Intraarticular fractures of the distal humerus comprise 1% of all fractures in adults. Triceps reflecting and olecranon osteotomy approach provide adequate exposure in intraarticular fracture with its own advantage and disadvantages. Forty consecutive patients with fractures of the distal humerus were treated over a 36-month period. The patients were randomly allotted into two groups; group A consists of twenty patients with olecranon osteotomy and group B consists of twenty patients with triceps reflecting approach. In both the groups fracture was fixed using orthogonal or parallel plating techniques. Clinical outcome was assessed using the DASH SCORE, radiological union and complications was noted in both the group and compared. In group A the mean DASH score was 15.9 points. Three patients underwent a second procedure for hardware removal, 2 patients had non-union at osteotomy site, one patient had transient ulna nerve neuropraxia and one patient had superficial infection. In group B the mean DASH score was 14 points. There was no statistical significance between both groups regarding final outcome except complications were more in osteotomy approach. We conclude both approach is an effective procedure with an excellent or good functional outcome but osteotomy approach has more complications.

Patients with recurrent patella instability, who have an abnormal patellofemoral alignment (patella height or tibial tubercle-trochlear groove (TTTG) distance), benefit from tibial tubercle transfer along with medial patellofemoral ligament (MPFL) reconstruction. Between July 2008 and April 2013, 18 patients (21 knees) with recurrent patellar instability underwent combined MPFL reconstruction and tibial tubercle transfer. All patients had abnormal patellofemoral alignment in addition to MPFL insufficiency. 15 patients (16 knees) with a mean age of 24 years (16–41) had a mean follow up of 26 months (6–55). We assessed the outcome using KOOS, KUJALA, activity level and patient satisfaction scores. All patients had a stable patella. There was a significant improvement in outcome scores in 12 out of 15 patients. At final follow up KOOS score had improved from 68.25(44 to 93.9) to 77.05(48.8 to 96.4) and KUJALA score had improved from 63.3(41–88) to 78.06 (45 to 99). 9 patients showed excellent results and achieved at least a pre-injury level of activity. 4 of these had activity level better then preoperative level. 6 patients had a lower activity level than pre-injury (1 – ongoing physiotherapy, 1 – because of lack of confidence, and 4 – Life style modification). 14 patients were satisfied and happy to recommend this procedure. There were 3 postop complications, with 2 cases of stiffness and 1 case of non-union of the tibial tuberosity. Our prospective study has shown that restoration of tibial tubercle-trochlear groove index, Patella height and Medial Patellofemoral Ligament reconstruction yields good results in carefully selected patients.

Current perception is that standard Cefuroxime only [C4] based prophylaxis regimen demonstrated higher association with C Difficile (C. Diff) diarrhoea. This has prompted change in antibiotics prophylaxis combination regimens like Flucloxacillin-Gentamycin (F-G], Teicoplanin- Gentamycin [T-G] and single dose Cefuroxime-Gentamycin [C-G]. The current study was done to investigate the association of C. Diff diarrhoea and surgical site infection (SSI) rate with Cefuroxime only regimen prophylaxis in fracture neck of femur surgery. A retrospective analysis for 2009–2012 was performed for 1502 neck of femur fracture patients undergoing surgery. The factors studied were ASA grade, SSI, C. Diff diarrhoea rates in patients with Cefuroxime (induction plus two doses) based prophylactic regimen. The data was obtained from coding department and further streamlined based on microbiology. 1242 patients were included in the study who received Cefuroxime only regimen. The Male : Female distribution was 353 : 889. The average ASA grade was 3. The analysis demonstrated that C. Diff diarrhoea rate in the study population was 1.29%. The SSI rate stood at 3.06% with superficial infection at 2.5 % and deep at 0.56 %. Our single centre based study demonstrated low C. Difficile related diarrhoea rates with Cefuroxime only regimen. The SSI rates were also low as compared to the current literature thus concluding that Cefuroxime only antibiotic regimen can safely be administered in neck of femur surgery.

We reported the outcomes of patients with Charcot neuropathy who underwent hind foot deformity correction using retrograde intramedullary nail arthrodesis. Twenty one feet in 20 patients, aged 45 to 83 years, with a mean BMI of 32.7 and a median ASA score of 3, were included in this study.

