Any intervention for limb with compromised bone and soft tissue in paediatric age group is often studded with complications of flare of infection, wound breakdown, delayed healing or failure of grafting. We report our experience with managing 8 such cases with periosteal sleeve taken from tibia along with fibular grafting.

The lesion was gap non-union following bone sequestration in 7 cases (2 proximal humerus; 4 femur and one metacarpal) and one case tibia vara in post osteomyelitic tibia. The infective lesions were silent for minimum of 1 year before this procedure. The periosteal sleeve was taken from proximal tibia and fibular graft was also procured from same leg. Following freshening of bone ends, the fibular graft was applied at non-union/osteotomy site and enclosed in the freshly harvested periosteal sleeve. The limb was protected in plaster cast for 6 weeks and assessed clinicoradiologically at 3 and 6 weeks intervals.

Uneventful union followed in 7 cases in 6 weeks time. In one case of proximal humerus, the osteosynthesis attempt failed. The periosteal and fibular graft site posed minimal morbidity for the child.

A prospective, randomized, double-blind study was done on 50 patients undergoing primary cementless total hip arthroplasty to determine the effect of tranexamic acid on intra- and postoperative blood losses and on the transfusions requirements.

50 patients were randomized to tranexamic acid (15 mg/kg) given as a bolus intravenous injection or placebo (normal saline) given intravenously, 15 minutes before the incision. The intraoperative and postoperative blood loss (at removal of the drain 24 hours after the operation) and the number of blood transfusions required were recorded. The patients were screened for deep venous thrombosis with bilateral compression Ultrasonography using Colour Doppler imaging on the tenth postoperative day. The Haemoglobin level was measured preoperatively and on the 3rd postoperative day. The D-dimer levels were measured preoperatively and 24 hrs postoperatively.

Patients receiving tranexamic acid had a mean intraoperative blood loss of 410 ml (range, 300-510 ml) versus 615 ml (range, 515-750ml) (p value<0.05) in patients receiving placebo, a postoperative blood loss of 210 ml(range, 150-325ml) versus 490 ml(range,370-540ml) (p value<0.05), and a total need for 8 blood transfusions versus 30. Only 6 out 25 patients in tranexamic acid group required blood transfusion whereas 18 out of 25 patients in the placebo group required transfusion. In the group receiving placebo the mean fall in haemoglobin was 2.9g/dl (range, 2.5-3.2) and in the group treated with tranexamic acid 1.6 g/dl (1.3-2) (p<0.05). At 24 hrs postoperatively, mean plasma D-dimer concentration in the Tranexamic group was half of that in the control group. No patient in either group had any evidence of deep vein thrombosis on bilateral compression Ultrasonography using Colour Doppler imaging done on the tenth postoperative day

Tranexamic acid 15 mg/kg given as a single preoperative bolus dose reduces peroperative and postoperative and total blood loss, and transfusion requirements in primary cementless total hip replacement surgery without any increased risk of thrombus formation.

This clinical study was performed to establish the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) after shoulder surgery. The incidence of venous thrombo-embolism complicating shoulder surgery is poorly described in literature. As VTE is a potentially fatal condition we wanted to make surgeons aware of the problem and to try to establish any risk factors contributing to it.

We reviewed retrospectively clinical records of all patients who had any procedure performed on their shoulder between 2001 and 2009 in our institution. In operating theatre coding database we identified 920 patients. Their records were assessed for any admissions due to proven DVT or PE; we looked for any radiological results suggestive of or confirming venous thromboembolism.

We identified 920 patients who had surgical procedure under GA on their shoulder. 126 patients had shoulder arthroplasty, other procedures commonly undertaken were: subacromial decompression, shoulder stabilization and shoulder manipulations. There was 1 fatal PE in this group – patient died within 48 hours following total shoulder replacement, post mortem revealed massive pulmonary embolism with no sing of neither upper nor lower limb DVT. There were 3 cases of symptomatic DVT confirmed by USS Doppler. No upper limb symptomatic DVT was identified. There were 7 patients who had negative tests for suspected thrombosis (2 negative tests for suspected PE, 5 negative tests for suspected DVT).

There is very limited evidence in literature on VTE following upper limb surgery. Recent studies suggest that DVT incidence following arthroplasty is as high as 13%, with further 3% incidence of PE. In our study we examined occurrence of symptomatic VTE only. According to our results the incidence of symptomatic DVT following shoulder surgery is about 0.35% and symptomatic PE about 0.1 %. We did not manage to show any risk factors associated strongly with post operative DVT in our group. The prevalence of asymptomatic VTE is probably much higher and further research needs to be undertaken in that area. On base of our experience we would not recommend routine anticoagulation as a DVT prophylactic after shoulder surgery unless there are additional risk factors.

