Prompt mobilisation after the Fracture neck of femur surgery is one of the important key performance index (‘KPI caterpillar charts’ 2021) affecting the overall functional outcome and mortality. Better control of peri-operative blood pressure and minimal alteration of renal profile as a result of surgery and anaesthesia may have an implication on early post-operative mobilisation.

Aim was to evaluate perioperative blood pressure measurements (duration of fall of systolic BP below the critical level of 90mmHg) and effect on the post-operative renal profile with the newer short acting spinal anaesthetic agent (prilocaine and chlorprocaine) used alongside the commonly used regional nerve block. 20 patients were randomly selected who were given the newer short acting spinal anaesthetic agent along with a regional nerve block between May 2019 and February 2020. Anaesthetic charts were reviewed from all patients for data collection. The assessment criteria for perioperative hypotension: Duration of systolic blood pressure less than 90 mm of Hg and change of pre and post operative renal functions.

Only one patient had a significant drop in systolic BP less than 90mmHg (25 minutes). 3 other patients had a momentary fall of systolic BP of less than 5 minutes. None of the above patients had mortality and had negligible change in pre and post op renal function. Only one patient in this cohort had elevation of post-operative creatinine levels but did not have any mortality. Only 1 patient died on day 3 post operatively who had multiple comorbidities and was under evaluation for GI cancer. Even in this patient the peri-operative blood pressure was well maintained (never below 90mmHg systolic) and post-operative renal function was also shown to have improved (309 pre-operatively to 150 post-operatively) in this patient.

The use of short-acting spinal anaesthesia has shown to be associated with a better control of blood pressure and end organ perfusion, less adverse effects on renal function leading to early mobilisation and a more favourable patient outcome with reduced mortality, earlier mobilisation, shorter hospital stay and earlier discharge in this elderly patient cohort.

The resection of distal femur and proximal tibia during TKR is 90° to mechanical axis but in a normal knee, the joint line is 3°varus. We measured various angles on long-leg alignment radiographs. The mean age was 58.7 years. The mean HKA axis was 4.3°± 0.5°, mPTA was 3.8°±0.5°, mLDFA was 3.6±0.5° and aLDFA was 8.6°±0.5°. The mean HKA & MPTA were approximately 4°varus, mLDFA 4° valgus & aLDFA 8°valgus. The alignment of the knee to its mechanical axis during TKR is therefore not anatomic. This raises a question whether the knee should be aligned to its kinematic axis instead of mechanical axis.

This study looks at the long-term outcome and morbidity following non-operative management of both-columns fractures (BCF) with secondary congruence.

A retrospective review was carried out of all both-columns acetabular fractures managed non-operatively from 1984 to 2004. Patients were clinically assessed using a modified Merle d’Aubigne (Matta’s modification) score and quality of life assessed using the SF-36 health survey. The results of the SF-36 scores for this group of patients were compared with the UK normative values and the student t-test was applied to compare the respective means. All these patients were managed according to the senior consultant’s protocol. Original acetabular radiographs were examined to confirm the classification had been correct. Late radiographs were inspected for the presence of union, avascular necrosis, non-union, secondary osteoarthritis (OA) and heterotopic ossification.

In the last 20 years, 57 patients have been managed non-operatively. 10 had died from unrelated causes and 16 were lost to, or declined follow-up. This left 31 patients available for assessment with at least 12 months following injury. The age at the time of injury ranged from 14 – 89 years. The majority of injuries were sustained in road traffic accidents.

The mean hip score was 15.5. 72% of the clinical scores were in excellent or good categories at the time of review. The SF-36 scores were not statistically significantly different from the normal population (P< 0.05). All fractures had clinically and radiologically united at follow-up. Surprisingly, there were no cases of heterotopic ossification or avascular necrosis. 4 patients developed secondary OA of the hip.

Most of the BCF demonstrate ‘secondary congruence’ after the injury assessed on Judet and pelvic radiographs. Good clinical outcomes with minimal complications can be achieved with conservative management of such fractures with secondary congruence, particularly in the older patients.

The aim of this study was to investigate the function, limitations and disability of a large cohort of active golfers following total knee replacement (TKR). The study group comprised the membership of the New Knee Golf Society (NKGS) and 211 members were reviewed with a questionnaire which asked the patient’s experience & difficulties of playing golf before and after TKR.

