The anterior femoral cortical line (AFCL) is an anatomical landmark which has been used by the senior author for 20 years to assess femoral rotation in over 4000 TKR's. The AFCL describes the alignment of the anterior cortex of the distal femur proximal to the trochlear articular cartilage.

The AFCL was compared with the surgical epicondylar (SEA), anteroposterior (Whiteside's line) and posterior condylar (PC) axes using 50 dry-bone cadaveric femora, 16 wet cadaveric specimens, 50 axial MRI's and 58 TKR patients intra-operatively.

In the dry-bone/cadaveric femora (measuring relative to the SEA the AFCL and Whiteside's AP axis were 1° externally rotated and the PC axis was 1° internally rotated. By MRI (relative to the SEA) the AFCL was 8° internally rotated, Whiteside's was 2° externally rotated and the PC axis was 3° internally rotated. In the clinical study (measuring relative to a perpendicular to Whiteside's line alone) the AFCL was 4° degrees internally rotated, which equates to 2-3° of internal rotation relative to the SEA.

The AFCL is another axis, completing the ‘compass points’ around the knee. It may prove particularly useful when one or all of the other reference axes are disturbed such as in revision TKR, lateral condylar hypoplasia or where there has been previous epicondylar trauma. We suggest building in 5° external rotation with respect to the anterior femoral cortical line for femoral component rotation.

Introduction: Osteoporosis is a skeletal disorder characterised by decreased bone mineral density (BMD) and a subsequent increased risk of fragility fractures. This disease is commonly associated with postmenopausal females with an increasing incidence into later life, over 50% of females over 80 have osteoporosis. At the opposite spectrum of life, decreased BMD is traditionally associated with the female athletic triad, with hormonal imbalance leading to skeletal insufficiency. Considered a “silent disease” until a fracture occurs, as orthopaedic surgeons we must be able to identify those at risk of osteoporosis and refer promptly for dual energy x-ray absorptiometry (DEXA) scanning to prevent future fragility fractures in this specific patient cohort.

Methods: We carried out an epidemiological analysis of all female patients under the age of 30 referred for DEXA scanning in a university teaching hospital over a 3 year period. We analysed mode of referral, risk factors, T-score and subsequent fractures with an aim to highlight an underestimated level of osteopenia/osteoporosis in the younger patient.

Results: We identified 102 patients eligible for our study, with a mean age of 25.34 (Range- 17–29). As per the World Health Organisation (WHO) osteopenia was defined as osteopenia as a T-Score between −1 and −2.5, with osteoporosis below −2.5. The mean T score of these patients was −1.037 (range −3.2 to 2.4). Medical teams initiated the majority of referrals (77%), followed by General Practitioners (17%), Gynaecologists (4%), Paediatricians (1%) and Surgeons(1%). Risk factors included excess steroid use for medical conditions (41%), decreased body mass index (BMI) (27%), ceoliac disease (12%) and radiological evidence of osteopenia (7%). 34% of these patients had suffered a fall with 12% of patients suffering from a fragility fracture.

Conclusion: We identified a definite cohort of young female patients who had a mean T-score within the levels for osteopenia. Over one third had suffered a fall and 12% had suffered a fragility fracture despite a young age. With ever increasing patient numbers in both fracture and orthopaedic clinics and increased pressure on resources, it is imperative that we still take thorough histories to identify those young female patients that are at risk of osteoporosis. With appropriate follow up and investigations, they can be started on necessary treatment and prevent subsequent fragility fractures, the incidence of which appears to be underestimated.

Background: The purpose of this study was to assess the anterior femoral cortical line (AFCL) as an additional anatomical landmark for determining intraoperative femoral component rotation in total knee arthroplasty. The AFCL was compared with the Epicondylar axis, the anteroposterior (AP) axis (Whiteside’s line), and the posterior condylar axis. Dry bone, cadaver, MRI and intra-operative measurements were compared.

Methods: Fifty dry bone femora, and 16 wet cadaveric specimens were assessed to identify the AFCL and this was compared against the 3 reference axes discussed above. Photographs were taken of the specimens with K-wires/marker pins secured to the reference axes and then a digital on-screen goniometer was used to determine the mean angular variations with respect to the Epipcondylar axis.

In the clinical trial, 58 consecutive patients undergoing total knee arthroplasty were included. After a routine exposure the AP axis was marked on each distal femur. The AFCL was then identified and the anterior femoral cortical cut was made parallel to this line. The angle between this cortical cut and the perpendicular to the AP axis was measured using a sterile goniometer.

