Summary Statement

Fretting and corrosion has been identified as a clinical problem in modular metal-on-metal THA, but remains poorly understood in modern THA devices with polyethylene bearings. This study investigates taper damage and if this damage is associated with polyethylene wear.

Summary Statement

Service industry metrics (the net promoter score) are being introduced as a measure of UK healthcare satisfaction. Lower limb arthroplasty, as a ‘service’, scores comparably with the most successful commercial organisations.

In our department, currently there is variation in the number of xrays that patients receive following ORIF of distal radius fractures.

This audit investigated the use of xrays following ORIF of distal radius fractures. Patients were identified from daily trauma lists. Patients who had a primary ORIF or ORIF following failed conservative management were included in the study. PACS was used to identify the number of post-operative xrays performed. These were correlated with clinic letters to see if there was any change in management following xray review.

Between July and November 2013, 102 patients were admitted with distal radius fracture. Of these, 35 (mean age:51 years) had an ORIF. Four were not followed-up in Scotland. Of the remaining 31 patients, eleven had one post-operative xray, seventeen had two and three had three xrays. Of the patients who had one xray, seven had the xray in the first three weeks, the rest at six weeks. Patients who had two xrays had an xray at two and 6 weeks. Of the three patients who had three xrays, two had comminuted fractures that required further CT investigation, one for a suspicion of an intra-articular screw, the other for possibility of non-union. The third patient had no apparent reason for requiring three xrays. Thus of the 31 patients in the study, 29 did not require any further investigations.

The results show a variation in the frequency of post-operative xrays after fixation of distal radius fractures. In most cases the management plan was unchanged after plain xrays were undertaken. This suggests that a protocol driven approach to follow-up after fixation of distal radius fractures could reduce the burden on fracture clinic and radiology departments.

We propose that unless indicated by intra-operative findings or post-operative concerns, patients should have xrays at the two week review appointment.

Many psychological factors have been associated with function after joint replacement. Personality is a stable pattern of responses to external conditions and stimuli. The aim of this study was to investigate the relationship between personality, joint function, and general physical in patients undergoing total hip (THR) and knee replacement (TKR).

We undertook a prospective cohort study of 184 patients undergoing THA and 205 undergoing TKA. Personality was assesed using the Eysneck Personality Questionaire, brief version (EPQ-BV). Physical health was measured using the EuroQol (EQ-5D). Joint function was measured using the relevant Oxford Score. Outcomes were assessed at six months. Multivariable models were constructed.

The stable introvert personality was most common. Unstable introverts had poorer pre-operative function with hip arthrosis, but not knee arthrosis. Personality was not directly associated with post-operative function – the only independent predictors were pre-operative function (p=0.002) and comorbidity (p<0.001). While satisfaction after TKR was associated with personality (p=0.026), there was no association after THR (p=0.453). The poorest satisfaction was in those with the unstable introvert personality type.

Personality was a predictor of preoperative status. It did not have a direct association with postoperative status, but may have as preoperative function was the main predictor of postoperative function, personality may have had an indirect effect. Personality was also a predictor of satisfaction after TKR. This suggests that predicting satisfaction after knee replacement is more complex. Therefore certain patient may benefit from a tailored preoperative education to explore and manage expectations.

Expectations of patients requiring knee arthroplasty surgery have become higher than in the past, with more strain being put on modern prostheses by fitter and younger patients. The objective of this study was to analyse the survivorship of primary knee arthroplasties at a minimum of ten years, with end points of revision and death. Patients who had a total (TKA) or unicompartmental (UKA) knee arthroplasty performed at a university teaching hospital were identified from the local arthroplasty database. Electronic and operative records were analysed to determine parameters including operative indication, subsequent revision surgery, and patient mortality. Results were collated and analysed using PASW software.

A total of 1023 patients were recruited, with 566 (55%) female and 457 (45%) male. Minimum follow up was 10.1 years, with an average of 12.1 years (S.D 0.87). 64.9% of patients were alive at follow up, with an average age of 79.7 years (S.D 8.7). 92.8% were operated on for osteoarthritis (OA), 6.6% for rheumatoid arthritis (RA) and 0.6% for other indications. Kaplan–Meier analysis estimated survival of 94% (S.D 0.008) at eleven years, with no statistical difference found in survivorship of knees operated on for OA or RA. Similarly no statistical difference was found between survivorship of UKA or TKA implants. Of those that died by follow up, 95.2% did so with their original implant.

We conclude that both TKA and UKA offer a lasting solution for patients, with excellent outcomes achieved in both rheumatoid and osteoarthritic patients.

This study assessed the effect of concomitant back pain on the Oxford knee score (OKS), Short-Form (SF)-12 and patient satisfaction after total knee replacement (TKR). It involved a prospectively compiled database of demographics and outcome scores for 2392 patients undergoing primary TKR, of whom 829 patients (35%) reported back pain. Compared with those patients without back pain, those with back pain were more likely to be female (odds ratio (OR) 1.5 (95% confidence interval (CI) 1.3 to 1.8)), have a greater level of comorbidity, a worse pre-operative OKS (2.3 points (95% CI 1.7 to 3.0)) and worse SF-12 physical (2.0 points (95% CI 1.4 to 2.6)) and mental (3.3 points (95% CI 2.3 to 4.3)) components.

One year post-operatively, those with back pain had significantly worse outcome scores than those without with a mean difference in the OKS of 5 points (95% CI 3.8 to 5.4), in the SF-12 physical component of 6 points (95% CI 5.4 to 7.1) and in the mental component of 4 points (95% CI 3.1 to 4.9). Patients with back pain were less likely to be satisfied (OR 0.62, 95% CI 0.5 to 0.78).

