Ossyfying periarticular lipoma is a very rare entity. Lipomas undergo involutional changes like chondrification, calcification and very rarely ossification. These changes result in altered clinical, radiological and histopathological features leading to diagnostic challenge in differentiation from the soft tissue tumor like synovial sarcoma, liposarcoma and rhabdomyosarcoma.

We present a series of three cases of ossifying lipomas presenting as soft tissue tumor around the knee, shoulder and hip joints. All the tumors revealed calcification and ossification on plain X-rays and on MRI/CT Scans. Clinico-radiological evaluation lead to a similar diagnostic dilemma in our series and a confirmed diagnosis of ossifying lipoma became possible only after histopathology. All the three tumors were excised completely without any recurrence during last 3 1/2 years of follow-up.

We recommend the early imaging by MRI/CT scan with closed core biopsy to exclude the malignant pathology and complete excision of the tumor with early mobilization of the adjacent joint.

The use of wound drains in arthroplasty patients is controversial. Previous work including a meta analysis looking at closed drainage systems has shown no benefit in their use. It is postulated that retransfusion drains may offer an advantage over closed drains and cut allogenic transfusion requirements and aid wound healing. This study was designed to assess the use of retransfusion drains in hip and knee replacement patients and prove the null hypothesis that there is no difference in post op haemaglobin levels or transfusion with their use.

Following an initial pilot audit of blood drainage in such patients we designed a protocol for a prospective trial. In a prospective randomised controlled study we evaluated the use of retransfusion drains in primary hip and knee arthroplasty patients. Eighty patients were randomised to removal of the drain at six or twenty-four hours post op, to assess the most efficient and beneficial use of such drains. The rate of blood drainage, post-operative haemaglobin (Hb) levels, blood transfusion, hospital stay, complications and rehabilitation observed. The two groups were comparable, have a follow up of two years and all attempts to control variables were made.

The drop in haemaglobin, hospital stay, complications and rehabilitation between both groups revealed no significant difference in all respects. Wound healing appeared better in six-hour group for hip and knee patients. There is no effect of type of joint or age on the drop in Hb. The TKR patients drained sig. more blood than the THR patients. The rate of blood loss is discussed. The amount of blood drained that was retransfused was 94% efficient. The allogenic transfusion rates were higher in the six-hour knee group. Three patients required post operative antibiotic but at latest follow up all patients were reported as having no problems and no evidence of infection.

This study concludes that retransfusion drains offer no advantage in the arthroplasty patients’ care.

A prospective evaluation comparing functional results in conventional and percutaneous femoral nailing techniques was performed.

4 patients (8 nails) were operated on with a conventional IM nailing technique (CT), and 4 (8 nails) with the percutaneous technique (PT).

Limited trochanteric approach was performed, allowing the setting up of the sighting device for the nail.

Patient was positioned on the lateral side, hip at 60° flexion. A long k-wire was passed through the skin, along the axis of the medullary canal in the anterior-lateral part of the Piriformis fossa, into the medullary canal. A small skin incision was performed, and then a cannulated drill introduced over the k wire. The reamer guide was pushed down to the distal femoral metaphysis. Percutaneous flexible reaming was then performed in a conventional manner, taking care to introduce the reamer through the gluteus medius with no torque. Section was performed through the same incision with a modified intramedullary saw. The nail was inserted, fixed on a modified sighting device. The continuous passive machine was set up in the recovery room or in the intensive care unit. Physiotherapy was directed towards maintaining knee range of motion. Patients were evaluated for scar size, muscle function, leg raise and range of motion (ROM).

Follow-up averaged 30 (CT) and 11 (PT) months. Gain averaged 61 mm (CT) and 79 mm (PT). Scar size for nail insertion ranged from 6 to 11 cm (CT) and 1.1 to 3 cm (PT). Total number of operations from nail insertion to removal, including GA for ratcheting (GAR) and GA for other complications (GAC) was: 18 (CT, all nails removed) 9 (PT, among them 3 removal operations on the waiting list). On postoperative day 1, all patients with PT returned to a subnormal ROM. At one week, Knee flexion averaged 93° (CT) and 131° (PT). For CT, it increased gradually, passing 100° at 8 weeks, and 130° at 20 weeks. In PT, the minimum obtained was 126° at 10 weeks, passing 130° at 13 weeks. In CT, the decreased knee flexion was 90° (5 knees) and 80° (1 knee), while in PT; only 2 knees went below 110° (85 and 95°). Trendelenburg sign was negative in all PT by 3 months.

Percutaneous IM nailing, along with a good physiotherapy programme, seems to improve tremendously the outcome and decrease the complication rate, even in large limb lengthenings, which are considered as major surgery and often are associated with numerous complications.

Clinical investigations and tests need to be validated by studying their inter-observer and intra-observer errors, but there has been no documentation of such verification in diagnostic knee arthroscopy. We performed a prospective study to find out to what extent the findings in knee arthroscopy differ between two different surgeons.

Two senior specialist registrars (M.S. and A.J.) who took part in this study worked with the senior author (ACW) for a period of eight and seven months respectively. A total of 78 knee arthroscopies admitted from routine waiting list were studied. The specialist registrar first performed arthroscopy when the supervising consultant stayed away from the operating room. His findings were recorded on a proforma by an independent third person before the consultant returned to the operating room and repeated the EUA and arthroscopy without prior knowledge of the trainee findings. Findings from the consultant arthroscopy were then recorded separately on the same proforma.

The following findings were recorded:

Examination under anaesthesia

The inter-observer variations in diagnostic knee arthroscopy were found to be high. Given the seniority and experience of the two trainee senior registrars involved in the study, and allowing for the Hawthorne effect, the results of the study cast doubt on this procedure being performed un-supervised. It also questions the validity of any therapeutic intervention based on the findings of un-supervised arthroscopies.