Introduction: The increasing popularity of minimal access surgery in orthopaedic surgery has resulted in increasing use of intra-operative fluoroscopy. The radiation dose received by the surgeon varies from procedure to procedure depending on several factors such as duration of procedure, direct exposure to radiation beam and distance from the radiation source. In particular hand and wrist injuries often involve direct fluoroscopic exposure to the hands of the surgeon and assistant during the procedure.

Aim: We undertook a prospective study to directly evaluate the exposure of the surgeon’s and assistant’s hands and thyroid glands during K-wiring procedures of the hand and wrist. In addition we evaluated the efficacy of a lead thyroid shield in limiting the radiation dose to the thyroid gland. In addition we undertook a questionnaire of orthopaedic surgeons and trainees in Ireland to assess the availability of thyroid shields and current practice in wearing them.

Method A total of 30 cases were evaluated. Dosimeter film badges (TLD) were obtained from the Radiological Protection Institute of Ireland (RPI). Two dosimeters were worn by each of the surgical team: one on the dorsum of the dominant hand and a second worn on the neck during the procedure. The number of fluoroscopic exposures, number of times that hands were caught in the image field, the total dosage of radiation for the procedure and the length of time of exposure were recorded. In 20 cases the surgical team undertook standard precautions of a lead jacket. In a random selection of 10 cases the surgical team also wore a thyroid shield.

Results. The mean dose to the surgical teams’ hands was 1.8 cGy (95% CI + 0.6). The mean dose to the thyroid gland was 0.6 cGy in unprotected cases. Notably the dose to the assistants’ hands was higher though this did not reach statistical approval. In cases in which a thyroid shield was worn a significant decrease in dose was noted (p< 0.05). 35% of surgeons had completed a radiation protection course with junior trainees being less likely to have completed such a course.

Conclusion: Significant cumulative radiation dose to the hands and thyroid gland occurs following K-wiring of extremities. The dose to the thyroid gland can be effectively decreased by the use of a thyroid collar. Junior trainees whose operative times and hence radiation exposure are higher, have limited radiation protection training. The mandatory use of thyroid shields and early introduction of radiation protection training may help minimise further radiation exposure.

Introduction: Therapeutic bone marrow transplantation has increased survival in Hurler syndrome, but the effects on musculoskeletal development remain unclear. Long term reports on mobility are poor, with many patients gradually losing walking ability in later childhood secondary to hip subluxation and joint contractures. As previous cohorts are small, data is limited.

Methods: We detail the follow up of twenty patients over a mean of 94 months (range 1 – 17.4 years). Radiographs were assessed for hip dysplasia using acetabular angle of Sharp, centre edge angle of Wiberg and tibiofemoral shaft angle. Clinical examination was performed at an annual multidisciplinary assessment by one clinician and compared against age matched controls. 3D gait analysis was performed on eight older children, and deviance in kinematic variables was plotted against controls with Mann-Whitney U test for statistical analysis.

Results: All patients demonstrated characteristic ace-tabular dysplasia. Fourteen patients have undergone containment surgery at a mean of 4.4 years. Innominate osteotomy is an essential part of this. Mean preoperative acetabular angle was reduced from 34 ± 4° to 22 ± 3°. Femoral head containment is maintained, with mean centre edge angle in older patients 39 ± 7°. Genu valgum is observed early, and five patients underwent medial epiphyseal stapling at a mean of 7.8 years, decreasing tibiofemoral angle by a mean of 8.0°. All patients are currently independently mobile, with restriction of internal hip rotation being the only significant clinical finding (P< 0.001). Joint contractures were not noted. Walking speed and stride length were comparable to controls, but endurance is reduced by about one quarter. Gait analysis demonstrates a characteristic pattern, with anterior pelvic tilt secondary to thoracolumbar gibbus, relative hip flexion throughout the gait cycle, valgus knees and compensatory pronated feet; all measured deviations were significant (P< 0.001).

Conclusions This large group maintained successful hip containment and good mobility throughout childhood. Innominate osteotomy alone has been used recently. Despite plain film appearance, genu valgum is a functional problem in gait, and we would anticipate greater use of corrective stapling in the future. This is the first report of gait analysis in Hurler syndrome, and features specific to the condition are described.

Introduction: There is little epidemiological data on childhood injury in Ireland, despite large numbers of referrals to fracture clinics particularly in the summer months. Information is difficult to obtain retrospectively, and our aim was to quantify paediatric injury referrals to our clinics and analyse trends in injury patterns.

Methods: A prospective injury surveillance system was initiated in our department. Parents were asked to record demographic information and a brief description of the injury at fracture clinics or admission to the ward. Diagnosis and treatment was completed by the attending doctor. Details were transferred to a customised database for analysis.