After adjusting for confounding variables, concomitant back pain was an independent predictor of a worse post-operative OKS, and of dissatisfaction. Clinicians should be aware that patients suffering concomitant back pain pre-operatively are at an increased risk of being dissatisfied post-operatively.

Cite this article: Bone Joint J 2013;95-B:1632–9.

Introduction:

First generation highly crosslinked polyethylenes (HXPLEs) have proven successful in lowering both penetration and osteolysis rates. However, 1^st generation annealing and remelting thermal stabilization have been associated with in vivo oxidation or reduced mechanical properties. Thus, 2^nd generation HXLPEs were developed to improve oxidative stability while still maintaining material properties. Little is known about the in vivo clinical failure modes of these 2^nd generation HLXPEs.

The purpose of this study was to assess the revision reasons, wear, oxidative stability, and mechanical behavior of retrieved sequentially annealed Vitamin E diffused HXLPE in THA and TKA.

Introduction:

Degradation of modular head-neck tapers was raised as a concern in the 1990s (Gilbert 1993). The incidence of fretting and corrosion among modern, metal-on-polyethylene and ceramic-on-polyethylene THA systems with 36+ mm femoral heads remains poorly understood. Additionally, it is unknown whether metal debris from modular tapers could increase wear rates of highly crosslinked PE (HXLPE) liners.

The purpose of this study was to characterize the severity of fretting and corrosion at head-neck modular interfaces in retrieved conventional and HXLPE THA systems and its effect on penetration rates.

Background:

Previous studies regarding modular head-neck taper corrosion were largely based on cobalt chrome (CoCr) alloy femoral heads. Less is known about head-neck taper corrosion with ceramic femoral heads.

Nerve damage is a complication of THA and TKA procedures. The incidence of subclinical nerve injury following arthroplasty is unknown. The aim was to determine the prevalence of asymptomatic nerve deficits in an arthroplasty population group, and the incidence of post-operative changes in nerve function. A Secondary aim was to identify the nature of any deficits. And the association between nerve deficits and history of backache.

A non-randomised prospective series of patients undergoing lower limb arthroplasty for osteoarthritis were studied at a single hospital. The peroneal nerve was investigated using nerve conduction in forty patients. Twenty patients had upper limb testing to differentiate between a polyneuropathy or isolated lower limb neuropathy.

Nerve function deficits were detected in the peroneal nerve in fifteen patients pre-operatively and fifteen post-operatively, of those twelve had A waves detected suggestive of a generalised neuropathy. Ten patients who had upper limb testing had a conduction defect (five had asymptomatic Carpal tunnel). There was a positive correlation between presence of post-operative deficit and age(r=0.389, p=0.013). A negative correlation was found for presence of post-operative A waves and BMI(r=−0.370, p=0.019).

The prevalence of pre-operative subclinical peroneal neuropathy is much higher than expected in this group (37.5%) of arthroplasty patients. There is a strong correlation between presence of post-operative conduction abnormalities and age. There is no relationship between peripheral neuropathy and history of backache or residual post-operative deficit.

We aimed to review the outcome of Agility total ankle replacements carried out in our institution between 2002 and 2006.

Follow-up consisted of clinical and radiological review pre-operatively, then at 6 weeks, 6 and 12 months, and annually until 10 years post op. Clinical review included the American Orthopaedic Foot and Ankle Score, satisfaction and pain scores. Case notes were reviewed to determine intra and post-operative complications.

30 arthroplasties were performed in 30 consecutive patients. Pre-operative diagnosis was rheumatoid arthritis(16), primary osteoarthritis(12) and post-traumatic osteoarthritis(2). After a mean follow up of 6.2 years (1.4–10.1), 4 patients had died, and 22 out of the remaining 24 were available for follow-up. Intra operative complications included lateral malleoli fracture(3) and superficial peroneal nerve injury(2). Post operative complications included 1 early death, but this was not related to the surgical procedure. Two patients developed deep infections of the prosthesis. One underwent removal of the implant; the other is on long term oral antibiotic therapy. One patient had delayed union of the syndesmosis and six patients had non-union. On clinical assessment, patients' AOFAS scores improved from mean 40.4 pre-op to 83.5 post-op (p<0.001). Radiological assessment of the tibial component revealed 25 (93%) patients had lucency in at least one zone in the AP radiograph.

We found a relatively high level of re-surgery and complications following Agility total ankle replacement. A 7% revision rate is much higher than would be tolerated in knee or hip arthroplasty, but compares favourably to other studies of TAR. Despite radiological features which suggest loosening, the high rate of re-surgery and complications; patients are generally satisfied with the procedure, reporting lower levels of pain and improved function. Overall we feel that the Agility ankle is an acceptable alternative to ankle arthrodesis, however patients need to be warned of the risk of re-surgery.

Few doctors answer their bleep by stating who they are. Answering the phone in a formal manner is of utmost importance in the hospital setting especially by on-call teams who are normally referred patients by other specialties, general practitioners and in some cases by other hospitals.

An audit to evaluate the internal hospital communication was completed. In the first part of this audit, junior doctors within the orthopaedic department at the RAH were bleeped. Doctors were expected to answer by initiating the conversation by stating (1) name, (2) department, (3) grade and (4) a greeting. A list of omissions was recorded. If the call went through switchboard, it was expected that the hospital name was stated. The second part of the audit extended to other specialties in the RAH as well as orthopaedic departments in hospitals within the Greater Glasgow and Clyde health board (NHS GGC).