Giant cell tumours of tendon sheaths have been given multiple denominations due to the uncertain pathologic nature of this lesion. Various contributory factors have been accounted for a wide variation in their recurrence rates. Owing to their high recurrence rates ranging from 9% to 44%, these tumours continue to present with treatment dilemma. There is a lack of consensus regarding how to best manage the balance between extensive dissection and preservation of normal tissues for normal function and recovery versus the risk of recurrence. The authors studied 46 patients with histopathologically confirmed Giant cell tumours over a period of 9 years between 1997 and 2006. The average follow-up in this case series was 35 months. This study aims to analyse the distribution of giant cell tumours of tendon sheaths in hand and our experience with their resection in a District General Hospital with possible predictors associated with recurrence. The referral letters, radiographs, operative and histology records were reviewed. The data was carefully analysed including patients' age and sex at the time of presentation and surgery, presenting symptoms, any associated trauma and the anatomical location of the tumour. A telephonic questionnaire was conducted and the patients with any complications or recurrence were reviewed. Our recurrence rate of 8.6% (4 patients) is lower than previously reported in the literature when the patients did not receive post-operative radiotherapy. Recurrence was seen to be statistically higher in cases where the tumours were excised piecemeal as opposed to removed in one piece and in patients with osseous erosions which were confirmed radiologically and intra-operatively. No atypical mitosis was reported on histology. None of our patients received radiotherapy post-operatively. Other factors including age, size, degenerative joint disease and location within the digit were not confirmed as risk factors in our study. We recommend meticulous surgical technique by an experienced hand surgeon and warning patients of the risk of recurrence if any risk factors were identified.

Most common current surgical treatment options for cuff tear arthropathy (CTA) are hemiarthroplasty and reverse total shoulder replacement. At our unit we have been using Reverse Total shoulder replacement (TSR) for CTA patients since 2001. We present our results of Reverse TSR in 64 patients (single surgeon) with a mean follow up of 2 years (Range 1 to 8 years). There were 45 males and 19 females in the study with a mean age of 70 years. Preoperative and postoperative Constant scores were collected by a team of specialist shoulder physiotherapists. Preoperatively plain radiographs were used to evaluate the severity of arthritis and bone stock availability.

90% patients showed an improvement in the Constant score post operatively. The mean improvement in Constant score was 25 points. The mean Pain Score (max 15) improved from 6.3 to 11.8; the mean ADL Score (max 20) improved from 6.8 to 12.3; the mean Range of Motion score (max 40) improved from 10.8 to 20.2; but the mean Power Score (max 25) only improved from 0.9 to 4.9. The differences in improvement were statistically significant in each category. A total 6 patients (10%) required 10 revision surgeries for various reasons. Two patients dislocated anteriorly who were treated by open reduction. Two patients required revision of the glenoid component due to loosening after a mean of 2 years. One patient required revision of the humeral component with strut grafting secondary to severe osteolysis. Only one patient required revision of both humeral and glenoid components secondary to malpositioning. Three patients died for reasons unconnected with their shoulder problems and surgery. Radiographic analysis at the latest follow up (mean 24 months) showed inferior glenoid notching in 40% cases. Heterotrophic ossification was not seen in our series.

We conclude that reverse TSR is a viable option for treatment of cuff tear arthropathy however glenoid loosening and scapular notching remains an issue.

Suture anchors have gained popularity in recent years, particularly owing to their ease of use for attaching soft tissues to bone and improved biomechanical properties. Three methods to reattach avulsed finger flexor tendons to the distal phalanx were biomechanically compared: a 1.8mm metal Mitek barbed suture anchor, twin 1.3mm PLA suture anchors (Microfix), or a pull-out suture over a button. The suture-anchor interface was tested by pulling the suture at 0, 45, 90° to the anchor's axis. The anchors were tested similarly in plastic foam bone substitute. Repairs of transected tendons in cadaveric fingers were loaded cyclically, then to failure.

The results were subject to statistical analysis using Student t test (p< 0.001) and 1-way ANOVA (p<0.0001). The suture failed prematurely if pulled across the axis of the anchor. Conversely, fixation in bone substitute was stronger when pulling at an angle from the axis. Cyclic loads caused significantly more gap formation in-vitro with twin 1.3mm anchors than the other methods; this method was significantly weaker. The 1.8mm anchor gave similar performance to the pull-out suture and button, while the twin 1.3mm anchors were weaker and vulnerable to gap formation even with passive motion alone.

