Hip fractures commonly occur in older patients, with high levels of frailty and comorbidity. Many of these patients have limited mobility before their fracture, and even after surgery, their mobility may remain limited. It is therefore not surprising that they are at a high risk of developing pressure sores, particularly on their heels, and a variety of devices and interventions have been proposed to reduce this risk. Foam or air mattresses, designed to reduce contact pressure on the patient’s whole body, are now routinely used in many healthcare systems. However, there is wide variation in their design. We developed the WHiTE 14;PRESSURE 3 trial to address the lack of evidence in this area. This is a three-arm multicentre randomized trial including health economic evaluation and recruiting patients from NHS hospitals in the UK. The trial compares standard strategies for the prevention of pressure sores with standard care plus a constant low-pressure device and with standard care plus a heel off-loading device. This annotation describes the development of this trial.

Cite this article: Bone Joint J 2025;107-B(2):135–138.

We evaluated the use of unreamed expanding nails in prophylactic stabilization of impending fractures in patients with multiple bone mets.

During 2004–2008 we treated 25 impending fractures due to metastasis (11 male, 14 female patients) with so-called expanding intramedullary nails. All they had multiple bone mets and signs of impending fracture due to extensive osteolysis. We stabilized 6 impending humeral fractures, 15 femoral and 1 tibial with antegrade nailing and 3 pertrochanteric with cephalomedullary nailing. Fluoroscopy was used to check the nail entry-point. No medullary reaming was performed. The nails were not interlocked at the mid-shaft but fixed rather firmly within the medullary cavity after introducing normal saline under pressure that expands its walls. The operation time ranged from 12min (humerus) to 25min (pertrochanteric). No blood transfusion was necessary. On follow-up (8–41 mos) all patients were reviewed. In all cases the risk of impending fracture was remarkably decreased. The patients with humeral fractures regained function quickly. The patiens with lower limb fractures were mobilized immediately post-op and were allowed to walk with TWB.

Surgery of impending fractures of long bones in patients with multiple bone mets is palliative. It aims in safer patient’s mobilization, fracture risk reduction, pain control and function restoration in order to render the patient capable to continue the treatment for the main disease. The expanding nailing is indicated in selected cases as it can be inroduced quickly and effectively with minimal blood loss and morbidity.

Introduction: It has been shown that acrylic bone cement is weakened by its porosity, which enhances the formation of micro-cracks that contribute to major crack propagation. It has also been observed, that mixing procedures play a significant role in determining the quality of bone cement produced. A high degree of porosity is found to exist in cement that is inadequately mixed.

Currently mixing system allow for the preparation of the bone cement under the application of a vacuum in a closed, sealed chamber by means of a repeatable mixing action. These systems are perceived to be repeatable, reliable, and operator independent. The objective of this study is to evaluate the quality and consistency of acrylic bone cement prepared by scrub staff in an orthopaedic theatre using a commercially available third generation vacuum mixing syringe, in terms of the level of voids within the cement microsturcture.

Materials and Methods: The mixing devices were stored at 23°C ± 1°C for a minimum of 24 hours prior to mixing. The acrylic bone cement (Palacos R® with gentamicin, Biomet Merck, UK) was stored at 4°C ± 1°C for a minimum of 24 hours prior to mixing.

Bone cement was mixed using a commercially available third generation mixing device (vacuum = −550mmHg) at Musgrave Park Hospital, Belfast, Northern Ireland. The cement was mixed according to the device manufacturers’ instructions for use. Mixing was carried out during a joint replacement surgery by a number of experienced theatre scrub staff (n = 35). The cement remaining at the end of the procedure was allowed to cure within the delivery nozzle, made from linear low-density polyethylene (LLDPE) and having an internal diameter of 10mm. 205 nozzles were collected post-operatively and stored at 23°C ± 1°C prior to testing. The percentage porosities were determined by measuring the apparent densities based on Archimedes principle and, as a direct result; it was possible to calculate the mean percentage porosities.

Discussion: It can be observed that the majority of the theatre nurses, ie 46.8% prepared bone cement using the vacuum mixing system containing a porosity of between 2% to 4%. A cement porosity of this range would be the accepted optimum content for acrylic bone cement. However, 6.4% of the theatre nurses prepared cement demonstrating a porosity content ranging from 8–16%, which is highly unsatisfactory when you consider that the cement mixing system is perceived to be a consistent and reliable mixing device that is operator independent.