Forty-three bleeps were made to doctors of various grades over a period of two months. Nine bleeps (two from other hospitals) were not answered. Five doctors answered their bleep in full. Only twenty-one doctors stated their name whilst eleven stated their grade. In both instances the department was not necessarily stated. The results were similar between the different departments as well as between the seven hospitals offering an orthopaedic service within NHS GGC. Of the thirteen on-call doctors that were bleeped as an external call through switchboard, only one doctor stated the hospital name. This has implications since most hospitals within NHS GGC share a common switchboard.

These results emphasise the need for a protocol within NHS GGC for a standard etiquette for intra and inter hospital communication to ensure that patient safety and confidentiality is safeguarded.

Introduction

Sequentially annealed highly crosslinked polyethylenes (HXLPEs) were introduced in total knee replacement (TKR) starting in 2005 to reduce wear and particle-induced osteolysis. Few studies have reported on the clinical performance of HXLPE knees. In this study, we hypothesized that due to the reduced free radicals, sequentially annealed HXLPE would have lower oxidation levels than gamma inert-sterilized controls.

Introduction

Wear debris generation in metal-on-metal (MOM) total hip arthroplasty (THA) has emerged as a compelling issue. In the UK, clinically significant fretting corrosion was reported at head-taper junctions of MOM hip prostheses from a single manufacturer (Langton 2011). This study characterizes the prevalence of fretting and corrosion at various modular interfaces in retrieved MOM THA systems used in the United States.

We assessed the effect of mental disability on the outcome of total knee replacement (TKR) and investigated whether mental health improves post-operatively. Outcome data were prospectively recorded over a three-year period for 962 patients undergoing primary TKR for osteoarthritis. Pre-operative and one year Short-Form (SF)-12 scores and Oxford knee scores (OKS) were obtained. The mental component of the SF-12 was stratified into four groups according to level of mental disability (none ≥ 50, mild 40 to 49, moderate 30 to 39, severe < 30). Patients with any degree of mental disability had a significantly greater subjective physical disability according to the SF-12 (p = 0.06) and OKS (p < 0.001). The improvement in the disease-specific score (OKS) was not affected by a patient’s mental health (p = 0.33). In contrast, patients with mental disability had less of an improvement in their global physical health (SF-12) (p < 0.001). However, patients with any degree of mental disability had a significant improvement in their mental health post-operatively (p < 0.001).

Despite a similar improvement in their disease-specific scores and improvement in their mental health, patients with mental disability were significantly more likely to be dissatisfied with their TKR at one year (p = 0.001). Patients with poor mental health do benefit from improvements in their mental health and knee function after TKR, but also have a higher rate of dissatisfaction.

Cite this article: Bone Joint J 2013;95-B:360–6.

Introduction

The purpose of this multicenter study was to assess the oxidative stability, mechanical behavior, wear and reasons for revision of 2nd generation sequentially annealed HXLPE, X3, and compare it to 1^st generation XLPE, Crossfire. We hypothesized that X3 would exhibit similar wear rates but lower oxidation than Crossfire.

We reviewed the outcome of Agility total ankle replacements carried out in our institution between 2002 and 2006.

Follow-up consisted of clinical and radiological review pre-operatively, at 6 weeks, 6 and 12 months, and annually until 10 years post-op. Clinical review included the American Orthopaedic Foot and Ankle Score, satisfaction and pain scores.

30 arthroplasties were performed in 30 consecutive patients. Pre-operative diagnosis was rheumatoid arthritis (16), primary osteoarthritis (12) and post-traumatic osteoarthritis (2). After a mean follow up of 6.2 years (1.4–10.1), 4 patients had died, and 20 out of the remaining 24 were available for follow-up. Complications included lateral malleoli fracture (3), superficial peroneal nerve injury (2), one early death, unrelated to the surgical procedure, delayed syndesmotic union (1), non-union (6) and deep infection (2), of which one underwent removal of the implant; the other receives long-term oral antibiotics. AOFAS scores improved from mean 40.4 pre-op to 83.5 post-op (p<0.001). Radiological assessment revealed 25 (93%) patients had lucency in at least one zone in the AP radiograph.

We found a relatively high level of re-surgery and complications following Agility total ankle replacement. A 7% revision rate is much higher than would be tolerated in knee or hip arthroplasty, but compares favourably to other studies of TAR. Despite radiological loosening, and the high rate of re-surgery and complications; patients are generally satisfied with the procedure, reporting lower levels of pain and improved function. Overall, we feel that the Agility ankle is an acceptable alternative to arthrodesis, however patients should be warned of the risk of re-surgery

We aimed to review the outcome of Agility total ankle replacements carried out in our institution between 2002 and 2006.

Follow-up consisted of clinical and radiological review pre-operatively, then at 6 weeks, 6 and 12 months, and annually until 10 years post op. Clinical review included the American Orthopaedic Foot and Ankle Score, satisfaction and pain scores. Case notes were reviewed to determine intra and post-operative complications.

30 arthroplasties were performed in 30 consecutive patients. Pre-operative diagnosis was rheumatoid arthritis(16), primary osteoarthritis(12) and post-traumatic osteoarthritis(2). After a mean follow up of 6.2 years (1.4–10.1), 4 patients had died, and 22 out of the remaining 24 were available for follow-up. Intra operative complications included lateral malleoli fracture(3) and superficial peroneal nerve injury(2). Post operative complications included 1 early death, but this was not related to the surgical procedure. Two patients developed deep infections of the prosthesis. One underwent removal of the implant; the other is on long term oral antibiotic therapy. One patient had delayed union of the syndesmosis and six patients had non-union. On clinical assessment, patients' AOFAS scores improved from mean 40.4 pre-op to 83.5 post-op (p< 0.001). Radiological assessment of the tibial component revealed 25 (93%) patients had lucency in at least one zone in the AP radiograph.