In the MRI study, 50 axial knee images were assessed and the most appropriate slice/s determined in order to identify the AFCL and the other 3 reference axes and then their relationship was measured by an on-screen goniometer.

Results: In the cadaveric study the AFCL was a mean 1° externally rotated to the epicondylar axis (SD = 5°), White-side’s line was 1° externally rotated (SD = 4°) and the posterior condylar axis was 1° internally rotated (SD = 2°)

By MRI and with respect to the epicondylar axis, the AFCL was a mean 5° externally rotated (SD= 3), White-side’s Line was 1° externally rotated (SD = 2) and the posterior condylar axis was 3° internally rotated (SD = 2).

In the clinical study in 8 patients it was impossible to draw the AP axis because of dysplasia or destruction of the trochlea by osteoarthrosis. In the remainder the mean difference between the anterior femoral cortical line and Whiteside’s AP axis was 4.1 degrees internally rotated (SD = 3.8°). The lateral release rate for this cohort was 4%.

Conclusion: The anterior femoral cortical line provides an additional reference point, completing the ‘compass points’ around the knee. It has been shown in this study to be reliable in the laboratory, on MRI and in a clinical setting for assessing rotation of the femoral component. It may prove particularly useful when one or all of the other reference axes are disturbed such as in revision TKR, lateral condylar hypoplasia or where there has been previous epicondylar trauma.

Purpose: To assess the anterior femoral cortical line (AFCL) as an additional anatomical landmark for determining intraoperative femoral component rotation in total knee arthroplasty. The anterior femoral cortical line (AFCL) is an anatomical landmark which has been used by the senior author for 20 years to assess femoral rotation in over 4000 TKRs. The AFCL describes the alignment of the anterior cortex of the distal femur proximal to the trochlear articular cartilage.

Methods: The AFCL was compared with the surgical epicondylar axis (SEA), anteroposterior axis (Whiteside’s line) and posterior condylar (PC) axis using 50 dry-bone cadaveric femora, 16 wet cadaveric specimens, 50 axial MRI scans and 58 TKR patients intra-operatively.

Results: In the dry-bone and cadaveric femora (measuring relative to the SEA) the AFCL and Whiteside’s AP axis were 1° externally rotated and the PC axis was 1° internally rotated. With MRI (relative to the SEA) the AFCL was 8° internally rotated, Whiteside’s was 2° externally rotated and the PC axis was 3° internally rotated. In the clinical study (measuring relative to a perpendicular to Whiteside’s line alone) the AFCL was 4° degrees internally rotated, which equates to 2–3° of internal rotation relative to the SEA.

Conclusion: The AFCL is another axis, completing the ‘compass points’ around the knee. It may prove particularly useful when one or all of the other reference axes are disturbed such as in revision TKR, lateral condylar hypoplasia or where there has been previous epicondylar trauma. We suggest building in 5° external rotation with respect to the anterior femoral cortical line when judging femoral component rotation.

Heterotopic ossification (HO) is a common complication following total hip replacement with a number of papers reporting an incidence of greater than 40%. In an effort to reduce the degree of contamination of the abductor muscle bed with osteoprogenitor cells, we used a plastic protective shield during the preparation and reaming of the femoral head in the hope that this would result in a decreased incidence of HO.

One hundred and forty consecutive metal-on-metal resurfacing procedures (mean age 52.3 years) utilizing the Birmingham hip prosthesis were performed between March 1999 and May 2002. Pre-operative diagnosis included osteoarthritis (105), Dysplasia (19), AVN (8), Inflammatory arthropathy (8). In the first 70 cases wet swabs packed around the femoral head were used in an attempt to reduce bone contamination. For all subsequent cases, bone contamination was controlled by the use of the plastic shield. Patients were reviewed clinically and radiologically at a mean of 36.1 (range 24–62) months post operatively. Pre-operative and follow up radiographs were assessed for presence of HO according to the Brooker classification. Harris hip and UCLA activity scores were recorded pre- and post-operatively on all patients. Three patients were lost to follow up.

