Global surgical literature suggests that female trainees have less operative autonomy than their male counterparts. This pilot study had the primary objective to identify difference in autonomy by gender, and to power a national study to carry out further quantitative and qualitative research on this.

This was a retrospective, cross-sectional study utilising eLogbook data for all orthopaedic trainees (ST2-8) and consultants with CCT date 2016–2021 in a single Scottish deanery. The primary outcome measure was percentage of procedures undertaken as lead surgeon. 15 trainees and four recent consultants participated, of which 12 (63%) were male (mean grade 5.2), and 7 (37%) were female (mean grade 4.3). Trainees were lead surgeon on 64% of procedures (17595/27558), with autonomy rising with grade (37% ST1 to 85% ST8, OR 9.4). Operative autonomy was higher in male vs female trainees (66.5% and 61.4% respectively, p=<0.0001), with female trainees more likely to operate with a supervisor present (STU/S vs P/T, f 48%:13%, m 45%:20%).

This pilot study found that there was a significant difference in operative autonomy between male and female trainees, however this may be explained by differences in mean grade of male vs female trainees. Five trainees took time OOT, 4/5 of whom were female. Extension to a national multi-centre study should repeat the quantitative method of this study with additional qualitative analysis including assessing effect of time OOT to explore the reason for any gender discrepancies seen across different deaneries in the UK.

Objectives

The aim of this study was to investigate the structural integrity of torn and non-torn human acetabular labral tissue.

Aims

Asphericity of the femoral head-neck junction is common in cam-type femoroacetabular impingement (FAI) and usually quantified using the alpha angle on radiographs or MRI. The aim of this study was to determine the natural alpha angle in a large cohort of patients by continuous circumferential analysis with CT.

Aims

Hydroxyapatite coatings for uncemented fixation in total knee arthroplasty can theoretically provide a long-lasting biological interface with the host bone. The objective of this study was to test this hypothesis with propriety hydroxyapatite, peri-apatite, coated tibial components using component migration measured with radiostereometric analysis over two years as an indicator of long-term fixation.

Aims

Few studies have examined the long-term outcome of carpal tunnel release (CTR). The aim of this study was to evaluate the patient-reported long-term outcome of CTR for electrophysiologically severe carpal tunnel syndrome (CTS).

Objectives

Intramedullary fixation is considered the most stable treatment for pertrochanteric fractures of the proximal femur and cut-out is one of the most frequent mechanical complications. In order to determine the role of clinical variables and radiological parameters in predicting the risk of this complication, we analysed the data pertaining to a group of patients recruited over the course of six years.

Orthopaedics has been earmarked as one of the specialties that could make significant savings in the National Health Service. A large number of young adults are receiving total hip replacements and there has been a trend towards using uncemented implants. We describe the clinical and functional results at minimum 19 year follow up of cemented total hip replacements in patients under the age of fifty-five in our health region between 1990 and 1997. 104 cemented THRs performed in 100 patients under 55 years were included in this study. The follow-up data had been collected prospectively in the University database. 88.46% hips showed good to excellent results at final follow-up with a mean Harris hip score of 87.9±8.64. Revision was performed in 2 hips (1.92%), one for aseptic acetabular loosening and the other for late haematogenous infection. Probable radiological loosening was seen in 14 acetabular components (14.89%) and 4 femoral components (4.25%) at final follow-up. The mean rate of acetabular wear was 0.12mm/year and was not influenced by gender or diagnosis. The mean follow-up was 21.68±2.11 years (range 19 to 26 years) and the survivorship at 19 years was 98.07%. The GIRFT report looked at the economic aspect of implant selection and found that the cost of uncemented implants was almost double that of the cemented implants. Savings of atleast £10 million a year can be made if cemented implants were used. We recommend that in a publically funded health system like the NHS, cemented implants can be used in patients under 55 with good long term functional outcomes and large savings in the healthcare costs

Aims

To compare radiographic failure and re-operation rates of anatomical coracoclavicular (CC) ligament reconstructional techniques with non-anatomical techniques after chronic high grade acromioclavicular (AC) joint injuries.

Aims

We investigated changes in the axial alignment of the ipsilateral hip and knee after total hip arthroplasty (THA).