We found a relatively high level of re-surgery and complications following Agility total ankle replacement. A 7% revision rate is much higher than would be tolerated in knee or hip arthroplasty, but compares favourably to other studies of TAR. Despite radiological features which suggest loosening, the high rate of re-surgery and complications; patients are generally satisfied with the procedure, reporting lower levels of pain and improved function. Overall we feel that the Agility ankle is an acceptable alternative to ankle arthrodesis, however patients need to be warned of the risk of re-surgery.

Patient expectations and their fulfilment are an important factor in determining patient-reported outcome and satisfaction of hip (THR) and knee replacement (TKR). The aim of this prospective cohort study was to examine the expectations of patients undergoing THR and TKR, and to identify differences in expectations, predictors of high expectations and the relationship between the fulfilment of expectations and patient-reported outcome measures. During the study period, patients who underwent 346 THRs and 323 TKRs completed an expectation questionnaire, Oxford score and Short-Form 12 (SF-12) score pre-operatively. At one year post-operatively, the Oxford score, SF-12, patient satisfaction and expectation fulfilment were assessed. Univariable and multivariable analysis were performed. Improvements in mobility and daytime pain were the most important expectations in both groups. Expectation level did not differ between THR and TKR. Poor Oxford score, younger age and male gender significantly predicted high pre-operative expectations (p < 0.001). The level of pre-operative expectation was not significantly associated with the fulfilment of expectations or outcome. THR better met the expectations identified as important by patients. TKR failed to meet expectations of kneeling, squatting and stair climbing. High fulfilment of expectation in both THR and TKR was significantly predicted by young age, greater improvements in Oxford score and high pre-operative mental health scores. The fulfilment of expectations was highly correlated with satisfaction.

Unicompartmental knee replacements (UKRs) have inconsistent and variable survivorships reported in the literature. It has been suggested that many are revised for ongoing pain with no other mode of failure identified. Using a medial UKR with an all-polyethylene non-congruent tibial component from 2004–7, we noted a revision rate of 9/98 cases (9.2%) at a mean of 39 months. Subchondral sclerosis was noted under the tibial component in 3/9 revisions with well fixed implants, and the aim of this study was to investigate this as a mode of failure. 89 UKRs in 77 patients were investigated radiographically (at mean 50 months) and with SF-12 and Oxford Knee scores at mean follow up 55 months. Subjectively 23/89 cases (25%) had sclerosis under the tibial component. We describe a method of quantifying this sclerosis as a greyscale ratio (GSR), which was significantly correlated with presence/absence of sclerosis (p<0.001). Significant predictors of elevated GSR (increasing sclerosis) were female sex (p<0.001) and elevated BMI (P=0.010) on both univariate and multivariate analysis. In turn, elevated GSR was significantly associated with poorer improvement in OKS (p<0.05) at the time of final follow up. We hypothesise that this sclerosis results from repetitive microfracture and adaptive remodelling in the proximal tibia due to increased strain. Finite element analysis is required to investigate this further, but we suggest caution should be employed when considering all polyethylene UKR implants in older women and in those with BMI >35.

Up to 20% of patients are not satisfied with the outcome following total knee replacement (TKR), but little is known about the predictors of this dissatisfaction. This study investigated the pre- and post-operative predictors of dissatisfaction in a large cohort of patients undergoing TKR. We assessed 1217 consecutive patients undergoing TKR between 2006 and 2008 both preoperatively and six months after surgery, using the Short-form (SF)-12 health questionnaire and the Oxford Knee Score.

Detailed co-morbidity information was also gathered. Satisfaction was measured at one year and 18.6% (226 of 1217) of patients were unsure or dissatisfied with their replacement, 81.4% (911 of 1217) were satisfied or very satisfied. Multivariate regression analysis was performed to identify independent predictors of dissatisfaction. Significant (p < 0.001) predictors of dissatisfaction at one year included the pre-operative SF-12 mental component score, the co-morbidities of depression and pain in other joints, and the six-month SF-12 score. The most significant independent predictor of dissatisfaction at 1 year was poor improvement in Oxford Knee Score pain element at 6 months. Patient expectations were highly correlated with satisfaction.

Satisfaction following TKR is multifactorial. Managing patient expectations and mental health may reduce dissatisfaction rates. However, the most significant predictor of dissatisfaction is a painful total knee replacement.

Patient expectations and their fulfilment are an important factor in determining patient-reported outcome and satisfaction of hip (THR) and knee replacement (TKR). The aim of this prospective cohort study was to examine the expectations of patients undergoing THR and TKR, and to identify differences in expectations, predictors of high expectations and the relationship between the fulfilment of expectations and patient-reported outcome measures. During the study period, patients who underwent 346 THRs and 323 TKRs completed an expectation questionnaire, Oxford score and Short-Form 12 (SF-12) score pre-operatively. At one year post-operatively, the Oxford score, SF-12, patient satisfaction and expectation fulfilment were assessed. Univariable and multivariable analysis were performed. Improvements in mobility and daytime pain were the most important expectations in both groups. Expectation level did not differ between THR and TKR. Poor Oxford score, younger age and male gender significantly predicted high pre-operative expectations (p < 0.001). The level of pre-operative expectation was not significantly associated with the fulfilment of expectations or outcome. THR better met the expectations identified as important by patients. TKR failed to meet expectations of kneeling, squatting and stair climbing. High fulfilment of expectation in both THR and TKR was significantly predicted by young age, greater improvements in Oxford score and high pre-operative mental health scores. The fulfilment of expectations was highly correlated with satisfaction.