The functional outcome was recorded using the Oxford knee score. A total of 299 knees (TKR only) in 209 patients were included in the final analysis. The mean age was 70 years. Majority of the prostheses were cemented (95%) and had patellar resurfacing (90%). The mean post-operative period was 5 years. We found 196 patients (94%) returned to playing golf after a mean of 4.6 months following the TKR; 184 (88%) continue to play at review; 93% claimed significant improvement in their capability to play golf following TKR. However, none claimed to have achieved a significant improvement in their handicap.

Seventeen knees (5.7%) underwent revision surgery. Six knees (2%) were revised for infection at mean 17.3 months and eleven (3.7%) for aseptic loosening or instability at mean 5 years. Seven left knees (lead knee) of eleven right-handed golfers required revision for aseptic loosening. Varus collapse of the tibial component in the lead knee was observed.

The main problems experienced after playing 18 holes were knee stiffness (47%) and swelling (18%). Oxford Knee Scores: 69% excellent; 27% moderate functional impairment; 4% poor outcomes.

Although the capability to play improved the handicap remained the same. We found that the left TKR in a right-handed active golfer is more likely to require revision, which may be due to the increased torque on the lead knee.

Introduction: The aim of this study was to investigate the function, limitations and disability of a large cohort of active golfers following total knee replacement (TKR).

Materials & Methods: The study group comprised the membership of the New Knee Golf Society (NKGS), UK. 211 members were reviewed with a questionnaire which asked the patient’s experience & difficulties of playing golf before and after TKR. The functional outcome was recorded using the Oxford knee score.

A total of 299 knees in 209 patients were included in the final analysis. The mean age was 69.6 years. Majority of the prostheses were cemented (95%) and had patellar resurfacing (89.6%). The mean post-operative period was 5.1 years.

Results: 196 patients (94%) returned to playing golf after a mean 4.6 months following the TKR. 184 (88%) continue to play at review. 92.8 % claimed significant improvement in their ability to play and enjoy golf following TKR citing reduction in pain and improved walking ability as the reasons. However, none claimed to have achieved a significant improvement in their handicap.

17 knees (5.7%) underwent revision surgery. 6 knees (2%) were revised for infection at mean 17.3 months & 11 (3.7%) for aseptic loosening or instability at mean 4.9 years. 7 left knees (lead knee) of 11 right-handed golfers required revision for aseptic loosening.

The main problems experienced after playing 18 holes were knee stiffness (47%) & swelling (18%).

Conclusion: Although the ability to play improved the handicap remained the same. The left TKR in a right-handed active golfer is more likely to require revision which may be due to the increased torque on the lead knee.

Introduction: Despite worldwide vaccination programmes Polio is still endemic in some developing countries. Numerous new cases of polio are seen every year in India resulting in significant childhood deformity. The Rotary Club funds voluntary camps aimed at correcting deformities in children. I was part of the surgical team in Jan 2007 led by Mr. J. Clegg.

Clinical experience: Some 141 procedures were carried out in 3 days, 99 by SPR’s under senior supervision. The most frequent procedure was a supra-condylar femoral osteotomy, followed by hip and knee soft tissue releases. For more complex operations we assisted or observed. Some deformity corrections were for non-polio cases. Interesting cases in the OPD included skeletal dysplasias, rickets and congenital deformities.

Conclusion: At the time where MMC restricts overseas training opportunities, I believe this type of mini-fellowship provides valuable experience. Training programmes should have such opportunities available to all trainees.

Introduction: Aseptic loosening due to polyethylene wear is a mode of failure in knee arthroplasty. No study has evaluated the roughness of the articulating surface of retrieved femoral components & its role in creation of polyethylene wear. AIM The aim of our study was to investigate the in-vivo changes in the surface roughness of retrieved femoral components. Our hypothesis was that the surface finish of the femoral components, articulating with the polyethylene inserts deteriorated in accordance with the duration of implantation.