Aims

Analysis of the morphology of the distal femur, and by extension of the femoral components in total knee arthroplasty (TKA), has largely been related to the aspect ratio, which represents the width of the femur. Little is known about variations in trapezoidicity (i.e. whether the femur is more rectangular or more trapezoidal). This study aimed to quantify additional morphological characteristics of the distal femur and identify anatomical features associated with higher risks of over- or under-sizing of components in TKA.

We assessed the orientation of the acetabular component in 1070 primary total hip arthroplasties with hard-on-soft, small diameter bearings, aiming to determine the size and site of the target zone that optimises outcome. Outcome measures included complications, dislocations, revisions and ΔOHS (the difference between the Oxford Hip Scores pre-operatively and five years post-operatively). A wide scatter of orientation was observed (2sd 15°). Placing the component within Lewinnek’s zone was not associated withimproved outcome. Of the different zone sizes tested (± 5°, ± 10° and ± 15°), only ± 15° was associated with a decreased rate of dislocation. The dislocation rate with acetabular components inside an inclination/anteversion zone of 40°/15° ± 15° was four times lower than those outside. The only zone size associated with statistically significant and clinically important improvement in OHS was ± 5°. The best outcomes (ΔOHS > 26) were achieved with a 45°/25° ± 5° zone.

This study demonstrated that with traditional technology surgeons can only reliably achieve a target zone of ±15°. As the optimal zone to diminish the risk of dislocation is also ±15°, surgeons should be able to achieve this. This is the first study to demonstrate that optimal orientation of the acetabular component improves the functional outcome. However, the target zone is small (± 5°) and cannot, with current technology, be consistently achieved.

Cite this article: Bone Joint J 2015;97-B:164–72.

The effects of surgical approach in total hip replacement on health-related quality of life and long-term pain and satisfaction are unknown. From the Swedish Hip Arthroplasty Register, we extracted data on all patients that had received a total hip replacement for osteoarthritis through either the posterior or the direct lateral approach, with complete pre- and one-year post-operative Patient Reported Outcome Measures (PROMs). A total of 42 233 patients met the inclusion criteria and of these 4962 also had complete six-year PROM data. The posterior approach resulted in an increased mean satisfaction score of 15 (sd 19) vs 18 (sd 22) (p <  0.001) compared with the direct lateral approach. The mean pain score was 13 (sd 17) vs 15 (sd 19) (p < 0.001) and the proportion of patients with no or minimal pain was 78% vs 74% (p < 0.001) favouring the posterior approach. The patients in the posterior approach group reported a superior mean EQ-5D index of 0.79 (sd 0.23) vs 0.77 (sd 0.24) (p < 0.001) and mean EQ score of 76 (sd 20) vs 75 (sd 20) (p < 0.001). All observed differences between the groups persisted after six years follow-up. Although PROMs after THR in general are very good regardless of surgical approach, the results indicate that some patients operated by the direct lateral approach report an inferior outcome compared with the posterior approach. The large number of procedures and the seemingly sustained differences make it likely these findings are clinically relevant.

Cite this article: Bone Joint J 2014;96-B:590–6.

Corticosteroid use has been implicated in the development of osteonecrosis of the femoral head (ONFH). The exact mechanism and predisposing factors such as age, gender, dosage, type and combination of steroid treatment remain controversial. Between March and July 2003, a total of 539 patients with severe acute respiratory syndrome (SARS) were treated with five different types of steroid. There were 129 men (24%) and 410 women (76%) with a mean age of 33.7 years (21 to 59). Routine screening was undertaken with radiographs, MRI and/or CT to determine the incidence of ONFH.

Of the 129 male patients with SARS, 51 (39.5%) were diagnosed as suffering from ONFH, compared with only 79 of 410 female patients (19.3%). The incidence of ONFH in the patients aged between 20 and 49 years was much higher than that of the group aged between 50 and 59 years (25.9% (127 of 491) versus 6.3% (3 of 48); p = 0.018). The incidence of ONFH in patients receiving one type of steroid was 12.5% (21 of 168), which was much lower than patients receiving two different types (28.6%; 96 of 336) or three different types of steroid (37.1%; 13 of 35).

