We present the results of a new non-invasive lengthening nail enabling accurate control of the lengthening process and joint rehabilitation.

Introduction: Polymodal anaesthesia has become the core approach for the modern anaesthetist. Femoral, sciatic and obturator nerve blockade, individually or in combination, by means of either single shot or continuous infusion, are often used as adjuncts to general anaesthesia in knee arthroplasty.

Methods: We examine the outcome of 2 groups of 100 patients from 2 surgeons and their anaesthetists. All patients received a general anaesthetic. The first group receive a single shot femoral and sciatic nerve block, the second group a standard GA and local infiltration of the surgical field. Post operatively, both groups received identical analgesic regimes and rehabilitation programmes.

Results: Length of stay was prolonged in the nerve blockade group, with 21 of the 100 patients still in hospital on day 6 versus 9 patients in the local infiltration group. An initial advantage in flexion and extension in the nerve blockade group was reversed by day 2 and persisted thereafter. Motor dysfunction was seen to be more prevalent and of longer duration in the nerve blockade group. Muscle groups supplied by the sciatic nerve were 4 times more likely to be involved than those supplied by the femoral nerve. Dysaesthesia in the sciatic nerve dermatomes was 5 times more likely within the nerve blockade group, but less likely in the local infiltration group. No significant difference in rates of VTE. Pain control was superior and less analgesia was required in the nerve blockade group. Fewer patients required urethral catheterisation in the local infiltration group. One heel ulcer occurred in the nerve blockade group. Tourniquet time, significant as a possible contributor to nerve injury, was similar.

Conclusion: Nerve blockade in knee arthroplasty not recommended.

Viscosupplementation with hyaluronic acid (HA) is an established intervention for pain control in patients with mild to moderate osteoarthritis (OA) of the hip and knee. It is highly concentrated at the surface of the articular cartilage and the superficial layers of the synovial membrane. In the synovial fluid, HA acts as both a lubricant and a shock absorber. Due to the meshwork it forms with aqueous solutions, it acts as a semi-permeable barrier regulating metabolic exchanges between cartilage and the synovial fluid, and a viscoelastic shield around synoviocytes and adjacent nerve endings. Through its molecular size HA hinders the free movement of lytic enzymes and inflammatory mediators, and enhances chondrocyte metabolism. Osteoarthritis is associated with a decrease in concentration and average molecular weight of native HA in synovial fluid.

The mechanism of action of administered intra-articular HA is not completely understood, but as its clinical benefit exceeds its intra-articular presence, it is thought to perhaps induce native biosynthesis of HA and other extracellular matrix components and in particular suppress the inflammatory response and inhibit substance P, in addition to contributing to shock absorption by means of its viscoelastic properties.

Problems include inconvenience, expense and the logistical problems associated with multiple injections, injection technique and level of skill required by the administering physician, variable clinical response and adverse reactions.

In this independent, prospective, randomized trial, we compare efficacy and complications associated with treatment 100 athletes (112 knees) using durolaneTM and synvisc oneTM using the Visual Analogue Score, SF-36 V2 questionaire, and Oxford knee scores. Range of movement and absence from sporting activity is recorded at each visit. These assessments are repeated at 3, 6, 9 and 12 months. Significant improvement is seen in the VAS, SF 36 V2 and Oxford Knee Scores (p=0.01) and reduction in the use of analgesics and anti-inflammatories is seen with both products at 3 months post injection, with a significant advantage to the duro-lane group (p=0.001). At 6 months, this difference is extended even further. A small but statistical difference is noted in the time taken for the athlete to return to sporting activity following a rest period due to pain. Adverse reactions occur significantly less with the more effective product. We conclude that intra-articular HA a useful intervention in patients with mild to moderate OA of the knee, can produce sustained pain relief at 6 months, and can reduce the requirement for analgesia and anti-inflammatory medication during this time.