Systemic inflammatory conditions frequently affect both the small joints of the hand and the eye. Uveitis and scleritis is common in this group and patients are required to apply regular eye drops. Ophthalmic conditions are also common in patients with Osteoarthritis of the thumb CMCJ who have weakness and pain on pinch grip. Poor compliance with therapy due to difficulties in administering eye drops can cause permanent ocular and visual morbidity.

A laboratory based biomechanical study was performed to replicate the pinch forces applied to the 20 most frequently used eye drops. The minimum force required to disperse a drop from a full bottle held in the inverted vertical position was assessed on three occasions by placing the eye drop bottles between a finger and thumb simulator attached to a load cell. Recordings of two bottle types were repeated using 2 different ergonomic ‘aids’ produced by the pharmaceutical companies.

The data was compared to published data for pinch strength of general ophthalmology patients and to collected data for patients with thumb base CMCJ osteoarthritis.

Compressive forces varied significantly between different eye drop types from 6.4 newtons (Systane) to 20.8 newtons (Minims). The highest values were found in minims which is the most frequently used eye drop. The use of the Xalatan aid appeared to increase the force required from 7.7(+/−0.64) to 12.9 (+/−3.93) but this difference did not reach significance, p=0.08, the results for Allegan aid showed no significant difference 11.3(+/−0.91) to 9.9 (+/−1.18)p=0.17. The forces required to disperse a drop increased as the bottles became less full.

Forces required to disperse eye drops from bottles varies considerably and can be greater than the maximum pinch pressure of some patient groups which may be a cause of poor compliance. Some ergonomic aids designed to help with the application of drops do not appear to reduce the forces required.

We have reviewed the complication rate over a ten year period for removal of screws placed for slipped capital femoral epiphysis (SCFE) and have surveyed the views of orthopaedic surgeons with an adult hip practice in Scotland on leaving the metalwork in situ. Whilst screw removal is favoured by many orthopaedic surgeons, a recent review of the literature reported that the complication rate for removal of implants placed for SCFE was 34%.

Between 1998 and 2007 84 patients had insertion of screws for SCFE. Of these 54 patients had screws removed, 51 of these records were available. The median duration between insertion and removal of screws was 2 yrs 7 months. Of the 51 children, overall five (9.8%) had complications - three (5.9%) major and two (3.9%) minor. Two screws could not be removed; one patient sustained a fracture after screw removal and two developed an infection.

We assessed the attitudes of adult hip surgeons on this topic using an electronic questionnaire which was completed by 29 out of 40 recipients. 78.6% of respondents support routine removal and 21.4% favour leaving the screw permanently in place. 82.2% had needed to remove metalwork from a hip requiring arthroplasty in a patient whose metalwork was inserted during childhood; and described their experience of this including the complications encountered.

We have identified a lower complication rate following screw removal inserted for SCFE than in published series. Most adult hip surgeons support routine removal once the physis is closed but studies regarding the long-term outcome of retained orthopaedic implants are needed since even with this lower complication rate the question of routine removal remains unclear.

Patients undergoing total knee arthroplasty (TKA) experience significant postoperative pain. This impedes early mobilization and delays hospital discharge. A prospective audit of 1081 patients undergoing primary TKA during 2008 was completed. All patients followed a programme including preoperative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, postoperative high volume ropivacaine boluses with an intra-articular catheter and early mobilization. Primary outcome measure was length of stay. Secondary outcomes were verbal analogue pain scores on movement, time to mobilization, nausea and vomiting scores, urinary catheterization for retention, need for rescue analgesia, range of motion at discharge and six weeks postoperatively. The median day of discharge was postoperative day four. Median pain score on mobilization was three for first postoperative night, day one and two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterization rate was 6.9%. Rescue analgesia was required in 5% of cases. The median day of discharge was postoperative day four. Median range of motion was 85° on discharge and 93° at six weeks postoperatively. This comprehensive care plan provides satisfactory postoperative analgesia allowing early safe ambulation and discharge.

There is limited literature regarding the outcome of hip and knee arthroplasty (THR and TKR) in the Super-Elderly (≥80yrs). The aim is to compare the outcome of THR and TKR in the Super-Elderly with a standard-age cohort of patients. From January 2006 to August 2008; 1290 TKR and 1344 THR were performed at the study institute. Comorbidity, length of stay, patient satisfaction, Oxford knee or hip scores, and SF12 scores were recorded prospectively. The Oxford Score and SF12 were recorded at one year. The mode age range was 65-74yrs for TKR (n=492) and THR (n=495), deemed the standard cohort. 185 TKR and 171 THR were performed in the Super-Elderly. Outcome in this cohort was compared to the standard.

The standard cohort had a greater absolute improvement in Oxford knee scores (15.8 and 14.7.p=0.2). Improvement of absolute Oxford hip scores revealed no difference (20.0 and 20.2.p=0.8), but the Super-Elderly had a greater improvement in pain components (11.0 vs.12.0.p=0.05) with a lesser improvement of the functional components (9.0.vs.8.2.p=0.05). There was a greater improvement in the physical component of the SF-12 score in the standard cohort for both TKR and THR (10.6.vs.7.9.p=0.05 and 14.4.vs.10.4.p=<0.01, respectively).

No significant difference was seen in comorbidities, but the Super-Elderly patients had a longer hospital stay for TKR (6.2.vs.8.3.p=0.01) and THR (5.9.vs.9.0.p=0.01).

The Super-Elderly were more satisfied with their surgery (p=0.05).

Super-Elderly patients have comparable outcomes to their younger counterparts and are more satisfied with their surgery, but they may require a longer length of stay.

Infection of total hip replacement is a disaster, with a quoted incidence of 1-2%. Anecdotal evidence has led many to believe that aggressive management of early infection following hip replacement can prevent failure. As yet, there is no firm evidence. We have reviewed 20 consecutive cases of early infection (<6 weeks post-op) treated by open debridement and washout.

