Aim: To develop a device to improve the preparation of morcellised bone graft for use in revision arthroplasty surgery.

Background: Washing morcellised graft prior to impaction has been shown to improve the stability of the graft after impaction. By removing the cellular debris the chance of contamination is potentially reduced.

Methods: A readily available domestic appliance was identified which met the requirements of being able to contain the graft whilst allowing free drainage of the pulsed lavage solution. This hand held potato masher has an all metal construction with few moving parts and is therefore easily cleaned and sterilised between cases. The numerous perforations in the receiver of the masher ensure that the lavage solution rarely backs up and also that all of the cellular debris is washed through effectively.

Results: This device has been in regular use in this institution over the last two years. It allows a no touch technique for the preparation of morcellised graft in complex cases that require replacement of the bone stock.

This poster will demonstrate pictorially the technique for graft preparation and the quality of the prepared graft that can be obtained.

We present the case of a patient with Rheumatoid Arthritis who underwent a right total hip replacement as a young adult. At the time of surgery there was an intra-operative femoral fracture and the prosthesis and cement breached the cortex of the proximal femur postero-medially.

The fracture was detected on the post-operative film and the patient was treated non-operatively until the fracture consolidated. Despite having rheumatoid arthritis our patient went on to an active adult life having a family and she worked full time with this hip replacement. She subsequently required a socket revision at 15 years post index surgery and at the time the femoral component was well fixed, not scratched and left in situ.

Currently, the revision socket remains satisfactory, the stem still appears well fixed and clinically the patient is well.

Discussion: This case highlights the fact that not all intra-operative fractures require surgical intervention. They are low energy events with minimal soft tissue disruption and may heal satisfactorily. This case demonstrates that it should not be assumed that loosening and failure are inevitable.

Aim: A radiological review to assess component orientation in a consecutive series of primary total hip replacements performed by a high volume hip surgeon through either a standard or reduced size incision.

Background: Using a posterior approach and standard instrumentation the senior author has reduced his incision size in selected patients over the last 2 years. There is no fixed definition of incision size in this series, incision sizes fall between 10 and 15cm in most cases. The implication is that deliberate efforts were made to limit the incision length compared to a routine exposure at the start of surgery.

Method: From the operative records kept for the senior author a series of 48 patients was identified, with equal numbers having reduced or standard incisions. A radiological review was performed looking at the cementation, leg length and component orientation in both the AP and lateral planes.

Results: In the AP plane there was no significant difference in the alignment of the components. In the reduced incision group an increased number of stems were directed from anterior to posterior on the lateral x-rays.

The quality of the femoral cement mantles was significantly better in the standard incision group (75% Barrack A vs. 50% Barrack A)

On the acetabular side the components were better positioned and orientated in the small incision group but cementation was again improved in the standard incision group.

Conclusions: Reducing incision size does have an influence on cementation and the positioning of components during hip arthroplasty.

The orientation and cementation of components in both study groups would be considered acceptable in the majority of cases.

The authors recommend small audit studies of this nature as a way of providing ongoing feedback on the quality of their surgery thereby allowing improvements to be made to their surgical technique.

Background: Infection in total joint replacement remains one of the most devastating post operative complications. The majority of these infections are still caused by organisms normally found on the skin. The use of adhesive wound drapes has become commonplace in orthopaedic surgery but frequently these are detached from the wound edges at the end of surgery allowing contamination of the wound.

Aim: To develop a technique to improve the adherence of wound drapes.

Methods: The first part of this study was to experiment with a number of techniques to prepare the skin preoperatively. We were able to identify that a combination of initial Betadine in alcohol preparation, followed by re-preparation of the operative site with Chlorhexidine in alcohol produced the best combination of drape adherence. In a consecutive series of 100 patients we have used our original technique of preparing the wound for 50 patients followed by a further 50 patients prepared with the new technique.

Results: In the initial patient group all of the adhesive drapes were detached enough to expose the skin edges in at least one part of the wound by the end of the surgical procedure. With the new technique we have had no detachments of the adhesive drape.

There have been no complications or skin reactions related to this method of skin preparation. There has been no significant difference in the incidence of early post operative wound infection.

Conclusion: This technique of operation site preparation provides an excellent means of preventing detachment of adhesive wound drapes. We have found it reliable, safe and effective to date and it adds little to the overall procedure time. We recommend this technique as a way of ensuring that the skin edges remain covered throughout primary and revision procedures.

We present the case of an elderly lady who was treated surgically as an infant for osteomyelitis of the left distal femur. Throughout the whole of her adult life she describes episodes where the thigh has become more painful and warm followed by a watery discharge from a sinus on the upper medial aspect of the thigh. This sinus has discharged at least weekly up until the present day. No further surgery has been performed on the proximal femur since childhood.