Results: Overall compliance was excellent. Of 397 recorded referrals, 66% had confirmed fractures, and 20% of these were admitted for operative management. There was an equal sex distribution, and mean age at presentation was 9.1 years. The peak hour of injury was 7 – 8 pm, with fairly even distribution throughout the week. 62% of injuries were due to falls. 39% of injuries occured in or about the home, including 61% of all falls greater than 1 metre, most often from walls and slides. Other common locations for injury were school (16%) and sportsfields (14%). Gaelic football and soccer were the predominant sports causing injury. Fractures occuring during unsupervised sport were more likely to need surgery. Road traffic accidents were an uncommon cause of injury. Home ‘bouncy castles’ and trampolines were a notable cause of injury, causing 6% of all fractures, particularly of the upper limb. Predictably, 41% of all fractures involved the radius. Fractures of the distal humerus, diaphyses of radius, ulna and tibia were most likely to need operative management.

Discussion Analysis yielded a timely insight into the local epidemiology of childhood injuries. In comparison with other studies, sports related injuries were frequent and road accidents were unusually few in our group. Many injuries occurring late in the evening needed early reduction, with almost two thirds of surgical procedures performed out of hours with significant implications on theatre and radiology staffing. A large proportion of higher energy trauma occured in or about the home, representing a potential area for injury prevention stratgies.

The aim was to demonstrate that day case Anterior Cruciate Ligament (ACL) reconstruction, without the use of a tourniquet, is clinically effective, cost effective, safe and “patient choice” procedure.

Fifty patients who underwent day case, arthroscopic, ACL reconstruction without the use of a tourniquet, but using saline and epinephrine, pump regulated, irrigation. The same surgeon performed each case for the period May 2003 to April 2005. Seven patients had their tendons reconstructed with the use of patellar tendon grafts, the remainder, 43 patients, had hamstring tendon grafts. The study included 6 women and 44 men. This prospective study assessed cost effectiveness, clinical efficacy by measuring post-operative pain and postoperative results and finally whether this procedure remained the “patient choice”. The mean age was 30.6 years, (range 16 – 46). In addition to assessing level of immediate post operative pain the patients were also assessed at two weeks and six weeks for pain, range of movement, swelling and for the occurrence of any early post-operative complications.

We were able to show that there was a significant cost benefit, approximately one third to a half in comparison to other local surgeons; that the study was clinically effective and that there were no reported early complications; and that all 50 patients would choose to have the surgery again as a day case procedure with this technique.

We would like to present day case ACL reconstruction without the use of a tourniquet, as a safe option for the carefully selected patient.

This is a report of 30 patients who underwent arthroscopic, Anterior Cruciate Ligament (ACL) reconstruction without the use of a tourniquet, but using saline and epinephrine, pump regulated, irrigation. Each case was performed as a day case by the same surgeon for the period May 2003 to December 2004. 5 patients had their tendons reconstructed with the use of patellar tendon grafts, the remainder, 25 patients, had hamstring tendon grafts. The study included 4 women and 26 men. This prospective study assessed cost effectiveness, clinical efficacy by measuring post-operative pain and post-operative results and finally whether this procedure remained the “patient choice”. The mean age was 30.6 years, (range 17 – 46). In addition to assessing level of immediate post operative pain the patients were also assessed at two weeks and six weeks for pain, range of movement, swelling and for the occurrence of any early post-operative complications. We were able to show that there was a significant cost benefit, approximately one third to a half in comparison to other local surgeons; that the study was clinically effective and that there were no reported early complications; and that all 30 patients would choose to have the surgery again as a day case procedure with this technique. We would like to present day case ACL reconstruction as a safe option for the carefully selected patient and as a procedure that could perhaps be included in the orthopaedic basket for day case surgery in the UK.

Introduction. Acute distal biceps rupture can be a devastating injury and surgical repair offers the only real chance of full recovery. We report on a new surgical technique in which the use of suture anchors and a modified de-tensioning suture was employed to protect the repair in the early post operative recovery period and aid early rehabilitation and return to full pre-injury activity.

Materials & Methods. Using the standard anterior incision the distal biceps tendon was approximated to the radial tuberosity using two Mitek sutures and a sliding stitch. Using 2-0 Vicryl, de-tensioning sutures were used to attach the medial and lateral sides of the tendon to the underlying brachialis muscle. Post-operative recovery encouraged isometric contractions as early as 24 hours and after 2 weeks allowed flexion and extension with gravity eliminated. Six weeks onwards full active movement commenced with gradual increase in stretching and strengthening exercise.

Results. 14 patients underwent this procedure and all returned to pre-injury activity levels within 9 months. Follow up (6–14 months) demonstrated all had regained pre-injury levels of strength in flexion and supination.

Discussion. Using two suture anchors, it is suggested that load bearing strength is greater than the trans-osseous method, providing even tension is applied to both anchors. This can be achieved using a sliding stitch. De-tensioning sutures restore the isometric pull on biceps in the early phase and protects the repair.