The cases were 19 total hip replacements and 1 hemiarthroplasty. All had prolonged wound I discharge and elevated inflammatory parameters. No differentiation was made between superficial and deep infections because at this stage the deep fascia had not yet healed. 13 cases had positive cultures (6 staphylococcus, 5 coagulase negative staphylococcus, 1 coliform, 1 streptococcus). 7 cases had either negative cultures or mixed growth, but were clinically infected. Intravenous antibiotics were given after debridement until the wound healed.

Thirteen (65%) were clinically and radiologically free of infection at a minimum of 1 year follow-up. Failure to eradicate infection was treated by revision surgery and this was performed in 4 patients. Of the remaining 3 patients, one underwent excision arthroplasty, one was infected but refused surgery and one was infected but medically unfit for surgery. There is no control group, but it would be ethically very difficult to organise. As expected, we had small numbers and a mixed collection of organisms, so statistical comparisons are limited.

In conclusion, these patients represent a very high risk of ongoing infection. 13 hips (65%) had no evidence of ongoing infection at a minimum of 1 year follow up. This study supports aggressive surgical management of early infection following hip replacements. Eradication of early infection can be achieved without removal of the implant.

We aimed to investigate the treatment and outcome of patients over 65 years of age with tibial Pilon fracture. Patients were treated by primary open reduction and internal fixation or external fixation (EF) as determined by local soft tissue conditions. Patient course, incidence of radiological osteoarthritis and functional outcome using the SF-36 questionnaire were recorded. All patients were evaluated serially until discharge from final follow-up. The mean follow-up time was 28 months (12-45). Statistical analysis was performed using Analyse-it(tm) software for Excel.

In total 25 patients were studied. Two patients died before completion of treatment and were excluded from the final analysis. Therefore, 23 patients (10 male) were included with a mean age of 70.9 years (range 66-89) and a mean ISS of 10.25 (range 9-22). There were 4 grade IIIb open injuries.

Three patients suffered superficial tibial wound infection. Two patients underwent early secondary amputation due to deep bone sepsis within 8 weeks of injury. One patient in the ORIF group underwent primary arthrodesis, which was subsequently revised due to non-union. 3 patients underwent secondary bone grafting to enhance healing, performed at 2, 6 and 9 weeks. 2 patients with metal work failure underwent subsequent revision of ORIF and progressed to union; the mean time to union was 33.8 weeks. At final follow-up 7 (28%) patients had radiological features of osteoarthritis but none had symptoms severe enough to warrant ankle arthrodesis. There were significant differences from the USA norm in physical function score, role physical score, and physical component score, (p< 0.01).

We aimed to quantify the health related quality of life in a series of patients suffering a variety of different tibial injuries. Patients with previous tibial injury, randomly selected from our trauma database, who successfully completed their entire course of treatment at our institution, were recalled for final assessment. Mean time to final follow-up was 37.4 months. Statistical analysis was performed using SPSS computer software.

Overall, 130 patients were evaluated. There was no significant difference in the self-care dimension between the groups. Psychological problems were common in patients with IIIb and IIIc fractures, as well as amputees, with the highest incidence in those with IIIc fractures. Patients who had undergone amputation and those with IIIb open fractures reported problems with mobility significantly more frequently than those who had IIIc type injuries. However, this could be partially attributed to the significant difference in mean age between groups, with patients sustaining IIIc injuries being younger (31.9 vs 46.9). Patients with IIIb and IIIc type fractures reported significantly more problems with pain compared with those who had undergone amputation. Interestingly, patients who had undergone fasciotomy reported pain as frequently as amputees. Regarding the VAS, only patients with closed fractures reported significantly different scores from the mean of all the other groups.

These data represent the health related quality of life of patients having suffered the full spectrum of tibial injury and should be considered when determining the treatment options for these patients.

Primary arthroplasty may be denied to very elderly patients based upon the perceived outcome and risks associated with surgery. This prospective study compared the outcome, complications, and mortality of total hip (TKR) and total knee replacement (TKR) in a prospectively selected group of patients aged ≥ 80 years with that of a control group aged between 65 and 74 years. There were 171 and 495 THRs and 185 and 492 TKRs performed in the older and control groups, respectively. No significant difference was observed in the mean improvement of Oxford hip and knee scores between the groups at 12 months (0.98, (95% confidence interval (CI) −0.66 to 2.95), p = 0.34 and 1.15 (95% CI −0.65 to 2.94), p = 0.16, respectively). The control group had a significantly (p = 0.02 and p = 0.04, respectively) greater improvement in the physical well being component of their SF-12 score, but the older group was more satisfied with their THR (p = 0.047). The older group had a longer hospital stay for both THR (5.9 versus 9.0 days, p < 0.0001) and TKR (6.2 versus 8.3 days, p < 0.0001). The rates of post-operative complications and mortality were increased in the older group.

Introduction: The health benefits of physical exercise are well recognised. In recent years the department of health has been encouraging the UK population to exercise more. We aimed to determine if there was any change in the number and pattern of sport and exercise related injuries attending a city Emergency Department (ED) over the past two decades.

Methods: We undertook a prospective comparative study of patients attending an ED over two time periods: Aug 85 – April 86 and Aug 04 – April 05. All identified patients had a standardised proforma inserted into their notes which was prospectively completed by the attending clinician at the time of consultation.