Materials and Methods: 22 femoral components, all Freeman-Samuelson prostheses, were retrieved from 18 male and 4 female patients at revision knee surgery. The mean age at revision was 68.4 years and the mean period of implantation was 55.64 months. 18 implants were retrieved for aseptic loosening and 4 for infection. Firstly, the surfaces of femoral components & polyethylene inserts were visually inspected for modes of damage in the articulating areas. The surface finish measurements were performed with a contact stylus profilometer with a 2-mm-radius stylus tip and a cut-off length of 0.8mm. The surface roughness was characterised by measuring Ra(mm), which is the arithmetic mean of the absolute values of the measured height deviations taken within the evaluation area and measured from the main line or surface. Both condyles were examined as separate areas articulating with the tibial components from 0° to 60° and 61° to 120° of knee flexion. Surface roughness (Ra) measurements from the sides of the patellar groove at the top of the femoral flange, which do not articulate either with the patella or tibia, were taken as control. The Ewald method of assessing the orientation of the components was applied to derive the coronal angle of the knee (CAK).

Results: The mean CAK was 7.2° ± 1°. Dull edged parallel scratching and burnishing were the main modes of damage identified on the surface in the articulating areas. Visual analysis of polyethylene inserts failed to identify embedded Polymethyl-methacrylate debris or any other damage, which matched the location of the altered surface finish of the femoral components. The mean Ra values recorded were: Control: Mean-0.0230 mm, SD- 0.00821. Medial Femoral condyle (0° – 60°) – 0.0225 mm, SD – 0.00797, P=0.832 Medial Femoral Condyle (61° – 120°) – 0.0244 mm, SD – 0.00532, P= 0.189 Lateral Femoral condyle (0° – 60°) – 0.0263 mm, SD – 0.00694, P= 0.078 Lateral Femoral Condyle (61° – 120°) – 0.0253 mm, SD – 0.00758, P= 0.286 No statistically significant difference was seen in the mean roughness (Ra) of the articulating areas when compared to that of the control (P< 0.05).

Conclusion: This study showed that the surface finish of these implants did not deteriorate during the period of implantation. On this basis we believe that a well-aligned and well-fixed femoral component, without any accumulated wear debris beneath it, does not require mandatory exchange if the revision is carried out for isolated failure of the tibial prosthesis even if the femoral component has fine scratching or burnishing on its surface.

Aim: The aim of our study was to investigate the in-vivo changes in the surface roughness of retrieved femoral components.

Our hypothesis was that the surface finish of the femoral components deteriorated in accordance with the duration of implantation

Materials and method: 22 femoral components (all Freeman-Samuelson prostheses) were retrieved from 18 male and 4 female patients at revision knee surgery. The mean age at revision was 68.4 years and the mean period of implantation was 55.64 months. 18 implants were retrieved for aseptic loosening and 4 for infection. The surfaces of femoral components & polyethylene inserts were inspected for modes of damage in the articulating areas. The surface finish measurements were performed with a stylus profilometer. The surface roughness was characterised by measuring Ra (micron-meter), which is the mean of the measured height deviations within the evaluation area. The articulating surface on both condyles was examined seperately. Ra measurements from the sides of the patellar groove at the top of the femoral flange, which do not articulate either with the patella or tibia, were taken as control. The Ewald method of assessing the orientation of the components was applied to derive the coronal angle of the knee (CAK)

Results: The mean CAK was 7.2° ± 1°. Parallel scratching and burnishing were the main modes of damage on the surface in the articulating areas. Inspection of polyethylene inserts failed to find embedded Polymethyl-methacrylate debris or any other damage, which matched the location of the altered surface finish of the femoral components.

The mean Ra values were:

Control: Mean-0.0230 mm, SD- 0.00821.

Medial Femoral condyle (0 – 60) = 0.0225 mm, SD – 0.00797

Medial Femoral Condyle (61 – 120) = 0.0244 mm, SD – 0.00532

Lateral Femoral condyle (0 – 60) = 0.0263 mm, SD – 0.00694

Lateral Femoral Condyle (61 – 120) = 0.0253 mm, SD – 0.00758

No statistically significant difference was seen in the mean-Ra of the femoral condyles compared to that of the control (P less than 0.05).

Conclusion: The surface finish of these implants did not deteriorate during the period of implantation. On this basis we believe that a well-aligned and well-fixed femoral component, without any accumulated wear debris beneath it, does not require mandatory exchange if the revision is carried out for isolated failure of the tibial prosthesis.

Introduction We describe an arthroscopic technique of excising a lesion from within the posterior septum of the knee. To our knowledge this has not been described in the literature.

Case History A 35-year old male taxi-driver presented with pain in the back of his right knee. Examination did not reveal any abnormality except pain on flexing the knee beyond 90-degrees. MRI showed a multiloculated ganglion in the posterior compartment of the knee. The ganglion was located within the posterior septum and successfully excised arthroscopically. 6-months postoperatively the patient is assyptomatic.