The use of massive endoprostheses following bone tumour resection is well recognised. Where possible, joint salvage rather than joint replacement is usually attempted. However cases arise where there may be insufficient bone stock following tumour resection to allow fixation of a joint sparing prosthesis. We report a series of 4 patients (age4–12) treated between 1994 and 2008, in which irradiated autologous bone has been combined with a diaphyseal or distal femoral replacement in order to preserve the native hip joint. There were 3 cases of osteosarcoma and 1 cases of Ewings sarcoma. After a mean follow up of 53 months (range 9–168) all patients had survived without evidence of local recurrence or metastases. One implant was revised after 14 years following fracture of the extending component of the growing endoprosthesis. There have been no cases of loosening or peri-prosthetic fracture. This is the first report of irradiated autologous bone with joint sparing endoprostheses in the skeletally immature patient.

Introduction: Reconstruction of segmental skeletal defects after malignant bone tumour removal has been a topic of much debate. Autoclaved or irradiated autologous bone used in the treatment of malignant bone tumours of the proximal femur in skeletally mature patients has been well reported with a high incidence of fracture and non-union. On follow up, our series of skeletally immature patients showed excellent osteo-integration with native bone and allowed preservation of the native hip joint.

Results: We review survival of the patient, implant, any complication and the presence of disease progression.

Introduction: Primary or secondary bone tumours of the distal tibia are uncommon. Before the development of endoprostheses in the 1970’s, the primary treatment for these was below knee amputation. Limb salvage is now possible without adversely affecting survival largely due to improvements in chemotherapy. We report the clinical and functional outcome of six patients who underwent limb salvage with endoprosthetic reconstruction of the distal tibia and ankle joint for malignancy.

Methods: Retrospective review of all patients who underwent limb salvage with endoprosthetic reconstruction of the distal tibia and ankle joint at our institution. Data was collected from the bone tumour database, medical records, imaging studies, clinic reviews and individual structured patient questionnaires. MSTS and TESS scores were used to assess functional outcome.

Results: Six patients underwent distal tibial replacement for malignant bone tumours of the distal tibia. There were 4 males and 2 females with a mean age of 31.2 years (range 13 to 68) and mean follow-up of 35 months (range 13 to 76). One patient died of non-neoplastic disease at 76 months. Two patients had Ewings sarcoma, two had osteosarcoma, one had malignant fibrous histiocytoma and one had adamantinoma.

No patient had metastases at presentation and no patient developed local recurrence or distant metastases post-operatively. Four patients developed infection, for which two required below knee amputation and two suppressive antibiotics. Hardware failure was seen in one patient with infection which was managed by below knee amputation. One patient required sub-talar fusion and calcaneal osteotomy for persistent ankle pain.

A child who underwent the procedure age 13 developed a 5 cm leg-length discrepancy once skeletally-mature. Mean MSTS and TESS scores for the three patients who still had a functioning endoprosthesis were 77% and 79% respectively.

Conclusion: Limb salvage with distal tibial combined with ankle joint replacement can be used as an alternative to below knee amputation in patients with bone tumours of the distal tibia. Due to the difficulties in achieving adequate soft tissue cover, patients should be counselled regarding the high potential complication rate which can lead to significant morbidity, functional deficit and further surgical intervention.

For any fracture classification, a high level of intraobserver reproducibility and interobserver reliability is desirable. We compare the consistency of the AO and Frykman classifications for distal radius fractures using digitised radiographs of 100 fractures by 15 orthopaedic surgeons and 5 radiologists using a Picture Archiving and Communications System (PACS). The process was repeated 1 month later. Reproducibility moderate for both the AO and Frykman systems, reliability only fair for both the AO and Frykman systems. In each case reproducibilty using the Frykman system was slightly greater. The assessor’s level of experience and specialty was not seen to influence accuracy. The ability to electronically manipulate images does not appear to improve reliability compared to the use of traditional hard copies, and their sole use in describing these injuries is not recommended.

These fractures are common, approximately one sixth of all fractures and the most commonly occurring fractures in adults. Their multitude of eponyms hint at the difficulty in formulating a comprehensive and useable system. The Frykman classification is most popular, but limited- does not quantify displacement, shortening or the extent of comminution. The more comprehensive AO system is limited in its complexity with 27 possible subdivisions. Computerised tomography shown to give only marginal improvement in consistency of classification.