Cite this article: Bone Joint J 2014;96-B:259–62.

It is probable that both genetic and environmental factors play some part in the aetiology of most cases of degenerative hip disease. Geneticists have identified some single gene disorders of the hip, but have had difficulty in identifying the genetics of many of the common causes of degenerative hip disease. The heterogeneity of the phenotypes studied is part of the problem. A detailed classification of phenotypes is proposed. This study is based on careful documentation of 2003 consecutive total hip replacements performed by a single surgeon between 1972 and 2000. The concept that developmental problems may initiate degenerative hip disease is supported. The influences of gender, age and body mass index are outlined. Biomechanical explanations for some of the radiological appearances encountered are suggested. The body weight lever, which is larger than the abductor lever, causes the abductor power to be more important than body weight. The possibility that a deficiency in joint lubrication is a cause of degenerative hip disease is discussed. Identifying the phenotypes may help geneticists to identify genes responsible for degenerative hip disease, and eventually lead to a definitive classification.

This study utilised NJR primary hip data from the 6. th. Annual Report to determine the rate and indication for revision between cemented, uncemented, hybrid and resurfacing prosthetic groups. Regression analysis was performed to identify the influence of gender and ASA grade on these revision rates. Validity of the data was interrogated by exploring for episodes of misclassification. Results. We identified 2,264 misclassified episodes within the four groups (Misclassification rate 2.7% primary, 4.3% revision procedures). Analysis was performed using the “reclassified dataset”. The Kaplan-Meier revision rates at 3 years were 0.9% (95%CI: 0.8%-1.0%) for cemented prostheses, 1.9% (95%CI: 1.8%-2.0%) for uncemented hips, 1.2% (95%CI: 1.0%-1.4%) for hybrids and 3.0%, (95%CI: 2.7%-3.3%) in the resurfacing group. The trends in revision rates were comparable to those published in the NJR (6. th. Ed. n. ) with significant differences across all groups (p< 0.0001). Revision rates in the under 55 year age group showed an identical hierarchy with cemented and hybrid arthroplasty having the lowest revision rates. Cox Regression analysis indicated that both the prosthesis group in isolation and the interaction between prosthesis group and ASA grade significantly influenced the rate of failure (p< 0.001). Indications for revision showed significant differences in rates for, pain, aseptic loosening, dislocation and malalignment between prosthesis types (p< 0.001). The indications including Aseptic loosening, pain, malalignment and dislocation all demonstrated similar trends in revision rates between prosthetic groups with cemented hips having the lowest rates followed by ascending rates for hybrid, uncemented and resurfacing groups. The exception being dislocation with resurfacings having the lowest revision rates. Discussion. This study provides important baseline revision rates by indication for each prosthetic group from which future comparisons can be made. Areas of misclassification within the NJR dataset have been reported back for future annual analysis

We report a prospective analysis of clinical outcome in patients treated with medial patellofemoral ligament (MPFL) reconstruction using an autologous semitendinosus graft. The technique includes superolateral portal arthroscopic assessment before and after graft placement to ensure correct graft tension and patellar tracking before fixation. Between October 2005 and October 2010, a total of 201 consecutive patients underwent 219 procedures. Follow-up is presented for 211 procedures in 193 patients with a mean age of 26 years (16 to 49), and mean follow-up of 16 months (6 to 42). Indications were atraumatic recurrent patellar dislocation in 141 patients, traumatic recurrent dislocation in 50, pain with subluxation in 14 and a single dislocation with persistent instability in six. There have been no recurrent dislocations/subluxations. There was a statistically significant improvement between available pre- and post-operative outcome scores for 193 patients (all p < 0.001). Female patients with a history of atraumatic recurrent dislocation and all patients with history of previous surgery had a significantly worse outcome (all p < 0.05). The indication for surgery, degree of dysplasia, associated patella alta, time from primary dislocation to surgery and evidence of associated cartilage damage at operation did not result in any significant difference in outcome.

This series adds considerably to existing evidence that MPFL reconstruction is an effective surgical procedure for selected patients with patellofemoral instability.