Anatomy of the posterior septum The posterior septum is located between the posterior cruciate ligament (PCL) and the posterior capsule dividing the posterior cavity of the knee into seperate posteromedial and posterolateral compartments. It is triangular in shape, formed by the reflections of the synovium from the PCL.

The Technique The posterior septum of the knee was approached through the intercondylar notch by the anterior portals. Slow and careful dissection was carried out in the V-shaped space between the anterior and the posterior cruciate ligaments. The synovium of the septum was resected and the space within the septum entered. The ganglion was successfully removed. There was no complication. The relatively central placement of the anterior portals is important to gain access to the posterior septum via the notch.

Discussion and conclusion Intra-articular ganglion cysts are uncommon. Reported prevalence ranges from 0.2% to 1.3%. Ganglion cysts arising from the anterior and the posterior cruciate ligaments have been well described. The ganglion cyst within the posterior septum has not been reported.

The anatomy of the posterior septum makes it inaccessible to routine arthroscopic examination. It has close proximity to the vascular structures. We approached the posterior septum from the anterior portals through the intercondylar notch. The ganglion was successfully excised.

Introduction: Seven patients underwent successful revision total knee replacement for aseptic loosening. Bovine bone graft was used to reconstruct bony defects in all.

Materials and methods: This is a retrospective review. Between April 2000 and March 2003, bovine bone (Tutobone™, Wescott-Medical, UK) was used in 7 revision arthroplasty cases (4 right knees & 3 left). There were 5 males and 2 females. The average age was 70.4 years. All revisions were carried out for aseptic loosening of the prostheses associated with massive osteolysis and bone loss.

The bone defects on the tibia and femur were as follows: (Obtained from operative records. Classified according to Anderson Orthopaedic Research Institute classification)

The tibial defects were corrected by impaction grafting and femoral condyle defects were corrected by using bovine bone as bulk grafts. Semi-constrained constrained stemmed cemented modular knee prostheses (TC3, Depuy) were used in all. Clinical outcomes were recorded by the Oxford Knee Score. Serial radiographs were evaluated for graft density, integration, implant loosening, alignment and subsidence.

Results: At recent follow-up, radiographs showed good graft integration, no loosening, and no subsidence of the implant and good prostheses alignment. The average Oxford Knee Score was 20.4.

Conclusion & discussion: Bovine bone substitute is an alternative. The bone defects in these patients were successfully reconstructed with bovine bone. It is an osteo-conductive matrix with intact type-I collagen that provides mechanical stability. It is also cost effective.

Early results are encouraging but long-tem follow-up is needed.

Two cases of assymptomatic hip dislocation discovered incidentally are presented.

Case 1- A 63-year old lady had an uncemented primary total hip replacement of the left hip for painful osteoarthritis in July 1993. She made an uneventful recovery post-operatively. This lady had no neurological abnormality and was mobilising independently. In April 2001,8 years later she was admitted as an emergency for suspected diverticulitis of the colon. Plain radiographs performed showed dislocated hip prosthesis.

Case 2- This 75-year old lady, an active farmer, had right hip arthroplasty in July 1990 for painful osteoarthritis and made an uneventful recovery subsequently. She also did not have any neurological abnormality and was mobilising independently too. Dislocated prosthesis was discovered radiologically in December 2001 during a pre-operative work-up for the left hip (the other hip) arthroplasty.

Discussion: Late dislocation is more common than was thought previously. Several separate processes, some distinct from those associated with early dislocation, can lead to late dislocation. It can occur in association with a long-standing problem with the prosthesis that manifests late (such as malposition of the implant or recurrent subluxation), it can occur in association with a new problem (such as neurological abnormality, trauma or polyethylene wear), or it can occur in association with combination of these factors.

Both these patients were mobilising independently and did not suffer from any neurological abnormality. Both these patients had asked to be discharged after an initial 2-year follow-up. They had not experienced any problem with the hip replacement. These dislocated prosthesis were discovered incidentally. Revision arthroplasty was carried out successfully in both these patients

These cases emphasise the need for long-term clinical and radiological follow-up in hip arthroplasty patients as hip dislocations can be assymptomatic and not detected by clinical examination. Radiological review alongside evaluation using scoring systems is recommended.