Radiographs of 100 fractures selected. Anteroposterior and lateral view for each. 15 orthopaedic surgeons and 5 radiologists recruited as assessors, including 5 specialist registrars. Each given a printed description of Frykman and AO classifications. Radiographs could be manipulated digitally. Intra and inter-observer reproducibility analysed. A comparison made comparing reproducibility between radiologists and surgeons, consultant orthopaedic surgeons and trainees. Statistical methods; analysis involves adjustment of observed proportion of agreement between observers by correction for the proportion of agreement that could have occurred by chance. Kappa coefficients compared using the Student t test incorporating standard errors of kappa for these groups.

Median interobserver reliability was fair for both the AO (kappa = 0.31, range 0.2 to 0.38) and Frykman (kappa = 0.36, range 0.30 to 0.43) systems. Median intraobserver reproducibility was moderate for both the AO (kappa = 0.45, range 0.42 to 0.48) and Frykman (kappa = 0.55, range 0.51 to 0.57) systems. In each case the Frykman system was statistically (p< 0.01) more accurate. Level of experience, or specialty was not seen to influence accuracy (p< 0.01).

Our results demonstrate that using them in isolation in determining treatment and comparing results following treatment cannot be recommended

Hip fracture is a common serious injury in the elderly. Between 1982 and 1998 the number of hip fractures reported annually in Scotland in patients over 55 years rose from 4,000 to 5,700. The optimum method of treatment for the various fracture types remains in contention.

We compare outcome measures between displaced, intracapsular fractures in patients over 70 years fixed with cannulated screws and sliding hip screw with side plate.

Between 1998 and 2005 a total of 30,482 patients were reviewed by the Scottish Hip Fracture Audit (SHFA). Of these 15,823(53.3% of the total) had sustained intracapsular fractures. 13,587 of these occurred in patients aged 70 or over. Of these 2,428 had undisplaced and 11,159 displaced fractures. Chi test statistical analysis compare outcome measures in this group of displaced intracapsular fractures with respect to aspects of early failure.

534(3.9%) of patients were treated conservatively. 509 (4.7%) fractures were fixed using cannulated screws and 499 (4.6%) using a sliding hip screw. Readmission within 120 days for any cause occurred in 62 patients(14.1%) treated with cannulated screw fixation and in 63 patients(15.7%) for those treated with a sliding hip screw(P=0.509). Of these 36 patients(8.2%) in the former and 23 patients(5.7%) in the latter group were readmitted for complications related to hip fracture(P=0.033). Mortality within this period included 69 patients(13.5%) in the CS and 98(19.6%) in the SHS group. In terms of re-operation within 120 days of the original admission, 53 patients(10.6%) receiving cannulated screws compared to 24 patients(4.8%) treated with a sliding hip screw requiring further surgery(P=0.0006). The fracture was seen to displace in 12(22.6%) patients originally treated with cannulated screws compared to 6 patients(25%) treated with sliding hip screw(P=0.156). More significantly the fixation device was seen to have migrated in 24(45.3%) of the cannulated screw as compared to 7(29.2%) patients in the sliding hip screw group(P=0.002). Periprosthetic fractures were recorded in 4(7.5%) of the former and 3(12.5%) in the latter group(P=0.708). Wound infection was higher in the SHS group(2 patients) as compared to the screw fixation group(1 patient)(P=0.565).

Statistical analysis demonstrates a dramatic difference exists between these 2 fixation types in terms of re-operation within 120 days of the original admission for which published literature has previously only recorded biomechanical, in vitro comparisons.

Data regarding specific implant factors such as number of screws, position, configuration, starting point, thread length and use of washers in cannulated screws, and position, tapping, supplementary screw and compression screw in sliding hip screws was not recorded and may be considered to bias our results.