Results: We observed a 35% increase in sporting injuries over the 19 year period (1000 injuries out of 37036 new patients vs 1351 out of 37526, p< 0.0001). The total number of new patients attending the ED remained unchanged during this time. Males remain the majority of patients with sports injuries (86%). We noted a change in age distribution with a relative increase in patients under 16 yrs (p< 0.0001), a decrease in 16–24 yrs (p=0.0002) and an increase in patients over 40yrs (p< 0.001). There was a significant reduction in patients presenting out of hours and a significant increase in the delay to presenting at ED with the majority of patients presenting over 4 hours after the injury. Football remains the commonest cause of sports injury accounting for half of all sports injuries, followed by rugby but there has been a relative decline in skiing, martial arts jogging and squash as a cause of injury and a significant increase in injuries due to snowboarding, skateboarding and basketball.

Conclusion: There has been an increase in the number of sports injuries attending hospital, which may represent a general increase in sport and exercise participation among our population.

Computer-assisted surgical techniques in knee replacement procedures have been shown to increase the accuracy of implant positioning and reduce the incidence of alignment and soft-tissue balancing “outliers”. The use of this technology as a training tool is less widely reported. However, the recent implementation of the EWTD 48-hour working week for junior doctors has focussed attention on the issues of surgical training and experience. Recent evidence from trainee logbooks has shown a significant downward trend in operative exposure and this is forcing changes in the principles of how training should be delivered. Trainees are actively required to demonstrate operative competence in order to progress but are increasingly faced with limited opportunities to acquire these skills. On the other hand, trainers also face difficulties with the prospect of supervising less accomplished trainees which raises ethical issues of patient protection. We present a trainee’s perspective of experience gained in a unit routinely using computer-assisted technology and highlight the potential to enhance the learning process.

Navigation systems provide constant visual and numerical feedback via a computer simulated interpretation. Initially this displays relevant functional anatomy, helps in the identification of anatomical landmarks and demonstrates sagittal and coronal plane deformities which can be difficult to accurately assess “by eye”. Computer-assisted systems have the benefit of displaying only bony anatomy which improves visualisation. This can then be compared to the palpable, clinical deformity on the table. The geometry of the native knee is also made clear with the navigation system leading to a better understand of the objectives of TKR. There are some aspects of the biomechanics of the knee which are difficult to appreciate, such as the changes in varus-valgus alignment during flexion and extension. This may be very subtle and difficult to pick up manually but can look quite dramatic on the computer.

The position of cutting jigs which are held to the bone by pins can be altered by inadvertently lifting or hanging on them with the saw, when making the bone cuts. Additionally the cut can be altered by advancing the cutting block closer to the bone, for example if cutting the tibia with a posterior slope. Both these effects can be quantified by using the navigation tools to confirm the cut that has been made. Trainers can have the benefit of seeing the alignment and confirming the cuts made by a trainee without having to get closely involved with the operation. Cementation technique is also open to scrutiny with the ability to compare pre and post cementation alignment.

The positive feedback obtained from computer assisted surgery is educational to the trainee, by giving an undisputable computer generated graphic of what they are doing during the different stages of total knee arthroplasty. It also shows what has been achieved at the end of the procedure. This can give both the trainer and trainee more confidence in the procedure and ensures patient safety.

Introduction: Foot and ankle involvement in rheumatoid arthritis is common. Pain and disability secondary to planovalgus deformity and the arthritic process are difficult to control with conservative measures. Arthroplasty of the ankle is associated with high failure rates and does not completely correct the deformity. Arthrodesis of the hindfoot is a good option to alleviate pain, correct the deformity and improve functional ability, however has not been well reported in the literature.

Aims: To determine change in quantitative measures of patient health, pain and functional ability following hindfoot arthrodesis in patients with rheumatoid arthritis, and to assess patient satisfaction postoperatively.

Methods: 24 consecutive additive hindfoot arthrodeses were performed by a single surgeon on 22 patients with rheumatoid arthritis. Patients were assessed preoperatively using the Short Form-12 Health Survey (SF-12), Manchester-Oxford Foot Questionnaire (MOXFQ) and pain scores. These assessments were repeated at 6 and 12 months postoperatively, with an additional satisfaction questionnaire.

Results: There was a marked and sustained improvement in the post-operative SF-12, MOXFQ and pain scores, with 71% of patients reporting no pain at 12 months. 19 out of 22 patients reported being satisfied or very satisfied with the operation. Bony union was achieved in all patients, both on clinical and radiological criteria. Most patients returned to normal footwear, some with slight modification to facilitate a more normal gait cycle.

Conclusions: This study shows that additive hindfoot arthrodesis can be a very effective procedure in the management of moderate to severe ankle and hind-foot disease in rheumatoid arthritis. Patients should be counselled regarding the considerable recovery period; however significant improvement in the patient’s general health, foot function and pain can be expected.

This prospective study assessed the effect of social deprivation on the Oxford hip score at one year after total hip replacement. An analysis of 1312 patients undergoing 1359 primary total hip replacements for symptomatic osteoarthritis was performed over a 35-month period. Social deprivation was assessed using the Carstairs index. Those patients who were most deprived underwent surgery at an earlier age (p = 0.04), had more comorbidities (p = 0.02), increased severity of symptoms at presentation (p = 0.001), and were not as satisfied with their outcome (p = 0.03) compared with more affluent patients. There was a significant improvement in Oxford scores at 12 months relative to pre-operative scores for all socioeconomic categories (p < 0.001). Social deprivation was a significant independent predictor of mean improvement in Oxford scores at 12 months, after adjusting for confounding variables (p = 0.001). Deprivation was also associated with an increased risk of dislocation (odds ratio 5.3, p < 0.001) and mortality at 90 days (odds ratio 3.2, p = 0.02).

