases (“Minor surgery”). We received 87 (64%) replies over 3 months. The survey revealed that certain procedures were being performed as a day-case in fewer than 35% of centres in the UK. These included excision of tarsal coalitions, tendon transfers, metatarsal osteotomies and open posterior releases for equinus. These same procedures are performed routinely as day-cases at Birmingham Children’s Hospital.

We focussed on a single surgeon series with a once weekly afternoon operating list. We identified 24 “major operations” on 19 patients that were performed as a day case over 21 months. The parents of each patient were contacted by telephone to complete a satisfaction survey. We demonstrate that there were no problems that should have warranted an inpatient stay.

Conclusions: Most paediatric foot and ankle surgery can be performed satisfactorily as a day case which has obvious cost implications for the NHS. Although this is an accepted practice among adults, the majority of paediatric orthopaedic units are yet to accept this protocol.

Introduction: We describe the successful treatment of advanced Perthes’ disease in 5 patients using a combined pelvic and femoral osteotomy. To our knowledge, there are no reports in orthopaedic literature describing simultaneous pelvic and femoral osteotomy as treatment for healed Perthes disease.

Method: There were 4 males and 1 female, age range 10 years to 18 years (mean 13 years). All five patients were rated as Stulberg IV. We used a Tonnis pelvic osteotomy and a 20° valgus femoral osteotomy. Clinical parameters, measured pre and post operatively, included range of movement, Harris hip and pain scores (patient and parent perception of pain on an analogue scoring system).

Results: The mean improvement in Harris hip score was 30 points and the mean reduction in pain score was 6. Range of movement was not affected. Complications included one case of non-union of the femoral osteotomy, successfully treated by open reduction and internal fixation with bone graft.

Conclusions: Simultaneous pelvic and femoral osteotomy may improve symptoms and function in symptomatic patients with healed Stulberg IV Perthes disease

Introduction: Abnormal hip morphology, seen with conditions such as slipped capital femoral epiphyses and femoral head necrosis, can lead to repetitive contact between the femoral neck and the acetabular rim. Impingement is a significant cause of hip pain in young adults and may be a mechanism for the development of early osteoarthritis. The senior surgeon has modified a technique to debride the pathology responsible for femoroacetabular impingement through a mini anterior approach, obviating the need to dislocate the hip. We describe this technique and present early clinical outcomes.

Method: Between Jan 2006 and June 2008, ‘notchplasty’ for the surgical treatment of femoroacetabular impingement was performed by the senior author (AHN) or directly under his supervision in 38 hips. There were 17 male patients and 21 female patients with an average age of 31 years. Patients have been followed according to a prospective protocol with Oxford and Iowa hip scores obtained pre-operatively, at 3 months and at 1 year.

Results: This study is still in progress. Twenty nine patients have had 3 month follow up and 13 of these have now been followed up to one year. Four patients are still less than 3 months post op. Data was unobtainable for 5 patients. 1 patient was excluded from the study.

The overall Oxford hip score improved significantly from a mean pre-operative value of 35 to a mean post operative value of 22.9 at 3 months (p< 0.001).

The mean score at 1 year increased slightly to 27.3 points but this remains lower than the pre operative average.

We report no cases of osteonecrosis. One patient has since been scheduled to undergo resurfacing arthroplasty.

Conclusions: The technique described is a new method for managing these patients whilst avoiding the pit-falls of current operative methods. The method avoids detaching the straight head of rectus, thereby tremendously improving postoperative mobilisation. However, the long term benefit of debridement of the head-neck junction for Cam-type femoroacetabular impingement remains to be seen.

Introduction: Obligatory external rotation during flexion is well recognised as a cardinal feature of Slipped Upper Femoral Epiphyses (SUFE). We have evaluated the significance of acetabular version in contributing to the external rotational deformity that is seen in otherwise normal hips. We present a small case series focussing on the characteristics of this pathology, highlighting its significance and outlining a treatment strategy.

Method: Five patients (eight hips) presented with disabling hip pain during non-sporting activities. All their hip radiographs had been reported as normal. The rotational profile of both acetabulum and femur in these patients was evaluated by MRI and CT scans.

Results: Clinical examination revealed otherwise normal hips but for an external rotation deformity which got worse on hip flexion. The average external rotation deformity with the hip in extension was 60 degrees, which worsened to 90 degrees during hip flexion. Three of these hips had been previously treated with in situ pinning for SUFE. Other hips were in patients who were either skeletally mature or close to skeletal maturity. We found that all were “profunda hips” with severe acetabular retroversion. The abnormality in acetabular version was best defined on axial imaging.

Conclusions: The femoral head is a spherical conchoid. The concept of version of the hip (both femoral and acetabular) as described by McKibbin, Tonnis and Ganz is reviewed. Femoral retroversion is common in patients with SUFE, but the addition of acetabular retroversion makes these hips disproportionately symptomatic. This deformity causes a combination of pincer and cam impingement, which is responsible for the marked disability. SUFE alone causes cam impingement, whilst a corresponding degree of slip without retroversion and profunda of the acetabulum is not that disabling.

Aim: To compare outcomes in patients who suffered a severe slipped upper femoral epiphysis (SUFE) treated by either a modified Dunn or Imhauser Osteotomy.

Method: A consecutive group of patients were identified retrospectively from the operative records of a single surgeon at two hospitals since 2003. Patient Notes were used to extract age at presentation, duration of symptoms, stability, and time to surgery. Radiographs were examined to determine: the slip angle; and the degree of correction achieved. Patients were assessed using the Harris and Oxford Hip Scores.

Results: Seven patients had a modified Dunn osteotomy and 11 patients an Imhauser osteotomy. Of those only 6 of the Dunn patients and 7 of the Imhauser patients could be recalled for clinical assessment. The average time to clinical assessment from osteotomy was 13.5 months for the Dunn group and 32 months for the Imhauser group. Post-operative lateral radiographs showed a mean angle of deformity correction of 63 degrees in the Dunn and 36 degrees in the Imhauser groups. There were no postoperative complications in either group, specifically no avascular necrosis.

In the Dunn group the Harris Hip Score ranged from 78 to 100, mean 92 (excellent) and the Oxford Hip scores from 12 to 21, mean 17. The Harris Hip Score for the Imhauser group ranged from 50 to 98, mean 76 (fair), and the Oxford scores from 13 to 34, mean 25. Range of motion was similar for both groups in all directions.

Conclusions: The Dunn and Imhauser osteotomies both give good clinical results in the severe SUFE patient. However the Dunn Osteotomy group had better Harris and Oxford Hip Scores, reflecting improved functional outcome.

Introduction: Methicillin-sensitive staphylococcus aureus (MSSA) has been the predominant aetiological agent in acute osteomyelitis (AHO) in children. Recent studies from the United States have demonstrated an increase in community-acquired Methicillin-resistant Staphylococcus aureus (CA-MRSA) infections, which have been linked to increased morbidity.

Aim: a) to compare the patterns of AHO including the incidence of CA-MRSA in two tertiary children’s hospitals in Canada (The Hospital for Sick Children) and the United Kingdom (Southampton General Hospital) respectively, b) to compare the clinical course of MSSA versus CA-MRSA AHO in children in these two institutions.

Method: A retrospective review was carried out of all children up to 16 years, who were diagnosed with AHO at both centres over a five-year period. Demographic information, diagnostics, aetiology, treatment and outcomes was collected for comparison across both institutions and between MSSA and CA-MRSA identified patients.

Results: 99 cases of AHO were identified in Toronto (HSC) and 82 cases in Southampton (SGH) over the given time frames. The male: female ratios were 1.5:1 at HSC and 1.7:1 at SGH. The most commonly identified organism at both sites was MSSA, representing 42% of cultures at HSC and 22% at SGH. 2 Cases of CA-MRSA were identified at HSC, while 1 case was identified in Southampton, confirmed to be PVL-positive. No cases of Haemophilus influenzae were identified at either site. There were no significant differences in the median lengths of stay, rates of operative intervention, or complications between the two institutions. CA-MRSA cases were on average younger (7.5 yrs vs 9 yrs) and were all girls, compared with 32% girls in the MSSA group. CA-MRSA patients had similar initial laboratory profiles with the MSSA patients, except for significantly higher C-Reactive Proteins (200 vs 64) (p < 0.05). CA-MRSA patients experienced a significantly longer hospital stay (23 vs 8 days); were more likely to undergo surgical intervention (2/3 vs 34/59); were treated with longer duration of IV antibiotics (34 days vs 10.5 days); and longer total duration of antibiotics (61 days vs 46 days). 1/3 CA-MRSA patients required admission to the ICU for sepsis

Conclusions: MSSA remains the predominant aetiological agent in AHO at two large children’s hospitals in Canada and the UK. The patterns of infection are similar at both sites. CA-MRSA AHO infections have been identified at both centres, and although these remain uncommon, they are associated with a more severe clinical course. One can expect the incidence of CA-MRSA strains to rise, necessitating increased vigilance.

Aim: To compare acetabular development and hip stability over time in patients treated for developmental dysplasia of the hip (DDH) by open reduction combined with either varusderotation (VDRO) or innominate (IO) osteotomies.

Method: Patients who underwent open reduction for DDH, combined with either VDRO (38 patients) or IO (33 patients), between 15 months and 4 years of age were reviewed. Both groups comprised a single surgeon consecutive series, differing only in the type of osteotomy performed. A total of 490 postoperative radiographs over a maximum follow-up period of 13.6 years were analyzed. We used repeated measures analysis of variance to compare the change in acetabular index (AI) as well as several other radiographic indices of acetabular development and hip stability over time.

Results: After osteotomy, the AI decreased in both groups but the magnitude of the decrease was significantly different between groups over time (p< 0.0001). The AI of patients undergoing VDRO never decreased as much as that of patients undergoing IO, with a mean difference of 10.4 degrees after 4 years (p< 0.0001). Similarly the IO group demonstrated more favourable acetabular architecture and hip stability over time compared to the VDRO group, as quantified by change in the acetabular floor thickness (p< 0.03), lateral centring ratio (p< 0.0001) and superior centring ratio (p < 0.0001).

Conclusions: Acetabular remodelling after IO was more effective at reversing acetabular dysplasia and maintaining hip stability than VDRO. Long-term follow-up of VDRO will be necessary to determine if late improvement occurs. IO may be preferable over VDRO in the treatment of hip dislocation after walking age.

Introduction: Blount’s disease is an idiopathic, non-physiological form of genu varum. Deformity usually occurs in the proximal tibia with progressive varus, but also with valgus in the distal femur. Treatment in the infantile stage includes observation or bracing, and surgery for acute marked proximal tibial varus. Recurrence is common with conventional surgery after the age of four.

Method: A new surgical technique is proposed as definitive treatment of this condition which includes an arthrogram to visualise the knee joint, acute elevation of the varus aligned medial tibia plateau with second plane correction of posterior slope deformity, lengthening and derotation of the tibia by application of a Taylor spatial frame, application of an 8 plate on the distal femur to correct valgus deformity and finally proximal tibial and fibular epiphysiodesis to prevent recurrence.

Results: Five patients with Blount’s disease had this definitive corrective procedure performed at a mean age of 9.8. Radiographs and CT scans taken pre-operatively demonstrated marked medial plateau varus deformity and increased posterior slope. Surgery was performed by the senior author. Follow-up X-rays demonstrated satisfactory alignment, length and rotation of the lower limb.

Conclusions: This new surgical technique allows correction of all deformities of Blount’s disease at one operation and maintains alignment, length and rotation clinically and radiologically at follow-up.

Introduction: Early treatment with antibiotics is advocated in the management of septic arthritis. Whilst some argue for mandatory arthrotomy we have used arthrotomy selectively. The results of this approach over a ten year period were reported 20-years ago.

Aim: To review the outcome of joint aspiration and selective rather than mandatory arthrotomy for the management of septic arthritis in children.

Method: We compared the outcome for cases of septic arthritis in children reported from this centre in the decade 1982–1991 (Group I) with a contemporary cohort, from 1997–2006 (Group II) using the same criteria for diagnosis and the same treatment principles.

Results: Group I comprised 61 children, Group II 42. The mean incidence of septic arthritis in children (< 13 years old) was similar for Groups I and II (2.9/100,000 and 3.1/100,000). Infection caused by Haemophilus species declined from 10 of 56 (18%) in Group I to none in Group II. Staphylococcus Aureus reduced from 27/56(48%) in Group I to 13(31%) in Group II. As previously, infections particularly of the infant hip were at highest risk of causing permanent joint damage. There were eleven (18%) sequellae in Group I and two (5%) in group II.

Conclusions: These results continue to support joint aspiration for the management of early acute septic arthritis in children. However involvement of the hip in infants requires arthrotomy, as does late (≥4 days) diagnosis in older children.

Introduction: Percutaneous in situ pinning of severe SUFE can lead to problems. We describe our technique and results for surgical dislocation to reduce severe SUFE.

Method: Ganz’s approach of greater trochanteric flip, safe dissection and surgical dislocation to preserve the femoral head blood supply was followed to anatomically reduce the femoral head. We have treated 16 cases in this way, but describe nine with a minimum follow up of 2 years. Their mean age was 13.6 years (9 to 16 years). All had severe SUFE with four acute on chronic and two unstable slips. Two were previously pinned and another had a partially fused growth plate. The mean follow up was 3.1 years (2.1 to 4.6 years).

Results: All patients had a good to excellent outcome. Their pre-operative deformity was 84 degrees (65 to 110) measured by AP and cross table lateral x-rays, CT or MRI scans. The average hip external rotation deformity was 70 degrees. Post operatively internal and external rotation and all other movements were similar to the contra-lateral uninvolved hip. None developed avascular necrosis (AVN) or chondrolysis

Conclusions: This technique is demanding but can give good results for severe SUFE.

Introduction: The management of spasticity of children with cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, orthotists, occupational therapists, physiotherapists and orthopaedic surgeons. Botulinum toxin A therapy in the lower limb has been shown to relieve spasticity and to improve the function in the short term. However, the use of Botulinum toxin A in the upper limb remains controversial.

Aim: To assess any improvement following upper limb Botulinum toxin A injections and to evaluate patient’s and parents’ expectation and satisfaction of the procedure.

Method: During 2007 a total of 36 spastic cerebral palsy patients underwent 47 episodes of Botulinum toxin A injections to the upper limb. There were 22 male and 14 female with a mean age of 6 years old. A questionnaire was devised to assess the outpatient consultation, peri-operative care and the post-operative outcome. Subjective improvement and the patient’s and parents’ evaluation of the procedure were also recorded.

Results: Good to excellent results were achieved in most areas. Daily activities were improved by 52% with an average duration of 4 months. The majority of the patient achieved their expectation. Most patients/parents were satisfied with the procedure and would consider further injections.

Conclusions: Botulinum toxin A injection to the upper limb was generally well received with good short term results. Most would consider further injections.

Aim: To evaluate the accuracy of ultrasound to locate the gastrocnemius musculotendinous junction (GMTJ) prior to surgery. There is no clear clinical method to precisely localise this junction, either in the paediatric or adult populations.

Method: Twenty calves in 12 paediatric patients with a diagnosis of spastic gastrocnemius muscle (GM) contracture underwent ultrasound examination prior to slide lengthening (Strayer). Surgeons did the ultrasound examination after only a short introduction to the method, using a portable ultrasound machine (Sonosite 180 PLUS) with a linear (5–10 MHz frequency range) transducer.

Only the GMTJ of medial head was located as it usually has a lower attachment and is thicker. The soleus muscle has short multipennate fibres running obliquely between aponeuroses overlying its anterior and posterior surfaces. GM has long parallel fibres and merges distally with the posterior aponeurosis of the soleus muscle. The GMTJ has a unique conical appearance on ultrasound. Pre operative skin markings were compared with the location of GMTJ during surgery.

Results: All ultrasound-guided locations of GMTJ were found to be accurate within 5mm at time of surgery.

Conclusions: This study indicates that ultrasound of the calf muscles by a surgeon prior to surgery is an accurate and reliable way of centering the incision over the GMTJ. The distinct morphological structure of the soleus muscle and overlying GM heads means that even surgeons with little ultrasound experience can perform the examination.

Aim: To determine the value of the Pirani clubfoot-scoring system at initial presentation in predicting subsequent relapse.

Method: All clubfoot patients treated by one surgeon from 2002 to 2006 were included. Treatment followed the standard protocol, involving weekly stretching and casting until the foot was corrected, followed by Achilles tenotomy and plasters for 3 weeks. Thereafter, the child was placed in a foot abduction splint.

Relapses within 6 months of instigating the foot abduction splint were classed as early and subsequent relapses as late.

The severity of clubfoot was assessed using the Pirani scoring system which comprises two sub-scores – Midfoot Contracture Score (MFCS) and Hindfoot Contracture Score (HFCS). MFCS and HFCS can each be 0.0–3.0, giving rise to a Total Pirani Score (TPS) of 0.0–6.0.

Results: Sixty-one clubfoot patients were treated, with five lost to the follow-up. A total of 89 clubfeet were treated. There were 3 early and 19 late relapses. The average interval between initiating the foot abduction splint and late relapse was 23 months. TPS median was 4.5 in the no relapse group, 4.0 in the early relapse group, and 5.0 in the late relapse group. MFCS median was 2.0 in the no relapse group, 2.0 in the early relapse group, and 2.0 in late relapse group. HFCS median was 2.5 in the no relapse group, 2.5 in the early relapse group, and 3.0 in the late relapse group. Higher HFCS was statistically significant when comparing the late and no relapse groups (p< 0.05, 95% CI −0.5–0.0).

Conclusions: Higher Pirani scores were associated with late relapses, but HFCS is a stronger predictor of potential late relapse. Close follow-up is advised for patients at risk.

Introduction: Previous studies on ankle arthroscopy have reported the results of treatment in adult patients. To our knowledge there are no studies reporting the out-come in children.

Aim: To analyse retrospectively the outcome of ankle arthroscopy in children.

Method: Between March 2005 and September 2007, twenty-two children (14 boys and 8 girls) underwent ankle arthroscopy for post-traumatic pathology. Their average age was 13.5 years (range 8.6 to 18). The symptoms were ankle pain (21 out of 22), instability (7) or clicking (6). Indications for arthroscopy were no response to conservative treatment, including physiotherapy, for at least 12 weeks or a grade 3 or 4 osteochondral defect (OCD) on imaging.

In five patients radiographs revealed an OCD. MR scans were obtained in eleven patients, which revealed OCDs in five, evidence of tarsal coalition in two, features suggesting posterior ankle impingement in 1 and normal scans in the remaining three.

At arthroscopy OCDs were visualised in nine cases, two of which were grade 4, four were grade 3 and three were grade 2. The grade 4 lesions were debrided and drilled, the grade 3 lesions had their edges debrided and the rest were stable. There were 3 false positive MRI scans where an OCD was reported but not seen on arthroscopy.

Impingement lesions were seen in twelve ankles (8 antero-lateral, 2 syndesmotic, 1 medial and 1 posterior), which were debrided. MRI scans had been performed in eight of these twelve cases but only one suggested an impingement lesion.

Results: Seventeen of our twenty- two patients had complete relief of symptoms at 3 months. They were back to their normal activity including sports. Three patients had persistent pain at 3 months. Two of these showed features of instability, one of which went on to have a Brostrom repair; the second had a repeat arthroscopy and debridement while the third improved with restricted activity. The average AOFAS score improved from 52 pre-operatively to 79 at 3 months following surgery.

Conclusions: Ankle arthroscopy has a successful outcome in paediatric patients with a painful ankle where conservative treatment has failed. MR imaging lacked sensitivity for diagnosing soft tissue impingement of the ankle.

Aim: To review our experience with epiphysiodesis using three different methods to correct LLD and to establish the efficacy of these procedures.

Method: A retrospective review of 42 patients from 1999 to 2008 with at least one year follow-up recorded type and location of the epiphysiodesis, average operating time and hospital stay, complications, method of prediction, timing and the final LLD. CT scanograms and mechanical axis view with grids were used to assess LLD.

Results: Epiphysiodesis was as per Canale for 26, by Metaizeau screw in 14 and by staples in 2. Average operation time was 42 minutes for Canale type, 45 minutes for the screws and 56 minutes for the staple cases. The pre operative LLD of 3.7 cms In the Canale group, improved to 1.2 cms over an average follow-up of 2.1 yrs. There were 4 minor and 2 major complications with a 92% success rate. For the screw group, the mean change was 1.8 cms over 2.2 yrs with 2 minor and 2 major complications giving a success rate of 85%. With staples the success rate was 100% and the mean change was 1.8 cms at an average of 2.3 yrs. In 14 cases where bone age reports were available, the multiplier method seemed better at predicting estimated LLD at skeletal maturity and timing of epiphysiodesis than the Moseley chart.

Conclusions: Percutaneous epiphysiodesis by any method is reliable, minimally invasive and with acceptable complication rate when compared to a corrective osteotomy or open Phemister-type epiphysiodesis. Our experience suggests that the Canale method has the least complications and best success rate. Paleys multiplier method was better at predicting LLD and timing of epiphysiodesis than the Moseley Chart.

Aim: To review our experience with hemi-epiphysiodesis using different methods for the correction of angular deformity about the knee.

Method: This was a retrospective review of 73 patients (101 knees) who underwent hemi-epiphysiodesis from 1999 to 2008. Assessment looked at the type and degree of deformity, implants used, average operating time and hospital stay, complications, degree of correction and the average time to correction.

Results: There were 50 boys and 23 girls with bilateral deformity in 28 cases. There were 88 valgus and 13 varus knees. Average follow-up was 17 months. Staples were used in 28 cases, “8” Plates in 24, Screws in 16 and Drilling in 5 cases. The distal femoral physis was involved in 46 knees, the proximal tibial physis in 21 and both physes in 34 knees (total 135 physes). Average operation time and hospital stay were similar for all methods. There were 6 minor and 3 major complications with staples with an average correction time of 14 months, 3 minor complications with an average correction time of 11 months with “8” plates, 3 minor and 1 major complication with an average correction time of 14 months with screws and 1 minor complication with drilling with an average correction time of 13 months. The outcome was considered as resolved in 47 and pending in 26 cases, with all showing progressive correction of deformity.

Conclusions: Hemi-epiphysiodesis by any method is an effective way to correct angular deformities about the knee in skeletally immature individuals within a reasonable time limit and with minimal morbidity when compared to a corrective osteotomy. Our experience suggests that “8” plates achieve faster correction with the least complications when compared to other methods. Valgus knee deformities corrected faster than varus ones.

Introduction: Benign bone-forming tumours are common in children and adolescents. Careful radiographical and histological study is necessary to distinguish slow growing from more aggressive bone forming tumours. We reviewed 25 cases of primary benign bone forming tumours of the spine to investigate whether there were any obvious differences in their biological behaviour in adults compared to children.