For any fracture classification, a high level of intraobserver reproducibility and interobserver reliability is desirable. We compare the consistency of the AO and Neer classifications for proximal humerus fractures with an assessment of the digitised radiographs of 100 fractures by 10 orthopaedic surgeons and 5 radiologists using the General Electric Picture Archiving and Communications System (PACS), allowing manipulation of the image. This process repeated 1 month later.

Reproducibility and reliability moderate for both the AO and Neer systems. Reproducibility using the AO/ ASIF system was slightly greater. The assessor’s level of experience and specialty did affect accuracy. The ability to electronically manipulate images does not improve reliability and their sole use in describing these injuries and comparing similarly classified fractures from different centres is not recommended.

Fractures of the proximal humerus are common. Most undisplaced or minimally displaced, and treated conservatively. Up to one fifth may benefit from surgery. As decisions regarding treatment are based on the fracture type, a radiological classification should be easy to use and have a high degree of reliability and reproducibility to serve as a useful discriminator, creating standards by which treatment can be recommended and outcomes compared.

Radiographs of 100 fractures of the proximal humerus selected. A true anteroposterior, scapular lateral, and axillary radiograph taken for each fracture. 10 orthopaedic surgeons and 5 radiologists recruited as assessors, including 5 specialist registrars. Each given a printed description of both Neer and AO classifications, a goniometer and ruler. The assessment preceeded by short lecture. Radiographs could be manipulated digitally for size, contrast, brightness, orientation and the negative image displayed. We did not require assessors to determine subgroups for reasons of simplicity. Reproducibility and reliability analysed using Kappa statistical methods. Coefficients for agreement compared using the Student t test incorporating the standard errors of kappa for these groups. A comparison made between radiologists and surgeons, and then consultant orthopaedic surgeons and trainees.

In each case the AO/ASIF system was statistically (p< 0.01) more accurate.

Agreement was greater for less complex (one and two part, and type A) fractures.

Level of experience produced a statistically (p< 0.01) significant difference in accuracy. Specialty did not.

Our analysis comparing the Neer and AO systems uses the largest group of assessors reviewing the largest number of radiographs reported in the literature.

We concur with others in concluding that using these systems in isolation in determining treatment and comparing results following treatment cannot be recommended

The use of massive endoprostheses following bone tumour resection is well recognised. Where possible, joint salvage rather than joint replacement is usually attempted. However cases arise where there is insufficient bone following tumour resection to allow adequate fixation of a joint sparing prosthesis. We reporta series of 4 patients (aged 4–12), treated between 1994 and 2008, in which irradiated autologous bone has been combined with a diaphyseal or distal femoral replacement in order to preserve the native hip joint.

There were 3 cases of osteosarcoma and 1 case of Ewing‘s sarcoma. After a mean follow-up of 53.5 months (range 9–168), all four patients are alive without evidence of local recurrence or metastases. One implant was revised after 14 years following fracture of the extending component of the growing endoprosthesis. There have been no cases of loosening or periprosthetic fracture.

This is the first report of irradiated autologous bone with joint sparing endoprostheses in skeletally immature patients.