A suture anchor embedded at between 45 and 90o to the direction of pull gave greater strength than if the pull was in-line. The absorbable 1.3 mm Microfix PLA anchors appeared to be a weak construct, even when twin 1.3 mm anchors were compared to a single metallic 1.8 mm Mitek anchor or the pull-out suture over button technique. All three methods are likely to be satisfactory for reattachment of finger flexor tendons if a low load or non-loading rehabilitation of the hand is planned; however the gap formation on cyclic loading with the Microfix is a concern even if patients are restricted to passive motion.

In this study we reviewed all Total Elbow Replacements (TER) done in our hospital over eight years period (1997 – 2005), 21 patients (16 females, 5 males) were available for follow up and four were lost (two died and two moved out of the region) with average age of 65 years (range 44 – 77), all procedures were done by two upper limb surgeons (CHB & RGW). 16 patients (14 females, 2 males) had the procedure for Rheumatoid Arthritis and 5 patients (3 males, 2 females) undergone the procedure for post-traumatic arthritis.

The average follow up was 61 months (range 12 – 120 months), the Mayo Clinic performance index, the DASH scores and activities of daily living (adopted from Secec Elbow Score) assessment tools were used. In addition, all patients were assessed for loosening using standard AP and lateral radiographs. Sixteen patients had Souter-Starthclyde prosthesis whilst three had Kudo and two had Conrad-Moorey prosthesis.

All procedures were done through dorsal approach and all were cemented, the ulnar nerve was not transposed in any of the cases. The average elbow extension lag was 27 degrees (range 15 – 35) with flexion up to 130 degrees (range 110 – 140). Supination was 65 degrees (range 15 – 90) and pronation was 77 (range 55 – 90). The average DASH score was 51.3 (range 19 – 95), the Mayo elbow score was 82 (range 55 – 100) and the average Activities of daily living Secec Score was 17 (range 10 – 20).

There were four complications, three ulnar nerve paresis which recovered and one wound complication which needed a flap cover. Two needed revision surgery, one for a periprosthetic fracture and one for loosening. Two patients showed radiological signs of loosening but were asymptomatic. The survival rate with revision as the end point is 95% for aseptic loosening and 90% for any other reason.

Our study proves TER has good medium term results with good functional outcome and high patient satisfaction rate.

The carpometacarpal joint of the thumb is one of the most common locations of degenerative arthritis. Surgical options include trapezio-metacarpal fusion, replacement or resection arthroplasty with or without interposition.

We report the medium term results of a Modified Thompson's suspensionplasty. The radial half of the APL tendon was looped around the FCR tendon to create the suspension. The remainder of the tendon is then used for interposition.

We carried out a retrospective review of 50 patients (67 hands) who underwent this procedure from January 1999 to December 2005. There were 41 female (52 hands) and 9 male (15 hands). The average age at the time of surgery was 62 years (range 41 years – 79 years). The average follow up was 5.33 years (1-9 yrs). 22 patients also had a concurrent second procedure to the same thumb and a further three had a third procedure.

The average PRWHE score was 25 (0 – 80) and the average DASH score was 40 (24 – 100)

There were eight complications which included four persistent radial sided wrist pain. Two of these underwent tenotomy of FCR, whilst two responded to conservative measures. Two patients had symptoms related to scapho-trapezoid arthritis, which responded to an injection. One patient had superficial infection which settled with oral antibiotics, whilst another patient had early chronic regional pain syndrome. Overall the satisfaction rate was 90% with 48 patients (96%) willing to undergo the same procedure again.

We conclude that the modified Thompson's suspensionplasty gives excellent medium term results.

Total knee replacement (TKR) can be associated with significant post-operative blood loss requiring blood transfusion and haematinics. With increase in the use of navigation for total knee replacement, it is anticipated the blood loss may be lower as the medullary cavity is not breached. Hence, a prospective study was performed to compare the blood loss and the transfusion rates between patients with navigated and conventional total knee replacement.

Between September 2006 and December 2009, nearly 100 patients underwent total knee replacement by a single surgeon. Patients who underwent revision total knee replacement and complex primary total knee replacement were excluded. There were 73 patients with an average age of 70.3 (47-91) years. There were 37 males and 36 females with an average BMI of 30. Thirty eight patients underwent navigated TKR and 35 patients conventional TKR. Left knee was replaced in 29 patients, right knee in 40 patients and 4 patients underwent non-simultaneous bilateral total knee replacements. Cruciate retaining prosthesis was used in 17 patients and cruciate substituting prosthesis in 56 patients. Patella was not replaced in any patient.