Eighteen patients (12.9%) were noted to have HO on follow up radiographs. Sixteen patients in the initial group when no shield was used developed HO (Brooker I [10], II [2] & III [1]). Only two patients developed HO (Brooker I) following introduction of the protective shield. This modification in surgical technique was statistically significant in decreasing incidence of HO. All patients with radiological abnormalities were asymptomatic. We propose that this protective shield should be used during resurfacing hip arthroplasty as prophylaxis against ectopic new bone formation.

This study reviewed the subjective, clinical, and radiological outcome of 24 patients (31 feet) treated by basal metatarsal osteotomy with a modified McBride procedure for severe (intermetatarsal angle > 150) hallux valgus, carried out at our institution with an average follow-up time of 29 months.

At the time of follow-up, 40% of the patients were very satisfied, 45% were satisfied, and 15% were not satisfied. The mean Hallux – Metatarsophalangeal – Interphalangeal scale score raised significantly from 39 points (17 – 64) pre-operatively, to 82 (39 – 96) points at follow-up (p < 0.001). The Lesser - Metatarsophalangeal – Interphalangeal scale score raised significantly from 46 points (26 – 69) pre-operatively, to 84 (33 – 97) points at follow-up (p < 0.001). The radiological angles, including M1-M2, M1-P1, M1-M5, and DMAA improved significantly (p < 0.001). 12 of these cases had a M1-M2 angle post correction > 15°. Among the 9 complications recorded, 7 were minor and 2 required an additional procedure.

The basal metatarsal osteotomy coupled with a modified McBride procedure resulted in an overall high satisfaction rate, as well as significant clinical and radiological improvements in our series. Nevertheless, the range of motion of the first MTP joint remained low: 30 – 75° in 67% and < 30° in 6%. Furthermore, the failure to correct the M1-M2 angle to < 15° in 12 cases was probably due to the severe nature of the M1-M2 angle in these patients pre-operatively (21–33°).

Basal metatarsal osteotomy with a modified McBride procedure remains a safe procedure with excellent results, both subjectively and objectively, in patients with severe hallux valgus

We undertook this study to determine whether the concerns regarding early complications following hip resurfacing were justified. One hundred and twenty-nine consecutive resurfacing procedures (118 patients, mean age 52.3 years) utilising the Birmingham hip prosthesis were reviewed at a mean of 36.1 (range 24–62) months. Pre-operative diagnosis included osteoarthritis (94), Dysplasia (19), AVN (8), Inflammatory arthropathy (8). Immediate post-operative x-rays were analysed for prosthesis placement and interface gaps. Follow up films were assessed for lucent lines, osteolysis, bone resorption and component migration. Harris hip and UCLA activity scores were recorded pre and post operatively on all patients. Three patients were lost to follow up. Five cases were revised. Three cases due to femoral neck fracture. One patient developed late infection and subsequently fractured. All four patients underwent successful revision to an uncemented stem. One patient required revision of the acetabular component due to migration following a fall three years postop. Five cases of osteolysis were seen (Acetabulum (3), Femur (2)). Four cases of bone resorption at the femoral neck were noted. Two patients developed significant heterotopic ossification (Brooker II & III). All patients with radiological abnormalities were asymptomatic. The mean Harris hip score pre-operatively was 56.4 increasing to 97.5 post-operatively. The mean UCLA activity score pre-operatively was 3.3 increasing to 7.4 post-operatively. Kaplan-Meier survivorship was 94.7% at 5 years. Surface replacement gives excellent clinical results and offers significant advantages over conventional hip replacement. Long-term results are awaited to fully evaluate the effects of resurfacing arthroplasty.

Introduction: The advent of digital radiological technology affords orthopaedic surgeons with the opportunity to better assess prosthetic alignment. The purpose of this study was to determine whether a post-operative digitalised 3-foot standing film better helps the surgeon than the standard weight-bearing short analogue antero-posterior film.

Materials and Methods: A single surgeon’s series of 68 consecutive patients were included in this prospective study. The axial alignment, mechanical, anatomical axes and distance of the post-operative mechanical axis from the centre of the knee, of 71 total knee replacements were determined using computer software on digital 3 feet standing films (Agfa ADC-2S system). These results were compared to similar measures determined using a goniometer and standard short standing analogue antero-posterior films. Both sets of results were compared to the intra-operative distal femoral valgus cut used by the surgeon.