Materials and Methods: Twenty five cases of primary benign bone forming tumours of the spine were identified from the Scottish Bone Tumour Registry: this data is collected prospectively. A retrospective review of this data was performed. There were 9 osteoid osteomas, 15 osteoblastomas and 1 aggressive osteoblastoma. These cases were divided into group A (children) and group B (adults).

Results: There were 16 patients in group A (6-osteoid osteoma, 9-osteoblastoma, 1-aggressive osteoblastoma), 10 boys and 6 girls. The mean age was 12.1 years (range, 6–16 years). There were 2 cervical, 4 thoracic, 8 lumbar and 2 sacral tumours. There were 9 patients in Group B (3-osteoid osteoma, 6-osteoblastoma), 7 boys and 2 girls. The mean age was 26.6 years (range, 18–53 years). There were 1 cervical, 6 thoracic, 2 lumbar and none sacral tumours.

Twenty two tumours were excised and 3 had curettage performed (1 child and 2 adults). There were 2 recurrences (one osteoid osteoma, one osteoblastoma), one from the excision group and one who had curettage, both in adults. These were successfully treated with re-excision. Mean follow-up was 8 years and all were alive at the time of final follow-up.

Conclusions: Benign bone forming tumours of the spine are extremely uncommon. In children they occur more commonly in lumbar spine, while thoracic involvement predominates in adult patients. Good outcomes are obtained with surgical treatment. Recurrence occurred only in the adult group: both of these patients had successful outcomes following further treatment.

Purpose: To compare the postoperative cerebrospinal fluid (CSF) leak rate in two consecutive cohorts of patients undergoing intradural spinal tumour excision with 2 different dural closure techniques.

Methods and Result: Data for this study was collected retrospectively from case notes. Between January 1994 and December 2001 forty seven intradural (thirty two extramedullary and fifteen intramedullary) spinal tumour excisions were performed. The dural incision was closed using vicryl 6.0. Operations of nine patients in this group (19 %) were complicated by CSF leak. From 2002 onwards the closure method for dural incisions was changed to single layer continuous prolene 6.0 suture in conjunction with a check valsalva manoeuvre prior to closure of wound incision in an attempt to reduce the incidence of CSF leak. Fifty three (thirty three extramedullary and twenty intramedullary) patients underwent intradural spinal tumour excision between January 2002 and October 2008. Three (5.7%) patients developed cerebrospinal fluid leak and one (1.9%) patient developed a pseudomeningocele post operatively. All four patients were subsequently managed with a lumbar drain. In both groups of patients good exposure of the proximal and distal aspect was achieved prior to dural closure. Statistical analysis comparing the outcome of both groups was performed using Fisher’s exact test – p values calculated were 0.0381 (one-tailed) and 0.0618 (two-tailed).

Conclusion: Single layer continuous prolene suture in conjunction with a check valsalva manoeuvre is superior to vicryl alone for the closure of the dura post intradural spinal tumour excision. The reduction in the leak rate may be due to the valsalva manoeuvre itself rather than the different suture material. Along with good exposure to the proximal and distal aspect of the incision we feel that this can reduce post operative cerebrospinal fluid leak in intradural spinal tumour excision operations.

Purpose of study: There is a controversy in the surgical treatment of unstable thoracolumbar burst fractures scoring high on the Load Sharing Classification (LSC). We have been treating unstable thoracolumbar fractures with postero-lateral fusion using short segment instrumentation and in this study we investigated our complication rate.

Methods and results: We retrospectively reviewed notes and radiographs of patients presenting with thoracolumbar burst fractures and stabilised with a short-segment instrumented postero-lateral fusion between 1998 and 2007. We identified 31 patients who had adequate documentation and radiographs. Twenty patients had a high (> =7) LSC score and none of these fixations failed. Overall early and late complication rate was low (one wound infection, one dehiscence and four unrelated infections), the one metalwork failure related to infection. Fifty-five percent of patients returned to full-time work. Approximately 50% of correction of kyphosis was lost but the average kyphosis at final follow-up was 11 degrees that we thought was acceptable.

Conclusion: We concluded that treating unstable burst fractures with posterior instrumented fusion alone using a pedicle screw construct does not result in late instrumentation failure, high complication rate or unacceptable final deformity.

Ethics approval: None

Interest Statement: None

Introduction: A retrospective analysis was performed to determine the oncological outcome of patients with Ewing’s sarcoma of the spine treated with combined chemotherapy and radiotherapy for definitive local control.

Materials and Methods: Fifteen patients were identified from the Scottish Bone Tumour Registry with a histologically confirmed Ewing’s sarcoma affecting the axial skeleton. All case notes and imaging were retrospectively reviewed.

Results: Primary vertebral Ewing’s sarcoma accounted for 8.3% of all malignant spinal lesions in our registry. The mean age was 17.8 years (between 4 and 39 years). There was a male predilection with 9 male and 6 female patients. Site was evenly distributed between cervical (4), dorsal (5) and lumbosacral (6) regions. Progressively worsening back pain was the first symptom in all the patients. Satisfactory imaging studies were available in all with plain radiographs (15), bone scan (11), CT-scan (12) and MR Scan (9) patients.

Biopsy was performed in 11 patients and surgical treatment was carried out in 3 patients including curettage (2) and excision with bone grafting (1). All patients were treated with adjuvant radiotherapy while 87% also received adjuvant chemotherapy. Seven patients were alive with no evidence of disease at a mean 6 year follow-up. Six patients died of metastatic disease, one due to local recurrence and one with persistent primary disease. The mean follow-up time was 65 months (median 28 months; ranging from 12 to 218 months).

Conclusions: Primary vertebral Ewing’s sarcoma comprised 8.3% of our National Registry’s primary malignant spinal lesions. Progressive vertebral pain in the late second decade and male gender should raise the suspicion of Ewing’s sarcoma. Ewing’s sarcoma of the spine treated with combined chemotherapy and radiotherapy for definitive local control achieved a 45% five year survival.

Introduction: The management atlanto-axial fractures, particularly those of the odontoid peg, remains controversial. We managed patients with C1/C2 fractures non-operatively in rigid immobilization until CT-scanning confirmed bony union, rather than for the standard 3-month period. We examined whether this improved outcomes and reduced the need for surgery.

Method: All patients admitted to our unit with atlanto-axial fractures between 2001–2007 were retrospectively analyzed. All fractures had the ‘intention-to-treat’ conservatively in either halothoracic vest (85%) or Aspen collar (15%). Rigid immobilization was maintained until CT-scanning demonstrated bony fusion. Functional stability was subsequently assessed with flexion-extension radiographs after removal of rigid immobilization.

Results: Twenty-seven patients were studied. Nineteen had odontoid peg fractures (10 type II; 9 type III). The remainder consisted of 3 Hangman’s, 3 lateral mass and 2 atlas ring fractures. 83% of patients progressed to union at an average of 13.2 weeks (range 5–22). Six complications related to halo immobilization were observed (three skull perforations/pin-site infections). All of these patients progressed to union non-operatively.

Failure of non-operative management was deemed as non-union or poor patient tolerance of halo, and occurred in 4 patients (17%). All four had type II odontoid peg fractures, and had transarticular screw fixation. One postoperative complication of screw fracture was recorded.

Conclusion: Non-union rates of conservatively managed atlanto-axial fractures with standard 3-month rigid immobilization have been reported as high as 35%. In our series, CT-imaging to confirm bony union prior to removal of the rigid immobilization (prolonging immobilization where necessary) significantly lowered the rate of non-union and therefore the need for subsequent surgery.

Ethics approval: None Audit

Interest Statement: None

Purpose: To investigate whether patients who present with Lumbar radicular signs and symptoms and who have MRI scans reported as showing no nerve root compression, improve following Nerve Root Injection (NRI).

Methods: The clinic notes and MRI results of 127 patients who underwent NRI under the care of two spinal surgeons were reviewed retrospectively. Those patients with radicular pain and MRI scans reported as showing no nerve root compression were evaluated further. All patients had a selective NRI using a standard image intensifier guided oblique approach with 40 mg Kenalog and 1 ml 0.25% bupivacaine injected around the nerve root. The patients’ symptoms and signs were noted at the follow up appointment six weeks later.

Results: 43 of the 127 patients who underwent selective NRI had MRI scan reports suggesting no nerve root compression. Of the 47 patients 30 (69%) reported a significant improvement (p=0.0009) in their leg pain following the NRI, the remaining 13 patients reported no relief.

Conclusions: Clinicians treating patients presenting with lumbar radicular signs and symptoms should not rely on MRI report alone in the diagnosis and management of the patient. The results show that patients who exhibit lumbar radicular signs and symptoms who have non-concordant MRI results may still benefit from treatment (NRI).

Ethics approval: None required

Statement of interest: None

Purposes: To assess the influence of patients’ positioning following caudal epidural injections on the outcome.

Methods and Results: 58 patients with low back pain and sciatica undergoing caudal epidural injection were prospectively and randomly allocated into 2 groups. 28 patients (Group 1) were positioned on the side (same side of sciatica) following the injection while 29 patients (group 2) were laid on the back. Patients were assessed using Oswestry disability index and the leg pain intensity was scored using Numerical pain intensity scale before surgery and after 6 weeks following the procedure. Pre-and postoperative pain scores were reviewed for each individual patient and the rate of improvement or worsening was noted. In group 1, 92.8 % of patients had their leg pain improved and 7.2 % remained unchanged. In group 2 however, 77% of patients did improve whereas 13.7% failed to do so and 6.8 deteriorated on the pain scale. There was a statistically significant difference in the degree of pain score improvement in favour of Group1 (Mean: 2.75 points on the scale for group 1 versus mean: 1.31 for group 2, P< 0.001, Mann-Whitney test). No difference was noted between the two groups in the improvement in the disability index (P< 0.14).

Conclusions: Lying on the symptomatic side following caudal epidural injection has improved the result in terms of pain control. Such a simple manoeuvre could add benefit to the injection in terms of pain for which the procedure is mainly indicated. The longstanding functional disability remained unchanged.

Ethics approval: None

Interest Statement: None

Introduction: There is little evidence for the long term efficacy of selective nerve root injections (SNRI) in the control of lumbar radiculopathy. We report the 5 year results of a prospective study of SNRI in the lumbar spine.

Methods: All patients considered to be operative candidates by two treating surgeons (JMP and DJS) with unilateral/bilateral radicular leg pain were included. Patients had a mean history of radicular symptoms of 12.8 months (4 months–3 years). All had an SNRI under image intensifier control with local anaesthetic and steroid. Each patient was evaluated pre-operatively, 2 months, 6 months, 1 year, 2 year and 5 years with VAS and ODI scores.

Results: Sixty-two consecutive patients were reviewed. The mean age of patients was 54.5 years (36–80 years). 92 injections were performed. Symptoms were caused by degenerative disease (n=32), disc herniation (n=25), and previous surgery (n=3).

The ‘disc’ group was significantly younger than ‘degenerative’ group (49.4 yrs vs. 58.4 yrs; p=0.004). There were significant improvements in low back pain (LBP), leg pain (LP), and ODI at 2 months in all patients. At 5 years the disc group did better with both leg and back pain; whilst there was only a significant reduction in leg pain in the degenerative group. Over 90% (n=56) of patients had no operative intervention; a subgroup of 8 had further injections. Within the degenerative group, ODI and VAS deteriorate early on indicating that a second injection option in this group may be worthwhile.

Conclusion: At five-years, most patients avoid operative treatment because of improved symptom control with SNRI. Regression analysis showed “duration of symptoms” and “age” is predictive of good outcome at one year post SNRI, but gender and, diagnosis are not.

Background: Nerve Root pain is a problem caused by mechanical compression from disc herniation or foraminal stenosis, which stimulates an inflammatory response. We present a review of the evidence for corticosteroid infiltration in nerve root infiltration (NRI).

Methods: Medline, Embase, trial registries, conference proceedings and article reference lists were searched to identify randomised controlled trials of the use of NRI in the treatment of radicular pain. For the purpose of this meta-analysis, the control group “no steroid” was chosen to encompass various subtypes. The primary outcomes were Oswestry Disability Scores (ODI) and Visual Analogue Scores (VAS) for pain. Outcomes were compared at 3 and 6 months from injection. For the purpose of the meta-analysis, repeat injection and progression to surgery are grouped as a composite endpoint.

Results: We identified 96 papers; but only 5 RCT’s which included 402 patients receiving NRI; 202 were randomised to receiving steroids. No trials reported significant intergroup differences in baseline VAS or ODI.

At 3 months there was no significant difference in VAS or ODI between the groups. Only two trials reported ODI data at 6 months but a significant effect in favour of the control arm was noted (P = 0.040). Four of the five trials reported the need for further injection or surgery due to failure but no significant difference between the groups was found (P = 0.038).

Conclusion: Our analysis suggests that the addition of steroids to local anaesthetic agents or placebo solutions confers no additional benefit, but the theoretical risk of infection. Further information is needed on hospital stay, economic and long term responses, and is required to counter confounding with small trials and study numbers, and any methodological heterogeneity.

The study was designed to quantify the hit/miss ratio of non-radiologically assisted caudal epidurals, assessing both accuracy of entry into the epidural space and adequacy flow of contrast and therapeutic agents to the level of pre-defined pathology.

We studied 146 consecutive patients listed for a caudal epidural under sedation for either radicular pain or spinal stenosis. When the surgeon was happy with placement of the needle its position was assessed using image intensifier and injection of radio-opaque dye (Omnipaque). The epidurogram was also used to confirm the level of pathology had been reached by the steroid and local anaesthetic.

Three patients were excluded because of inadequate records. Five patients did not attend for their procedure. Of the remaining 138 patients Consultant spinal surgeons carried out 75 procedures and the remaining 63 cases were performed by “middle grade” surgeons. 36 of 138 patients (26%) had placement of spinal needle outside the epidural space after first blind placement. Hit rate was not related to surgeon grade, patient age or patient diagnosis. In 6% of cases the radio-opaque dye did not reach the level of documented pathology had been reached by the dye. 2 patients had a “spinal” pattern of block requiring overnight admission, there were no other complications recorded.

A miss rate of 26% in the blind placement of spinal needles through the sacral hiatus in caudal epidurals is unacceptable. We would therefore recommend position of the needle is confirmed radiologically and epidurogram is used to confirm accurate delivery of the therapeutic agents.

Interest statement: none

Ethics approval: none (study of current practice)

Objective: We prospectively compared the techniques of skip laminectomy and laminoplasty for the treatment of cervical spondolytic myelopathy in terms extent of decompression achieved, axial pain, postoperative range of cervical motion, patient and surgical outcomes.

Methods and results: We studied fifty consecutive patients operated on for cervical spondolytic myelopathy and spinal cord compression as demonstrated on MRI between the levels C3–4 to C6–7. Each patient had a minimum follow-up of two years (2.2 – 4.3 years). Twenty-five patients underwent skip laminectomy and twenty-five patients underwent laminoplasty. Decompression was assessed by pre- and post-operative MRI. Cervical range of motion was assessed by pre- and postoperative flexion and extension radiographs. Patient outcomes were assessed by evaluation of pre-and postoperative neurology and SF12 scores for mental health, physical health and axial pain.

Less blood loss and operative times were found with skip laminectomy. Similar degrees of decompression with both techniques. Significantly improved axial pain scores with skip laminectomy. Significantly improved preservation of range of movement with skip laminectomy.

Conclusion: Skip laminectomy is an effective procedure for reducing the incidence of postoperative morbidities, such as persisting axial pain, and restriction of neck motion often seen after laminoplasty, and provides adequate decompression of the spinal cord as demonstrated on MRI for a minimum follow-up of two years.

Objective: To assess outcome in patients with syrinx and non-syrinx associated Chiari malformations undergoing Foramen Magnum Decompression (FMD).

Methods: 61 patients undergoing FMD for Chiari malformations were prospectively studied with disease specific, generic (SF 36) and subjective (surgeon assessed) outcomes. 34 patients had complete data. Disease specific outcomes were visual analogue pain scores, Neck and Myelopathy disability indices and the Hospital anxiety and depression score. SF 36 scores were compared to normative data. Data were collected pre-operatively, at 3 months and during long-term follow up (12–60 months).

Results: Subjective improvements in headache and neck pain post-operatively were seen in both syrinx and non-syrinx associated patients. Visual Analogue scores showed an improvement in Arm pain, Paraesthesia and Hand tingling by 3 months in the syrinx group only. Non-syrinx patients showed significant improvement post-operatively in the Neck disability index and the SF-36 domains for physical function, role physical and bodily pain by 12 months. Comparison with the SF 36 normative data showed that patients still have significantly impaired quality of life 12 months post operatively despite the improved scores achieved following surgery.

Conclusion: FMD is able to relieve symptoms and improve quality of life in patients with both syrinx and non-syrinx associated Chiari malformations. The SF-36 data presented in this paper allows the health gain associated with FMD to be quantified but its utility as a sole measure of outcome in this complex disorder will be discussed.

Ethics approval: None

Interest Statement: None

Background: Several recent studies have compared incorporation of autograft with that of allograft or synthetic bone substitutes in anterior cervical discectomy and fusion (ACDF). These studies have almost universally relied on plain radiography to assess bone incorporation despite the fact that we know, from similar lumbar spine studies, that bone ingrowth is over-estimated.

Our aim was to determine the exactly whether bone incorporation may be correctly assessed by this method by comparing the results to those obtained by spiral CT imaging.

Methods: 15 patients underwent ACDF. Helical CT scans were obtained. Fusion was defined as trabecular continuity across the disc space anterior, through and posterior to the cage proximally and distally and assessed by two of the authors independently.

Results: 14 of the 15 patients appeared to have solid incorporation of bone graft/substitute on plain radiography, 19 out of 20 cages. These findings were not however replicated on CT imaging. The autograft was not considered to have been incorporated proximally above the cage in 5 cases and distally in 6 cases.

Discussion: The implication of our results is that there is at least a false positive rate of bone incorporation of 20–25%. Pseudarthroses are generally painful and therefore we would recommend that spiral CT imaging is performed in patients who have ongoing pain following ACDF.

Ethics approval: COREC Ethics committee number 06/S1104/34

Interest Statement: None of the authors have received any grants to carry out this research.

Statement of purpose: To profile the neurological lesions associated with scoliosis, evaluate the role of preoperative MRI and determine the proportion of patients requiring surgery for an intradural lesion.

Methods: The records of patients undergoing surgery to treat scoliosis over a 5 year period were reviewed as part of this retrospective single centre study.

Results: 1926 patients underwent 2714 procedures to treat scoliosis. 45 patients from this cohort were referred for an opinion regarding at least one of the following neural axis abnormalities: Syrinx (47%); Chiari malformation and cerebellar ectopia (40%); tethered cord (13%); persistent central canal (9%); diastematomyelia (7%); neurofibromata (7%); syndromes other than neurofibromatosis (7%); tumours (4%) and vascular lesions (2%).

18 patients underwent surgery to treat a neural axis lesion: Foramen magnum decompression (12); cord untethering (4) and the surgical treatment of diastematomyelia (2).

Conclusions: The authors believe their series to be the largest to date.

Preoperative MRI scans should extend from the cranio-cervical junction to the sacrum, reflecting the potential locations of neural axis lesions.

Radiologists present at units treating scoliosis should be able to identify both commonly occurring lesions such syrinx and intradural pathology.

A significant proportion of patients required surgery to treat their neural axis lesions. Centres treating patients with scoliosis should therefore have the necessary facilities to treat not only scoliosis but also its associated intradural spinal lesions.

Ethics approval: None Audit

Interest Statement: None

Purpose of study: To demonstrate the safety and efficacy 3 and 4-level ACDF with stand-alone (no additional anterior fixation) intervertebral cages.

Methods and results: A consecutive cohort of 19 patients undergoing 3 (n=15) and 4-level (n=4) ACDF with Solis cages over 4 years was studied (mean follow-up 24 months). Outcome measures were clinical (VAS scores for neck and arm pain, myelopathy scores) and radiological (disc height, kyphotic angles, fusion).

Neck pain scores improved from 5.1 pre-operatively (range 0–10, s.d. 4) to 2.8 post-operatively (range 0–10, s.d.5), t=3.7, P< 0.0002.

Arm pain scores improved from 5.3 pre-operatively (range 0–10, s.d. 5) to 2.5 post-operatively (range 0–8, s.d. 3), t=2.8, P< 0.009.

Pre-operative myelopathy scores averaged 10.6 (range 7–16, s.d. 4.7) rising to 12.8 post-operatively (range 10–17, s.d. 3.9). Although there was no statistically significant change in myelopathy scores, no patient experienced a worsening of their myelopathy score after surgery.

There were no operative complications. Radiological follow-up demonstrated early improvement in disc space heights (pre-op 3.1 mm, range 1–6 mm; post-op 5.6 mm, range 4–9 mm) but, at 12 months, two patients demonstrated asymptomatic evidence of cage settling and loss of disc height. There was no incidence of pseudarthrosis. No patient has thus far required further surgery.

Conclusion: Multi-level cervical disc disease can be managed safely and effectively by 3 or 4-level discectomy and fusion with stand-alone intervertebral cages.

Ethics approval: None – audit

Interest Statement: None

Purpose of study: Cervical corpectomy is a well established procedure for spinal pathology. We have applied this technique using a titanium standalone cage or a cage with cervical locking plate filled with bone debris of the corpectomy for vertebral reconstruction. The study was aimed to determine the efficacy and assess the morbidity of this procedure.

Methods: Case notes of all patients who underwent cervical corpectomy from March 2004 to September 2008 were reviewed retrospectively.

Results: 47 patients were identified 28 male and 19 female. The mean age was 58 (range 40 to 82). Single level corpectomy was performed in 21 patients, 2 levels in 19 and 3 levels in 6 patients. One case was abandoned and one had additional laminectomy and lateral mass fusion. 89% of cases needed corpectomy for degenerative disease, whilst 11% for malignant disease.

Complications included dural tear in 5 patients, subsidence in 4, laryngeal nerve palsy in 2, postoperative haematoma in 2 and infection in 1 patient.

At mean follow-up of 25 months (range 3 to 52), 84% were better, 10% remained same and 4 % of patients worsened.

Conclusion: Cervical corpectomy is a safe and effective method of managing cervical pathology. It not only provides stable vertebral reconstruction but also eliminates donor graft site related morbidity.

Ethics approval: None Audit/service standard in trust Ethics committee COREC number:

Interest Statement: None Local grant/National grant Commercial/industry support

Aim: In sub-axial cervical vertebrae the lamina appears to project perpendicular to the ipsilateral pedicle axis, and forms a reliable trajectory for avoidance of vertebral artery injury in lateral mass (LM) screw placement: the aim is to confirm these observations.