Background. We present the results of cementless total hip arthroplasty using anatomically adapted stem and hemispherical cup with a fully coated Spongiosa metal surface, first introduced in 1982, which aims to achieve a surface structure approaching that of human cancellous bone. This implant is still being used in clinical practice with minor modifications. Aim. The aim of the study is to determine the long-term outcomes of spongiosa-I metal surface hip arthroplasty over minimum of twenty years follow-up. Material and Methods. Between 1983 and 1985, 209 consecutive total hip arthroplasty procedures were performed using the Spongiosa-I metal surface chrome-cobalt total hip arthroplasty. We reported clinical and radiological outcomes, frequencies and reasons of revision, influence of gender and age on the outcome and complications. Results. The outcomes of 159 patients were reviewed. We lost the follow-up of 40 patients none of whom had revision surgery. The mean follow-up time was 262 months. There were 19 hips revisions, including 14 stem revisions, two cup revisions and three revisions of both components. The mean Harris hip score for patients who didn't have revision surgery was 81.9 points. According to the criteria of Engh et al., all implants were graded as stable bone in growth. The probability of survival of both components at twenty years, with any revision as the end point, was 97%. The probability of survival of the acetabular component was 98% and that of the stem component only was 86%. Component durability was significantly increased in the older group of patients. Conclusion. The results of Spongiosa -I hip arthroplasty were excellent at a minimum of twenty years of follow-up. The outcomes of the femoral stem components were very good, while the survival rates of the acetabular component were better than any reported results in the English literature

The benefit of arthroscopy of the hip in the treatment of femoroacetabular impingement (FAI) in terms of quality of life (QoL) has not been reported. We prospectively collected data on 612 patients (257 women (42%) and 355 men (58%)) with a mean age at the time of surgery of 36.7 years (14 to 75) who underwent arthroscopy of the hip for FAI under the care of a single surgeon. The minimum follow-up was one year (mean 3.2 years (1 to 7)). The responses to the modified Harris hip score were translated using the Rosser Index Matrix in order to provide a QoL score. The mean QoL score increased from 0.946 (-1.486 to 0.995) to 0.974 (0.7 to 1) at one year after surgery (p < 0.001). The mean QoL score in men was significantly higher than in women, both before and one year after surgery (both p < 0.001). However, the mean change in the QoL score was not statistically different between men and women (0.02 (-0.21 to 0.27) and 0.04 (-0.16 to 0.87), respectively; p = 0.12). Linear regression analysis revealed that the significant predictors of a change in QoL score were pre-operative QoL score (p < 0.001) and gender (p = 0.04). The lower the pre-operative score, the higher the gain in QoL post-operatively (ρ = -0.66; p < 0.001). One year after surgery the QoL scores in the 612 patients had improved in 469 (76.6%), remained unchanged in 88 (14.4%) and had deteriorated in 55 (9.0%).