All patients presented with severe hindfoot deformities and 15 had recurrent ulceration. All patients were treated with hindfoot corrective fusion and seven patients also underwent simultaneous mid foot fusion using a bolt or locking plate. After a mean follow up of 26 months, none of the cases required any form of amputation. Eighty percent of patients with ulceration achieved healing and all but one patient returned to independent ambulation. One nail fracture and three mid foot metal work failure resulted in fixation failure requiring revision surgery. Distal locking screw displacement occurred only with standard screws but not with hydroxyapatite-coated screws. The AAOS-FAO score improved from 50.7 to 65.2 (p=0.015). The EQ-5D-5L improved from 0.63 to 0.67 (p=0.012) and the SF-36 PCS from 25.2 to 29.8 (p=0.003). Single stage deformity correction with intramedullary hindfoot arthrodesis nail is a viable treatment option for severe Charcot hindfoot deformity with ulceration and instability.

Proximal Femoral Nail Antirotation (PFNA) I one of the implants commonly used to stabilise subtrochanteric fractures or communited inter/pertrochanteric fractures. The aim of this project was to assess the outcome of PFNA in a busy District General Hospital. Between November 2009 to November 2012, 76 patients underwent PFNA. These patients were identified from the local hip fracture database, which is prospectively collected.

The mean age of the patients was 80.11 years (range of 26.83 to 98.53). 27 were male and 49 female. Right hip was involved in 36 cases and left hip in 40. 9 patients required revision surgery due to failure of the primary surgery. 2 patients died due to other causes. 5 out of the 9 patients who underwent revision surgery had their primary surgery performed by a trainee under consultant supervision and a consultant surgeon performed the other 4 cases. In our series failure rate was 11.8%. We conclude that although PFNA is an excellent device to fix subtrochanteric or communited intertrochanteric fractures of the proximal femur one needs to be cautious and follow the correct operative technique to avoid failures.

Evidence suggests that there 17% rise in cycling related injuries in the last year. The objective of the study is to analyze the pattern of injuries in cyclists who were treated as a MTC. This is a retrospective study performed at a Tertiary Trauma Centre in central London. All cyclists who were admitted as MTC to hospital between January 2011 and August 2013 were included. Overall there were 518 patients who were treated as vehicle- related Major Trauma Cases, out of which 118 (23%) were cyclists. Of the 118 cyclists, 98 (83%) were male and 20 (17%) female. The mean Injury Severity Score was 19.2 ±11.1 (mean/SD). There were 58 (49%) patients who required ITU support. Major proportion of patients (68 patients – 61%) sustained neurological injuries. There were 2 (1.7%) deaths, both due to neurological injuries. In comparison to other group of vehicles there is less number of bicycles on the roads. Our results show that the proportion of cyclists involved in road traffic incidents is higher (23%) than other vehicles. Our results show that large proportions (61%) of cyclists sustain neurological injuries, reinforcing the previous evidence that safe protective head gear is vital for cyclists.

Revision arthroplasty poses many challenges including extensile exposure and difficulty in safe removal of cemented/uncemented femoral component and/or distal cement particularly from a poor bone stock. Extended trochanteric osteotomies are associated with complications including non-union, proximal migration of the trochanter or osteotomised segment, wire breakage and difficulties associated with reattachment of the fragment. We present a technique of trochanter sparing extended anterior femoral osteotomy (AFO) through a modified Hardinge approach in reducing the difficulties associated in conventional and ETO. We assessed the performance of this technique in 23 patients with a maximum follow-up of 10 years. No trochanteric escape or fractures seen in any cases. No proximal migration, subsidence or failure of femoral component seen. Union was seen in all cases. Mean time for union was 3 months. 1 patient developed recurrent dislocations that required constrained liner.

Improvement in Harris Hip scores was noted from 13 (pain) and 9 (function) pre-operatively to 39 (pain) and 22 (function) (p<0.05). Extended trochanter sparing AFO allows extensive exposure similar to traditional ETO. It heals reliably without the use of vertical wires, trochanteric plates or grips. The avoidance of abductor mechanism and osteotomy through weakest anterior non weight bearing area of the proximal femur may be a significant advantage.

In a prospective randomised controlled trial, 51 patients who did not receive a bone plug during total knee replacement surgery were compared to 49 patients who received a bone plug. The primary outcome measure was the need for allogenic blood transfusion requirement and the secondary outcome was the post-operative blood loss and decline in haemoglobin levels. The patients had autologous re-transfusion from their closed drainage system. The two groups did not differ in the demographics. The mean intra-operative blood loss was slightly more in the no plug group (difference of 41.25 millilitres), which was not statistically significant. There was no statistically significant difference in total post-operative blood loss and drop in haemoglobin levels. Only one patient had two units of allogenic blood transfusion in the no bone plug group while none required allogenic blood in the bone plug group. There was no statistically significant difference in the amount of blood re-transfused from the drain between the two groups. Our findings did not show any statistically significant difference in post-operative blood loss, decline in haemoglobin levels and the need for allogenic blood transfusion in total knee replacement surgery.