Hip fracture is a common serious injury in the elderly. Between 1982 and 1998 the number of hip fractures reported annually in Scotland in patients over 55 years rose from 4,000 to 5,700. The optimum method of treatment for the various fracture types remains in contention. The purpose of this study was to compare outcome measures between displaced, intracapsular fractures in patients over 70 years fixed with cannulated screws and sliding hip screw with side plate. Between 1998 and 2005 a total of 30,482 patients were reviewed by the Scottish Hip Fracture Audit (SHFA). Of these 15,823(53.3% of the total) had sustained intracapsular fractures. 13,587 of these occurred in patients aged 70 or over. Of these 2,428 had undisplaced and 11,159 displaced fractures. We performed a Chi test statistical analysis comparing outcome measures in this group of displaced intracapsular fractures with respect to aspects of early failure. 534(3.9%) of patients were treated conservatively. 509 (4.7%) fractures were fixed using cannulated screws and 499 (4.6%) using a sliding hip screw. Readmission within 120 days for any cause occurred in 62 patients(14.1%) treated with cannulated screw fixation and in 63 patients(15.7%) for those treated with a sliding hip screw(P=0.509). Of these 36 patients(8.2%) in the former and 23 patients(5.7%) in the latter group were readmitted for complications related to hip fracture(P=0.033). Mortality within this period included 69 patients(13.5%) in the CS and 98(19.6%) in the SHS group. In terms of re-operation within 120 days of the original admission, 53 patients(10.6%) receiving cannulated screws compared to 24 patients(4.8%) treated with a sliding hip screw requiring further surgery(P=0.0006). The fracture was seen to displace in 12(22.6%) patients originally treated with cannulated screws compared to 6 patients(25%) treated with sliding hip screw(P=0.156). More significantly the fixation device was seen to have migrated in 24(45.3%) of the cannulated screw as compared to 7(29.2%) patients in the sliding hip screw group(P=0.002). Periprosthetic fractures were recorded in 4(7.5%) of the former and 3(12.5%) in the latter group(P=0.708). Wound infection was higher in the SHS group(2 patients) as compared to the screw fixation group(1 patient)(P=0.565). Statistical analysis demonstrates a dramatic difference exists between these 2 fixation types in terms of re-operation within 120 days of the original admission for which published literature has previously only recorded biomechanical, in vitro comparisons. Data regarding specific implant factors such as number of screws, position, configuration, starting point, thread length and use of washers in cannulated screws, and position, tapping, supplementary screw and compression screw in sliding hip screws was not recorded and may be considered to bias our results.

Regional anaesthesia, and the supplementation of either general or spinal anaesthesia with nerve block is well established and becoming increasingly more popular. Femoral, sciatic and obturator nerve blockade, in alone or in combination, by means of single shot or continuous infusion has been shown to significantly improve pain control and post operative nausea and vomiting (PONV). We identify equally significant morbidity associated with this practice, with delayed post operative rehabilitation, increase in length of stay, reduction in range of movement and local adverse symptoms at the site of injection and paraesthesia at 3 months post operatively.

2 surgeons were recruited to contribute 100 consecutive total knee replacements each to this study. Each worked exclusively with a one anaesthetist. Each had a predictable and different practice. One employed either spinal or general anaesthesia which the surgeon supplemented with end of operation infiltration of soft tissues in the surgical field including the capsule and skin incision with ropivacaine 300mg, adrenaline 500μg and ketorolac 30mg with normal saline added to make a volume of 100ml. The second employed either spinal or general anaesthesia but supplemented this with a single combined femoral and sciatic nerve block performed pre-operatively. Intravenous opiate analgesia administed via patient controlled analgesia pump for 24 hours post operatively, paracetamol 1g 6 hourly and ibuprofen 300mg 8 hourly where appropriate were prescribed by both anaesthetists. We recorded the incidence of insertion of urinary catheter, deep venous thrombosis diagnosed within 3 and 12 weeks, recovery of lower limb power to grade 5/5, range of movement achieved in each postoperative day and at 12 weeks post operatively, length of stay in addition to PONV and pain scores using the visual analogue scale (VAS) and collected every 6 hours. Localised pain and tenderness at the site of injection was noted at 12 weeks, and persistent paraesthesia.

As predicted patients in the group receiving nerve block has significantly less pain and post operative nausea and vomiting (p< 0.05). There was no statistically significant difference in the use of urinary catheters (p = 0.052) or the incidence of deep venous thrombosis (p=0.58). There was however a significant difference in the recovery of lower limb power (p = 0.023), range of movement recorded at 24hr intervals (p=0.038) (at 12 weeks p=0.54) and length of stay in hospital (0.038). One patient had an almost complete femoral nerve palsy at 12 weeks and required a manipulation under anaesthesia of her knee following recovery of same.

Nerve blockade is an increasingly popular method of controlling post-operative pain. We demonstrate some adverse effects on rehabilitation following this practice in addition to the increased financial and logistical burden of a longer inpatient stay.