The average pre-operative haemoglobin was 13.26 (8.7-18.4) g/dl in the navigated group and 13.47 (9.6-15.8) g/dl in the conventional group. The average tourniquet time was 110(90-150) minutes in the navigated group and 96.7(60-145) minutes in the conventional group. Seven patients in the navigated group and 3 patients in the conventional group did not have documentation of the tourniquet time. The average post-operative haemoglobin in the navigated group was 10.34 (7.5-14.8) g/dl and 10.03 (7.5-12.2) g/dl in the conventional group. Six patients each in the navigated group and conventional group required blood transfusion. Six patients in the navigated group and 8 patients in the conventional group were started on haematinics.

This study does not show any significant difference in the blood loss as estimated by the average drop in the post-operative haemoglobin between navigated and conventional total knee replacement. There was also no difference in the rates of blood transfusion between both the groups. However the average operative time was marginally higher in the navigated group than the conventional group.

We conducted a retrospective study to compare the blood loss following Primary Total Knee Replacement (TKR) to see effectiveness of Tranexamic acid (TXA).v/s Cell Salvage.

This was a retrospective study conducted from Aug 2008 to Dec 2009. We compared two groups. Group A was given TXA IV (two doses – first dose before tourniquet release and second dose six hours post-operative) and in group B post op cell salvage was used. 84 knees were included in this study with 42 patients in each group. The surgical technique, implants used and post-operative Thromboprophylaxis care were same in both groups.

The corrected mean Hob drop in Group A was 1.76g/dl (Range-0.7 to 4.3) while that in Group B was 2.32g/dl (Range-0.7 to 5.3). Use of TXA lead to a 24.13% decrease in mean Hob drop and 3.7% fall in mean drain output following TKR in our study. Two thromboembolic events in the form of deep vein thrombosis (DVT) confirmed by Duplex US scan, were noted in each group. There was no difference in complication rate i.e. drain site infection and wound leaking in either group. Costs - The cost of two doses of TXA is £3.81 per patient and cost of bellovac drain was £85 per patient.

We found TXA was more effective and cheaper than autolougus blood transfusion and there was no increase in thromboembolic complications

We present the medium to long term clinical results of 112 Uncemented custom Computer Assisted Design Computer Assisted Manufactured (CAD-CAM) total hip arthroplasties performed between 1992 and 1998 in 111 patients. Fifty three males and 58 females were included. Mean age was 46.2 years (range 24.6yrs - 62.2 yrs). Average duration of follow up was 156 months (120 – 204 months). The mean Harris Hip Score (HHS) improved from 42.4 to 90.3, mean Oxford Hip Score (OHS) improved from 43.1 to 18.2 and the mean WOMAC hip score improved from 57.0 to 11.9. There was 1 revision due to failure of the acetabular components but there were no failures of the femoral components. There were no revisions for aseptic loosening. The worst case survival in this cohort of custom femoral components at an average 13 year follow up (range 10-17 years) was 98.2% (95% Confidence interval 95% to 99%). Survival of the femoral component alone was 100%.

These results are comparable with the best medium to long term results for femoral components used in primary total hip arthroplasty (THA) with any means of fixation.

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

Bearing diameter and acetabular component orientation have been shown to be important variables effecting blood metal ion levels following hip resurfacing arthroplasty. So far no studies on bilateral hip resurfacings have taken into account these variables.

We examined the serum ion results of patients under the care of two experienced hip resurfacing surgeons who carry out ion analysis as part of routine post operative care. Surgeon 1: Patients were implanted exclusively with a “third generation” resurfacing device. Surgeon 2: Patients were implanted with the same “third generation” device and also a low clearance “fourth generation” resurfacing device. Only ion results from patients who were 12 months post surgery were included. Bilateral patients were matched to unilateral patients according to the surgeon performing the operation; the resurfacing system implanted and cup inclination and anteversion angles. The ion data from each bilateral group was tested against the corresponding unilateral groups using the Mann Whitney U test for non parametric data. Significance was drawn at p<0.05.

Surgeon 1: There were 310 patients with unilateral joints and 50 with bilateral joints. There were no significant differences with regard to time to follow up, activity levels, joint sizes or cup orientations. Serum chromium (Cr) and cobalt (Co) concentrations were significantly greater in the bilateral group (p<0.001). Median ion levels were greater in the bilateral group by a factor of >2 in the smallest joint sizes and <2 in the largest joints. Surgeon 2: There were 11 patients with bilateral third generation resurfacing joints and 50 with unilateral joints of the same design. The same relationship as described above was identified. There was a notable difference in the fourth generation implant group (n=13 bilateral, n=100 unilateral). Median ion levels for patients receiving bilateral joints of sizes <47mm were ten times greater than in the corresponding unilateral group.

