Total hip replacement (THR) is an option in a subset of patients with a neck of femur (NOF) fracture. The Scottish Intercollegiate Guidelines Network (SIGN) and National Institute for Clinical Excellence (NICE) provide guidance on the use of THR in patients with a NOF fracture. We compare our experience and recommend changes at a local level to allow successful implementation of the guideline to improve patient care.

From July 2008 to July 2011, 36 THRs preformed for trauma were identified retrospectively by cross-referencing several databases (Bluespier, Worcestershire, UK and surveillance of Surgical Site Infection (SSI), Scotland). 7 exclusions (3 failed internal fixation, 1 chronic NOF fracture, and 2 extra-capsular fractures) leaving 29 patients. All operations were carried out under the supervision of a hip surgeon. Outcome data (see results) was collected from electronic sources. Statistical analysis preformed using Fisher's exact test for categorical data.

Median age 62 years (44–88), time to surgery 4 days (2–8), American association of anaesthesia grade 2 (2–4) and hospital stay was 12 days (6–18). The first operator was a consultant in 23 cases and registrar in 6. 9 hips were cemented, 5 uncemented and 15 hybrid. 13 (44.8%) patients had a complication including 8 major (27.6%) complications. A blood transfusion was required in 11 (37.9%) patients. There were 2 (6.9%) deaths. A delay to surgery of more than 2 days was associated with increased risk of major complication (p< 0.03). ASA, Age, Grade of surgeon or Cement not associated with major complications.

Our results are inferior to those in the literature. We have identified potential causes; mainly a delay to surgery increasing risk of major complication. In keeping with the current guidelines we recommend that local pathways are instigated to ensure THRs for trauma may be preformed in a timely fashion.

Current fracture-clinic models, especially in the advent of reductions in junior doctors hours, may limit outpatient trainee education and patient care. We designed a new model of fracture-clinic, involving an initial consultant led case review focused on patient management and trainee education.

Prospective outcomes for all new patients attending the redesigned fracture-clinic over a 3-week period in 2010 (n=240) were compared with the traditional clinic in the same period in 2009(n=296). Trainees attending the fracture clinic completed a Likert questionnaire (1 [strongly dissagree] − 5 [strongly agree]) assessing the adequacy of education, support, staff morale & standards of patient care.

The percentage of cases given consultant input increased significantly from 33% in 2009 to 84% in 2010 (p< 0.0001), while the proportion of patients requiring physical review by a consultant fell by 21% (p< 0.0001). Return rates were reduced by 14.3% (p< 0.013) & utilization of the nurse lead fracture clinic improved by 10.1% (p< 0.0028). These improvements were most marked in the target group ?StR2 (24.2% & 22.3% respectively). There were significant improvements in staff perception of their education from 2 to 4.75 (p< 0.0001), provision of senior support from 2.38 to 4.5 (p=0.019), morale from 3.68 to 4.13 (p=0.0331) & their overall perception of patient care from 3.25 to 4.5 (p=0.0016). A&E staff found the new style clinic educational, practice changing & that it improved interdisciplinary relations, but did not interfere with their A&E duties.

Our model of fracture-clinic redesign has significantly enhanced consultant input into patient care without additional funding. In addition, we have demonstrated increased service efficiency and significant improvements in staff support, morale and education. In the face of current economic and training challenges, we recommend this new model as a tool for enhancing patient and trainee experiences.

Early failure of metal-on-metal (MoM) total hip replacements (THR) is now well established. We review 93 consecutive patients with CPT¯ stems MoM THR. Our series demonstrates a new mechanism of failure, which may be implant combination specific.

Between January 2005 and June 2009, 93 consecutive MoM total hip replacements were preformed using CPT stems by 3 surgeons at our unit. 73 CPT¯ stems, Metasul¯ Large Diameter Heads (LDH) with Durom¯ acetabulae and 20 CPT¯ stems, Metasul¯ 28mm diameter heads in Allofit¯ shells (zimmer). Clinical outcomes were collected prospectively before surgery, at 3 months, 1 year, 2 years, 3 years, and at 5 years post surgery. Revision for any cause was taken as the primary endpoint and the roentgenograms and explanted prostheses were analyzed for failure patterns.

In the LDH/Durom¯ group a total of 13 (18%) patients required revision (figs. 1) at a median of 35 months (range 6-44). 6 (8%) for periprosthetic fracture. All 6 periprostethic fractures were associated with minimal or no trauma and all had ALVAL identified histologically.

To date there have been no failures in the CPT¯/28mm head Allofit¯ group. Several failures demonstrated bone loss in Gruen zones 8 ± 9 ± 10 (fig. 2).

We demonstrate an unacceptably high rate of failure in CPT¯ MoM LDH hip replacements, with a high failure secondary to periprosthetic fracture and postulate a mechanism associated with local toxicity to metal ions. We strongly advise against this combination of prosthesis.

Current fracture-clinic models, especially in the advent of reductions in junior doctors hours, may limit outpatient trainee education and patient care. We designed a new model of fracture-clinic, involving an initial consultant led case review focused on patient management and trainee education.

Outcomes for all new patients attending the redesigned fracture-clinic over a 3-week period in 2010 were compared with the traditional clinic in the same period in 2009. Health professionals completed a Likert questionnaire assessing their perceptions of education, support, standards of patient care and morale before and after the clinic redesign.