Conclusion. All cases operated on in this way have made excellent recoveries and have returned to full pre-injury levels of activity. We therefore recommend this technique as a way of enhancing rehabilitation in what can be a devastating injury for the active sporting individual

There is little data regarding the epidemiology of childhood injury in Ireland. This is difficult to obtain retrospectively. The aim of this study was to prospectively evaluate paediatric trauma referrals to our department, describe their epidemiology, and identify potentially preventable injuries in children. Our unit at the National Childrens Hospital is located in a growing suburban area in South Dublin. Injury surveillance was conducted on orthopaedic referrals by distributing a form to parents of children attending fracture clinics or admitted acutely for surgery. Parents were asked for demographic information, and a brief description of the injury in terms of location, mechanism and circumstance of injury. Diagnosis was completed by the attending doctor and data was transferred to a computerised database. We analyzed data from the 397 referrals in the first month of this study. The mean age of injury was 9.1 years and the male: female ratio was 1.3:1. The peak hour of injury was 7 – 8 pm. Only 33% of injuries occured during the weekend. 62% of injuries were due to falls, usually form the standing position. The most common location for injury was in or about the home (39%), and other notable locations were school (16%) and sportsfield (14%). 61% of falls greater than 1 metre occurred at home, mostly from walls and childrens slides. 20% of injuries occurred while participating in organized sport, including Gaelic football, soccer and hurling. Injuries occuring during unsupervised sport were more likely to need surgery. Domestic ‘bouncing castles’ and trampolines, increasingly popular in our area, were a notable cause of significant trauma to the upper limb. 7% of injuries occurred by falling from a bicycle, but vehicular road traffic accident was an uncommon cause of injury. 263 children had confirmed fractures, other injuries consisting largely of sprains to the ankle, elbow and wrist. Predictably, the bones most commonly fractured were the radius (41%), phalanges (15%) and humerus (11%). 20% of fractures needed operative management, mostly forearm manipulation under anaesthesia. 63% of operative cases were performed outside of normal working hours. Several countries utilise injury surveillance as a means of development and evaluation of injury prevention strategies. In our initial study, basic surveillance has outlined local characteristics of chilhood trauma, and some trends were noted. In particular, we suggest home injuries need further attention in out catchment area.

The restoration of pain-free stable function in gleno-humeral arthritic cases in various situations such as rotator cuff deficiency, old trauma and failed total shoulder arthroplasty is a challenging clinical dilemma. The Bayley-Walker shoulder has been designed specifically for very difficult cases where surface replacement devices do not provide sufficient stability. This device is a fixed-fulcrum reversed anatomy prosthesis consisting of a titanium glenoid component with a CoCrMo alloy head that articulates with an UHMWPE liner encased in a titanium alloy humeral component that has a long tapered grooved stem. The centre of rotation of the Bayley-Walker shoulder is placed medially and distally with respect to the normal shoulder in order to improve the efficiency of the abductor muscles. An important problem in devices of this type is obtaining secure and long-lasting fixation of the glenoid component. The glenoid component relies on fixation through the cortical bone by using threads, which protrude through the anterior surface of the scapula at the vault of the glenoid. It is HA coated for subsequent osseointegration. The purpose of this study was to investigate fixation of the glenoid component.

A 3D finite element model of the glenoid component implanted in a scapula was analysed using Abaqus. The implant was placed in position in the scapula, with the final 2–3 screw threads cutting through the cortical bone on the anterior side at the vault of the glenoid due to the anatomy in this region. The analysis was performed for two load cases at 60° and 90° abduction. A histological study of a retrieval case, obtained 121 days after implantation, was also conducted.

The FEA results showed that most of the forces were transmitted from the component to the cortical bone of the scapula, the remaining load being transmitted through cancellous bone. In particular the area where the threads of the glenoid component penetrated the scapula showed high strain energy densities. Histology from the retrieved case showed evidence of bone remodelling whereby new bone growth resulting in cortical remodelling had occurred around the threads.

Both the FEA and histological study show that fixing the component at multiple locations in cortical bone may overcome the problems of glenoid loosening associated with constrained devices. The Bayley-Walker device has been used on a custom basis since 1994; 81 Bayley–Walker shoulders for non-tumour conditions and 43 Bayley-Walker glenoid components have been used in association with a bone tumour implant, with good early results. Radiographically, radiolucencies have not been observed and overall the comparisons with the original Kessel design are positive.

A computer-based image analysis system has been developed as a research tool in total hip replacement. The system has been programmed to take multiple measurements from coronal plane radiographs. Poor quality radiographic images can be enhanced and standardised. The measurements which can be obtained include stem subsidence, cup migration, cup wear, and stem loosening. Reproducibility and accuracy were +/- 0.01 mm and +/- 0.5 mm respectively. The present application is in retrospective research, but prospective monitoring of radiographs is planned.