Material and Methods: 51 digital cervical spine CTs (255 vertebrae; 25 female 26 male; mean age 37.4 range:18–80). Exclusions: Severe degeneration, malformation, tumour, trauma.

Measurement (axial view):

Angle of ipsilateral outer lamina cortex to pedicle axis

Results: Average lamina-pedicle angle (standard deviation):

Females: Right: C3–84.8°(2.6), C4–85.2°(3.1), C5–86.7°(3.3), C6–89.2°(2.5), C7–92.3°(2.4);

Conclusion: The angle formed by the lamina and ipsilateral pedicle ranges from 84° at C3 to 92° at C7. Although the angle is not exactly perpendicular at all levels as hypothesised, the lamina forms a useful reference plane for pedicle screw insertion in the sub-axial cervical spine.

LM screws placed parallel to the lamina find sufficient LM width and are highly unlikely to injure the vertebral artery in bi-cortical placement. This technique appears favourable over conventional 30° LM placement.

Ethics approval: None needed

Interest Statement: None

Purpose: To determine the clinical effectiveness of a stand alone interspinous distraction device

Method: Prospective consecutive longitudinal study in five hospital sites. Outcome measures Oswestry Disability Index (ODI), Visual Analogue score for leg and back (VAS Leg, VAS Back). Implant failure determined by removal and revision.

A cohort of 69 patients having clinical and radiological evidence of spinal stenosis. Selected according to recommendations of clinical trials groups for the x-stop, i.e. sitting tolerance of greater than 30 minutes.

Clinical outcome data at average of 10 month (6–24) available for 66 patients (95% FU).

Average age 67 years ( Range 49–84). The average outcomes were Pre op ODI 42, Post op ODI 27. A change from baseline of 15 points. Pre op VAS leg 7.2 post op 4.4, and VAS Back Pre 4.8, post op 3.6

Taking a 16 point change in ODI as representing a clinically significant improvement half the study group failed to achieve this. A small number (17 patients 25%) had a dramatic improvement of greater than 24 points, which significantly skews the average change from baseline.

17 Revisions have occurred so far (24% failure rate)

Conclusion: A small proportion of successful results occur, however implant failure and revision rate is high.

Ethics approval: NPIAG registered audit

Interest Statement: No commercial or grant support

Purpose: To determine if the short term benefits we reported from X STOP implants for lumbar radiculopathy were maintained at 2 yr follow up

Methods and Results: We followed all patients, of one neurosurgeon (TG), having XSTOP implants to treatment lumbar radiculopathy secondary to foraminal stenosis. We measured patient-reported pain and disability outcomes (Oswestry disability index, ODI; Short Form 36 bodily pain scale, SF-36 BP) immediately pre-op and approximately 2 years post op. Changes were examined in terms of statistical significance (Wilcoxon signed ranks test) and clinical significance (effect sizes – mean change divided by SD change).

2 yr follow up data were available for 13 of the 15 people who had the surgery. One had died of an unrelated condition before follow up, the other had further lumbar surgery thus affecting the interpretation of the data. Mean duration of follow up was 30.5 months.

Both ODI and SF-36 BP detected sustained improvements 2 yrs after surgery. Results for both scales were statistically significant (z = −3.059 & −3.062; p = 0.002). Mean change scores for both scales were substantial (ODI = 31.7; SF36 BP = 47.4), and effect sizes were very large (ODI = 1.35; SF-36 BP = 1.37) indicating clinically significant improvement. There have been no complications.

Conclusions: These provisional data, albeit from a small sample, provide increasing evidence to imply that the X STOP procedure may suit people with radiculopathy secondary to foraminal stenosis. Moreover, it has been safe and does not jeopardise future surgery in the event of failure.

Ethics approval: None, Audit

Interest Statement: None

Purpose: To describe the clinical, biomechanical and radiological features of a spinal implant failure

Method: Over a two year period 45 patients had treatment of spinal stenosis with the X-stop device. 38 had a single level treated, 7 had two level implants. Average age 68. Pre op walking distance 120 meters, Pre op Oswestry Disability Index (ODI) 45%.

11 patients have had implants removed, a 24% implant failure rate. Clinical failure also occurred in two patients unfit for revision. Prospective data on standard spine outcomes were analysed as well as the radiological and biomechanical features of failure.

Results: One year survivorship was 71%. At 6 months the average walking distance improved to 1430 meters, and the average ODI improved to 26%. Some patients exhibit dramatic improvements which obscures the failures.

There were two modes of failure, early, with a failure to improve after the procedure, and late, with an initial improvement and subsequent deterioration.

A consistent feature of late failure is bone resorption around the implant. This is apparent on post operative radiographs and is a progressive. Scalloping and erosion of bone is seen at revision surgery with the implant within a fibrous capsule. Late spinous process fracture occurred in a two level implant as a result of erosion.

Retrieved implants demonstrate scouring of the PEEK surface which increases with time.

Conclusion: Long term surveillance should be mandatory. The implant should be withdrawn from clinical use until trials establish long term efficacy and safety.

Ethics approval: Registered with Hospital new procedures advisory group audit

Interest Statement: No commercial support

Purpose: To report the clinical and radiographic prospective results of a consecutive series of patient with a minimum two year follow-up with the Charite Total Disc Arthroplasty (TDA).

Methods: Between 2001 and 2005 sixty patients underwent a Charite TDA (Depuy Spine, Raynham, MA) at either L4–5 or L5-S1. The primary indication for surgery was discogenic low back pain confirmed by provocative discography. Clinical assessment was carried out preoperatively and postoperatively at 3, 6, 12 months, and once a year thereafter using the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) for back and leg pain, and SF-36. Radiographic analysis included: angle of sagittal rotation, translation of the rostral vertebra onto the caudal vertebra, anterior vertical motion (AVM), middle vertical motion (MVM), posterior vertical motion (PVM), pre- and post-operative lumbar lordosis, disc height and subsidence of the TDA. The radiographic measurements were performed using the GE Medical Systems Centricity PACS Software Version 1.0.

Results: There were 36 female and 24 male patients with a mean age of 39 (range 21–59). The mean duration of low back pain was 70 months. Twenty-five percent claimed work compensation status. The mean post-operative hospital stay was 4.8 days. A statistical significant improvement was demonstrated between the mean pre-operative ODI (50) and all post-operative intervals (p< 0.0001) which had declined to 27.7 by one year. Similarly, pre-operative VAS back pain (8.0), leg pain (6.1), SF-36 physical component summary score (33.5) and mental component summary score (41.8) remained improved (p< 0.0001) by three months (4.1, 3.1, 51.7, 62.0 respectively).

The mean pre and post-operative lumbar lordosis was 34.58 and 53.48 respectively. The mean sagittal rotation was 6.5 degrees at 5 year follow-up, while the mean translation was 0.83 mm. The mean AVM, MVM and PVM were 0.59 mm, −3.96 mm and 3.69 mm respectively at 5 year follow-up.

Conclusion: This study demonstrates satisfactory clinical results in carefully selected patients. The radiographic assessment confirmed preservation of movement at the replaced disc during flexion and extension of the lumbar spine.

Interest Statement: No financial benefits or funding has been received for the completion of this study.

Aims: To establish whether self rated disability and physical function in people with Chronic Low Back Pain (CLBP) are correlated.

Design/Methods: The study was observational/correlational in design. One hundred patients attending orthopaedic surgical clinics or for physiotherapy at the Northern General Hospital (NGH) site of Sheffield Teaching Hospitals (STH) were recruited for the study. Once consent was obtained patients were asked to complete the Oswestry Disability Index (ODI) and undertake the Harding battery of physical performance.

Results: The Pearson product moment correlation coefficients were calculated for the group using SPSS v.13. The results show low negative correlations for the whole group with low to moderate negative correlations for the male group. There were no statistically significant correlations for the physical performance measures and ODI in the female sub-group.

Pearson correlation Co-efficient results for all participant

Conclusions: The lack of correlation between self-rated disability and physical performance suggests that the two constructs are un-related and as such should be measured separately. There were significant differences between the physical performance parameters between genders. This enhances the findings of previous studies which, together with this study suggest that the level of physical performance should not be extrapolated from self-rated disability questionnaires.

Ethics Approval: The study was approved by the North Sheffield ethics committee (ref: 07/H1308/120) and Sheffield Teaching Hospitals NHS Foundation Trust (ref: STH 14280)

Statement of interest: None

Purpose: To investigate subsidence of the Charite total disc arthroplasty (TDA) and to identify if a discrepancy between vertebral endplate and the Charite footprint predispose to subsidence.

Methods: Between July 2001 and May 2008 64 patients underwent a Charite TDA (DePuy Spine, Raynham, MA). They were prospectively followed at 3, 6, 12 months, and once a year thereafter.

The following measurements were performed on the replaced motion segment using a lateral radiograph:

The anterior-posterior (AP) dimension of the end plates.

The ratio between the actual and radiographic AP length of the metal endplate was calculated and utilized as the correction factor for the error of magnification on all other radiographic measurements.

Results: At L5-S1 the mean subsidence was 1.87 mm and occurred exclusively at the posterior part of the inferior end plate of L5. The mean posterior uncoverage was 3.5 mm (L5) and 0.27 mm (S1).

At L4–L5 the mean subsidence was 1.48 mm (L4) and 0.56 mm (L5). Posterior uncoverage of L4 and L5 vertebrae were 4.81 and 2.22 mm, respectively.

Subsidence of more than 1 mm was present in all cases where the posterior uncoverage of the end plate with the TDA was more than 2 mm (odds ratio: 5.7). Subsidence was non – progressive in all cases.

An anatomic mismatch exists between L5 and S1 endplates in the AP dimension; in more than half the patients S1 is shorter than L5.

Conclusion: The radiographic measurements suggest an increased likelihood of subsidence with more than 2 mm of posterior uncoverage of the end plate by the TDA. The endplate AP length of S1 is frequently less than that of L5. Implant selection based on the smaller S1 endplate may produce worrisome uncoverage of the L5 inferior endplate leading to an increased risk of subsidence and possible catastrophic failure. TDA design should afford modularity to compensate.

No financial benefits or funding has been received for the completion of this study.

Aims

to determine what aspects of people’s lives (domains of impact) where most affected by their spinal problems,

Methods & Results: Data was collected prospectively. New patients attending the spinal clinic completed a questionnaire about their symptoms. They were also asked to list, in order of importance to them, the 3 aspects of their daily life most affected by their symptoms. Responses were in free text format, summarised with the most appropriate single word response (e.g. walking) and grouped. Thoraco-lumbar and cervical pain/pathology were analyzed separately. We computed: (1) the total number of domains of impact identified; (2) the frequency (%) each domain was listed 1st; (3)the frequency (%) each domain was listed 1st, 2nd, or 3rd

Cervical pathology (n=200 people).

19 domains were identified. Of domains identified as first most important (n=164) 3 domains predominated: work (28%), sleep (24%), walking (24%). Others ranged from 0 – 7.6%. Of all domains identified by all people (n=399), 4 predominated: sleep (62%), work (54%), walking (41%) sitting (36%). Others ranged from 0.6% to 9.8%.

Thoraco-Lumbar pathology (n=537 people).

25 domains were identified. Of domains identified as first most important (n=429) 4 domains predominated: walking (49%), working (18%), sitting (12%) and sleeping (11%). Others ranged from 0 – 7.6%. Of all domains identified by all people (n=1096), 4 predominated: sleep (76%), work (50%), walking (47%) sitting (45%). Others ranged from 0.2% to 11.9%.

Conclusions: People with spinal problems consistently identify 4 main domains of impact: working, walking, sleeping and sitting. This is not reflected by SF-36 and ODI. Further work is required to ensure that scale selection for assessing the impact of spinal pathology and its management is evidence based.

Ethics approval: none

Interest statement: none

Racial and ethnic disparities in pain perception diagnosis and management have become apparent in different specialities.^1,2 We aimed to assess the differences in symptom perception, as expressed in the oswestry disability score, between different ethnic groups in a UK population before and after surgery.

Oswestry Disability Scores (ODI) (completed at every outpatient visit), and other information were obtained retrospectively for 1568 patients seen at our spinal unit over the last two years. Statistical analysis using analysis of variance (ANOVA) was used to determine any true difference in ODI scores between Caucasian, Afro-Caribbean and South Asian different groups pre and post surgery.

Overall scores were significantly higher for the South Asian group when compared with the white using analysis of variance (ANOVA) p< 0.001. Afro-Caribbean patients also showed a trend to higher overall scores from the white group p=0.091 (least squares difference post-hoc test).

From a total of 280 patients who had undergone surgery, South Asians had significantly higher pre-operative scores compared to Caucasians (p> 0.001). Afro-Caribbean’s also scored higher than Caucasians pre-operatively although the difference was not significant (p=0.091). Scores for South Asians and Afro-Caribbean’s remained higher than those for Caucasians postoperatively. All groups however, did show a statistically significant reduction in ODI score compared to the pre-operative score.

Despite the differences in symptom perception or expression we have found to exist between ethnic groups, we conclude that in appropriately selected patients, this does not affect their ability to benefit from surgery

Ethics approval: none

Interest statement: none

Introduction: There is still no standard approach to applying the Romberg test in clinical neurology and the criteria for and interpretation of an abnormal result continue to be debated.

Methods: Detailed clinical examination of 50 consecutive patients of cervical myelopathy was performed prospectively. For the walking Romberg sign, patients were asked to walk five metres with their eyes open. This was repeated with their eyes closed. Swaying or inability to complete the walk with eyes closed was interpreted as a positive walking Romberg sign. This test was compared to common clinical signs to evaluate its relevance.

Results: Whilst the Hoffman’s reflex (79%) was the most prevalent sign, the walking Romberg sign was present in 74.5% of the cases. The proprioceptive deficit was evident by only using the walking Romberg in 21 out of 38 patients that had a positive Romberg sign. Though not statistically significant, the mean 30 metre walking times were slower in patients with standing Romberg test than in those with positive walking Romberg test and fastest in those with neither of these tests positive. The combination of either Hoffman’s reflex and/or Walking Romberg was positive in 96% of patients.

Conclusion: The walking Romberg sign is more useful than the standing Romberg test as it shows evidence of a proprioceptive gait deficit in significantly more patients with cervical myelopathy than is found on conventional neurological examination. The combination of Hoffman’s reflex and walking Romberg sign has a potential as useful screening tests to detect clinically significant cervical myelopathy.

Ethics approval: none

Interest statement: none

Aim: To analyse the impact of implant position in the outcome of Charite III Disc Replacement implants.

Methodology: 160 Charite III Lumbar Disc Replacements that were implanted between 1990 and 2000. The average age was 46 years with 62 Males and 98 Female subjects. An independent observer (HN) administered Pain score (VAS 1–10) for Low Back Pain (LBP) and Oswestry Disability Index (ODI). These clinical outcome parameters were compared with coronal and sagittal position of the implants from the latest available radiographs. Those with operation at L3L4 (small numbers = 20) and inadequate radiographs were excluded.

Results: 48 implants were optimally placed and 70 implants were placed sub optimally. Both the groups were in similar age groups (45.02 years, SD 7.61 and 48.31 years, SD 8.04). Clinical: No statistical or clinically significant difference was observed in LBP on VAS (4.92 V/S 4.41), ODI (42.8 V/S 38.0) and in Patient Satisfaction at an average follow up of 70 months. Movements: Average movement at optimally placed discs at L4L5 was 4.4o(95% CI 2.3–6.7) and at L5S1 was 5.9o(95% CI4.2–7.5) and at sub optimally placed disc at L4L5 was 3.8o(95% CI 2.4–5.1) and at L5S1 was 3.8o(95%CI 2.3–5.3).

Conclusions: Clinical and radiological results after Charite III Disc Replacement is NOT dependent on positioning of implants.

Ethics approval: None

Interest Statement: None

Purpose: Self reported walking distance is a clinically relevant measure of function, our aim was to report patient accuracy and understand factors that might influence perceived walking distance.

Method: A prospective cohort study. 103 patients were asked to perform one test of distance estimation and 2 tests of functional distance perception using pre-measured landmarks. Standard spine specific outcomes included the patient reported claudication distance, Oswestry disability index (ODI), Low Back Outcome Score (LBOS), visual analogue score (VAS) for leg and back, and other measures.

Results: There are over-estimators and under-estimators. Overall the accuracy to within 10 yards was only 5% for distance estimation and 40% for the two tests of functional distance perception. Distance: Actual distance 121.4 yds; mean response 268yds (95% CI 192.8–344.15), Functional test 1 actual distance 32 yards; mean response 78.4 yds (95% CI 58.6–97.3) Functional test 2 actual distance 21.4yds; mean response 51.9yds (95% CI 38.3–65.5). Surprisingly patients over 60 years of age (n=43) are twice as accurate with each test performed compared to those under 60 (n=60) (average 70% overestimation compared to 140%; p=0.06). Patients in social class I (n=18) were more accurate than those in classes II–V (n= 85): There was a positive correlation between poor accuracy and increasing MZD (Pearson’s correlation coefficient 0.250; p=0.012). ODI, LBOS and other parameters measured showed no correlation.

Conclusions: Subjective distance perception and estimation is poor in this population. Patients over 60 and those with a professional background are more accurate.

Ethics approval: not required

Interest Statement: none

Introduction: Current evidence on the indications for and efficacy of non-rigid lumbar stabilisation remains unclear. The aim of this study was to review the results of this system in thirty four patients who underwent this procedure between 2002 and 2006.

Methods & Results: Validated outcome measures including Visual Analog Score (VAS), Roland Morris Disability Questionnaire (RMDQ), Modified Zung Score and Modified Somatic Perception Questionnaire (MSPQ) were evaluated preoperatively and at 1 year post operatively. Subjective patient outcome (much better, better, same, worse) was assessed at final followup Kaplan-Meier Survival analysis was performed using need for revision surgery as endpoint. The indications for surgery in thirty patients was radicular pain and back pain, these patients underwent discectomy (12 patients) or decompression (18 patients) in addition to Dynesys. Two patients who had only back pain underwent Dynesys alone. There were statistically significant improvements in VAS, RMDQ, Modified Zung and MSPQ scores at 1 year. However at final followup 46% of patients had a unsatisfactory subjective patient outcome (worse or the same). 25% of patients required revision surgery (posterolateral fusion) for ongoing pain (seven patients) or infection (one patient).

Conclusion: We recommend that all patients undergoing this procedure are counselled regarding the high rate of revision surgery and patient dissatisfaction. Routine use of this implant should be subject to the findings of larger studies and randomised controlled trials.

Ethics approval: None

Interest Statement: None

Purpose of the study: To determine the safety of the use of bone morphogenetic protein-7 (BMP-7) in anterior cervical surgery

Methods and results: A prospective consecutive cohort of 132 patients underwent anterior cervical discectomy and fusion using interbody cages. In 123 of these patients BMP-7 was also used. The dose of BMP-7 was controlled (one half to one unit; 1.75–3.5 mg BMP-7 & 0.5–1.0 gm collagen) and contained (no BMP-7 was placed outside the cage).

The primary outcome measure was the presence of clinical adverse events during the first 30 days. The secondary outcome was the extent of radiological soft tissue swelling at the C6 level as measured on plain radiographs in the early post-operative period and compared to a historical post-operative anterior cervical fusion cohort.

There was no mortality and no re-operation in this series. 2.4% of patients experienced complications: transient brachalgia (1/123), persistent dysphagia (1/123), sudden dysphagia and dysphonia (1/123).

Mean pre-vertebral soft-tissue measurement in 20 patients from the BMP-7 group was 20.9 mm (16–27 mm). This compared with 18.7 mm (15–25 mm) in 7 patients from the non-BMP-7 group, and 18 mm in the historical control group.

Conclusions: BMP-7 can be used safely in anterior cervical fusion surgery. A slight increase in post-operative pre-vertebral swelling was not clinically significant. The effect of BMP-7 on the rate and timing of fusion, as well as clinical outcome, is yet to be elucidated.

Ethics approval: None-audit

Interest Statement: None

Purpose: To review the existing practice of coding in spinal surgery and ascertain its accuracy for surgical procedures, co-morbidities and complications.

Methods: A retrospective review of 70 cervical and 100 lumbar consecutive spinal surgeries performed since April 2006 was conducted. The clinical coding data and hospital notes were reviewed.

Results: Coding data of 5 cervical spine surgeries were not available. Of the 165 cases, the accuracy of primary procedural codes was 93.9% (90.8% cervical & 96% lumbar). This reduced to 77.6% (75.4% cervical & 79% lumbar) when the accuracy for entire description of performed surgery was considered. Medical co-morbidities were coded appropriately in 64.2% of the patients (55% cervical & 70% lumbar). The procedural codes did not specifically reflect the surgery performed and lacked reproducibility. Surgical levels were coded incorrectly in 9% of the cases. Cervical surgeries were coded as lumbar in 4 and posterior surgery as anterior in 3 cases respectively. The commonly missed co-morbidities were drug allergies, hypercholesterolemia, smoking and alcoholism. Post-op adverse events were coded in 75% of the cases (16/20 cervical & 5/8 lumbar). The accuracy was better for lumbar as compared to cervical spinal surgeries.

Conclusion: Coding is a universal language of communication and its accuracy is important not just for PbR, but for data quality, audit and research purposes too. The financial implications regarding PbR governed by HRG codes (dictated by OPCS 4.4 & ICD–10 codes) are discussed. Following this study, a clinical coding facilitation form has been introduced to improve data quality.

Ethics approval: None

Interest statement: None

Introduction: Spinous process osteotomy (SPO) and multiple laminotomy can be used for multi-level lumbar decompression. We conducted an experimental study to compare the effects of these two methods on spinal kinetics.

Method: Ten fresh calf spines (L2- sacrum) were mounted in dental stone and segmental motion of L3 relative to L5 was assessed using an electromagnetic 3-D motion detection system (FASTRAK, Polhemus, Colchester, VT, USA). Pure moments of 0, 2.5, 5, 7, and 10 Nm were used in flexion/extension, right/left lateral bending, and right/left axial rotation. The moments were generated by applying two equal and opposite forces (weights) to the perimeter of a plastic circular disc, which was fixed to the superior end plate of L3 by three screws. In five spines decompression was performed at L3/4 and 4/5 using standard laminotomy technique. Decompression using SPO was done at L3–5 through a unilateral approach in the rest. Segmental mobility between the two methods was compared using the Mann-Whitney test.