We prospectively reviewed a consecutive series of 101 patients with mobile bearing total knee replacement (TKR) and 72 patients with the fixed bearing cruciate retaining TKR. Patients were assessed for diagnoses, range of motion, pre- and post-operative Oxford knee scores and complications. In the mobile bearing group of 113 knees in 101 patients, 97 had minimum 10-year follow up. By ten years, 16 patients had died of unrelated causes. Mean Revised Oxford Knee score improved from 16 pre-operatively to 42 at last follow up. The mean range of flexion was 115 degrees (75 – 130). One patient dislocated the bearing and needed manipulation. One patient reported superficial infection which resolved with antibiotics. One patient had deep vein thrombosis and one had non-fatal pulmonary embolism. In the fixed bearing group, 89 TKR's were performed in 72 patients. The mean age was 71.9 years and the mean follow up was 12.1 (10–14.1) years. 19 patients died during this study period. The mean range of flexion was 111.2 (80–135) degrees of flexion at latest follow- up. There was an improvement in the mean Oxford knee score from 16.2 preoperatively, to 42.5 to date. One patient required revision surgery at 12 years for polyethylene wear. One patient developed deep infection 10 years after the primary procedure but declined revision surgery. At ten years no revisions were performed in either group. This series has highlighted excellent results with both fixed and mobile bearing CR knees with hundred percent survival at ten years.

The final alignment of Patient Specific Instrumentation (PSI) TKA relies on the accuracy and the correct placement of the 3-D moulds, precision of saw cuts, soft tissue balancing and cementing technique. We aimed to compare the predicted alignment between PSI and Articulated Surface Mounted (ASM) computer navigation. Eight consecutive patients underwent knee replacement using MRI based PSI (Zimmer) with planning of 0º femoral and tibial mechanical alignment. After placing the conventional cutting blocks over the pins (placed according to PSI), the predicted alignment of cuts was verified with ASM navigation. PSI technique was used regardless of navigation values and alignment was compared.

Good correlation was found for tibial cuts (maximum variation: coronal plane – 1º, sagittal plane – 2º) and femoral cuts in the sagittal plane (maximum variation 2º). However, in two patients the coronal plane variation in femur was > 2º (3º and 4º respectively). Navigation predicted combined final alignment of 5º valgus and 4º valgus in these patients. However, long leg standing x-rays revealed neutral and 1º valgus alignment in those two patients respectively, matching closely with PSI prediction. Final alignment in long-leg standing x-rays were independently reported by a musculoskeletal radiologist. Six knees were in neutral mechanical alignment (including the 2 navigation predicted outliers). The remaining 2 knees had a maximum deviation of 2 degrees from neutral. We conclude that there was overall good correlation between PSI and navigation. Even in cases where navigation predicted more than 3º combined varus/valgus alignment, PSI prediction was more accurate on long leg views.

There has been a lot of focus on the value of anatomic tunnel placement in ACL reconstruction, and the relative merits of single and double bundle grafts. Multiple cadaveric and animal studies have compared the effects of tunnel placement and graft type on knee biomechanics. 45 patients who underwent ACL reconstruction were included into our study. Femoral tunnel position was analysed by two independent doctors using the radiographic quadrant method as described by Bernard et al., and the mean values calculated. Forty-one of these patients completed a KOOS questionnaire. The mean ratio ‘a’ was 26.57% and mean ratio ‘b’ was 30.04% as compared to 24.8% (+/− 2.2%) and 28.5% (+/− 2.5%) respectively quoted by Bernard et.al, as the ideal tunnel position. Only twenty-three of these femoral tunnels were in the anatomic range. Analysis of forty-one KOOS surveys (23 anatomic, 18 non-anatomic) revealed no significant difference in total score or subscales between the anatomic and non-anatomic groups (p= >0.05). Our study suggests that the ideal tunnel position, as described by Bernard et.al. may not be ideal and fixed.

The purpose of this study was to evaluate the results of selective anatomic augmentation of partial anterior cruciate (ACL) ligament tears in 36 consecutive patients with mean 3years follow-up. Our hypothesis is that this selective augmentation of partial ACL tears could restore knee stability and function. In a consecutive series of 314 ACL reconstructions, 40 patients in which intact ACL fibers remained in the location corresponding to the anteromedial or posterolateral bundle were diagnosed perioperatively. All patients underwent selective augmentation of the torn bundle, while keeping the remaining fibers intact using autogenous hamstring graft. 38 patients (28 males, 10 females) were available with minimum 3 year follow- up. 26 cases had AM bundle tears and 12 cases had PL bundle tears respectively. Patients were assessed with International Knee Documentation Committee (IKDC) 2000 Knee Evaluation Form, Lysholm score; instrumented knee testing was performed with the arthrometer (KT 2000).