309 and 240 patients attended the clinics in 2009 and 2010 respectively. There was an increase in consultant input into patient management after the redesign (29% versus 84%, p<0.0001), while the proportion of patients requiring physical review by a consultant fell (32% versus 9%). The percentage of new patients discharged by junior medical staff increased (17% versus 25%) with a reciprocal fall in return appointments (55% versus 40%, p<0.0005). Overall, return appointment rates fell significantly (55% versus 40%, p=0.013). Staff perception of education and senior support improved from 2 to 5, morale and overall perception of patient care from 4 to 5.

Our model of fracture-clinic redesign has significantly enhanced consultant input into patient care without additional funding. In addition, we have demonstrated increased service efficiency and significant improvements in staff support, morale and education. In the face of current economic and training challenges, we recommend this new model as a tool for enhancing patient and trainee experiences.

Post-operative regimes involving the use of intra-articular local anaesthetic infiltration may allow early mobilisation in patients undergoing total knee arthroplasty. Few studies have evaluated such regimes outside specialist arthroplasty units. We aimed to determine whether an enhanced recovery programme including the use of local anaesthetic administration could be adapted for use in a district general setting.

Following introduction of this regime to our unit, 100 consecutive patients undergoing primary total knee arthroplasty were reviewed. 56 patients underwent a standard analgesic regime involving a general or spinal anaesthetic and oral analgesics post operatively (group1). 48 patients underwent the newly introduced regime, which included pre-operative counselling, peri-articular local anaesthetic infiltration at operation and intra-articular local anaesthetic top-up administration post-operatively for 24 hours (group 2). Length of stay, post-operative analgesic requirements, and range of knee motion post-operatively were compared.

Median length of stay was less for patients in group 2 compared with those in group 1 (4 days compared to 5 days, p<0.05). Patients in group 2 required lower total doses of opiate analgesia post-operatively. 90% of patients in group 2 were ambulant on the first post operative day, compared with less than 25% of patients in group 1. Mean knee flexion on discharge was greater in patients in group 2 compared with those in group 1 (85 degrees compared with 75 degrees). No infective complications from intra-articular catheter placement were observed. However, technical difficulties were encountered during the introduction period, including loss of catheter placement, leakage of local anaesthetic and adaptation of nursing time for top-up anaesthetic administration.

A rehabilitation regime involving local anaesthetic infiltration for total knee arthroplasty can successfully be adapted for use in a district general setting. Our results suggest if initial technical difficulties are overcome, this regime can provide effective postoperative analgesia, early mobilisation and reduced hospital stay.

We have encountered radiological reports of ‘normal Graf α-angles’ when the femoral head was subluxed. We therefore developed a simple method to determine femoral/acetabular congruency known as the 50/50 method. We compare our method to the established Graf method.

Two identical, randomly assorted sets of 100 ultra-sonograms were evaluated. All ultrasonograms were of patients under 3 months of age within our DDH screening program. The images were assessed to be either ‘normal’ or ‘abnormal’ by 6 FY1’s using each method after reading brief instructions. (Images were classified as normal or abnormal by consensus between an orthopaedic consultant and radiologist who also examined and preformed dynamic screening on each infant).

The mean proportion of abnormal scans with agreement and normal scans with agreement was 0.52 (95% CI 0.39–0.69) and 0.92 (CI 0.87–0.96) respectively, indicating moderate agreement (kappa 0.41, CI 0.12–0.71) for inter-observer variability using the Graf method. On average the inter-observer variability using the 50/50 method for abnormal and normal scans with agreement was 0.60 (CI 0.35–0.84) and 0.92 (95% CI 0.85–0.99) respectively with moderate agreement (kappa 0.50, CI 0.20–0.80). Intra-observer variability between the Graf and 50/50 methods revealed moderate agreement (mean kappa 0.41, CI 0.17–0.66) with the average proportion of abnormal and normal scans with agreement of 0.50 (CI 0.32–0.69) and 0.91 (CI 0.83–0.98) correspondingly. The accuracy of each test was equal, ranging from 84% to 93%.

The 50/50 method is straightforward to both use and teach. Moreover, it successfully serves as “red dot” system to flag up abnormal hips at clinic. The 50/50 method is at least as good as Graf with regard to accuracy, inter-observer and intra-observer variability. We recognise that dynamic screening remains the gold standard.

Outcomes following total ankle replacement (TAR) have been less favorable than hip and knee arthroplasty. The Mobility TAR is a newly introduced mobile bearing ankle prosthesis which, unlike its predecessor the Agility, does not require fusion of the tibiofibular syndesmosis which in theory should reduce the rate of early failure. No studies have been published yet reporting follow-up longer than 1 year after surgery with this prosthesis.

From June 2006 to May 2008, 50 Mobility TARs were performed in our unit. Data have been collected prospectively on all 50 patients and all have been reviewed annually since surgery. Follow up ranges from one to three years.

The mean age was 65 (range 35–79). 20 patients (40%) were male. 10 underwent additional concurrent procedures (six calcaneal osteotomies, one 1st metatarsal osteotomy, two lateral ligament reconstructions, one subtalar arthrodesis). There was one early wound breakdown which subsequently healed without causing deep infection. There were no malleolar fractures. In two prostheses the talar component has subsided over two years resulting in painful loosening. Interestingly both these patients had postraumatic osteoarthritis with a fibular malunion. Both have been listed for revision to arthrodesis. One further patient has a loose talar component without subsidence and is awaiting exploration with a view to revision. There was one deep infection presenting at 18 months. One further patient reports continued hindfoot pain, thought to be from the subtalar joint and is being worked up for arthrodesis. The mean American Orthopaedic Foot and Ankle Society scores (scale 10–100) increased from 30 to 69 scores following surgery.

TAR using the Mobility prosthesis gives good early clinical results. Further follow-up studies are required to see if this performance is maintained in the long term.