Bearing diameter and component design are critical factors in determining metal ion levels following bilateral hip resurfacings. Surgeons must consider the potential implications of gross increases in metal ion levels prior to performing bilateral hip resurfacings in smaller patients.

The purpose of this study was to evaluate early results of a new as yet not described minimal invasive posterior gluteus maximus splitting approach for total hip arthroplasty (THA) and also metal on metal hip resurfacing.

A new minimal invasive gluteus maximus splitting posterior approach is described backed up with intra-operative videos. This single incision approach allowed THA to be carried out through an incision ranging from 5.5 cm. to 9 cm. and metal on metal (MOM) resurfacing through an incision ranging from 7.5 cm. to 10 cm. Intra-operative fluoroscopy is not needed. The patients were not selected according to body mass index (BMI). All patients are suitable for this approach except for severely obese patients. 30 patients underwent THA (both cemented and uncemented) and 20 underwent MOM resurfacing. Early results at average 6 months indicate low post-operative pain scores, low blood loss (less than 5% needing transfusion), early mobilisation and discharge from hospital. Patients also returned to normal activities early with excellent cosmetic results and high patient satisfaction scores. There were no complications.

THA and MOM hip resurfacing can safely be done through a minimally invasive gluteus maximus splitting approach with excellent early results without any complication

Hip fracture is associated with highest mortality following trauma in the elderly. The objective of this study is to evaluate the association between duration of anaesthesia and duration of surgery with 30 days mortality following hip fracture surgery.

This retrospective cohort study reviewed patients underwent surgery following hip fracture in a district general hospital. Patients less than 65 years, periprosthetic and pathological fractures were excluded. Totally 254 patients were included in the study, who had surgery between February 2005 and September 2008 (20 months period). Mortality details retrieved through National Statistics database. Chi Square tests and Logistic regression analyses were performed to check the relationship between 30 days mortality and all independent variables including duration of anaesthesia and duration of surgery.

The incidence of 30 days mortality following hip fracture surgery was 9.4%. The commonest reason of death was cardiac failure and chest infection. Patients who had General anesthesia (GA) had more complications and mortality in comparison with those who had regional anaesthesia. GA increases the odds of 30 days mortality to 2.5 times. Patients under American Society of Anesthesiologists (ASA) II had decreased odds of 30 days mortality than ASA III & IV (odds Ratio 0.16). However duration of anesthesia up to 120 minutes and duration of surgery up to 90 minutes were not associated with 30 days mortality (P>0.05). The 30 days mortality following dynamic hip screw fixation surgery was 14.6% and intra medullary nail was 12.5%. The 30 days mortality in cemented hemi-arthroplasty was 6.9% and uncemented hemi-arthroplasty was 6%. The 30 days mortality was nil in the group of patients who had undergone cannulated hip screw fixation.

In elderly people following hip fracture surgery 30 days mortality was not affected by duration of anaesthesia and duration of surgery. However 30 days mortality was related with GA, ASA III & IV and post-operative complications mainly cardiac failure and chest infection. These patients need specialist medical care

With the ever increasing rate of total hip replacement and life span of these patients, there has been an upward trend towards the incidence of peri-prosthetic fractures. Previous studies does suggest the implant cost to as high as 30% of the total reimbursement in primary hip arthroplasty but this figure is much higher in periprosthetic fractures where long stem revisions are commonly used

A prospective comparative study analyzing the total cost of hospital stay for a cohort of 52 consecutive patients with peri-prosthetic fractures of long bones treated in two hospitals from October 2007 to march 2009 was conducted. Demographic data, fracture classification and method of surgical treatment along with the length of hospital stay were recorded in detail. The total cost calculated was then compared to the range of reimbursement price based on HRG (human Resource Group) coding. The implant cost was determined from the buying cost by each institution.

52 patients were available for review. Average age of the patients operated was 78.5 years. 69 percent of the peri-prosthetic fractures in our series were around the proximal femur. The average cost of stay was £ 16453 (£ 1425- 26345). The reimbursement to the hospital ranged from £ 1983 to £ 8735.

Hospital source utilization for peri prosthetic fractures is quite high compared to the reimbursement being given to hospitals for treating such patients. This can be as low as £ 1500 as acute phase tariff to £ 9100 for elective revisions and the implant cost can vary from 50% to 200% of the total reimbursement cost. Current recording system for peri-prosthetic fracture is unclear resulting in discrepancy between resource utilization and reimbursement thus resulting in substantial financial losses for hospitals that perform these procedures.