Results: Mean range of motion in the specimens before intervention was-lateral bending (32.70 ± 7.6 SD), rotation (13.10 ± 4.8 SD), flexion/extension (19.30 ± 7.1 SD). There was statistically significant difference between mean increase in lateral bending after SPO to that following laminotomy (4.00 ± 1.5 SD vs 0.60 ± 1.6 SD; p=0.008). Mean increase in flexion- extension after SPO was not significantly different from that after laminotomy (4.50 ± 1.1 SD vs 3.90 ± 3.8 SD; p= 0.75). There was no difference in the mean increase in axial rotation after SPO compared to that following laminotomy (7.90 ± 3.6 SD vs 6.80 ± 5.0 SD; p= 0.75).

Conclusions: Both laminotomy and SPO produced increased range of motion in a calf spine model. SPO produced significant increase in lateral bending although its clinical significance is unknown.

Ethics approval: none

Interest Statement: Local grant (Research Fund, Centre for Spinal Studies, Robert Jones and Agnes Hunt Hospital, UK

Spinal lipomatosis is seldom reported in spinal literature and although the condition occurs commonly, we seldom recognise it in reviewing spinal MRI scans. We aim to highlight the condition and show MRI signs to allow easier recognition. We also introduce a new method of evaluation of the severity of the condition using T1 MRI axial views to evaluate the area of the spinal canal involved in the pathological process.

We have evaluated 30 patients with a diagnosis of spinal lipomatosis made on sagittal MRI scanning of the spine. The T1 and T2 axial images have been evaluated using standard digital software which allows calculation of the surface area occupied by fat and allows representation of this as a ratio to total canal diameter. This has then been correlated to the traditional method of classifying lipomatosis on sagittal MRI sequences.

We have found this method useful and believe it provides a more accurate representation of how fat in the canal may produce symptoms of nerve compression. This shows that the condition behaves more like our traditional understanding of spinal stenosis with symptoms more likely when the relationship of fat to canal reaches greater than 50%. This approach to spinal lipomatosis has not been described before but we feel produces a better understanding of the condition than we have had before by using a classification based on purely on sagittal MRI sequences.

Ethics approval: None Audit

Interest Statement: No conflict of interest

Introduction: In this study we have studied the range of motion within Dynesys treated discs and levels adjacent to flexible stabilisation.

Dynesys was designed to offer physiological motion at the lumbar spine. An advantage which is superior to abolishing movements through spinal fusion.

Methods: A cohort of 75 post-Dynesys patients had weight-bearing lateral lumbar spine x rays in flexion/extension positions. Evaluation was done through PACS™ digital software. Flexibility at individual disc level was measured as the differences between flexion/extension angles accurate to within 1°. Motion was evaluated at the index and immediate adjacent levels.

Results: Patients with single level Dynesys had an average ROM of (3+/−4.7) at L5-S1 and (5.1+/−2.9) at the immediate adjacent level. Two levels Dynesys was associated with a ROM of 5+/−3.6 at L5-S1 & L4–5 and 3.5+/−1.8 at their immediate neighbour disc. Across three levels, Dynesys favoured a ROM of 5.3+/−2.5 at the operated sites and 1.6+/− 2 at the adjacent level.

Discussion & Conclusion: This study is the first radiological research to confirm the flexibility of Dynesys. Controlled motion at the dynesys treated disc levels share to distribute global spinal movements. This will advantage the next disc segments and protects them from risk of developing “accelerated adjacent segment disease”.

This study aims to evaluate the accuracy of sheer off self limiting screw drivers and to assess repeatability with age.

It has been reported that overzealous tightening of halo pins is associated with co-morbidity. Our unit has recently received a tertiary referral where the patient over tightened a pin leading to intracranial haematoma, hence our interest in this subject. The torque produced by six new and nine old screw drivers was tested using an Avery Torque Gauge and a Picotech data recorder. These devices are designed to produce a torque of 0.68 Nm, any greater than this is potentially hazardous. Accepted error for each device was +/− 10%. The average torque produced by the new screw drivers was 0.56 Nm with a range of 0.35–0.64 Nm (SD 0.120). The older screw drivers produced an average torque of 0.67 Nm ranging from 0.52–0.85 Nm (SD 0.123).

In conclusion, sheer off self limiting screw drivers are not accurate devices. The older devices are more likely to produce a torque exceeding a safe range and therefore we would recommend the use of new devices only.

Ethics approval: none audit.

Interest statement: none local grant.

Introduction: Spinal surgical procedures are associated with significant morbidity. It is vital the patients are aware of the potential complications and the implications. The General Medical Council published guidelines regarding consent in June 2008.

Aim: To examine the adequacy for consenting for spinal surgical procedures and focussing on documentation of serious risks.

Methods: Case notes of seventy consecutive patients who had undergone spinal surgery were retrospectively reviewed. The consent forms were examined for documented procedures, complications, grade of the consenting member and timing of the consent.

Results: The documented procedure on the consent form and the operation sheet matched in all seventy cases (100%). Consent was taken by the consultant in 50% of the patients, 30% were consented by middle grade doctors and 20% were consented by the junior doctor. The consenting person was present at the procedure in 63% of the cases. Sixty percent (60%) of the patients were consented in the pre-admission clinic, 23% were consented on the day before the procedure and 17% were consented on the day of the procedure. Common and serious complications such as infection (84%), bleeding (76%), pain (67%), bladder and bowel problems (84%), paralysis (70%) and nerve root damage (67%) were clearly documented.

Conclusion: Two-thirds of the patients are given adequate information to obtain informed consent in the pre-admission clinic. Majority of the patients are aware of the common and the serious risks associated prior to the procedure.

Interests: None

Ethics approval: None

Introduction: Giant cell tumours are locally highly aggressive and extremely unpredictable bone tumours. Treatment of spinal GCTs remains controversial. We report our experience of 11 Giant cell tumours of the spine identified from the Scottish Bone Tumour Registry.

Materials and Methods: Details of 11 cases of histologically confirmed Giant cell tumours of the spine (9 benign and 2 malignant) between 1960 and 2004, were extracted from the Scottish Bone Tumour Registry. The casenotes and radiographs were retrospectively reviewed.

Results: There was a slight feminine predominance of 7 cases. Mean age was 34 years (range, 16 to 61 years). The sacrum (5) was most common location, followed by lumbar (3), thoracic (2) and rarely in cervical (1). Operative intervention was carried out in 5 (curettage-1; excision-5). Three also received supplemented bone grafts. Radiotherapy (including some of the operative cases) was administered in 9 patients. There were 5 recurrences (45.4%). There were 7 survivors 2 of whom still had evidence of persistent primary disease. Two died with unrelated illnesses and two from local recurrences.

Conclusions: Axial GCTs behave aggressively with a high recurrence rate (45%). Radiotherapy is useful in the management of GCTs of the spine and conservative surgery with local radiotherapy is a viable treatment option in some selected patients.

Purpose: To assess the outcomes in consecutive 32 patients of two level cervical disc replacement

Methods: In this article, we report 2-year results of anterior cervical decompression and two level cervical disc replacements (prestige) in 32 patients with a diagnosis of symptomatic cervical spondylosis. Dynamic assessment with lateral radiographs of the cervical spine in flexion/extension was done pre and post op. All of them had partial uni/bilateral uncinectomy, which adds in lateral bending. The median age of all patients was 46 years (range 32–61). Levels of surgery included between seven C3–C7, most common were C5–6, C6–7.

Results: Neck and arm pain as well as disability scores (VAS, ODI and SF36) were significantly improved by 3 months and remained improved at 2 years. Radiography revealed the complete motion (From flexion to extension) at upper disc replacement level of 11% and 9.6% at the lower level. There is a significant decrease of the facet joint articulation overlap in the sagittal plane. As the diameter of socket is slightly larger than the ball in prestige disc replacement, it helps in additional axial movement. There was reduction in motion at the adjacent segments above and below, preventing adjacent segment problems.

Conclusion: Twenty-four months after surgery, patients who underwent two level cervical disc replacements demonstrated greater improvement in neurologic function and neck pain. It helps in restoring sagittal balance, functional outcome of patient because of increased lateral bending, axial rotations and flexion-extension.

Ethics approval: done from appropriate authorities

Interest Statement: There is no local grant, national grant, commercial/industry support for this article. There are no interest or gain from any source for this article.

Aim: To investigate the incidence of headache and facial pain in patients with neck pain and/or brachalgia and determine any potentially causal relationship.

Methods & Results: Sequential patients referred to the spinal clinic for assessment of their cervical spine were asked to shade on pain drawings, the distribution of pain and sensory disturbance which they were experiencing.

The distribution of shading was categorised as head pain (subdivided into face, vertex and occiput) and arm pain. The incidence of head pain and its distribution was analysed along with its relationship to arm pain.

Data collected from patients presenting with thoracolumbar pain over the same period was used as a control.

Of 200 patients presenting to the clinic with cervical problems, 58 had head pain. 50 had occipital pain, 28 had vertex pain and 8 had facial pain. None of the thoracolumbar patients had head pain although 12 had upper limb pain.

Of the 26 cervical patients who had unilateral arm pain & head pain, the head and arm pain were always on the same side.

Conclusion: Head & facial pain in association with neck pain and brachalgia is common. The homolaterality of symptoms suggest the potential for causal relationships hitherto unrecognised in the literature. It is possible that some patients given medical diagnoses for their headache (e.g. migraine) might have surgically treatable cervical pathology. Clearly, further investigation to elucidate this potential relationship is required.

Introduction. A redesign of a joint replacement service to increase throughput and reduce length of stay despite a reduction in junior doctors hours, recognised that Orthopaedic Nurse Practitioners (ONP) based on the US Surgeons’ +

+ Assistant model would play a pivotal role in managing patient flow efficiently.

Redesigning the Service. The ONP has input at every step of the patient journey. In Outpatient Clinic they see follow-up and selected new patients, commencing the informed consent process if appropriate. They run an information program to patients awaiting surgery, are involved in Pre-Admission clinic, assist in theatre and oversee post-operative care monitoring progress, ensuring earliest possible safe discharge and prescribing as necessary. Continual Audit, Research and development to improve the service are part of the role.

Outcomes. The impact of the introduction of the role after 4 years together with service redesign has been:

An increase in the number of new referrals seen in OPD by 50% from 8 to 12 per clinic.

Conclusion. Based on the US Surgeons’ Assistant model, with involvement at every step of the patient journey, ONPs have been the most important single element in the redesign of the joint replacement service to meet a massive increase in demand. Further ONPs are being recruited to fill the gap envisaged by a reduction in junior doctors hours as a result of the European Working Time Directive.

Introduction: The diagnosis of acetabular retroversion has traditionally been established by the presence of a cross-over sign on a plain pelvic radiograph. This however can be greatly influenced by the radiograph’s quality and degree of pelvic tilt. The aim of this study was to look at the relationship between cross-over and true anatomical version as measured in relation to an anatomical reference plane. The secondary aim was to determine whether in true retroversion there was excess coverage of the femoral head anteriorly.

Materials and Methods: Radiographs of 33 patients (64 hips) being investigated for symptoms of femoro-acetabular impingement were analysed. The presence of a cross-over sign was documented and the extent of cross-over was measured by noting the point on the rim where the cross-over occurs. CT scans of the same hips were analysed to determine anatomical version, and to calculate total, anterior and posterior coverage of the femoral head. This was done in relation to the anterior pelvic plane after correcting for pelvic tilt.

Results: The sensitivity, specificity and positive and negative predictive values for the cross-over sign were 92%, 55%, 59% and 91% respectively. The cross-over distance was correlated with 3D version (p=0.01). There was no significant difference in total cover of the femoral head between the anteverted and retroverted subgroups (71% vs. 72% respectively; p=0.55). Anterior cover was higher in the retroverted subgroup (35% vs. 32%; p = 0.0001), and posterior cover was significantly lower in this subgroup (37% vs. 39%; p = 0.002).

Discussion: Although the cross-over sign was sensitive enough to identify 92% of the retroverted cases, its specificity was low with just under half of the anteverted cases being labelled as retroverted. The findings for femoral head cover suggest that retroversion is characterised by posterior deficiency and increased cover anteriorly.

Aim: Our aim was to find the effect of implementation of European working time directive (EWTD) on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum.

Methods: This reaudit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England.

Results: An orthopaedic trainee of registrar level (Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. In previous audits done in 2003 and 2005, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively.

Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in Northwest of England are mirrored elsewhere in United Kingdom, the implications for orthopaedic training are significant.

Introduction: Patient-reported outcome and satisfaction scores have become increasingly important in evaluating successful surgery. There is continued enthusiasm for metal-on-metal resurfacing of the hip, particularly as an alternative to total hip replacement (THR) in young, active patients with osteoarthritis. However, although mid-term survivorship data is promising, it remains unclear whether patient-reported outcomes following resurfacing match those following THR.

Patients and Methods: This case-matched control study compared patient-reported outcome and satisfaction data following hip resurfacing and total hip arthroplasty. Thirty-three consecutive patients selected for hip resurfacing were compared with 99 patients undergoing cemented total hip replacement (THR), matched for age, sex and pathology. Participants completed a Short-Form 12 Health Survey (SF-12) and Oxford Hip Score (OHS) questionnaire pre-operatively and 6 months post operatively, with an additional patient satisfaction questionnaire.

Results: There was no difference in length of hospital stay. Both groups reported improved outcome scores, with mean OHS improvements of 19.5 (95% CI: 17.0–22.1), and 20.6 (95% CI: 18.6–22.5) following resurfacing and THR respectively. There were similar improvements in SF-12 PCS of 14.2 (95% CI: 9.5 to 14.2) and 15.2 (95% CI: 13.2 to 18.2) for the resurfacing and THR groups respectively. The improvement in outcome scores did not differ between the two groups on multivariate regression analysis (P=0.509 for OHS, P=0.629 for SF-12 PCS). Both groups reported high levels of satisfaction, which tended to be better in patients undergoing hip resurfacing (97.0% vs 92.9%), with resurfacing patients reporting better pain relief (P=0.022) and better heavy lifting (P=0.038) at 6 months.

Discussion: This study shows that the short-term patient-centred outcome scores for hip resurfacing are at least as good as for conventional hip replacement, with slightly higher levels of satisfaction.

Introduction: Patients presenting with fracture of the femoral neck are usually elderly, and often have extensive co-morbidity. Patients who are considered too unwell for surgery are often keep being delayed until assumed optimised or treated non-operatively. These patients have a high morbidity and mortality and present significant nursing difficulties.

Materials and Methods: We describe a technique of fixation of fracture of the femoral neck under direct infiltration local anaesthesia; that can be performed on the sick elderly patient without the risks associated with general or regional anaesthesia. In a series of twenty eight patients all diagnosed with serious co-morbidity (ASA4) on pre-operative assessment. Twenty three patients suffered from extracapsular fracture neck of femur and five intracapsular fracture neck of femur. All patients were informed about the risks of anesthesia by the senior anesthetist prior to surgery. A mixture of 20 mls n.saline + 20mls of 1% lignocaine with 1:200,000 adrenaline + 20mls 0f.25% plain marcaine (total 60 mls used). This can be increased up to 140 mls in the same ratios.

Results: All patients were operated by various grade registrars. Twenty four (24) DHS and four Hemiarthro-plasty were performed. The patients were all able to complete the surgery using this technique; none required conversion to another form of anaesthesia.

The average duration of surgery was 44 min. All patients survived the procedure and until discharge form hospital.

Discussion: Finlayson and Underhill (1988) suggested that extracapsular fractures are supplied predominantly by the femoral nerve and are therefore more amenable to this type of treatment.

We recommend the consideration of this technique for management of patients with severe co-morbidity and fracture of the femoral neck in order to optimise their chance of survival and avoid the morbidity associated with bed rest.

Introduction: Patients who develop proximal femoral growth arrest present a typical deformity of short femoral neck, high riding greater trochanter, and caput valgum. This is seen usually seen in Perthes, AVN due to treatment of CDH, and sometimes in epiphyseal dysplasia.

Method: We present a series of 34 cases (34 hips) treated at the above institutes. The cases treated in Berne were prior to 2002. Twenty patients were females. There were 24 patients with Perthes, nine with old healed and treated DDH, and one with epipyhseal dysplasia. All had Trendelenburg or delayed Trendelenburg sign. They had an average shortening of 3.5 cms, and their age range was 14 yrs to 64 yrs. Pre-op assessement was done with plain radiographs, CT scan, and or MRI scan.

Results: Their Merle D’Aubigne score improved from 13 (10 to 15) to 17 (15 to 18) at the latest follow up. Twenty four (70%) had good to excellent result. Five have since undergone a total hip replacement, and five have some pain but can do reasonable amount of activity. The follow-up is 6 years (2 to 13 years). There was one trochanteric non-union, but no cases of AVN.

Discussion: We describe the technique of biomechanically improving the moment arm and muscle length with this procedure. This helps the soft tissues to strengthen, improve force vectors in the correct direct in the hip, perhaps improve the longevity of the joint and also prepare the hip soft tissues for future THR.

Introduction: Femoroacetabular impingement (FAI) causes pain in young adults and osteoarthritis. Genetic factors are important in the aetiology of osteoarthritis. We aimed to investigate the extent to which FAI has an underlying genetic basis, by studying the siblings of patients undergoing surgery for FAI and comparing them with controls.

Methods: 66 patients (probands, 29 male, 37 female, mean age 39.1 years) treated surgically for FAI provided siblings for the study. Probands were classified as having cam, pincer or mixed FAI. 101 siblings (55 male, 56 female, mean age 38.2 years) were recruited. The control group consisted of their 77 partners and was age and gender-matched. All subjects were assessed clinically and radiologically (standardised AP Pelvic and cross-table lateral radiographs of each hip). Radiographs were scored for the presence of osteoarthritis, and morphological abnormalities.

Participants were classified as:

Normal morphology, no clinical features

Results: The sibling relative risks were significant for groups b, c, and d (ranging between 2–5, p< 0.01). Pro-bands and siblings shared the same pattern of abnormal morphology. Gender specificity was apparent: pincer abnormalities common in sisters but not in brothers. The brothers of probands with cam deformities almost universally demonstrated the same deformity, but only 50% of sisters did.

Discussion: Genetic influences are important in the aetiology of FAI. Whether the morphological abnormality is determined at conception or by an inherited predisposition to an acquired event during development warrants further study. Symptoms are variable, indicating a spectrum of disease progression. These cohorts present an opportunity to prospectively study the natural history of the condition, improve understanding of the mechanisms and pathology, and potentially to be recruited into clinical trials.

Aim: The aim of this study was to assess the role of Hip Arthroscopy in the patient with a symptomatic Resurfacing arthroplasty of the hip.

Patients and Methods: Twelve consecutive patients who presented to our clinic with a painful resurfacing and indeterminate or normal investigations underwent an arthroscopy of their resurfacing were prospectively enrolled into the study following appropriate consent. The pre-operative investigations included haematological indices and acute phase reactants to rule out infection along with plain radiographs and an isotope bone scan.

Results: (table deleted)

Conclusions: Assessment of a symptomatic resurfacing is usually difficult and becomes more challenging in the background of normal or indeterminate investigations. However, in this situation, we found that in experienced hands, hip arthroscopy can be utilised as an effective tool for aiding diagnosis and offering therapeutic interventions in these patients.

Introduction: Subtle deformity of the hip joint may cause osteoarthritis. In femoroacetabular impingement (FAI), cam deformities damage acetabular cartilage. Whether surgical removal of cam lesions halts progression is unknown. Sensitive, non-invasive assays of chondral damage are required to evaluate early treatment efficacy.

Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) permits inference of glycosaminoglycan (GAG) distribution. We aimed to determine whether hips with cam deformities have altered GAG content, using dGEMRIC.

Methods: Subjects were recruited from a prospective cohort study. All were clinically and radiographically assessed. Hips with a normal joint space width (> 2.5mm) were eligible for dGEMRIC. 32 Hips (18 male, 14 female, mean age 51.7 years, none of whom had been investigated for hip pain) with (n=21) and without (n=11) cam deformities were scanned.

2 regions of interest (ROI) were studied:

acetabular cartilage from 12 to 3 O’Clock (T1-Index-acet).

The average of all pixels within the given ROI defined the T1-index.

For each hip, the ratio of the GAG content T1-Index-acet/T1-Indextotal was calculated. Mean T1-Indexto-tal and T1-Indexacet/T1-Indextotal were compared.

Results: T1-Indextotal were similar (689ms v 700ms, p=0.79) but T1-Indexacet/T1-Indextotal was lower in cam hips (0.93 v 1.01, p=0.017), indicating localised depletion of GAG content. Cam hips with positive clinical signs had lower T1-Indextotal than cam hips without (629ms v 717ms, p=0.055), and non-cam hips (629ms v 722ms, p=0.049).

Discussion: Cam hips have lower GAG content of their anterosuperior acetabular cartilage. dGEMRIC identified more generalised disease in cases with positive clinical findings. Ratios of GAG content for specific ROIs enable mapping of chondral damage. This may aid understanding of early disease mechanisms, track progression, and facilitate assessment of the efficacy of surgical procedures.

Introduction: The clinical results of the modular Charnley Elite total hip system have been the subject of some interest in recent years. Some studies have shown significant subsidence and rotational instability in stems when used with low-viscosity cement. These unstable stems have been shown to fail early. The purpose of this study is to demonstrate our conflicting clinical results.

Materials and Methods: 616 modular Charnley Elite total hip arthroplasties were inserted between 1995 and 2002 at Wrightington Hospital, which is a tertiary referral centre and centre of excellence for joint replacement in United Kingdom. Both Consultants and trainees performed operations and a variety of surgical approaches were used. Normal viscosity bone cement was used in all patients. All patients were followed up prospectively.

Results: At mean follow-up of 8 years (range 5–12), 471 hips were available for review. 87 patients had died and 12 were lost to follow-up. 2.7% (13 cases) of femoral components and 2.9% (14 cases) of acetabular components had been revised for aseptic loosening. 10 hips (2.1%) underwent revision for deep infection and 2 (0.04%) for recurrent dislocation. The overall survival with aseptic loosening as an end point was 97% and for revision for any reason was 94.5%.

Conclusion: Our results show acceptable clinical survivor-ship for this implant when used with standard viscosity cement. This contrasts with the lower survivorship rates published by other centres. Our result should reassure patients and surgeons alike that this prosthesis can be associated with acceptable results in the medium term.

Introduction: Infection following hip arthroplasty although uncommon can have devastating outcomes. Obesity, defined as a BMI of ≥ 30, is a known risk factor for infection in this population. Coagulase negative Staph Aureus (CNS) is the commonest causative organism isolated from infected arthroplasties. This study was performed to determine if there has been a change in the causative organisms isolated from infected hip arthroplasties and to see if there is a difference in obese patients.

Methods: Data on all deep infection following primary and revision hips was obtained from the surgical site infection register from April 1998 to November 2007. All case notes were reviewed retrospectively.