Figure 2 illustrates a bar chart representing the bone cement porosity as a function of which orthopaedic theatre the cement was prepared. There was no significance difference when comparing the quality of the cement mixed in terms of porosity with the different theatres. The mean porosity values of the cement mixed ranged between 2.5% and 5.2% depending on which theatre was used.

Conclusions: Bone cement mixed using the commercially available third generation device in theatre by 35 scrub staff was found to have a high degree of variability. Thus demonstrating that even an alleged reproducible mixing system is independent on mixing technique when used in a clinical situation by a number of users. Thus illustrating the system is not wholly user independent.

As a consequence of this investigation it is recommended that the key to ensuring high quality bone cement, with a good mechanical strength, that can be consistently prepared in theatre by scrub staff are two fold.

The orthopaedic staff must be aware of the significance of cement mixing and how it is affected by a number of factors including the type of mixing system, vacuum level applied, and mixing technique.

Introduction: The Spotorno cementless femoral stem relies on proximal press-fit at time of surgery and subsequent osseointegration for long-term fixation. The aim of the study is to assess the long-term survivorship and clinical outcome of the Spotorno stem used in primary hip replacement surgery in younger patients.

Materials and Methods: 74 patients were identified who had undergone 90 THRs using the Spotorno CLS stem between January 1987 and May 1992. There was variation in the acetabular components used. 5 patients (6 hips) were lost to follow-up, leaving a study group of 84 hips. The patients were assessed using the Harris Hip Score and the Oxford Hip Score.

Results: Mean age at operation was 40.1years (range 23–65years). Commonest diagnoses were primary osteoarthritis, developmental dysplasia of the hip and rheumatoid arthritis. Mean duration of follow-up was 12.25 years (range 8½ – 15yrs 3months). At most recent follow-up, the mean Oxford Hip Score was 23.8 and mean Harris Hip Score was 81. Taking revision for any cause as an end point, 19 hips from the initial group of 84 had undergone some form of revision surgery at most recent review. 15 of the 19 hips that failed had aseptic loosening of the acetabular component, which was the Mecring component, and underwent revision of acetabulum only. Four stems were revised, 2 for loosening and 2 for infection. 80 out of 84 of stems originally implanted remained intact at most recent review, which represents a stem survivorship of 95.2% at mean 12.25yrs follow-up when used in young patients.

Conclusion: Our findings indicate excellent long-term survival of this titanium alloy stem when used in patients under 65years. We attribute this to stem design and the principle of proximal press-fit fixation. Careful consideration must be given to acetabular component selection in cementless total hip arthroplasty.

In Britain 8 million people consult their general practitioner annually with musculoskeletal conditions leading to referral of 1.5 million patients to Orthopaedics/ Rheumatology. Northern Ireland has the highest waiting lists for outpatients in Britain. The demand on orthopaedics continues to rise despite past attempts to reduce waiting lists. Trauma and orthopaedics accounted for 14% of the excess waiters for outpatients at June 2002. (DHSSPS Sept 2002) Roland et al 1991, etc. demonstrated that 43% of all orthopaedic referrals were inappropriate. In Belfast, G.P.s and Physiotherapists in partnership with the Regional Orthopaedic Service decided to pilot a Primary Care Orthopaedic Triage Service. The vast majority of orthopaedic referrals relate to three main body parts: lumbar spine 28%, knees 34% and hips 25% and these were chosen to be triaged for the pilot. Approval was sought and granted from Queen’s University Belfast Ethics Committee.

Phase 1 involved the training of 2 GPs and 2 physiotherapists at the Musgrave Park and Royal Victoria Hospital with the full cooperation of the orthopaedic surgeons.

Phase 2 tested independently the diagnostic capability of the trained professionals and assessed the appropriateness and management of orthopaedic referrals against the consultants decision as ‘gold standard’.

95 patients participated in the study.

55.8% of referrals were deemed appropriate by the consultants, compared to 44.6% by the GP/physio team. The Kappa statistical score was 0.79 reflecting a good level of agreement and is comparable to other clinical specialties (Sackett 1991). The sensitivity of the trained professionals on orthopaedic referrals was 83% and the specificity was 97%. Kappa value for management of inappropriate referrals was 0.83.

Orthopaedic referral can be acceptably triaged by primary care professionals reducing the number of onward referrals to outpatients by 40% and increasing the appropriate referrals from 56% to 97%.