We present a series of 11 patients with infected tibial intramedullary nails which were treated at our tertiary referral centre from January 2000 to November 2009. All of them were males and the mean age was 36 years (26 to 47 years). All the patients had sustained post traumatic fractures which were treated with intramedullary nail. Four patients (36%) had sustained open fractures in whom adequate soft tissue cover was provided by plastic surgeons. Five of them (45%) were smokers.

All of them underwent surgical debridement. Nine out of 11 patients had removal of metal work followed by one or more of the following procedures such as reaming, exchange nailing, excision of sequestrum, application of antibiotic beads and stabilisation with a frame with or without several bone grafts at a later date.

Out of 11 patients six (55%) had no further episodes of infection, three (27%) still need short courses of antibiotics when the disease flares up and two (18%) underwent amputation. Causative organisms were isolated in all the patients. Commonest organism was MRSA. Overall, most of the organisms were sensitive to Vancomycin and resistant to Penicillin.

Despite exploring most of the surgical procedures described for infected tibial intramedullary nails we have potentially eradicated infection only in about half of our patients. Hence we would like to emphasise that this condition still remains a serious problem and demands further insight in its management

Fractures of distal tibia are common and often present with dilemma of appropriate and safe management. The use of locking plates has changed the way these fractures have been managed as it avoids extensive soft tissue dissection and periosteal stripping

The aims of this study were to look at the results of stabilization and analyse the complications of fractures of distal tibia treated with Locked plates

We carried out a retrospective study of patients who underwent surgical treatment for distal tibial fractures using MIPO (Minimally invasive Percutaneous Osteosynthesis) technique. The data was gathered from theatre data base. We studied a period between Nov 2006 to May 2009. We collected patient demographics as well as the type of fractures, mechanism of injury, radiological union and associated complications. There were no open fractures in the study. The limb was splinted for two weeks after surgery in a back slab. The patients were followed up at 6 weeks, 3, 6, 9 and 12 months after surgery.

There were 45 patients in the study with 29 males & 16 females between ages of 20 – 87 (avg. 49 yrs). 24 patients sustained injury due to a fall, 12 were involved in RTA and the remaining 9 were sports related injuries. The mean time to surgery was 3.15 days (1 – 7) and surgery was carried either by the consultant or their direct supervision. The mean hospital stay was 7 days (2 – 35) and mean time to radiological evidence of callus was 9 weeks. All patients eventually returned to their preinjury employment. 76% showed radiological union at 6 months and 90% at 9 months.

There were 3 superficial wound infections, 2 deep infections whilst 2 needed bone grafting and 1 implant failure. 2 patients developed mild form of CRPS which resolved at 12 months. 11 patients had metal discomfort of which 9 had removal of hardware. All these patients had the tip snapped off.

MIPO with LCP is a reliable and reproducible technique in treatment of closed unstable fracture of distal tibia. Patients must be counselled about implant removal after fracture union. Avoid snapping the tip of the LCP.

Various operative treatments have been proposed for proximal humeral fractures.

The purpose of our study was to compare complications of plate versus nail for these proximal humeral fractures and to determine whether it is the implant or fracture and surgeon related factors which result in complications.

We had 74 patients operated from March 2006 till June 2008 for displaced 3 (49pts) or 4 (25pts) part proximal humeral fractures. 43 had plating (PHILOS) and 31 had a humeral nail inserted. 57 patients were over 60 years at presentation while 17 were younger than 60. All patients were followed regularly radiologically. The functional outcomes were assessed by Quick DASH score and were comparable in both groups at 1 year postoperatively.18 of the 43 patients in the Plating group had a radiological complication with 9 cases of screw cut-out, 5 fractures maluniting and 1 nonunion. There was no case of osteonecrosis. In the nailing group, 13 patients had radiological complications, with 8 patients having varus malunion, 3 having proximal screw loosening and 1 having osteonecrosis apart from the clinical complications of impingement and rotator cuff problems.

Given the similar complication rate and similar functional outcome achieved by both these techniques it is hard to determine if any one in particular is better than the other. The key determining factors for a proximal humeral fracture might actually be patient and surgeon related. It is important to achieve medial continuity and good initial reduction in these fractures to prevent them from collapsing into varus, especially with the nails. Also, patient age, osteoporosis and functional demand are factors determining success of surgery in these patients. We did not find the severity of the fracture to be a determining factor, maybe this was because the relative proportion of type 4 fractures in our series was less.

We present a novel approach to the management of patients with longstanding heel ulcers complicated by open calcaneal fractures. The principles of management of diabetic foot ulcers were combined with applied physiology of fracture healing.