Results: There were 49 patients with 51 infected arthroplasties; 25 infected Primary THAs and 26 infected Revision THAs. We found a female preponderance in the infected primary and revision THAs (n=30). 65.3% of all patients had a BMI of ≥ 30. Over the period studied, Coagulase negative Staph was the most common organism isolated (56.8%) followed by mixed organisms (37.2%) and Staph Aureus (25.4%). Multiple organisms were found exclusively in obese patients. In more than half of cases the causative organisms were resistant to ≥ 2 antibiotics.

Discussion: This study shows that over the last 10 years, CNS continues to be the most frequently isolated organism in infected hip arthroplasties. Multiple organisms with multiple antibiotic resistances are common in obese patients. On this basis we recommend that combination antibiotic therapy should be considered in obese patients.

Introduction and Method: For 16 years, now, we have been using custom made femoral stems (titanium stem, HA coated) based on preoperative patient CT scans in young patients presenting with symptomatic osteoarthritis of the hip. The aim was to provide optimum initial fit-and-fill of the stem in the femoral medullary canal, conferring the best chance of secondary osteoin-tegration. This, with a goal of long term survivorship. The custom stem also enables dialling-in correction of the (often abnormal) femoral neck version (in young patients presenting with arthritis) to a more normalised 15 degrees of anteversion.

Results: We present the long term results (5–16 year, mean of 10 years), clinical, survivorship and radiological, of 312 primary total hip arthroplasties in 280 patients, all of whom were under the age of 50 years of age (mean age 40).

At 10 years we have a survivorship, if femoral aseptic loosening is used as an end point, of 97.6%. There was a deep infection rate of 1.2%, and a dislocation rate of 1.9%. There were no cases of thigh pain, and no intra-operative femoral neck/shaft fractures.

Discussion: The under 50’s with hip arthritis requiring total hip arthroplasty are a highly challenging group, they are young, active and tend to have distorted anatomy. Our results are superior to those previously published using either cemented or standard uncemented stems. Thus, justifying the increased initial financial outlay on the custom-made stem.

Aim: To assess the infection rate following Primary Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin.

Material And Methods: All patients undergoing primary Total Hip and Knee joint replacements over 6 months (October 2007 to March 2008) at 3 participating hospitals were prospectively followed up to assess perioperative infection rates. Joint replacements were defined as having infection by the UK Health Protection Agency Surgical Site Surveillance (SSI) criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg body weight adjusted for body mass index.

This group of patients were compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals for infection rates in Lower Limb Arthroplasty using 3 doses of Cefuroxime 750mg as antibiotic prophylaxis.

Return to theatre data was collected independently after introduction of gentamicin to compare with previous data.

Results: 408 patients underwent Total Hip Replacements (THR) and 458 patients underwent Total Knee Replacements (TKR) during the study period. This was compared with 414 patients who underwent THR and 421 patients who underwent TKR during a 6 month period over 2 years.

Surgical site infection was detected in 9 THRs (2.2%) and 2 TKRs (0.44%) in the study group as compared to infection in 13 THRs (3.1%) and 12 TKRs (2.9%) in the control group.

Using the Fisher Exact test the infection rates in THRs were not significantly different between the 2 groups (p value – 0.52) but the infection rates were significantly reduced in the study group for TKRs (p value – 0.005).

There were no complications with the use of Gentamicin as antibiotic prophylaxis.

The return to theatre was 2.42% (28/1157) after introduction of Gentamicin as compared with 1.85% (37/2005) [p value – 0.172] before this. This was a cause for concern, although not a significant difference.

Cefuroxime is known to promote Clostridium difficile infection and was removed from the hospital pharmacy to help meet a UK government targets to reduce the incidence. The rate of Clostridium difficile infection was reduced within the hospital with the use of single dose antibiotic prophylaxis although other measures to reduce its incidence were also introduced.

Conclusions: This study shows that the use of single dose antibiotic prophylaxis using Gentamicin is effective in preventing SSI as defined in the HPA definition. It is safe to use and reduces rate of Clostridium difficile associated diarrhoea.

However, be wary of increased rate of return to theatre following use of gentamicin.

Further period of evaluation and study is needed before it is recommended for routine use in present or modified form.

Introduction: REEF™ is a modular distal locking implant, indicated for use in extensive loosening of femoral stems, peri-prosthetic hip fractures, and tumour surgery requiring distal anchorage to allow resection of the femur proximally. Very little experience with the REEF™ has been reported.

Objective: We report on a single surgeon series of 16 patients who underwent femoral reconstruction using the REEF™ during revision hip arthroplasty (THA).

Methods and Results: This is a retrospective analysis of prospectively collected data on 16 patients (14 females) who underwent revision THA using the REEF™, between 1998 to 2007with a mean follow-up of 16 months (range, 3 to 60).

Indications were peri-prosthetic fractures in 9 cases (Vancouver B1 in one case, B2 in 4 cases and B3 in 4), aseptic loosening with significant bone loss in 3 (Paprosky IIIA in one case, Paprosky IIB in one and Type IV in one), osteolysis (Paprosky IV) secondary to infection in 1, non-union of peri-prosthetic fracture in 2 (Vancouver B2 and B3) and fracture around a spacer in one case.

The mean HHS at 3 months post-operatively was 72 (range, 57 to 76). The median pre-operative/pre-injury University of California, Los Angeles hip rating system (UCLA) was 1. The median UCLA at longest follow-up was 3.5 (range, 1 to 4) with 10 patients having a score greater than 3. Mean time to clinical evidence of implant integration was 4 months (range, 2 to 12). No evidence of subsidence was noted. Four dislocations were seen. No dislocation was seen in the 6 patients who had a Posterior Lip Augmentation Device (PLAD™) inserted at the time of revision THA. One stem fracture occurred requiring revision surgery with a longer REEF™ implant. Two patients died in the immediate post-operative period.

Conclusion: Results of revision THA using the REEF™ implant are encouraging. We recommend the use of the REEF™ with the judicious use of PLAD™ in difficult revision THA.

Introduction: C-stem is a triple taper polished femoral stem. The rationale for this design is to achieve an evenly distributed proximal loading of the cement mantle. This design is thought to enhance stability of the stem inside the mantle and lead to bone remodelling medially. There is to our knowledge no randomized trial comparing this stem to a well documented stem. We chose to compare it to the best documented stem in the Norwegian arthroplasty register, the Charnley monoblock.

Methods: 70 patients scheduled for total hip replacement were randomized to either C-stem or Charnley monoblock. All received a 22 mm stainless steel head, OGGEE cup and Palacos Cement with Gentamycin. We used a transgluteal approach in all cases. Harris and Oxford hip scores were measured preoperatively and after two years. Standard X-rays were taken postoperatively and after two years. Radiostereometry (RSA) was done postoperatively and after 3,6,12 and 24 months.

Results: There was no significant difference in Harris or Oxford hip scores after two years.

RSA after two years: (table deleted)

Discussion: Polished tapered stems are designed to sink inside the mantle. Our results confirm this theory for the C-stem. The subsidence is comparable to other collarless tapered stems with good long-term survival. For all other migrations/rotations the C-stem is as stable as the Charnley monoblock. This predicts good long-term results for this stem.

Introduction: Primary total hip replacement remains one of the commonest orthopaedic procedures performed. It is yet to be clearly demonstrated whether use of a postoperative drain is of benefit in these procedures.

Methods: We carried out a prospective randomised study comparing the use of autologous reinfusion drains, closed suction drains or no drain to determine their influence on allogenic blood transfusion requirements, length of hospital stay and infection rates. Stratification was carried out for confounding factors.

Results: 153 patients were recruited into the study and randomised to one of the three closely matched groups. There was no significant difference between the mean intra-operative blood loss or post-operative haemaglo-bin levels between the 3 groups. 42% of the suction drain group required post-operative transfusion as compared to 17% of the reinfusion drain group and 12% of the group with no drains. This difference was highly significant (P=0.02) Mean time for the wound to become dry was 3 days, 3.9 days and 4 days in the no drain, re-transfusion drain and suction drain groups respectively. This difference was statistically significant (P=0.03). There was no statistically significant difference in the mean length of inpatient stay.

Discussion: This study demonstrates a significantly higher transfusion rate with closed suction drains compared to reinfusion drains or no drains. With the drive to reduce hospital stay our study supports the considered use of no drain or a reinfusion drain.

One of the many challenges in revision hip arthroplasty is massive bone loss. Subsidence of the collarless stem with impaction allografting has been reported by several authors. Impaction grafting has emerged as a useful technique in the armamentarium of the revision total hip arthroplasty surgeon. The original technique proposed by Ling has been associated with complications, including femoral shaft fractures, recurrent dislocations, and uncontrolled component subsidence. Modifications in that technique seem to be associated with a reduction in complications.

The aim of this study was to assess the functional outcome of radial impaction grafting in femoral bone defects and the use of collared long stem prosthesis.

A total of 107 patients underwent radial impaction allografting and collared long stem prosthesis during revision THA between 1997 and 2005. The patients with Paprosky type II, IIIA and IIIB defects were included in this study. Average duration between the primary and revision surgery was 9.4 years (Range 6–23 years). Assessment was done using Oxford Hip Score, Harris Hip Score and with plain X-rays. Three patients were lost to follow-up and three patients died due to unrelated causes.

The follow-up period lasted between 12 to 114 months (average – 68.8 months). Three patients who sustained post-operative peri-prosthetic fracture had standard stem inserted in them. None of the patients with long stem sustained peri-prosthetic fracture. Four patients had infection and underwent revision procedure. In this study, using revision for any cause as the end-point, survival of the femoral stem was 93.8%. Subsidence was not recorded in any of the patients in this study. Oxford Hip Score improved from mean pre-operative value of 41.2 to 19.2 post-operatively. Mean Harris Hip Score improved from 40.8 pre-operatively to 83.4 post-operatively.

Subsidence of the prosthesis is commonly encountered with collarless stems and this was not a problem in this study. The risk of peri-prosthetic fracture can be reduced by using long stem prosthesis which bypasses the existing cement mantle by at least two femoral diameters. The radial impaction grafting technique permits the use of revision femoral components with variable stem lengths, neck lengths, and neck offsets.

We conclude that radial imaction graftind along with collared long stem prosthesis is a good solution for massive femoral bone defects while performing total hip arthroplasty.

Introduction: In a climate of tightening budgets and rising cost the pressure on those performing complex and expensive surgery is ever increasing.

Patients requiring revision hip surgery are a particular burden on such limited resources.

Hospital trusts are dependent upon adequate remuneration for such complex procedures, a process reliant on accurate coding.

Methods: We performed a retrospective audit of our coding for revision hip surgery. This highlighted significant shortfalls in the coding process. We implemented necessary changes prior to a further prospective audit.

Results: The primary procedure was correctly coded in all our cases throughout, creating a standard tariff (mean £6,897).

However certain procedures enable an additional tariff uplift of up to 70%. Yet these additional procedures (performed in 81% of our procedures) had not been coded; loosing these additional tariff uplifts of 70%.

We involved and educated our coding staff, creating a ‘tick box’ sticker to be placed on every revision hip operation-record and completed by the operating surgeon.

Our subsequent tariff uplifts for these procedures have been significant.

Discussion: Joint replacement surgery is being performed in an ever younger and more active population. Patients are increasingly likely to outlive their prosthesis and peri-prosthetic fracture rates are set to continue rising.

In the modern NHS, surgeons must have a good understanding of complex tariffs. Coding staff are a notoriously poorly paid and undervalued component of any Hospital Trust, and invariably lack the surgical experience to interpret complex procedures.

Trusts must take measures to ensure such large tariff uplifts are not missed for complex procedures.

We explain the tariff process and discuss how improvements can easily be achieved by individual trusts.

Introduction: Numerous studies have been carried out to assess the efficacy of tranexamic acid on intra and post operative blood loss and its implications. Many of these studies conclude that there is a need to study the effects of tranexamic acid on actual post Operative blood transfusion, thromboembolic events and hospital stay.

We analyzed the effects of Tranexamic acid on Intra- operative blood loss, post Operative haemoglobin and haematocrit drop, blood transfusion requirement, incidence of deep vein thrombosis and hospital stay in Patients undergoing Total hip arthroplasty.

Methods: Prospective case control study involving 50 patients (25 in each category, ASA class I to III) operated by a single consultant. Patient were given single dose of Intra venous Tranexamic Acid (10 mg/kg,10 minutes pre-incision) and Intra operative blood loss was compared to control group analyzing dry and wet swab weights and irrigation fluid. The actual haemoglobin drop, blood transfusion requirement, average length of stay in hospital and incidence of DVT were noted.

Results: There was 30% reduction in intra operative blood loss in the study group. None of the other parameters show evidence of a statistically significant difference between the groups. The average hospital stay was 7 days in both the groups.

Discussion: We found out that Tranexamic acid makes little difference in terms of actual haemoglobin and haematocrit drop, blood transfusion requirement and hospital stay. Our study didn’t show any rise in deep vein thrombosis in treatment group. The only difference it made was reduction of intraoperative blood loss by 30%. To the best of our knowledge, ours is the only study which combines all these parameters.

Introduction: Between 1990 and 2000 we reconstructed 123 hips in 110 patients using impaction bone grafting with frozen, morsellised irradiated femoral heads and cemented sockets. This review presents the medium to long term survivorship of irradiated allograft in acetabular reconstruction in our cohort of patients.

Patients and Methods: Patients were reviewed in out-patients. Radiographs were examined for union, lucency and component migration.

The mean age at revision with allograft was 64.3 years (26 to 97). 86 hips (70%) in 74 patients were reviewed both clinically and radiologically.

At the time of review 28 patients (29 hips) had died and 5 patients (5 hips) were lost to follow up. Of those patients who had died 18 hips had been followed up to a mean of 66 months (12–145). A further 3 hips were unable to attend for clinical review but had accurate implant-allograft survivorship data.

Their data were included in survivorship analysis to the time of last clinical review.

Results: There have been 19 revisions; 9 for infection, 7 for aseptic loosening and 3 for dislocation. In surviving acetabular reconstructions, union of the graft had occurred in 64 out of 67 hips (95.5%). Radiolucent lines at the bone cement interface were seen in 12 hips (17.9%; 9 in a single DeLee zone and 3 in multiple zones) but none were considered loose. Migration of the acetabular component greater than 5mm was seen in 3 hips (4.5%). Survivorship analysis using revision as an end point for all indications at 10 years was 83.3% (95% C.I. 68 to 89%) and 71.3% (95% C.I. 58 to 84%) at 15 years

Conclusion: Acetabular reconstruction using irradiated allograft and a cemented cup is an effective reliable technique with good results in the medium to long term comparable to series using non irradiated freshly frozen bone.

Introduction: Leg length discrepancy in general and leg lengthening in particular has emerged as a topic of interest and a common cause for litigation

Theoretical considerations: Painful mobile hip functions in abduction. The load on the hip is reduced by pelvic tilt to the symptomatic side. For this to be possible the proximal lever - the head neck and the acetabulum - must be relatively intact.

Methods: A method to identify patients at risk for limb lengthening after total hip arthroplasty by establishing the aetiology of abduction deformity of the osteoar-thritic hip.

Clinically: by pelvic tilt to the symptomatic side apparent limb lengthening, restriction of adduction.

Radiologically: by a relatively well preserved geometry of the hip and infero-medial femoral “head –drop” osteophyte.

Results: In a group of 5000 patients presenting for primary Charnley low-frictional torque arthroplasty: 182 (3.64%) 80 males, 102 females, mean age 63 (20–80) were identified as being at risk for post-operative limb lengthening.

Aetiology – Primary: Unilateral 130, Bilateral 10.

– Secondary: Post-surgery 23, post-trauma 10, spinal 6, mixed 3.

122 (67%) had apparent limb lengthening – mean 3.2% and in 43 (24%) limb lengths were equal, 91% had a well preserved architecture and the proximal lever system.

Discussion: The tell tale signs in patients at risk for limb lengthening after total hip arthroplasty are: pelvic tilt to the symptomatic side with apparent limb lengthening, restricted adduction, history of backache, well preserved hip structure and normal contralateral hip.

Conclusion: Awareness of the pattern identifying patients at risk, detailed pre-operative assessment, avoidance of capsule excision and tight hip reduction are essential.

Introduction: Hip resurfacing has gained popularity for treating young and active patients with arthritis. Recent literature has reported increase revision rate amongst females as compared to males undergoing resurfacing. The aim of this study is to identify any differences in survival or functional outcome between male and female patients treated with metal-on-metal hip resurfacing.

Methods: All procedures performed between July 1997 to July 2003 were extracted from the database and grouped based on gender. 1266 patients (1441 hips, 582 female and 859 male patients) were identified. The preoperative diagnosis, Oxford hip score, component size, post operative complications and revisions were recorded. Failures included revision of either the femoral or acetabular components.

Results: The mean follow up was 5.5 years. There were 52 revisions in total (30 in female and 22 in male group). The 8 year survival in the male and female groups were 96.1% and 91.5% respectively which is significantly different (p=0.0006). The size of the femoral component was significantly associated with revision (p=0.0008). Cox proportional hazard modelling including gender, aetiology and femoral component size identified a diagnosis of osteoarthritis reduced the risk of revision of 0.2 times (p=0.0004). However, SUFE was significantly associated 5.57 times increased risk of revision (p=0.0019). With every millimetre increase in head size there was a reduction in risk of revision of 0.89 (p=0.0098). By inclusion of all variables in this model gender was found not to be significantly associated with failure.

Conclusion: This study demonstrates that although females may initially appear to have a greater risk of revision this is related to differences in the femoral size and pre-operative diagnosis between the genders. Patient selection for resurfacing is best made on size and diagnosis rather than gender.

Introduction: Leg length discrepancy (LLD) following total hip replacement (THR) is not uncommon. Some patients are symptomatic, with problems such as gait imbalance or back pain. LLD is a potential cause of litigation following THR.

We have observed that some patients perceive their LLD to be much greater than the true LLD. A large LLD is sometimes reported by therapists, despite only a small true LLD.

We have found that abduction tightness is a potent cause of apparent LLD, and report our investigations into this phenomenon.

Method: We have identified a series of patients with abductor tightness and a significant apparent LLD. The LLD becomes apparent when the operated leg is adducted to the midline (or when the patient stands with their ankles together). This causes the contralateral pelvis to elevate and the un-operated leg to “shorten”.

Clinical photographs and videos have been produced to demonstrate this phenomenon.

A 2-dimensional model has been made to demonstrate how the degree of abduction, offset and over-lengthening affect this phenomenon.

A computer model has been used to quantify these effects.

Results: An abduction contracture after THR will cause the un-operated leg to be apparently and functionally short, even in the absence of a true discrepancy.

Even with only minor abductor tightness, increasing the true length will disproportionately increase the apparent LLD.

Conclusion: An abduction contracture is a potent cause of apparent LLD. Even a small degree of true over lengthening will be greatly magnified by this phenomenon. We recommend careful clinical assessment for abductor tightness when examining patients complaining of a LLD after THR.

Introduction: Excellent medium term results have been reported with the BHR hip resurfacing implant. A number of modifications have been made to the latest designs in an attempt to preserve acetabular bone stock, improve function and prolong survival. We present the clinical and radiological results from the first independent series of ASR resurfacings.

Methods: The first consecutive series of 214 ASR hip resurfacings (192 patients) were followed up prospectively. No patients were lost to follow-up. The mean age of patients at implantation was 56 years and 40% were female. All patients had pre- and 2-year post-operative Harris Hip Scores (HHS) and UCLA activity scores. Radiographic and implant survival analysis was performed at 24–54 months following implantation.

Results: One hundred and seventy-three hips (87%) had an excellent Harris Hip Score (90 or above). Mean postoperative UCLA activity score was 7 and 92% were highly satisfied with the outcome. There were eleven revisions (5.1%). Four (1.9%) had femoral neck fractures (three had a femoral neck notch), two (0.9%) collapsed secondary to avascular necrosis and five (2.3%) were revised because of ongoing pain, as a result of metal wear debris.

Discussion: Although the fracture rate is similar to reports in the literature, the overall revision rate was higher. Rates of wear debris-related failure is concerning. Further investigation of specific implant failure is necessary.

Introduction: As candidates for arthroplasty become younger and life expectancy increases the required working life of a total hip arthroplasty continues to rise. Hip resurfacing offers potential further advantages in young patients as minimal bone resection makes for easier revision, and the design allows for an increased range of movement. The Birmingham Hip Resurfacing (BHR) is the first of the second generation hip resurfacings.

Reports are beginning to emerge of unexplained failure, pseudotumour formation, individual cases of metallosis. Joint registry data also demonstrates an unexplained high early failure rate for all designs of hip resurfacing. This paper examines the rate and mode of early failures of the BHR in a multi-centre, multi-surgeon series.

Methods: All patients undergoing BHRs in our two centres were recruited prospectively into our arthroplasty follow up programme. Patients have been followed up radiographically and with clinical scores.

Results: Mean radiographic and clinical follow up was to 43 months (range 6 – 90 months). Of the 463 BHRs two have died and three are lost to follow up. Thirteen arthroplasties (2.8%) have been revised. Eight for pain, three for fracture, two for dislocation and one for sepsis. Of these nine were found to have macroscopic and histological evidence of metalloisis. Survival analysis at 5 years is 95.8% (CI 94.1 – 96.8%) for revisions and 96.9% (CI 95.5 – 98.3%) for metallosis.

Discussion: Histopathological examination demonstrated a range of inflammatory changes including necrosis, inflammation, ALVAL and metal containing macrophages. Not all features were associated with each patient and it is likely that these features form part of the spectrum of metal wear debris disease.

The likely rate of metallosis is 3.1% at five years. Risk factors for metallosis in this series are female sex, small femoral component, high abduction angle and obesity. We not advocate use of the BHR in patients with these risk factors.

The aim of the paper is to provide an independent single surgeon experience with BHR after a seven-year follow-up.

A cohort of 117 hips in 101 consecutive patients operated by the senior author between Jan 1998 and Dec 2002 were assessed to note their clinical, radiological and functional outcome after a mean follow-up of 7 years (5–9.4 years). Primary osteoarthritis was seen in 73 hips and secondary in 44 hips. Their mean age at surgery was 54 years (range 20–74years). At latest follow-up their mean flexion was 100°and their mean functional outcome scores were respectively: Oxford hip score of 21.5 (12–52, mode 12); Harris hip score of 84.8 (25–100, mode 97), Charnley modification of Merle d’ Aubigné and Postel scores were 4.8 for pain, 4.3 for walking and 5.4 for movement; and SF-36 (physical component 43.9 and mental component 51.45). Failure in the study was defined as revision for any reason. Revision was undertaken in 8 hips (6.8%), five within the first year for periprosthetic fracture neck of femur and 3 hips after the end of 5-year follow-up (2 for advance collapse of the femoral component in patients’ with avascular necrosis of the femoral head and 1 hip for sepsis).