Introduction: In total hip arthroplasty (THA) an optimal fit and fill of the stem is essential for stable fixation. Thus femur morphology must be studied during pre-op planning (implant choice, sizing, positioning) or when a new stem is to be designed. Using plain AP x-ray analysis and the definition of a simple two-level parameter (canal flare index, CFI), Noble et al. identified an age related transition of the endosteal canal in AP view from a ‘champagne flute’ to a ‘stove pipe’. This reference data is 2D only, limited to the endosteal geometry and the elderly age range was defined as 60–90yrs so that the number of octogenerians > 80yrs was too low to analyze morphological features of this rapidly growing and critical THA patient population. In this study the endosteal and periosteal femur morphology of subjects > 80yrs was studied using 3D CT analysis. It was the goal to. describe age related changes of the femur morphology in 3D,. to study the influence of gender. to investigate if the results may affect fit & fill of current stem designs. Methods: High-resolution CT-scans (slice thickness 1mm) were made of 170 consenting volunteers (m/ f=101/69). The old group consisted of 119 subjects ≥80yrs (m/f=65/54, mean age: 84.1yrs [80–105]) and the young group of 51 subjects < 80yrs (m/f=36/15, mean age 67.8yrs [39–79]). After thresholding the bone boundaries in Mimics V12 (Materialise, B), the endos-teal and periosteal coordinates were analyzed for width, wall thickness, surface areas and various CFI’s relating dimensions at 20mm above LT and at a distal level (e.g. 60mm below LT, isthmus): Surface CFI (3D-CFI), frontal and lateral CFI based on the AP and ML projections (2D-CFI) and flaring in each of the four directions (1DCFI). Results: The surface CFI was sign. lower in subjects ≥80yrs (5.08 ±1.23) than in subjects < 80yrs (6.61 ±1.72, p< 0.0001). This difference was sign. larger in females than in males (−32% vs. −17%), an observation valid with reference to any distal level. Equivalent age differences were found in both the frontal and lateral 2D-CFI as well as the medial, lateral and anterior 1D-CFI with changes in the anterior direction (−26.3%) being most dominant. In addition wall thickness was sign. reduced in the very elderly. E.g. at 20mm above LT, the medial wall measured 10.40mm at < 80yrs and 7.61 at ≥80yrs, a reduction of −27% (p< 0.001). In females (−35%) this difference was sign. larger (males: −23%, p< 0.001) even when corrected for height. Discussion: The age driven transition of proximal femur morphology continues in the octogenarian population. This transition is not limited to two discrete levels in the AP plane as previously reported but it is a continuous 3D phenomenon with high directional asymmetry. In addition, this transition also affects the wall thickness and the periosteal shape. Furthermore a strong gender effect was identified with aging females showing increasingly and asymmetrically less flaring and thinner walls. An age and gender specific THA stem design seems necessary to fit the morphed femur. The asymmetric transition prohibits the effective use of current implant systems with proportionally scaled dimensions but favors a matrix sizing scheme with frontal and lateral dimensions changing independently

Purpose: It is well established that skeletal muscle ischemia followed by reperfusion induces oxidative damage, metabolic stress, and an inflammatory response. This ischemia-reperfusion injury has been studied extensively in experimental models and, importantly, in the clinical setting where it is associated with tourniquet (TQ) inflation during orthopedic trauma surgery. Of particular clinical concern is the notion that reperfusion upon TQ release is central to oxidative injury, since release necessarily follows surgery. Consequently, the effects of ischemia alone, without reperfusion, is poorly documented. That is, it remains unknown what are the effects of muscle ischemia, per se, on muscle properties that could influence functional recovery postoperatively or what preventative measures might be taken to minimize the potentially deleterious effects of the ischemic period alone. Hence the purpose of this study was to investigate changes in myofibrillar contractile protein oxidation over the course of TQ-induced leg muscle ischemia during orthopedic trauma surgery. Method: Among patients with unilateral ankle fractures requiring surgery at our institution, 24 subjects gave informed consent to participate. All subjects underwent standard general anesthesia. PRE surgical biopsies were collected from the peroneus tertius muscle (PT) immediately after TQ inflation and incision of the skin and underlying connective tissue. POST surgical biopsies were collected from the same muscle immediately before TQ release. Oxidation of PT myosin, actin, and total protein was quantified using Western blot analysis for 4-hydroxynonenal (4-HNE) modified proteins. Results are reported as mean ± standard deviation. Results: Total TQ time ranged from about 21 to 84 min (50.5±16). As anticipated, in PRE biopsies compared to POST biopsies there were large increases in the PT content of 4-NE modified myosin (174.4±128%; P< 1×10-6), actin (223.7±182%; P< 5×10-9), and total protein (567.5±378%; P< 5×10-7). Intriguingly, there was a much greater increase in PT protein oxidation in males than in females (43.3% difference; P< 0.05), although there was no relationship observed between PT protein oxidation and subject age. Surprisingly, there was no significant relationship between muscle protein oxidation and duration of the TQ-induced ischemia. Conclusion: TQ-induced skeletal muscle ischemia for 21 to 84 min during orthopedic trauma surgery leads to considerable oxidative muscle injury as measured by muscle protein oxidation, including of the functionally relevant contractile proteins myosin and actin. This injury occurs even without reperfusion. Interestingly, the extent of oxidative muscle injury appears to be influenced by gender, but is not dependent upon the duration of ischemia. FUNDING: MSFHR, COF, BCLA