Statistical analysis was performed to compare the preoperative and postoperative objective evaluation. At 3 year follow-up, 12 (31.6%) patients were graded A, 25 (65.8%) graded B and 1 C (2.6%) at IKDC objective evaluation. Lysholm's score and mean side to side instrumental laxity improved significantly. The results of anatomic single bundle augmentation in partial ACL tears are encouraging with excellent side to side laxity.

We present a study done to measure the change of angle of the acetabulum or cup, due to leg length discrepancy, deformity of hip and spine on standing. In 1998 a 3-dimensional reconstruction of hip model was prepared on CAD and the change of angle of the cup was measured as Functional Acetabular Inclination Angle (FAIA) with patient standing without squaring the pelvis. The FAIA on standing was compared with angle of the cup with patient in supine position with squared pelvis. The position of the cup changed on weight bearing due to multiple issues. The results showed that one centimetre of leg lengthening changed FAIA by 3°, 10° of abduction deformity resulted in apparent lengthening of 2.87 cm and loss of lordosis anteverted the cup on loading and vice-versa. We conclude that fixed hip deformities, leg length discrepancy and spine deformities can affect the angle of cup in hip replacement surgery and may prone to dislocations, impingement and segmental wear of the cup.

Trauma & Orthopaedic Department, Bronglais Hospital & Hywel Dda University Health Board, Aberystwyth, UK

Auto-CAD study is done to observe the effects of head neck ratio (HNR) in joint replacements. Total hip replacement joints were reconstructed on CAD with increasing diameter of the head keeping neck diameter constant in 1997. Simulation was done and Range of Movement (ROM), impingement and stability of the hip joint was noted. A graph was plotted with HNR on X-axis and ROM on Y-axis. It was observed that as the HNR increases the ROM of the joint is increased, impingement is reduced and stability is also increased. It is also observed that diameter of the head and neck is more important than considering only head diameter of the hip joint. The graphical analysis confirms that different diameters of the head may have same HNR depending on the neck diameter. So even in smaller diameter head the HNR may be more due to smaller diameter neck and may be more advantages than larger diameter head with bigger neck having smaller HNR. We conclude that HNR is more important than the head diameter alone in hip replacements.

London's Air Ambulance (LAA) was first set-up in 1989 as a direct result of a Royal College of Surgeons of England Report highlighting poor trauma care provision. Since its inception, the service's mission is to be an innovative and effective provider of advanced pre-hospital care. The service provides a senior Doctor and senior Paramedic to the scene of any incident within the M25 by helicopter, during the day, and by fast-response car at night. The vast majority of doctors are usually Emergency Medicine Physicians or Anaesthetists. During a 6-month tenure, doctors will usually have completed a number of procedures, which include rapid sequence induction of anaesthesia, pre-hospital blood transfusion, and, procedural sedation. In terms of innovations, the organisation was the first in the UK to provide a 24/7 service. It was also the first to start pre-hospital Rapid Sequence Induction of Anaesthesia for the severely injured; Resuscitative Thoracotomy for the victims of penetrating trauma; and pre-hospital Blood Transfusion for shocked polytrauma patients. The service also has a very thorough induction programme, for new Doctors and Paramedics, and a highly structured Clinical Governance process. The post offers a unique and privileged opportunity to treat the most severely injured at the roadside.

Accurate implant size estimation for internal fixation of long bone fractures can reduce intra-operative errors, operative time and radiation exposure. With the advent of pre-packed sterile implants, the exponential increase in the number of internal fixation devices and the lack of standard templates for them on PACS systems, templating has become increasingly difficult. This often results in the opening up of wrong implants leading to increased costs both in terms of increased operative time and additional implants. We describe a technique to determine implant size preoperatively using sterile implant boxes. Post anaesthesia and positioning, the pre packed implant box of approximate size is placed over the limb across the fracture site. An X-ray is then taken using the C-arm. In case of a plate, the number of holes desired on either side of the fracture, the shape of the implant and planned placement of screws are seen. Different implant boxes with the contained implant are placed and once the most appropriate implant for the particular fracture is reached, the box is opened and implant is kept ready for insertion. This technique has been found to be accurate, easy, reproducible and effective for estimating the implant size thereby decreasing the chances of opening wrong implants and saving the intra operative time substantially.