The Kaplan-Meier survival with revision as end point at minimum 5-years of follow-up was 95.7% (95% CI 92–99%) and overall survival at an average 7-years was 91.7% (95% CI 86–97.6%). All the failures were due to the femoral component. However, the reported survival with the use of traditional uncemented and cemented femoral stems is beyond 99% at similar period of follow-up. Patient selection particularly in patients with secondary osteoarthritis is therefore a critical factor when choosing BHR components.

Background: There are no large comparative metal ion studies of commercially available hip resurfacing devices which have taken into account the effects of femoral size and cup inclination and anteversion.

Patients and methods: Metal ion analysis is carried out routinely at our independent centre. We present the metal ion results of 95 unilateral ASR patients and 70 unilateral BHR patients. For all patients, acetabular cup orientation was assessed using EBRA software. Patients with other metallic implants and those within 12 months of surgery were excluded.

Results: Whole blood/serum chromium (Cr) and cobalt (Co) concentrations were inversely related to femoral component size in both the ASR and BHR group (p< 0.05). Cr and Co levels were only seen to increase in the BHR group when the cup was implanted with an inclination greater than 55°. A significant relationship was identifed between the anteversion of the BHR cup and Cr and Co (p< 0.05 for Co, Spearman Rank correlation), with an increase in ions observed at anteversion angles > 17°. Cr and Co were more strongly influenced by cup position in the case of the ASR, with an increase in metal ions observed at inclinations greater than 45° and anteversion angles of < 10° and > 20°.

Discussion: The increased tolerance of the BHR cup to inclinations between 45–55° is likely due to the larger BHR cup providing greater protection against edge loading. When the cohort was divided by gender, the median Cr concentrations of the male ASR patients were significantly lower than those of the BHR males (p< 0.001). This suggests that in larger components positioned at more satisfactory angles of inclination and anteversion, the lower clearance of the ASR proves more significant than the extra coverage provided by the BHR cup. The BHR appears to be more sensitive to changes in anteversion than inclination.

Introduction: Despite the satisfactory short-term implant survivorship of MoM hip resurfacing arthroplasty, symptomatic abnormal periprosthetic soft-tissue masses relating to the hip joint, ‘pseudotumours’, are being increasingly reported. These were found be locally destructive, requiring revision surgery in 75% of patients. Asymptomatic pseudotumours have not been previously investigated.

Methods: The aims were: (1) to investigate the prevalence of asymptomatic pseudotumours; and (2) to investigate their potential association with the level of metal ions. A total of 160 hips in 123 patients with a mean age 56 years (range 33–73) were evaluated at a mean follow-up of 61 months (range 13–88). Radiographs and OHS were assessed. Patients with a cystic or solid mass detected on the ultrasound/MRI had an aspiration or biopsy performed. Cobalt and chromium levels were analysed using Inductively-Coupled Plasma Spectrometer.

Results: Pseudotumours were found in 6 patients (5F: 1M). In 80% of bilateral cases, it was found in both sides. Histological examination showed extensive necrosis and diffuse lymphocyte infiltration. The presence of pseudotumour was associated with higher serum cobalt (9.2 μg/L vs. 1.9μg/L, p< 0.001) and chromium levels (12.0μg/L vs. 2.1μg/L, p< 0.001); higher hip aspirate cobalt (1182 μg/L vs. 86.2μg/L, p=0.003) and chromium levels (883μg/L vs. 114.8μg/L, p=0.006); and with inferior OHS (23 vs. 14 p=0.08).

Discussion: The prevalence of asymptomatic pseudotumour (5%) was higher than previously reported for the symptomatic pseudotumours (1%). There was a sixfold elevation of serum and a twelve-fold elevation of hip aspirate levels of cobalt and chromium in patients with pseudotumours. This suggests that pseudotumours may be a biological consequence of the large amount of metal debris generated in vivo. The association between pseudotumour and elevated metal ion levels might theoretically be explained by either systemic hypersensitivity responses to metal ions or local cytotoxic effects due to a high level of metal ions.

Introduction: Conversion of failed femoral components of total hip resurfacing to conventional hip replacement is reportedly a straightforward procedure. There is little published to qualify this and what is available suffers from small study numbers and various combinations pre and post-operative implants.

Method: Between 1997 and 2002, the Oswestry Outcome Centre prospectively collected data on 5000 Birmingham Hip Resurfacings (BHRs) performed by 141 surgeons, at 87 hospitals. To date 4526 have survived, 135 died and 165 are lost to follow-up.

174 have been revised, of which 60 were failures of the femoral component.

We reviewed modes of failure and post-revision clinical outcomes in this sub-group.

Results: Isolated femoral component failure accounted for 60 hips (1.2%). 28 femoral neck fractures, 14 femoral head collapses, 13 femoral component loosenings, 3 avascular necroses (AVN), 1 femoral loosening followed by fracture and 1 dislocation. Mean time to revision surgery was 2.6years (1.8years for neck fracture; 3.4years femoral loosening, head collapse and AVN).

All acetabular components were left in situ. At revision surgery 25 cemented, 25 uncemented and 10 unknown femoral prostheses were used with 56 BHR modular heads, 2 custom-made Exeter heads and 2 Thrust Plate heads.

47 patients completed outcome scores post-revision surgery. Median modified Harris Hip Score was 82 (IQ range=63–93) and Merle d’Aubigne score was 14 (IQ= 9.5–15) at a mean follow up of 3.9years post-revision.

The 4526 surviving resurfacings had a median hip score of 96 (IQ=87–100) p≥4.558x10-8 and median Merle score of 17 (IQ=14–18) p≥1.827x10-7. Mean 7.0 years follow up.

There was no difference in outcomes between cemented and uncemented revision components nor were there differences between fractured neck of femur and femoral loosening, head collapse or AVN.

Discussion: Following revision of the femoral component to a conventional hip replacement, function is significantly worse than surviving resurfacings.

In our independent centre, in the period from January 2003 to august 2008, over 1100 36mm MoM THRs have been implanted as well as 155 Birmingham Hip Resurfacing procedures, 402 ASR resurfacings and 75 THRs using ASR XL heads on SROM stems.

During this period we have experienced a number of failures with patients complaining of worsening groin pain at varying lengths of time post operatively. Aspiration of the hip joints yielded a large sterile effusion on each occasion. At revision, there were copious amounts of green grey fluid with varying degrees of necrosis. There were 11 failures of this nature in patients with ASR implants (10 females) and 2 in the 36 MoM THR group (one male one female).

Tissue specimens from revision surgery showed varying degrees of ‘ALVAL’ as well as consistently high numbers of histiocytes. Metal debris was also a common finding.

A fuller examination of our ASR cohort as a whole has shown that smaller components placed with inclinations > 45° and anteversions < 10 or > 20° are associated with increased metal ion levels. The 11 ASR failed joints were all sub optimally positioned (by the above definition), small components.

Explant analysis using a coordinate measuring machine and out of roundness device confirmed greater than expected wear of each component. The lower number of failures in the 36mm MoM group, as well as the equal sex incidence, suggests that the majority of these failures are due to the instigation of an immune reaction by large amounts of wear debris rather than adverse reactions to well functioning joints. It is likely that small malpositioned ASRs function in mixed to boundary lubrication, and this, combined with the larger radius of these joints compared to the 36mm MoM joints, results in more rapid wear.

Introduction: Metal on metal Hip Resurfacing Arthroplasty (MoMHRA) has gained popularity due to its perceived advantages of bone conservation and relative ease of revision to a conventional THR if it fails. This retrospective study is aimed at assessing the functional outcome of failed MoMHRA revised to THR and comparing it with a matched cohort of primary THRs.

Method: Since 1999 we have revised 53 MoMHRA to THR. The reasons for revision were femoral neck fracture (Group A, n=21), pseudotumour (Group B, n=16) and other causes (Group C, n=16: loosening, avascular necrosis and infection). Average follow-up was 3 years months (1.2–7.3). These revisions were compared with 106 primary THRs which were age, gender and follow-up matched with the revision group in a ratio of 2:1.

Results: The mean Oxford Hip Score (OHS) was 20.1 (12–51) for group A, 39.1 (14– 56) for group B, 22.8 (12–39) for group C and 17.8 (12–45) for primary THR group. In group A, there were three infections requiring further revisions. In group B, there were three recurrent dislocations, three patients with femoral nerve palsy and one femoral artery stenosis. In group C, there were no complications. The differences in clinical and functional outcome between group B and the remaining groups as well as the difference in the outcome between group B and control group were statistically significant (p < 0.05).

Conclusions: THR for failed MoMHRA was associated with significantly more complications, operation time and need for blood transfusion for the pseudotumour group. In addition, the revisions secondary to pseudotumour also had significantly worse functional outcome when compared to other MoMHRA revisions or primary THR.

Introduction: Modern metal-metal (MM) Hip Resurfacing (HR) was developed as a conservative option for young patients with severe arthritis. Whilst some centres have reported excellent early results, other series have found a high incidence of osteolysis and still others reported soft tissue necrosis and periarticular changes. These are not always detectable with conventional imaging. This is the first 10 year clinico-radiological and multi-slice CT assessment of hip resurfacings.

Methods: The study includes 124 consecutive single-surgeon HRs (113 patients), mean age 52.8 years (27 to 75), mean follow-up 10.6 (10.4 to 10.8 years). Diagnoses include primary osteoarthritis (102), osteonecrosis (6), dysplasia (12) and others (4). Five patients (7 hips) died 5 to 10.3 years later from unrelated causes. Unrevised patients are reviewed with questionnaires, conventional radiographs and CT assessment.

Results: With revision for any reason as the end-point there were seven failures 0.4 to 9.7 years after operation (one failed from femoral neck fracture, four due to femoral head collapse and two were deep infections, 94% 10-year cumulative survival. Five cases showed osteolysis and four had neck thinning. No aseptic loosening, migration or malorientation is found. No patient is awaiting a revision.

Discussion and Conclusion: The performance of MMHR continues to be good at 10 years. Arthroplasty devices are known to manifest two phases of failure, one during early years and another in later years. Early failure with this device has been low. The interim years continue to be promising and we are yet to find out when the late failures are likely to occur.

Introduction: End-stage hip arthritis secondary to femoral head avascular necrosis (AVN) in young patients is a therapeutic challenge. Hip resurfacing (HR) has been showing excellent medium-term results in patients with osteoarthritis. Destructive changes in a large segment of the femoral head from AVN can increase the risk of postoperative femoral neck fracture or femoral head collapse following a resurfacing procedure. Careful patient selection and precise operative technique are vital to success. This is a study of the results of HR in patients with arthritis secondary to femoral head osteonecrosis.

Methods: This is a single-surgeon consecutive series with a 4 to 14-year (mean 8.6) follow-up. 95 patients (104 hips) with Ficat-Arlet grade III or IV osteonecrosis and treated with HR at a mean age of 43 (range 18 to 68) years. Two patients died due to unrelated causes and none is lost to follow-up. Revision for any reason was the end-point. Unrevised patients were assessed clinically and with Oxford hip scores and AP and lateral radiographs.

Results: Nine failures (1 fracture, 5 femoral head collapse, 2 infections, 1 cup loosening) give a failure rate of 8.7% and a cumulative survivorship of 89% at 14 years. In one further patient the femoral component has tilted into varus. He is asymptomatic but knows that he may need a revision if symptoms develop. No other patient shows clinical or radiological adverse signs.

Discussion and Conclusion: Several studies suggest that the results of arthroplasty are generally worse in AVN compared to those in osteoarthritis. HR has demosntrated good results in young patients with good quality femoral head bone. Reviewing the above results it appears to us that the relatively poorer cumulative survival observed in patients with a diagnosis of AVN (89%) makes AVN a relative contraindication to hip resurfacing.

Introduction: We prospectively followed all hip fracture patients admitted between 2004–2006, identified cases where the intention was to treat conservatively and compared their functional outcome and mortality with a similar cohort treated surgically over the same period.

Methods: We recorded length of hospital stay, place of discharge, pre and post-fracture mobility and residence, 30 day and 1 yr mortality, re-admission and delayed surgery. The group treated surgically was recruited and matched for age, gender, pre and post fracture mobility, mental confusion and independence with the conservatively treated group.

Results: 25 patients were treated conservatively. 22 patients treated surgically over the same period were recruited. The mean hospital stay was 13 days in both groups. There were 4 extracapsular (3 displaced) and 21 intracapsular fractures (5 displaced) in the conservative arm and 11 extracapsular and 9 intracapsular fractures in the surgically treated arm. 4 patients from the conservative treatment group underwent late surgery 20 days – 2 months after the index event. Surgically treated group had 11 dynamic screw fixation, 1 cannulated screw, 1 total hip replacement and 7 hemiarthroplasty. 9/14 of the conservatively treated patients were mobile independently or with aid after treatment compared to 11/16 patients after surgery. 7/16 patients treated conservatively were living independently in their own residence, compared to 10/14 patients in the operatively treated patients. 1 month and 1 year mortality in conservatively treated group was 4/21 and 7/21 respectively compared to 1/20 and 5/20 in the operative fixation group. There was no statistically significant difference in mobility, residence or mortality between the two groups (Fisher exact test, p > 0.05).

Discussion: Conservative management after hip fracture in medically unfit patients does not result in statistically significant difference in functional outcome or mortality compared to patients treated surgically.

Introduction: We investigated the relationship between psychological distress and outcome after total hip replacement (THR) in the Exeter Primary Outcome Study (EPOS).

Materials & Methods: Data were collected from a number of centres across England between January 1999 and January 2002 for patients undergoing primary hip replacement using the cemented Exeter femoral component (Stryker). We recorded the Oxford Hip Score (OHS) for physical function and SF36 questionnaire for both physical and mental domain assessment annually for five years. We dichotomised the patients into the mentally distressed (MHS < 50) and the not mentally distressed (MHS ≥ 50) groups based on their pre-operative Mental Health Score (MHS) from the SF36 score.

Results: Complete data were available for 455 (407 not distressed and 48 distressed) patients. Pre-operative OHS and SF-36 score was significantly worse in the distressed group (both p< 0.001). Mean OHS improved from 43 to 20 at 1 year after surgery and remained the same thereafter in the non distressed group. In the mentally distressed group pre-operative mean OHS of 48 improved to 22 at 1 year after surgery. Maximum improvement in OHS occurred in the 1st yr after surgery. Mean MHS improved from 76 to 81 at 1 year after surgery and remained the same thereafter in the non distressed group. Mean MHS improved from 35 to 62 at 1 year after surgery, reaching 65 at 5 years after surgery in the mentally distressed group. The maximum improvement in MHS occurred in the 1st yr after surgery.

Conclusion: Pre-operative psychological distress did not compromise functional outcome after hip arthroplasty. There was a substantial improvement in mental distress in patients with mental distress prior to surgery. Both groups of patients experienced improvement in Oxford Hip Score, which was maximal by 1 year after surgery and was maintained over the 5 year follow up.

Background: There is no consensus on the most appropriate prosthesis for treating osteoarthritis (OA) of the hip in young, highly active patients. Modern hip resurfacing is bone conserving, more stable and theoretically easier to revise than total hip arthroplasty. Early results of metal on metal resurfacing have been promising. We have compared two well matched cohorts of patients with regard to function, pain relief and patient satisfaction.

Methods: This prospective study included 2 cohorts of well matched patients treated with hip resurfacing (137 patients, 141 hips) and custom uncemented (CADCAM) stems (134 patients, 141 hips). All procedures were performed by a single surgeon. Outcome measures included Oxford, WOMAC and Harris hip scores. Statistical analysis was performed using the unpaired student’s t- test.

Results: One hundred and thirty four and 137 patients were included in the hip replacement and resurfacing groups respectively. The mean age of these patients was 54.6 years. The mean duration of follow up for the resurfacing group was 19.2 months compared to 13.4 months for the replacement group.

Pre operative oxford, Harris and WOMAC scores in the THA group were 41.1, 46.4 and 50.9 respectively while the post operative scores were 14.8, 95.8 and 5.0. In the HR group, pre- operative scores were 37.0, 54.1 and 45.9 respectively compared to 15.0, 96.8 and 6.1 post operatively. The degree of improvement was similar in both groups.

Conclusion: There was no significant difference in short term outcome between the groups of patients treated with hip resurfacing and total hip arthroplasty in the short term.

Introduction: Metal-metal (MM) hip resurfacing is being increasingly used in the young. The main concern is the invariable systemic metal ion release. In young women the concern is that metal ions cross the placenta in pregnant women with MM bearing arthroplasties. We earlier presented an interim report on this subject the results of which ate established in a larger cohort

Methods: This is a controlled cross-sectional study of women of child-bearing age with MM resurfacings. (n= 22, mean age: 32 years, mean duration after resurfacing 60.3 months, 3 bilateral). The control group consisted of 24 pregnant subjects who did not have a metallic implant (mean age 31.3 years). Whole blood specimens were obtained from the mothers and umbilical cords at delivery.

Results: None of the babies had a congenital anomaly. Cobalt and chromium were detectable in all specimens including all controls. In the study group, mean cord metal ion levels were significantly lower than the maternal cobalt (p < 0.05) and chromium (p < 0.0001). In the control group, the mean cord blood metal levels differed very little from the maternal levels (p > 0.5). The mean difference in cord chromium between the study (0.33 μg/l) and control groups (0.21 μg/l) was not statistically significant, although the difference in cord cobalt was significant (0.41 μg/l).

Discussion: The differences between maternal and cord metal ions in the control patients is very small indicating that, under these circumstances the placenta allows an almost free passage of metal ions. The relative levels in the study group reveal that the placenta exerts a modulatory effect on metal transfer when maternal levels are above normal. Cobalt and chromium cross the placenta, irrespective of the presence of metal devices and therefore there is a need to continue efforts to reduce metal ion release.

Introduction: The advantages of metal on metal bearings (MoM) include improved wear characteristics and lower dislocation rate. Metal sensitivity and Aseptic Lymphocyte Dominated Vasculitis Associated Lesion (ALVAL) reaction are becoming increasingly recognised. The BOA has recently issued a statement regarding MoM bearings. They suggested that any revisions for symptoms of pain and soft tissue reaction should be reported to the MHRA and histological specimens forwarded to the Stanmore Retrieval Centre.

Methods and results: We report four patients (all females), who presented with late dislocation of a large diameter MoM bearing (three following total hip replacements and one following resurfacing). They all made good initial recovery with complete relief of pain. They developed pain around groin between one and two years following the surgery. Inflammatory markers were normal. MRI/Ultrasound scanning showed the presence of cystic lesions around the hip. They all presented with relatively late dislocation (26 months to six years). At exploration there was a large joint effusion with necrosis and detachment of the abductors. A characteristic finding was an avascular bare trochanter stripped free of any soft tissues. Histology showed a predominantly histiocytic response in keeping with the findings of Willert and Pandit.

Discussion: In the absence of any obvious causes for dislocation, one should have a high index of suspicion for the possibility of metal hypersensitivity causing joint effusion, muscle necrosis and thereby leading to instability due to the progressive periosteal and soft tissue erosion. These patients should be considered for early revision of the bearing surface to prevent further damage to the muscle and bone. If the abductors are completely detached a more constrained type of bearing should be used to improve the stability. To the best of our knowledge this is the first report of this unusual complication following MoM bearings.

Introduction: Metal-on-metal arthroplasties are being used for their increased durability and reduced requirement for revision. Previous data reports that metal-on-metal bearing surfaces release three times more cobolt and chromium ions than metal-on-polyethelene hip replacements. Data also suggests that these metal ions can cause DNA damage.

Method: A prospective study of patients (aged 60–80), meeting exclusion criteria were selected and randomised to metal-on-metal or metal-on-polyethylene articulation. Patients were reviewed preoperatively (control model) and at 3 months, 6 months and one year postoperatively. On each occasion blood tests were taken to quantify metal ion levels (chromium, cobalt, nickel, vanadium and titanium) and chromosome aberrations in T lymphocytes using 24 colour fluorescent in situ hybridization (FISH).

Results: The number of chromosome aberrations increased with time; in particular there was a statistically significant increase in aneuploidy after one year, there was also an increase in chromosome translocations. There was a similar increase in blood concentration of metal ions over this same time period which proved significant. Higher levels of metal ions were seen in the metal-on-metal group when compared with the metal-on-polyethylene.

Conclusion: This study has highlighted the effects of metal ions on chromosome replication in particular causing aneuploidy aberrations. This provides evidence of the short-term effects of metal-on-metal arthroplasty but further research needs to be undertaken to assess long-term risk and also the risk associated to other cell lines.

Introduction: Increased wear is associated with aseptic loosening and late dislocations. Hard on hard bearings may reduce wear but still have topics of concern such as free metal ions in metal on metal bearings and the risk for fracture in ceramic articulations. Ceramic heads against conventional polyethylene is also used with the intention to reduce wear. But this effect has not been conclusively documented in the literature and is still discussed. 87 patients were operated consecutively by the same surgeon with the same surgical technique. All patients received a cemented all poly cup sterilized with irradiation in inert atmosphere and a cemented stem. Head size was 28 mm in all patients. 40 patients received cobalt-chrome heads and 47 patients aluminiumoxid heads. The patients were followed with RSA for 10 years and analysed for wear.

Results: Mean (SEM) wear for the group with cobalt chrome heads was 0.93 mm (0.13) and for the group with aluminiumoxide was 0.43 mm (0.08) (p = 0.001).

Discussion: We found significantly less wear with aluminumoxide heads compared to cobalt-chrome heads. The wear results in the cobalt-chrome group correlate well to wear values in the literature for conventional polyethylene. Although the polyethylene in this study is partly cross-linked (3Mrad) it is not clear whether these results can be extrapolated directly to the use of highly cross-linked PE. If longer follow-ups confirm the mechanical stability of highly cross-linked PE, ceramic heads might contribute additionally to the reduction of wear.

In conclusion we found significantly reduced wear for aluminumoxide heads compared to cobalt chrome heads which could be beneficial for young and active patients.

Introduction: The successful outcome from metal-on-metal hip resurfacing is partly dependent on the restoration of the natural biomechanics of the hip joint. Valid measurement of the geometry of the reconstructed hip is challenging using plain radiographs. CT is more accurate and precise yet rarely used to assess hip geometry. Our aims were 1) to quantify the agreement between radiographic and CT measurement of horizontal femoral offset (HFO); 2) to determine the relationship between HFO and patient gender and size; and 3) To compare HFO of the reconstructed hip to the contralateral hip.