Results: Sixty-eight patients, 71 knees, average 68.1 (range 42–85) years were included in this study. The average length of time from surgery to complete radiological evaluation was 18.9 (range 2–40 months). A mean difference of 1.20 degrees was found between the valgus angles measured on digital long and standard short radiographs. This difference was statistically significant p< 0.05. Comparing both sets of films revealed a Pearson correlation co-efficient of 0.65. Comparing the valgus angle determined on the digital 3 foot standing film to the intra-operative valgus cut revealed a Pearson correlation co-efficient of 0.388, this figure compares to a correlation co-efficient of 0.240 when the standard short films are used. The postoperative mechanical axis was found to be on average 7.34 (range 0.0 – 30.6) mm from the centre of the knee and the implants were positioned on average 89.8° to the mechanical axis on digitalised films, both these measures were indeterminable on the short standard films.

Conclusion: Three-foot digital standing antero-posterior films are more accurate and better correlate with the surgeon’s pre-operative aims than standard short antero-posterior standing radiographs. Only digital films allow for accurate determination of the post-operative mechanical axis. Despite not using expensive computer aided navigation systems intra-operatively, implant positioning was very satisfactory. Short films are adequate for routine assessment of total knee replacements postoperatively but digital 3-foot standing films afford better accuracy and are preferable for research purposes.

Accurate and relevant patient chart notes are a key component in successful patient care. Hospital charts also constitute an important medicolegal record. The key to defensibility of at least 40% of medical claims rests with the quality of the medical records. With this in mind, we decided to assess the quality of chart note keeping in our unit. A retrospective review of fifty randomly chosen charts was performed. A scoring system was devised to audit ten key criteria comprising patient details, admission note, daily progress notes, signature clarity, consent form, operation note, post-operative plan, post-operative x-ray review, specification of right or left side and discharge letter. Members of the orthopaedic surgical staff were then informed of the chart review and the nature and purpose of the study was explained in detail. They were also told that there would be another chart audit at some random time over the following three months. Subsequently, a further fifty charts were assessed using the same criteria and scoring system. Overall, charts scored poorly in the areas of patient details, clarity of signatures, post-operative x-ray review and left-right specification. Criteria that scored satisfactorily included admission note, consent form, operation note, post-operative plan an discharge letter. Meticulous hospital notes are vitally important in the day-to-day management of patients for successful continuity of care and also for protection of the medical staff should any adverse outcomes arise. In this litigious society consultants and junior medical staff need to be reminded of the importance of optimal note keeping.

Aseptic loosening of the acetabular component is the major long-term complication of cemented total hip arthroplasty (THA). Failure of the acetabular cup occurs two to three times more frequently than failure of the femoral component. Third generation cementing techniques have improved the longevity of cemented components in THA. Although suction venting of the femoral shaft is a well-recognised practice, venting of the acetabulum during the cementing process has been little studied. This prospective study sets out to evaluate the effect of iliac wing vacuum aspiration on cement penetration of the acetabulum. Forty patients (Male 18, Female 22) aged 19–82 years (average 67+12 years) undergoing primary THA were entered consecutively into two study groups (20 hips per group). Reasons for THA included osteoarthritis (35) acetabular Dysplasia (2), rheumatoid arthritis (1), perthes (1) and conversion THA post dynamic screw (1)> A single consultant surgeon performed all procedures in a standard operating room with laminar flow. A posterior approach was used in all hips. Third generation cementing techniques were used for acetabular component insertion. Twenty-six millimetres internal diameter Charnley ogee LPW polyethylene cups (Depuy) with varying external diameters [43 mm (9), 47 mm (24), 50 mm (5) and 53 mm (3)] were used and implanted with “Simplex” polymethylmethacrylate cement (Howmedica). Group 1 underwent acetabular cement pressurisation for sixty seconds prior to insertion of cup. Group 2 underwent pressurisation with simultaneous vacuum suction of the ipsilateral ilium using an Exeter iliac wing aspirator. Pre-and post-operative haemoglobin values were recorded for all patients. Standard post-operative radiographs were reviewed blindly to assess penetration of cement. A custom-made template facilitated measurement of depth (mm) of cement penetration in three areas corresponding with Delee-Charnley acetabular zones. Cement penetration was enhanced in all zones following iliac wing vacuum aspiration. The effect of venting was statistically significant (zone I 21.1+6.4mm v 12.8+2.8mm. zone II 7.0+2.4mm v 5.5+2.0mm, zone III 5.3+2.4mm v 4.2+1.4mm). The bone cement mantle interface was also completely obliterated following iliac wing aspiration.