Case notes of 6 consecutive patients who presented to our diabetic foot clinic between January 2009 and December 2009 were reviewed. Type of diabetes, duration of heel ulcer, type of fracture and treatment given were recorded. Initial treatment consisted of regular local debridement and application of dressing. Vacuum Assisted Continuous (VAC) pump application was deferred until 6 weeks to preserve fracture hematoma and thereby initiate fracture healing. In all patients, VAC pump was started at 6 weeks and continued till healing of ulcer to adequate depth. Infection was treated aggressively with appropriate antibiotics according to the microbiology results.

The average age was 53 (40-60) and the mean duration of follow up was 6 months. All wound healed completely, fractures united and patients returned to previous function.

An open calcaneal fracture presents a severe injury likely to be complicated by infection and consequent osteomyelitis leading to amputations. In our group of patients, a novel treatment approach consisting of multidisciplinary model resulted in successful limb preservation and return to function.

Despite a lack of evidence, the UK's Department of Health introduced a policy of ‘Bare below the elbows’ attire to try to reduce the incidence of nosocomial infection. This study investigates the link between attire and hand contamination. A prospective observational study of doctors working in a District General Hospital was performed. The fingertips were imprinted on culture medium, and the resulting growth assessed for number of colony forming units, presence of clinically significant pathogens and multiply resistant organisms. These findings were correlated with attire, grade, gender and specialty. 92 doctors were recruited of which 49 were ‘Bare below the elbows’ compliant and 43 were not. There was no statistically significant difference between those doctors who were ‘bare below the elbows’ and those that were not for either the number of colony forming units (p=1.0), or the presence of significant organisms (p=0.77). No multiply resistant organisms were cultured from doctors' hands. ‘Bare below the elbows’ attire is not related to the degree of contamination on doctors' fingertips or the presence of clinically significant pathogens. Further studies are required to establish whether investment in doctor's uniforms and patient education campaigns are worthwhile.

Blount's disease is by far common cause of significant genu varum in paediatric age group. The deformity can range from simple varus deformity to significant varus, shortening of tibia and internal torsion of tibia, depending up on type and stage of Blount's disease. Several studies have shown excellent correction with the use of circular frame. The trend has moved from Ilizarov circular frame to Taylor Spatial Frame. The most accepted method of achieving correction of all components is by performing proximal tibial osteotomy and gradual correction of mechanical axis. Traditionally two additional procedures – fibular osteotomy and fixation of distal tibio-fibular syndesmosis are also added. However, the role of these additional procedures, which are not without their complications, is not well evaluated. A recent study had shown that correction of tibia vara without lengthening can be achieved without fibular osteotomy. However, use of distal tibio-fibular syndesmosis fixation (either with a wire or a screw) remains controversial. We present our experience in treating Blount's deformity with circular frame without stabilization of distal tibio-fibular syndesmosis.

10 patients were treated at our tertiary referral centre between 2000 to 2010. There were 7 boys and 3 girls. Age at surgery ranged from 8 yrs – 15 yrs. The mean patient age was 11.5 yrs. Two patients were treated with Ilizarov frame and 8 with Taylor Spatial Frame. Indications for surgery were unacceptable deformity (varus and internal rotation), with or without shortening. Varus deformity ranged from 10 degrees to 40 degrees. All tibiae were lengthened and the range of lengthening was from 1cm to 3.5cm. Fibular osteotomy was carried out in all patients. Tibio-fibular syndesmosis was never stabilized distally. All the patients were encouraged to mobilise full weight bearing as soon as tolerated and all of them had gradual correction of deformity usually starting a week following the surgery.

We achieved target correction of varus, internal rotation and leg length discrepancy in all patients. The commonest hurdle was superficial pin tract infection which resolved with short courses of oral antibiotics. Follow up ranged from 6 months to 10 yrs. Clinical and radiological evaluation of ankle did not show any abnormality in all these cases.

Satisfactory correction of Blount's disease (tibia vara and leg length discrepancy) can be achieved with circular frame without the stabilization of distal tibio-fibular syndesmosis.

The aim of this prospective study was to determine the prevalence of bone marrow oedema (BME) in asymptomatic knees of athletes and to investigate the factors associated with appearance of BME in this group.

A total of 25 asymptomatic athletes who competed at an international, national or county level during their most recent sport season were recruited in this study and had MRI scan of both knees (n=50). MRI scans were reported independently by two experienced musculoskeletal radiologists. Statistical analysis included Cohen's kappa test to identify inter-observer agreement for MRI diagnosis of bone marrow oedema and multiple logistic regression model to identify the factors associated with BME on MRI scan.