Method: We used plain radiograph and CT data from 42 patients (23 male and 19 female) from a consecutive series with unilateral metal-on-metal hip resurfacings. We measured HFO of both hips (component and contralateral) using plain radiographs (with PACS) and CT (with Robin 3D software). Pelvic width and radial head sizes were measured on CT. Measurements were made in triplicate by 2 observers.

We graded the contralateral hip for severity of joint space narrowing on plain radiographs.

Results: There was considerable disagreement between CT and plain radiographs for HFO. HFO was statistically different between genders (p=0.0004). HFO correlated with femoral head radius (0.57, p=0.0002), but not patient size (for height (0.29, p=0.13), or pelvic width (0.25, p=0.11). There was a wide range of HFO of the contralateral hips that was comparable to the reconstructed hip.

Conclusion: To our knowledge this is the first study to show the importance of measuring HFO using CT. HFO was found to be correlated to gender and femoral head radius, but not with any other parameters of patient size. The wide range of offset was considerably greater than is available from current total hip replacement designs. Hip resurfacing may overcome this.

Introduction: We investigated the incidence, risk factors and outcome of acute renal dysfunction (ARD) in patients with a fractured neck of femur.

Methods: 170 consecutive patients were prospectively included in the Scottish hip fracture audit database and retrospectively analysed. Historically, lack of consensus definition hindered accurate reporting of ARD. We defined ARD using the ‘RIFLE’ criteria recently described by the Acute Dialysis Quality Initiative (ADQI) Group.

Results: 27 patients (16%) developed ARD. Risk factors were male sex, vascular disease, hypertension, diabetes, chronic kidney disease and pre-morbid use of nephro-toxic medications (p< 0.01). Inpatient, 30 and 120 day mortality was higher in the ARD group 19%, 22% and 41% respectively, versus 0%, 4% and 13% in the non-ARD group (p< 0.01) Length of hospital stay was significantly longer in the ARD group; 20 days compared to 13 days for patients in the non-ARD group (p< 0.01). Pre and post-operative complications were 12 and 5 times more frequent respectively in the ARD group (p< 0.01).

Discussion: Acute renal dysfunction is an important adverse event in this population. Awareness of risk factors and serial measurements of renal function will enable early identification and focused monitoring of these patients.

Introduction: Peri-prosthetic fractures following hip resurfacing arthroplasty are difficult fractures to treat. The surgeon is faced with the task of either attempting to fix the fracture if feasible or revise the resurfacing implant to a conventional total hip replacement.

Method & Results: Here we report of a novel way of fixing a peri-prosthetic fracture following resurfacing hip arthroplasty using Polyaxial locking plate fixation. A 53 year old man sustained a intertrochanteric fracture below his resurfacing metal on metal hip prosthesis following a fall. He had his hip resurfaced 3 years back for osteoarthritis in another hospital. He underwent surgery to fix the fracture using a polyaxial locking plate with no post-operative complications. He was mobilised non-weight bearing for the initial six weeks and weight bearing as tolerated thereafter. He went on to union and was moblising without any problems in three months time. His follow-up x-rays at 8 months showed fracture healed with no evidence of prosthesis problems.

Discussion: There are various methods of treating a periprosthetic fracture of a well fixed resurfaced hip implant. The two types of management are open reduction and internal fixation and revision to a stemmed hip implant. These fractures can be fixed with cannulated hip screws, blade plate device or plating with screws avoiding the stem of the resurfacing prosthesis. We used the polyaxial locking plate device with good result thereby avoiding the need for revision surgery with its attendant risks. Using this implant is a useful alternative for these fracture patterns.

Introduction: We undertook an audit study to find out patient perception of being seen by a nurse practitioner in the clinic for a follow up appointment instead of a consultant and satisfaction with the joint clinic.

Methods and materials: 100 patients were surveyed following their post-operation review with the nurse. Data was collected prospectively over a period of 6 months. Patients were asked to complete the questionnaire on the day of their appointment and to hand the survey prior to leaving. Hence we had 100% response rate.

Results: Majority of the respondents were female (61%) with 50 % having had total hip replacements and the rest had knee replacements. 99% of respondents (94/95) felt that enough time was spent with them during the appointment. All respondents (100%) reported that they were able to ask questions and were answered satisfactorily. The consultant saw 26% of respondents; further 6% was seen by a registrar and the rest 68% were seen by the nurse specialist. Reasons for being seen by a doctor included check up or assessment, reviewing stitches and infection. 42% of respondents (33/79) were referred for further treatment either by the consultant (33%), nurse (64%) or registrar (3%). Reasons for further treatment included physiotherapy, plaster room, and further follow up (check up) appointment at 3–6 months to review the patient following surgery. 100% of respondents (97/97) were satisfied with the combined consultant/nurse clinic. 3 did not record their response. The vast majority of respondents (80%, 79/99) reported that they ‘don’t mind’ who they would have been seen by in the clinic.

Discussion: The results indicate that patients are satisfied with the current clinic arrangements i.e. nurse-led clinic with the consultant being available. Hence there is a definite role for nurse led clinics for joint replacement surgery follow-ups.

The review of the first 325 Exeter Universal hips reported good long term survivorship despite the majority of cups being metal backed. We have reviewed the long term performance of the concentric all-polyethylene Exeter cups used with the Universal Exeter stem.

Clinical and radiographic outcomes of 263 consecutive primary hip arthroplasties in 242 patients with mean age 66 years (range, 18 to 89) were reviewed. 118 cases subsequently died none of whom underwent a revision. Eighteen hips have been revised; thirteen for aseptic cup loosening, three for recurrent dislocation and two for deep infection. Three patients (four hips) were lost to follow-up. The minimum follow-up of the remaining 123 hips was 10 years (mean 13.3 years, range 10–17). Radiographs demonstrated 6 (6%) of the remaining acetabular prostheses were loose. The Kaplan Meier survivorship at 14.5 years with endpoint revision for all causes is 91.5% (95% CI 86.6 to 96.2%). With endpoint revision for aseptic cup loosening, survivorship is 93.3% (CI 88.8 to 97.8%).

This series included a number of complex cases requiring bone blocks and/or chip autograft for acetabular deficiencies. The concentric all polythene Exeter cup and Exeter stem has excellent long term results particularly when factoring in the complexity of cases in this series.

Introduction: Trochanteric bursitis is a common hip problem that can be refractory to treatment. The available modalities of treatment can be less effective. We evaluated the use of extra-corporeal shockwave therapy treatment for trochanteric bursitis.

Methodology: 22 patients with the clinical and radiological (in 6 patients) diagnosis of trochanteric bursitis were treated in a dedicated shockwave therapy clinic using Swiss dolocast radial shockwave therapy machine. 3 sessions of treatment were given one week apart, delivering 2000 impulses at 10 Hz at each session. Patients were evaluated prior to treatment, 3 months, 6 months and 12 months following their treatment. The visual analogue score (VAS) was used in all patients pre and post treatment. Hip disability and osteoarthritis score (HOOS) was performed post-treatment.

Results: Between December 2005 and November 2008 22 patients were treated for symptoms of trochanteric bursitis. There were 17 women and 5 men. The average age was 55.8 years (range 33–76 years). 6 patients had proven increase signal on MRI scan the rest were mainly clinical diagnosis and after a limited response to steroid injections. Their VAS improved from 10 to 5. Their post-treatment HOOS score averaged 255.

Of the 6 patients who had MRI proven increased signal 5 patients had significant improvement. The average improvement in the VAS was 10 to 2.3 and their HOOS scores were 349.2 (range 427–243).

Conclusion: Though the number of patients in this study is only 22 it seems that radial shockwave therapy treatment for trochanteric bursitis is promising, especially on those who have got high signal on MRI scans.

Introduction: There has been an introduction of short femoral stems with the aim of conserving bone. We present the short term results of short metaphyseal cement-less stem(Proxima^®, Depuy).

Material and methods: 25 patients in age group (25–40yrs), 15 males,10 females were implanted with a short metaphyseal cementless stem (Proxima^®, Depuy) and cementless acetabular cup. The average follow up was 2.3 years (1.4–2.5 yrs). Clinical evaluation using Harris Hip Score, Radiological evaluation and Bone Mineral Density were evaluated at 2weeks, 6 months, 12 months and yearly thereafter. a new zonal method suitable for short stem was used for radiological evaluation.

Results: The mean Harris Hip score improved from 44 to 95 at final follow up. There was no evidence of any radiolucent lines or osteolysis around the stems. All the stems showed evidence of osseointegration at one year follow up. There was no decrease in bone mineral density around the stems.

Discussion: The Short Metaphyseal cementless femoral stem is a bone conserving as well as bone preserving option for young patients especially in those in whom surface replacement is not an option.

Introduction: Previous studies have demonstrated the value of the tip-apex distance (TAD) and the location of the screw in the femoral head in predicting cut-out. Similarly surgeons’ volume has been shown to affect mortality and morbidity in various surgical specialties, including in trauma and orthopaedics.

Aim: To determine whether re-operation due to cut out at six month can be predicted using TAD, location of the screw and fracture type; and whether the experience of the surgeon is important.

Methods: Logistic regression was used to analyse data collected retrospectively from 241 patients with extracapsular fractures (Jensen’s modification of Evans’ classification: Class I – 90, Class II – 93 and Class III – 58), treated with a dynamic hip screw, classic hip screw or intramedullary hip screw from April 2005 to October 2007.

Results: There were 7 cut outs (2.5%) requiring re-operation within 6 months – 1 in the consultant group and 6 in the trainee group,. The model used was statistically significant (X2=23.6 [13df], p< 0.05). The tip-apex distance was a strong predictor (p< 0.05) of cut-out requiring re-operation at six months. The odds of the patient requiring re-operation due to cut out increases by a factor of 1.2 for each millimetre increase in the TAD. Location of the hip screw and fracture type were however not significant predictors. The first surgeon was a consultant in 54 cases and trainee in 187 cases. There was no statistically significant difference in re-operation rate due to cut out between patients operated on by consultants compared to trainees.

Conclusion: The TAD is a strong predictor of cut out requiring re-operation at 6 months. No difference was found in our series in re-operation rate due to cut out among cases performed by consultants compared to trainees.

Background: Joint replacements are being performed on ever younger patients at a time when average expectancy of life is continuing to rise. Any reduction in the strength and mass of periprosthetic bone could threaten the longevity of implant by predisposing to loosening and migration of prosthesis, periprosthetic fracture and problems in revision arthroplasty.

Aims & Objectives: This study aims to analyse and compare prospectively the femoral periprosthetic stress-shielding around 4/5th and 1/3rd porous coated cementless femoral stems in patients undergoing unilateral cementless total hip replacement done using DEXA scan by quantifying the changes in bone mineral density around femoral component.

Material & Method: Femoral periprosthetic bone mineral density was measured in the seven Gruen Zones with DEXA scan at 2 weeks, 1 years and 2 years after surgery in 60 patients who had undergone unilateral cementless total hip replacement, of which 30 patients had been implanted with 4/5th porous coated stems and other 30 patients with 1/3rd porous coated stems.

Results: At both one and two years postoperatively, bone loss due to stress-shielding was seen in both stems with maximum loss in zone VII and minimum in zone III, IV, V. The maximum mean percentage bone mineral density loss in 4/5th porous coated stems in zone VII was 16.03% at one year and 22.42% at 2 years as compared to loss of 10.07% and 16.01% in 1/3rd porous coated stems. Increased bone loss was seen in patients who had larger diameter stem (> 13.0 mm) and in patients with low bone mineral density in the unoperated hip.

Conclusion: Bone loss as a result of stress-shielding is more pronounced in 4/5th porous coated stems as compared to 1/3rd porous coated stems.

Leg length discrepancy (LLD) following total hip arthroplasty (THA) is a well-known and documented phenomenon. LLD can pose a substantial problem for both the patient and the surgeon. Patient dissatisfaction with LLD after THA is the most common reason for litigation against orthopaedic surgeons. Failure to restore limb length may lead to an unstable hip, whereas over-lengthening may cause low back pain, sciatic nerve palsy and early mechanical loosening.

Several intra operative techniques both invasive and non invasive have been reported in the literature to over-come LLD during THA. The accuracy of all the methods that measure from pins anchored into pelvis to point on the greater trochanter may be affected by the inherent variability of the leg position when measurements are made. Bending or dislodging the pins and using of calliper devices can be cumbersome during the THA surgery and can compromise the measurements.

Hence we describe a simple, safe and reliable intra operative technique to overcome LLD by using a stout braided suture material tied to the stout Judd pin used to retract the soft tissues in posterior approach. Utilising the routine incision for the posterior approach to the hip, this technique can be easily carried out in primary THA surgery as compared to other techniques used to avoid LLD, which require further incision, and specialised equipment which are time consuming, cumbersome and may not be very secure. This technique of using a suture mark over the Judd pin is simple, inexpensive and easily adaptable.

Introduction: “Force-closed”, tapered, polished, collarless stems, (e.g. C-stem, Exeter), are designed to subside in response to a gradual expansion of the cement/bone complex.

Above a certain threshold, distal migration may predict medium-to-long-term failure of “shape-closed” (collared, textured) stems. However, no such threshold exists for “force-closed” stems, and these may continue to migrate after 3 years. We believe that the tendency towards stabilisation 2–3 years postoperatively could be the best predictor of good long-term performance.

Method: Twenty OA patients (12F, mean age 66.6 years) were recruited for primary hip replacement with beaded C-Stem femoral components. Tantalum marker beads were injected into the proximal femur, and stems were inserted using CMW1 cement and the latest generation cementing technique via: a posterior approach (17), and a lateral, trochanteric approach (3). RSA X-ray examinations were performed at 1 week, 6 weeks, and at 3, 6, 12, 24 and 36 months postoperatively. The UmRSA system was used to measure and analyse the radiographs.

Results: By 36M the mean stem subsidence (1.05 mm) had levelled off to a low rate, and the mean internal rotation (2.5°) had not significantly changed during the final year (p = 0.08). The mean posterior migration of the stem centroid was 0.54 mm and posterior migration of the femoral head was 1.66 mm (0.25 mm/y during final year).

Discussion: At 36M the mean subsidence rate was very low, and the mean posterior migration was about one third of that reported by Sundberg et al. (BHS Meeting, 2007). Although the mean internal rotation was greater than that reported for the Exeter stem, it had stabilised during the final year. These low rates of migration at 3 years are consistent with the good results found in clinical studies of this femoral component.

Introduction: Modular prostheses were first developed for use in total hip arthroplasty (THA) in the 1980s as a potential solution to the problem of leg length inequality. There is much literature discussing the advantages and disadvantages of modularity in THA but there are few studies directly comparing modular and non-modular prostheses and their accuracy in restoring normal anatomy. Our aim was to assess whether modularity in THA improves the restoration of femoral offset and leg length.

Methods: An analysis of post-operative radiographs of 76 patients who underwent THA - 38 using modular and 38 using non-modular prostheses was undertaken. The femoral offset and leg length of the operated and un-operated hip were measured for each patient. Inter-and intra-observer errors were reduced to a minimum. A two-tailed T test was then applied to the data.

Results: Restoration of leg length (to within +/− 10mm of the un-operated hip) was achieved in 81.6% of patients in the non-modular group, compared to 78.9% in the modular group (p=0.60). On average, the modular system increases leg length of the operated hip by 0.64mm compared to the non-modular system, which reduces leg length by 3.76mm (p=0.016). The femoral offset is restored to within 5mm of the un-operated hip in 60.5% of modular THA and in 55.3% using a non-modular prosthesis (P=0.48). On average, modular prostheses increased offset by 0.85mm and non-modular prostheses by 0.15mm (P=0.64).

Discussion: The modular and non-modular hip prostheses are equally successful in achieving restoration of leg length and femoral offset to the pre-pathological state.

Introduction: Trochanteric bursitis (TB) in association with increased femoral offset components in THA has not previously been reported. We report 15 cases of postoperative TB, all of whom were noted to have high offset femoral implants. Increasing awareness of this complication when inserting femoral components is an important consideration for the arthroplasty surgeon, emphasizing the need for preoperative templating.

Methods: We retrospectively reviewed casenotes and postoperative radiographs patients attending outpatients following THA, with lateral hip pain. A diagnosis of trochanteric bursitis was made in individuals complaining of lateral hip pain, worse on exercising, and tenderness over the trochanter. The presence of a high offset femoral component was noted from casenotes radiographs. Patients with pre-existing TB, recent local trauma, or inflammatory disease which may contribute to TB, were excluded.

Results: 15 cases were identified in a 3 year period. Female to male ratio 1.3:1. The mean age was 68 yrs with a range of 54–81yrs. 7/15 cases (46%) underwent posterior approach to the hip, 8/15 (54%) underwent a Hardinge lateral or modified lateral approach. All patients had clinical features of TB at first postoperative follow up. Mean time to onset of symptoms was 7.2 months, range 2–12 months. All femoral implants had 5mm offset or greater. Postoperative X-rays showed a mean increase in offset of 10.2mm, range 3–18mm.

Discussion: The results indicate that an increase in femoral offset may increase a patient’s risk of trochanteric bursitis, following THA. The data suggest the operating surgeon should consider carefully the use of increased-offset implants, particularly in those at a higher risk or TB e.g inflammatory disorders. This study emphasises the importance of preoperative templating in total hip arthroplasty.

Introduction: Leg length discrepancy (LLD) following hip arthroplasty can produce abnormal loading leading to pain, increased wear and loosening of implants. The aim of this study was to investigate the relationship between LLD and static limb loading.

Methods: A pedobarograph was used to measure the limb loading of 19 normal volunteers aged 18 to 58. Each volunteer was asked to stand on the Pedobarograph with both feet so that their weight could be recorded. The load through the left leg was then recorded with the right leg on a platform level beside it. The platform was then raised in 1 cm increments to 6 cm, to simulate different levels of LLD. In each position 3 readings were taken with the right knee flexed (pelvis level), and straight (pelvis tilted).

Results: When the feet were level the left leg took 53 % of the load. As the height of the right foot was increased the load through the left leg increased in a non-linear fashion.

With the knee flexed, a 1 cm difference produced a 3 % increase in loading. This was significant (P< 0.05). All subsequent increases were also significant. The largest increase in load was observed between 1 cm & 2 cm (+5 %). At 6cm the left leg load was 70.9 %.

With the pelvis tilted, there were smaller increases in loading. These did not become significant until a difference of 5 cm. The maximum load was 62.1 % at 6 cm.

Discussion: The length-loading relationship was non-linear. The pelvis tilted stance produced less loading asymmetry, but more discomfort than the flexed knee stance.

Introduction: The ideal acetabular component has low wear, permanent fixation and physiological bone loading. Recently trabecular metal has been promoted as reproducing the modulus of trabecular bone with a cementless fixation. The aim of this trial was to see if a monobloc trabecular backed polyethylene acetabular component loaded the pelvis physiologically as a cemented polyethylene component.

Method: Between 2004 and 2006 54 patients were ran-domised to a cemented polyethylene acetabular component versus a monobloc trabecular backed polyethylene acetabular component. The primary outcome measurement was bone density in peri-prosthetic acetabular regions of interest measured preoperatively and post operatively at 6 weeks and 1 year. Secondary outcomes measured were radiographic and functional outcomes (HHS and Oxford score).

Results: Radiographically 8 patients in the trabecular group had a significant gap in zone II which resolved in 6 by 1 year. The cemented group had 3 patients with a radiolucent line (zone 1) at 1 year. HHS and OXFORD scores improved with no significant difference between the groups. Both groups had significant loss of bone density in the ilium and ischium. The trabecular group produced a significant increase in bone density in the superolateral region. The cemented group produced increased bone density in the superomedial region.

Discussions and Conclusions: There is a significant reduction in BMD for both groups in the upper pelvis and ischium in keeping with finite element modelling predictions. The press-fit group relative to the cemented group resulted in decreased BMD in the superomedial peri-prosthetic region. The trabecular monobloc cup therefore behaves more like a rigid cementless shell despite the properties of trabecular metal.

Introduction: The geometry of uncemented press-fit ace-tabular cups is important in achieving primary stability to ensure bony ingrowth. This study compares the in vitro primary stability of two widely used designs.

Methods: The primary stability of two uncemented ace-tabular cup designs (true hemispheric and peripherally enhanced) with the same 52mm diameter and produced by the same manufacturer, was tested in vitro. Polyethylene blocks of low and high density -representing softer and harder bone- were reamed using the manufacturers’ reamers. The cups were seated using an Instron 5800R machine. Peak failure loads and moments during uniaxial pull-out and tangential lever-out tests were used as measures of primary stability. Eighty tests were performed.

Results: Low density substrate: no difference between the two designs for seating force or stability, with the substrate under-reamed by 2mm.

High density substrate: the cups could not be adequately seated with a 2mm under-ream. Seating was achieved with 1mm under-ream for the hemispheric and 1mm over-ream for the peripherally enhanced design. There was a statistically significant difference in seating forces, with the hemispheric cup requiring less force (6264±1535N vs 7858±2383N, p< 0.05). There was a statistically significant difference in the stability ratio of pull-out force to seating force, favouring the hemispheric cup.

Discussion: No difference was seen in the low density substrate between the 2 cups.

In the high density, the hemispheric design had better characteristics (lower seating force and higher pull-out force to seating force ratio) than the peripherally enhanced design, which are more favourable in clinical settings.

Introduction: Direct exchange of total hip arthroplasty as a single stage revision procedure for aseptic loosening represents a significant proportion of the revision surgeon’s case load, accounting for 38% of cases in the Sheffield Lower Limb Arthroplasty Unit. In our unit current practice is to obtain preoperative negative hip aspirates and normal inflammatory markers and take 5 intraoperative deep tissue samples for microbiological culture. The aim of this retrospective, observational study was to evaluate the necessity of this technique.

Method: 100 consecutive direct exchanges to total hip replacements for aseptic loosening performed in our unit between 03/10/2005 and 31/07/2007 were identified using the arthroplasty database and their case notes reviewed. The microbiological results were evaluated by a microbiology consultant and the notes were examined. A minimum of 1 year follow-up was obtained in all patients.

Results: 42 patients were found to have one or more positive sample. Of these 37 were deemed by the microbiologist to be contaminants and 5 to have a significant growth. Of the 5 with significant growth, 2 patients were treated with systemic antibiotics as a result of microbial tissue sample growth. At the latest follow up appointment (range 22–33 months) these 5 patients were all clinically not infected.

Conclusion: The practice of obtaining routine deep tissue samples is essential for revision surgery performed for aseptic loosening. 5% of patients in our series had a significant bacterial growth despite being presumed to be aseptic which would otherwise not have been detected. The support of a microbiologist with dedicated arthroplasty interest is vital in determining the relevance of sample results.

Introduction: We undertook a questionnaire study to assess the compliance with DVT prophylaxis following lower limb arthroplasty surgery and evaluate reasons for non-compliance (if any).