Almost 10 years ago the patient presented with symptoms of osteoarthritis in the left hip. A total hip replacement was performed at that time without any further active measures aimed at eradication of the osteomyelitis.

Despite obvious concerns of the possibility of exacerbating the osteomyelitis and developing pan femoral disease this has not been the case. The hip replacement is symptom free, stable and there are no signs of infection clinically or radiologically.

Conclusions: Whilst we would not immediately recommend this course of action; the surgical treatment of long bone osteomyelitis if an arduous procedure for both patient and surgeon with high recurrence rates. This case demonstrates that in low demand elderly patients it may be possible to implant a hip replacement.

Aim: To review the study size and requirements of studies looking at factors affecting outcome following total hip arthroplasty.

Background: The orthopaedic literature is full of claims that new products out-perform older ones, cemented and un-cemented components are equal, cementing grades and mantles are all important and that component orientation is vital to longevity. We are also aware of patients who have performed well despite having numerous adverse features to their joint replacements.

We have searched the available literature for factors that have been implicated in the survival of hip replacements. We have used these to determine the likely study sizes required to provide meaningful data.

Method: We identified over 50 variables that have been implicated in the survival of hip replacements. Assuming all of them to be of equal relevance the study size required for multivariate analysis to be possible would be in excess of 50000. Some of these variables are less likely to be of great significance and this number could potentially be reduced to 25–30000.

Discussion: Because total hip replacement has a greater than 90% success rate at 10 years in nearly all series this makes the numbers required for multivariate analysis much larger. Individual factors affecting survival will be difficult to identify unless large series are considered.

Conclusion: The only way to reduce the numbers required for meaningful studies is to increase the matching of as many variables as possible to ensure that investigators conclusions are valid in the majority of small series orthopaedic studies.

The use of Joint Registers is likely to be the only way of obtaining the volume of data required to detect individual factors affecting survival. Care will still need to be taken interpreting this data as there are still numerous variables which are not accounted for in the Joint Register.

Intro: Quadriceps rupture following total knee arthroplasty is a devastating injury. Early operative repair is necessary to maintain the integrity of the extensor. Postoperative rehabilitation usually involves a prolonged period of immobilisation to allow the repair to consolidate. This immobilisation can cause irreversible stiffness in the patient with a total knee replacement. We present a method of rehabilitation to allow early range of motion.

Case Report: A 57 year old gentleman presented with bilateral tri-compartmental osteoarthritis, he had no other significant medical history. Bilateral synchronous total knee replacements were performed and the early post operative was unremarkable.

The patient fell whilst mobilising indoors at home during the fifth post operative week and sustained rapid hyperflexion injures to both knees. Ultrasound scans of the knees demonstrated bilateral discontinuities of the quadriceps mechanisms and a large fluid collection filling the defect.

The patient returned to the operating where a direct repair was achieved. Post operatively the patient was rested in bilateral cylinder casts until the sutures were removed at two weeks. For two week periods the knees were then mobilised in a hinged cast brace allowing 0–30, 0–60 and 0–90 degrees making the total time in cast 8 weeks

At the time of removal of the casts the patient had 110 degrees of flexion in the right leg and 85 degrees of flexion in the left. At six months postoperatively the patient flexes freely to over 100 degrees

Conclusion: Bilateral quadriceps ruptures in a relatively young patient can be managed with early repair and an aggressive rehabilitation regime. This case suggests that is possible to achieve a satisfactory outcome although the input required is significant.

Introduction: ACL reconstruction with PTFE grafts enjoyed a brief period of popularity approximately a decade ago but early failures led to the technique being largely abandoned for primary reconstruction. We present a case where a patient presented several years after initial reconstruction because of an increase in pain.

Case Report: A 43 year old man presented to the clinic because of an increase in knee symptoms without a specific history of trauma. He had previously undergone a PTFE reconstruction of his acl. X-rays at the time revealed a large, expanding cyst in his proximal tibia which was approximately 5x3x3cm.

Management: In view of the increasing bone loss it was decided to manage this case surgically. After thorough debridement of the cavity in the proximal tibia morcellised bone was grafted into the defect on the tibial side. The femoral side of the graft was removed but no further treatment was required. Histology of the lesion revealed copious amounts of PTFE debris.

Outcome: After 3 years of follow up the tibial graft has incorporated and radiologically the proximal tibia has consolidated well. Symptomatically the patient is improved and there have been no problems relating to instability.

Conclusion: Autologous grafting of the proximal tibia is a useful technique in this unusual circumstance. With the increase in synthetic graft use on the continent it is possible that more similar cases will present.