There was very good agreement between radiologists for diagnosis of BME (Kappa = 0.896). Seven participants (28%) were found to have BME. Six of the participants had BME in unilateral knees and one participant had BME in bilateral knees. The commonest location of BME was medial femoral condyle (62.5%) The amount of time spent in preseason training (34-38 weeks) was significantly associated with appearance of BME (P=0.048)

BME seems to be common in asymptomatic athletes and one should realize that this finding might not be related to the clinical complaints of the patients. The results of the present study show that there is a training effect associated with BME. Knowing what is a ‘normal’ or ‘abnormal’ scan is important for a competitive athlete, as erroneously diagnosing BME as the underlying cause of athletes' symptoms could lead to decreased playing time or inappropriate therapy.

We describe the clinical results of a technique of direct pars repair stabilised with a construct that consists of a pair of pedicle screws connected with a modular link that passes beneath the spinous process. Tightening the link to the screws compresses the bone grafted pars defect providing rigid intrasegmental fixation.

20 patients aged between 9 and 21 years were included in this prospective study. Each of the patients had high activity levels and suffered from significant back pain without radicular symptoms or signs. Patients had either no or grade I spondylolisthesis. Definitive pseudoarthrosis and fracture were confirmed via computerize tomography (CT). Magnetic resonance imaging was performed in every patient to assess the adjacent disc spaces which demonstrated normal signal intensity.

A midline incision was used for surgery. The pars interarticularis defect was exposed and filled with autologous iliac crest bone graft prior to screw insertion. After screw insertion, a link was contoured to fit, and placed just caudal to the spinous process, deep to the interspinous ligament of the affected level, and attached to each pedicle screw. There was early mobilization post-operatively without a brace. The average inpatient stay was 3 days. Post-operative complications included 1 superficial wound haematoma and two superficial wound infections which responded to antibiotic treatment. Follow-up was at 6 weeks, 6 months and at 18 months, and 24 months. Clinical assessments for all patients was via the Oswestry disability index (ODI) and visual analogue scores (VAS). At the latest follow-up, 18 out of the 20 patients showed a significant (p<0.05) improvement in their ODI and VAS scores. The mean post-operative ODI score was 8%. All patients had radiographs and CT scans which showed fusion rates of 80% in those patients followed up for a minimum of 24 months. This new technique for direct pars repair demonstrates high fusion rates in addition provides the possible benefits of maintaining adjacent level motion. Clinically this group had good-to excellent functional outcomes as indicated by visual analogue scales and the Oswestry Disability Index in 18 out of 20 patients studied with a minimum follow-up of 2 years.

Anterior cervical discectomy and fusion for radiculopathy and myelopathy has the complication of the development of adjacent segment degeneration. Furthermore, reoperations may be required to treat complications of fusion, such as non-union, graft collapse, or expulsion. Cervical disc arthroplasty lays claim to preserving cervical motion and reducing the risks of adjacent segment disease in the treatment of cervical radiculopathy.

We performed a prospective study in order to evaluate the radiological and clinical outcomes of cervical disc arthroplasty for single or two level disc disease with associated radiculopathy. Our study included a total of 26 patients. Each patient had cervical radiculopathy from nerve root compression due to degenerative disc disease at one or two levels. Diagnosis was made preoperatively on clinical examination and by means of MRI scanning. Each patient also had preoperative flexion and extension cervical spine x-rays in order to assess pre-operative range of neck movement.

The outcomes of surgery were assessed prospectively. Range of motion at final follow-up was measured by flexion and extension view x-rays of the cervical spine. Clinical outcome was assessed by means of VAS scores for pain, SF12 for mental and physical health and the neck disability index (NDI). All complications were recorded. 14 of the patients had a follow-up for two years and the remaining 12 patients had a follow-up for one year.

A Discovery disc arthoplasty by Scient'X was the implant used in all patients. A standard anterior cervical approach was used to achieve decompression and for the implantation of the prosthesis.

On follow-up all patients had either maintenance or an improvement in the range of movement. There was no evidence of progression of degeneration in the segments adjacent to the arthroplasty prosthesis. Improvements in SF12, VAS, and NDI scores were seen from preoperative levels in 25 of the 26 patients. Complications included one patient with a horse voice post-operatively and one patient with minimal improvement of radicular symptoms. Post-operative MRI scanning demonstrated adequate decompression with this procedure and showed no evidence of progression of adjacent segment disease. There were no cases of implant subsidence or dislocations.

We have found cervical disc arthroplasty to produce good clinical outcomes when used for single or two level cervical radiculopathy whilst maintaining neck motion with an acceptable complication rate. A longer follow-up is needed to further assess the risk of development of adjacent segment disease but we did not discover the development of adjacent segment disease in our study with a follow-up of upto 2 years