Method: Following joint replacement surgery, 50 patients (45 had THR, 5 had TKR) were asked to fill in anonymised questionnaire at 6 weeks. They were asked about awareness for DVT, information given, prevention methods, duration and type of prophylaxis given and their compliance with treatment.

Results: Most of the patients (45) were aware of the risk of DVT while 2 were not aware and 3 were not sure. 37 patients were given information during their clinic visit while 7 did not receive any information and 6 can’t remember. 32 patients remembered discussing risk of developing DVT while 9 did not and 9 were not sure. 34 patients (68%) were aware of prophylactic methods. Except for 2 patients, the rest 48 patients (96%) confirmed receiving prophylaxis. 48 patients (96%) had mechanical prophylaxis in the ward while 6 continued at home as well. 46 patients (92%)remembered receiving chemical prophylaxis both in the ward and at home thereafter.

36 patients received chemical prophylaxis (injections) for 10 days, 5 for 7 days, 8 for a few days and 1 patient for 6 weeks post-op. 38 patients (76%) self administrated the injections while 6 had family members help and 3 had district nurse visit. 47 patients (94%) received injections for the complete duration. 3 patients did not receive injections regularly at home (missed nurse visit – 1, not advised – 1, forgot to inject – 1).

Discussion: DVT compliance is still an issue in surgery especially when patients were asked to self-administer the injections. We achieved 94 % compliance with our protocol. This study shows that greater emphasis on patient education, awareness and motivation may help improve compliance.

Introduction: The Corail stem is a well proven femoral implant used for the past 22 years. It is the most common uncemented femoral stem used for total hip replacements in the UK. The stem was modified in 2004 with an increased neck taper to allow for an increased range of bearings and modular heads. This study reviews a series of primary total hip replacements using this recently modified Corail stem to assess if this implant is still performing to acceptable standards.

Method: A prospective patient database collated by 2 arthroplasty surgeons recorded data at the time of operation and subsequent follow up. All intra-operative and post-operative complications were recorded. Pre and postoperative oxford hip scores were analysed.

Results: 751 cases were reviewed. The average age was 63 with females accounting for 69%. The pinnacle cup was used in 83% of cases, with a polyethylene bearing in 48%. Survival of the stem at 3 years was 99.9% (1 periprosthetic fracture following a fall), the cup 99.6%, with overall survival of 99.5%. The most common intra operative complication was calcar fracture occurring in 0.9%. Dislocation occurred in 0.5%, subsidence in 0.3%, deep infection in 0.1% and leg length discrepancy requiring shoe raise in 0.1%. Average 3 year oxford hip score was 12.

Discussion: 3 year survival of both the femoral stem and the total hip replacement are above the quoted rates in the National Joint Registry’s 4th annual report for corail and uncemented stems (98.8% and 98.1% respectively), and also exceeds that of cemented stems (99.1%). The same report quotes similar rates of calcar fractures (0.8%), although we recorded no other perioperative complications. We conclude the new generation of Corail stem has excellent 3 year performance.

Introduction: Intra-articular injection (IAJ) with cortico-steroid and local anaesthetic has been used as both diagnostic and therapeutic intervention in osteoarthritis of the hip. Doubt remains about its efficacy in confirming the source of symptoms in patients with both hip and spinal arthritis. There are also concerns about the introduction of infection for patients undergoing surgery.

Methods: All patients undergoing Hip IAJ for osteoarthritis within a 6-month period in 2007 were reviewed for three surgeons at one institution retrospectively. Data was collated and analysed using a set protocol allowing 18 months follow-up period.

Results: 41 procedures (38 patients) had injections within the study period. Male: Female ratio was 17:24. Average age was 52 years. There were 54% right-sided procedures.

25/41 patients had full response to the injection. 80% were listed for surgery as a result (documented reasons in those not listed). 6/41 patients had a partial response to the injection – 66% were managed conservatively (due to co-morbidities elicited at review, or spinal pathology). 10/41 patients had no benefit – 3 were offered surgery (one after MRI confirmation, one after prolonged physiotherapy and one after discussion about diagnostic overlap).

Hip replacement completely reduced symptoms in 19/21 (90%) and partially in 2/21 (10%) (1 had undergone a successful pre-operative IAJ).

There were no deep infections in patients undergoing surgery after injection. 1 patient had a superficial infection (resolved at review).

Discussion: Diagnostic IAJ can be of value in patients when there are concerns whether the origin of symptoms is truly ascribable to the hip. Patients where injections are successful go on to undergo successful surgery without an increased risk of infection.

Introduction: One of the most important factors affecting the outcome of revision THR of the femoral stem is the variability of femoral endosteal geometry after removal of the in-situ stem. A custom made implant would greatly reduce the inventory of the ‘Off the shelf” (OTS) components. This study presents the medium to long-term results of a cohort of patients with this revision prosthesis.

Methods: During the period November 1991 to November 1998, 158 patients were implanted with a computer-assisted design and computer-assisted manufactured (CAD-CAM) revision prostheses (Stanmore Implants Worldwide, Biomedical Engineering Unit, RNOH) by the senior author (SMA). There were 97 males and 61 females. The average age was 63.1 years (34.6 – 85.9). The indications for revision surgery were aseptic loosening (135 cases, 85.4 %), peri-prosthetic fractures (6 cases, 3.8 %), infection (12 cases, 7.6%) and liner wear (3 cases, 1.9%).

Results: At 10 years all patients reported relief of pre-operative pain and the average hip flexion was 95o (90 o –110o). Oxford, Harris and WOMAC hip scores in the pre-operative and post-operative period were 41.1, 44.2 and 52.4 respectively and 18.2, 89.3 and 12.3 respectively (p< 0.0001, p< 0.0001, p< 0.0001).

There were 6 complications (3.8%) in this series; a periprosthetic fracture of the femoral diaphysis (1), posterior dislocation (2), failure secondary to aseptic loosening of the implant (1) and deep vein thromboses (2)

Discussion: These ten year results are encouraging and suggest that there is a role for the use of custom implants in revision THR, particularly where the anatomical variance of the proximal femur makes the use of OTS implants unsuitable.

Introduction: Serial reamers of incremental diameter are used in the preparation of the acetabulum in Total Hip Arthroplasty. If the reamer is blunt then the size of the reamed acetabulum may not accurately represent the size of the last reamer used. This inaccuracy may then adversely affect implant selection or implantation.

Methods: Traditional debris-retaining cheese grater ace-tabular reamers were used to create a cavity in a foam block, following a standardised technique. A casting was then made of the cavity, the diameter of the cast measured and compared to that of the reamer. Accuracy was defined as the difference between the observed and expected diameters. Measurements were collected for five different hip systems (78 reamers in total)

Results: Sixty-four out of the seventy-eight reamer tested were inaccurate. There was a significant difference between groups. Only reamers from one of the five systems tested consistently created cavities which accurately matched their stated size. Two systems consistently produced a cavity that was at least 1mm smaller than intended. In the majority of cases the mid-range reamers, sizes (46–52mm) were the most inaccurate.

Discussion: The majority of acetabular reamers in our study were inaccurate. If this is unintentional, it suggests reamers may become increasingly blunt with use and should be calibrated, sharpened or replaced.

Introduction: While the explant device has made revision of uncemented acetabular components technically easier, the unique design of the Birmingham Hip Resurfacing(BHR) acetabular component precludes the use of the standard explant extractor. The dual radius geometry of this socket causes impingement and damage to the curved blade of this device.

A novel adaptor was designed to correct for the differential radii and enable removal of the well fixed BHR socket with the explant. We present the results of our initial experience with this device.

Method: A prospective study was performed to evaluate the effectiveness of this device for revising the well fixed BHR socket. All cases were performed by a single surgeon via a posterior approach.

The explant cup extractor was used with its standard centering head and curved blades. The size of the explanted cup, last reamer size and size of the implanted component were recorded

Results: Three males and 7 females were included. Their average age was 58.1 years (48–65). Average time to revision of the BHR sockets was 24.2 months (7–40). Average explanted cup size was 51mm (46–58) and final reamer size 53.8mm (51–59). Average final socket size was54.8 (50–62). Overall there was a mean 2.8.mm size difference between the explanted cup and the final reamer.

Discussion: The thickness of the blade of the explant was 2mm therefore only 0.8 mm of bone was lost on average. The device enables a simple reproducible removal of the well fixed BHR sockets with preservation of acetabular bone stock.

Introduction: We present the results of a prospective study of the blood transfusion requirements in patients undergoing a Bernese periacetabular osteotomy (PAO) with the use of an intra-operative cell-saver and without pre-donated blood. These data were compared with an earlier audit of patients who underwent this procedure without use of a cell saver.

Material and Methods: A cohort of 50 patients (56 hips) underwent a PAO for hip dysplasia between December 2006 and November 2008 performed by the senior author. The average age was 29 years (17–51) and there were 38 females and 12 males. The average weight was 69.96 kg (46–110) and the mean duration of operation was 136 minutes (100–240). A cell saver (Fresenius-Hemocare, Germany) was used intra-operatively for this cohort. Pre-operative Hb, post-operative Hb taken the day after surgery and any units transfused were documented. A post-operative transfusion policy was adopted where a haemoglobin (Hb) concentration of < 7.5 g/dl was an indication for transfusion or where a patient was sufficiently symptomatic

Results: The mean pre-operative Hb was 13.60 g/dl (10.8–15.9) and the mean post-operative Hb was 9.91 g/dl (6.4–11.8). Overall 4 patients received post-operative allogenic blood transfusion; 3 patients receiving one unit and one patient receiving 2 units. No patients received intra-operative allogenic blood.

Conclusion: Compared to our previous audit, the use of the cell saver resulted in an improvement in the mean post-operative Hb, (9.2 g/dl compared to 8.0 g/dl). The transfusion rate was also reduced (7.27% compared to 10.8%)..

Introduction: Polymorphisms within genes encoding bone regulatory cytokines influence individuals’ susceptibility to osteolysis after THA. We aimed to determine whether single nucleotide polymorphisms (SNPs) within these genes influence the severity of these osteolytic lesions in 272 patients with established aseptic loosening.

Methods: Assessment of osteolytic lesions was made from pre-revision radiographs in conjunction with direct visualisation in those subjects undergoing surgery. Osteolytic lesions were defined as linear (AAOS pelvic and femoral osteolysis classification grade 0) or expansile, in the presence of segmental or cavitary defects (AAOS grade 1 or greater). We analysed 11 SNPs in the pro-inflammatory cytokines IL-1A, IL-1B, IL-1RA, IL-6 and TNF; 2 SNPs within the FRZB gene, which modulates osteoblast function; and 6 SNPS in the RANK/RANKL/OPG pathway, that modulates osteoclast function.

Results: Femoral Osteolysis: Carriage of the IL-6 −174C allele was 60% in the expansile osteolysis group versus 80% in the linear osteolysis group (χ2 test p=0.007). Carriage of the OPG −163G allele was 34% in the expansile osteolysis group versus 18% in the linear group (χ2 test p=0.03). The odds ratios for expansile osteolysis associated with carriage of IL-6-174G and OPG −163G were 2.7 (1.3 to 5.7, p=0.008) and 2.3 (1.1 to 5.0, p=0.03) respectively.

Acetabular Osteolysis: No differences in SNP genotype were found between osteolysis groups.

Discussion: The IL-6-174G allele and the OPG-163G allele are over-represented in subjects with expansile femoral versus linear osteolysis, but do not relate to severity of pelvic osteolysis. These differences in association may reflect differences in the mechanism of osteolysis between the bone sites, however, replication of the results are required to confirm this differential association.

Introduction: Total hip replacement (THR) in young patients is a controversial subject due to high failure rates reported in the literature. The purpose of this study was to show our short term results of primary total hip replacement in patients younger than 30 years of age.

Methods: Patients who underwent THR prior to the age of 30 years between 1998 and 2007 were identified and records of all patients were reviewed together with the radiographs till the last follow up.

Results: Forty three THRs were performed on 36 patients with an average age of 24.4 years (range, 17–30) and an average follow up period of 47 months (range, 7–109 months). There were 5 cases of Juvenile chronic arthritis, 2 Rheumatoid arthritis, 11 DDH, 2 septic arthritis, 1 pseudoachondroplasia, 4 Perthes disease, 2 seronegative arthitides, 2 SUFE and 7 AVN [alcohol, leukaemia, fracture, SLE (2), mannosidosis, idiopathic].

Thirty cemented THRs and 13 hybrid THRs were performed through trochanteric osteotomy approach (23), posterior approach (17), Hardinge approach (2) and anterior approach (1). In the cemented group there were 3 cases of superficial wound discharges, 1 recurrent dislocation, 1 complete femoral nerve palsy, 2 cases of neuropraxia and 1 case with persistent hip pain but no cases of infection. In the hybrid group there was one case of partial femoral nerve palsy. None of the patients has undergone any revision surgery till the latest follow up. Radiologically only one case showed aseptic loosening in both femoral and acetabular components, which is not revised as the patient is asymptomatic.

Discussion: THR is an elegant procedure and should be certainly considered in young patients suffering with disabling arthritic conditions affecting the hip joint. Our results show that THR - both cemented and hybrid types - is a successful and durable treatment.

Background: There is a paucity of published literature with regard to metal ion levels following bilateral hip resurfacings.

Method: Recent research has identified femoral component size and acetabular cup anteversion and inclination as important variables involved in metal ion release into the blood. We compared 13 patients with bilateral joints resurfaced using the ASR and 11 patients with bilateral BHRs to those with unilateral joints of similar size and cup inclinations/anteversions. Patients were excluded if the last procedure was within 12 months of blood sampling and if they had other metallic implants. Analysis of standing radiographs to determine cup orientation was carried out using EBRA software. Blood samples were analysed using ICPMS.

Results: Median whole blood Cr and Co values were higher in the BHR bilateral group when compared to the unilateral BHR group by a factor of 1.12 and 1.24 respectively. (5.17 vs 4.59 for Cr, 2.40 vs 1.93 for Co). The difference was significant for Co (p=0.030) but not for Cr (p=0.136). For the large ASR joints (53mm), median Cr and Co values were higher in the bilateral group by a factor of 1.5 and 1.85 respectively. (4.55 vs 2.97 (Cr) 2.83 vs 1.53 (Co)). The difference was significant for both Cr (p=0.001) and Co (p=0.022). For the small ASR joints (< 53mm), median Cr Co values were higher in the bilateral group by a factor of 1.95 and 2.30 respectively. (8.29 vs 4.25 (Cr), 6.78 vs 2.94 (Co)) (p=0.019 Co) (p=0.007 Co).

Conclusion: Metal ion concentrations are significantly greater in patients with bilateral resurfacings. The Cr Co concentrations observed in our patients with bilateral small ASR joints are double those in the published literature on bilateral 28mm metal on metal(MoM) joints implying that the lubrication achieved by small ASRs is sub optimal.

Introduction: The national comparative audit in 2007 of blood use in primary elective hip replacement, showed a 25% transfusion rate. Of those 93% received two or more units. Orthopaedic surgeons are large users of blood, so reducing blood use, should save costs and reduce risk from unnecessary donor exposure.

Methods: Over two years 221 consecutive primary total hip replacements were performed, on 84 male and 137 female patients, average age 70 years (42–91yrs). For each the Haematinics cell salvage system was used. Throughout the surgery the cell salvage system was used. At the end of the operation all swabs were washed, the washings were salvaged. Iodine/peroxide contaminated washing and swabs were discarded.

Results: Were we using blood at the level suggested by the comparative audit, 55 patients would have received an average of 2.4 units (132 units total). The actual number of patients transfused was 12, receiving an average of two units (24 units total). This is 108 units less with 43 fewer patients receiving allogenic blood. Using a test of proportions using the Normal distribution then the significance probability is extremely small (SP< 0.001) indicating that this group of patients had a significantly smaller number of transfusions than would be expected compared with the National Average. The transfused patients were older (78.9 vs. 69.8, p< 0.01), had a greater Hb drop (45 g/l vs. 31.2 g/l, p< 0.01), had a lower pre-op Hb (121.3 g/l vs. 138 g/l, p< 0.001), and a greater length of stay (12.8 days vs. 5.8 days, p< 0.05). Gender was not significant.

Discussion: Using the cell salvage system leads to a significant reduction in allogenic blood use. It may not be cost neutral once the use of disposables is factored in, but may represent a useful tool to cost effectively reduce allogenic blood use.

Introduction: Acetabular cup inclination is associated with higher wear in both UHMWPE and ceramic-on-ceramic hips. It has also emerged recently as a critical factor in the success of hip resurfacing. A direct correlation between socket inclination and serum metal ion levels has been demonstrated and concerns remain regarding edge loading and hypersensitivity. Resurfacing socket designs vary and manufacturers do not recommend specific inclination angles for their products. The aim of this study was to investigate the effect of cup geometry on the effective inclination for a variety of different designs of resurfacing socket.

Methods: The internal geometry of every available size of Birmingham Hip Resurfacing(BHR-Smith & Nephew), ASR(DePuy) and MITCH TRH(Stryker) socket was measured using X-ray templates. This data was used to calculate the difference between the apparent inclination and the true inclination for all sockets.

Results: BHR and MITCH TRH cups have lateralised internal geometries in that the centre of the internal surface is lateralised by 3.5mm in the case of the BHR and varies from 2 to 3.8mm in the MITCH TRH system. The ASR is concentric but the bearing surface is less than a hemisphere and there is also an internal groove which further reduces the bearing surface. The difference between apparent and true inclination was greatest in the ASR socket (13o–18 o) followed by the BHR (7o–10o) and then the MITCH TRH (6o–8o). This difference increased with decreasing socket size in both the BHR and ASR but was more or less constant in the MITCH TRH.

Conclusion: These results show that a socket measured at 45o of inclination may have a true inclination of up to 63o. This has important implications for surgeons who should have full knowledge of the design geometry of the socket being implanted and adjust the inclination angle accordingly.

Introduction: Of all hip arthroplasties conducted annually, a proportion will subsequently require revision for aseptic loosening and periprosthetic osteolysis. Osteolysis may develop ‘silently’ and monitoring of patients is recommended. This should include x-rays as progressive changes in size of a lesion may indicate a potential failure. Area measurement of osteolysis has been achieved in a number of ways but with techniques that are not readily available in routine clinical practice. The aim of this study was to develop a method for routine assessment of hip arthroplasty to quantify osteolytic changes seen on x-ray, applicable by any health professional and with good inter-observer reliability.

Methods: A morphometric grid is superimposed on an object of interest and the number of test points that fall within a defined area counted. A specialized grid was developed and initial testing was conducted on twenty simulated osteolytic lesions. Subsequent testing was on thirty-five arthroplasty x-rays with evidence of osteolytic lesions. Four observers recorded the number of crosses seen over each lesion. The observers were representative of health professions and levels of experience involved in arthroplasty review.

Data was analysed for both inter-observer and test-retest reliability using the intra-class correlation coefficient and the Bland-Altman method (use of two methods provides a better estimation of accuracy).

Results: The results for intra-class correlation coefficients on both simulated and actual lesions were all excellent (range 0.90 to 0.98) as confirmed by visual representation using the Bland-Altman method.

Discussion: Regular follow-up of hip arthroplasty with x-ray ensures that changes are monitored even when symptoms are absent. We believe that this tool can improve the process through quantitative assessment of osteolytic lesions. The scientific development supports the reliability of the tool when used by a number of raters and the simplicity of application makes it a useful addition to an arthroplasty clinic.

Introduction: It is well established that prompt medical management and early surgery for patients with fractured neck of femur has been shown to reduce mortality and reduce hospital length of stay. A Trauma Pathway Group (TPG) was established at Mayday Hospital, in August 2007 to assess local practises and to implement improvements, led by senior clinicians in Orthopaedics, Anaesthetics and Orthogeriatrics, and liaising with senior hospital managers within the trust. Here we present results after one year of the TPG.

Means and methods: We reviewed all patients admitted to Mayday with a fractured neck of femur over 60 years of age at admission between 1st October 2006 and 31st September 2007 (prior to the TPG) and between 1st October 2007 and 31st September 2008 (after the TPG).

We compared these two groups, focussing on pre-operative delays, length of stay in hospital and in-hospital mortality.

Results: There were 185 patients admitted to Mayday University Hospital between 1st October 2006 and 31st September 2007, and 212 between 1st October 07 and 31st September 2008. The average age of patients admitted was 83. 75% were female. There was no significant difference in mean age or sex between the two groups. The mean wait for surgery was reduced from 4.3 days to 1.3 days (p< 0.001). The mean length of stay was reduced from 33.5 days to 26.2 (p< 0.005). The in-hospital mortality was not significantly altered - 14.6% in the first year, and 16.0% in the second.

Discussion: The TPG has had a significant impact on the management of patients with fractured neck of femur. Our figures and feedback from staff and patients has been positive, and the work has increased the prominence of the care of these patients, so has enabled us to significantly improve the care of this extremely vulnerable group.

Background: Resurfacing cups may produce significant clinical problems when placed at the extremes of version, including increased production of metal debris and psoas tendonitis.

Methods: We obtained the femoral and acetabular components of two unused ASR (Articular Surface Replacement) and BHR (Birmingham Hip Resurfacing) devices. The components were placed in moulds at varying degrees of inclination and anteversion in a grid to simulate pelvic landmarks and AP radiographic images were captured. The true radiological anteversion was determined by rotating the x-ray beam so that it was perpendicular to the acetabular axis and measuring the angle subtended by the cup rim and the vertical axis.

Five blinded orthopaedic registrars then used EBRA (Einzel-Bild-Roentgen-Analysis, University of Inns-bruck, Austria) software to determine the radiological anteversion from the AP films. Twenty-five ASR and twenty-five BHR images were analysed.

At the same time each observer was asked to grade the cups as “1” (< 10°) “2” (10–20°) “3” (20–30°) or “4” (> 30°) depending on the appearances of the cup vertices.

Results: Mean error for each observer was −0.7 (minimum) to 1.6° (maximum). The range of standard deviations of error for each observer was +/− 2.2 (minimum) to 3.5° (maximum). Retroverted cups were not identified in the majority of cases.

Cups graded as “1” or “4” showed high sensitivity and specificity for the true grade as determined on the lateral radiographs.

Conclusions: EBRA software can be used to calculate the anteversion of resurfacing cups to a clinically acceptable degree. The clinician must be aware of the limitations of the software most notably the difficulty in identifying a retroverted cup and errors arising from poor quality radiographs in terms of pelvic rotation. The presented clinical grading system can be used as a rapid assessment tool to identify cups at the extremes of anteversion.

Introduction: There is increasing interest in the use of ceramic on ceramic bearings for hip replacement, due to recognition of their extremely low wear and biocompatibility of the wear debris [1].