A 36 year old gentleman presented to the Metabolic Bone Disease Clinic with a progressive history of thoracic and lower limb pain. He had originally been seen by the podiatrists with worsening foot pain for which no cause had been found. Initial investigation revealed a hypophosphataemic osteomalacia and a bone scan demonstrated multiple abnormalities suggesting old fractures.

Investigations were performed to establish the cause of the osteomalacia and we discuss the differential diagnosis and the progression towards a diagnosis based on the results of these tests. The most useful investigation in this case was an octreotide scan which indicated the presence of an endocrine tumour in the medial femoral condyle of the right knee.

Plain x-rays revealed no clear bony abnormality in the area of increased uptake on the octreotide scan. The lesion was therefore localised with an MRI scan.

This subsequently demonstrated the exact location of the lesion and in image guided biopsy was performed in theatre. This confirmed the presence of a benign Phosphaturic Mesenchymal tumour. This rare tumour is usually found in soft tissues and this case is atypical given that the lesion was wholly within the femoral condyle.

Despite the benign appearance of the tumour cells there were some areas of locally invasive growth and excision rather than curettage of the tumour was recommended. It was possible to preserve both the bulk of the femoral condyle and the articular surface although the knee was protected with a hinged brace for six weeks following surgery.

Follow up biochemistry results demonstrate that the serum phosphate and alkaline phosphatase are returning to normal. Symptomatically the patient is much improved.

Introduction: Large cysts of the proximal tibial metaphysis are an uncommon radiological finding amongst the elderly presenting to an arthroplasty clinic. We present two cases of such pathology in elderly patients. These were both associated with advanced degenerate disease in the knee.

In view of the size of the lesions these were both fully investigated with pre-operative radiology and an image guided biopsy. The first case was found to be a large degenerate myxoid cyst involving the majority of the tibial plateau. The second case appeared similar radiologically yet was a large metastasis from a bladder cancer. The only history offered by the after this had been established was that she had had a benign polyp removed some years previously.

Management: When dealing with unusual features of disease a cautious approach should be recommended. Both patients underwent staging investigations and biopsy prior to knee replacement surgery. In each case it was possible to graft the defect and using revision prostheses a good outcome has been achieved.

Conclusion: Large cysts appearing in association with degenerate disease of the knee are uncommon. Whilst these will often be related to the underlying arthritis this is not always the case and appropriate care should be taken to establish a diagnosis prior to surgery.

Introduction: The foot and ankle are common sites for benign tumours, ganglia and other conditions. The aim of this review was to look at the case mix requiring surgery that presented to a foot and ankle clinic over an eighteen month period.

Methods: Prospective data collection is performed for all patients presenting with lesions requiring surgery and this is stored on the tumour database in Oswestry.

Results: 80 cases presented over this period that required surgery.. There were 12 malignant primary tumours, 1 malignant metastasis, 5 cases of locally aggressive benign conditions (4 PVNS and 1 ABC) and the remaining 62 cases were benign conditions. There were more malignant conditions than there were ganglia.

Conclusions: In this series 16% of cases presenting as lumps to the foot and ankle clinic represented malignant disease. Although in most clinics this incidence will be diluted by other conditions of the foot and ankle, one must retain a high index of suspicion when dealing with lumps around the foot and ankle.

Aims: The purpose of this study was to review the success rates of a new management strategy when dealing with deep infection in knee arthroplasty.

Methods: Since 1998 a management plan consisting of an initial debridement, insertion of vancomycin loaded prostolac spacers and 2 weeks of intravenous antibiotics has been used. If inflammatory indices are improved at 12 weeks reimplantation occurs with antibiotic treatment until cultures are completed. The necessary data has been prospectively collected and reviewed to identify predictors of success.

Results: 34 patients have been identified with a minimum of 12 months follow up. 27 of these have at least 24 months follow up. With an endpoint of a functioning prosthesis clear of infection we have achieved an 82% success rate. If the inflammatory indices and frozen section were normal at the time of reimplantation this was 90% predictive of a successful outcome. Although 13 patients had a combination of abnormal blood tests, cultures and frozen sections at the time of reimplantation only 4 of these went on to develop recurrent infection. 2 patients with normal investigations at reimplantation went on to demonstrate residual infection.

Conclusion: Short courses of parenteral treatment can produce comparable results to previously published series when treating deep infection after knee replacement. Allowing weight bearing and range of motion exercise does not appear to hamper the eradication of infection. None of the investigations currently employed have been shown to be 100% reliable in this series of cases. Whilst attention to detail and careful planning are pre-requisites for this surgery one still has to prepared for failure.