Outcome, risk of dislocation and early mortality after a total hip replacement are affected by the socioeconomic status of the patient

Infection following hip arthroplasty although uncommon can have devastating outcomes. Obesity, defined as a BMI of ≥ 30, is a risk factor for infection in this population. Coagulase negative staphylococcus aureus (CNS) is the commonest causative organism isolated from infected arthroplasties. This study was performed to determine if there has been a change in the causative organisms isolated from infected hip arthroplasties and to see if there is a difference in obese patients.

Data on all deep infection following primary and revision hips was obtained from the surgical site infection register from April 1998 to Nov 2007. Case notes were reviewed retrospectively. There were 49 patients with 51 infected arthroplasties; 25 infected Primary THAs and 26 infected Revision THAs. We found a female preponderance in the infected primary and revision THAs (n=30). 63.2% of all patients had a BMI of ≥ 30, compared to only 34.7% of the non infected population (p< 0.0001). Over the period studied, CNS was the most common organism isolated (56.8%) followed by mixed organisms (37.2%) and staphylococcus aureus (25.4%). Multiple organisms were found exclusively in obese patients. In more than half of cases the causative organisms were resistant to more than two antibiotics.

This study shows that over the last 10 years, CNS continues to be the most frequently isolated organism in infected hip arthroplasties. Multiple organisms with multiple antibiotic resistances are common in obese patients. On this basis we recommend that combination antibiotic therapy should be considered in obese patients.

Up to 20% of patients are not satisfied with the outcome following total knee replacement (TKR). This study investigated the pre- and post-operative predictors of dissatisfaction in a large cohort of patients undergoing TKR. We assessed 1217 consecutive patients between 2006 and 2008 both before operation and six months after, using the Short-form (SF)-12 health questionnaire and the Oxford Knee Score. Detailed information concerning comorbidity was also gathered. Satisfaction was measured at one year when 18.6% (226 of 1217) of patients were unsure or dissatisfied with their replacement and 81.4% (911 of 1217) were satisfied or very satisfied. Multivariate regression analysis was performed to identify independent predictors of dissatisfaction. Significant (p < 0.001) predictors at one year included the pre-operative SF-12 mental component score, depression and pain in other joints, the six-month SF-12 score and poorer improvement in the pain element of the Oxford Knee Score.

Patient expectations were highly correlated with satisfaction. Satisfaction following TKR is multifactorial. Managing the expectations and mental health of the patients may reduce dissatisfaction. However, the most significant predictor of dissatisfaction is a painful total knee replacement.

We compared the outcome of arthroscopic repair of the rotator cuff in 32 diabetic patients with the outcome in 32 non-diabetic patients matched for age, gender, size of tear and comorbidities. The Constant-Murley score improved from a mean of 49.2 (24 to 80) pre-operatively to 60.8 (34 to 95) post-operatively (p = 0.0006) in the diabetic patients, and from 46.4 (23 to 90) pre-operatively to 65.2 (25 to 100) post-operatively (p = 0.0003) in the non-diabetic patients at six months. This was significantly greater (p = 0.0002) in non-diabetic patients (18.8) than in diabetics (11.6). There was no significant change in the mean mental component of the Short-Form 12, but the mean physical component increased from 35 to 41 in non-diabetics (p = 0.0001), and from 37 to 39 (p = 0.15) in diabetics. These trends were observed at one year.

Patients with diabetes showed improvement of pain and function following arthroscopic rotator cuff repair in the short term, but less than their non-diabetic counterparts.

Introduction: Infection following hip arthroplasty although uncommon can have devastating outcomes. Obesity, defined as a BMI of ≥ 30, is a known risk factor for infection in this population. Coagulase negative Staph Aureus (CNS) is the commonest causative organism isolated from infected arthroplasties. This study was performed to determine if there has been a change in the causative organisms isolated from infected hip arthroplasties and to see if there is a difference in obese patients.

Methods: Data on all deep infection following primary and revision hips was obtained from the surgical site infection register from April 1998 to November 2007. All case notes were reviewed retrospectively.

Results: There were 49 patients with 51 infected arthroplasties; 25 infected Primary THAs and 26 infected Revision THAs. We found a female preponderance in the infected primary and revision THAs (n=30). 65.3% of all patients had a BMI of ≥ 30. Over the period studied, Coagulase negative Staph was the most common organism isolated (56.8%) followed by mixed organisms (37.2%) and Staph Aureus (25.4%). Multiple organisms were found exclusively in obese patients. In more than half of cases the causative organisms were resistant to ≥ 2 antibiotics.

Discussion: This study shows that over the last 10 years, CNS continues to be the most frequently isolated organism in infected hip arthroplasties. Multiple organisms with multiple antibiotic resistances are common in obese patients. On this basis we recommend that combination antibiotic therapy should be considered in obese patients.

Introduction: Limb lengthening with external fixators has been associated with many complications including pin tract infections, damage to neurovascular structures, joint stiffness, delayed consolidation, and pain. These can lead to a detrimental functional outcome and psychological upset with a consequent negative impact on patients’ quality of life. The Intramedullary Skeletal Kinetic Distractor (ISKD) is a fully implantable device that may offer a better functional and psychological outcome. The aim of this study therefore was to evaluate the functional and psychological outcome in a series of patients undergoing femoral lengthening with the ISKD.

Methods: Twenty patients underwent intramedullary lengthening via ISKD. Eighteen of these had lost femoral bone length secondary to trauma, and two were affected by congenital limb shortening (one had both femora lengthened at different time intervals). Patients completed Toronto Extremity Salvation Score (TESS) (to evaluate subjective physical disability), and Short Form 36 (SF36) questionnaires pre and post-operatively.

Results: Patients’ post operative TESS scores demonstrated a significant improvement in patient perception of their physical disability. SF36 responses after surgery improved in several areas including physical functioning, role limitation due to emotional problems, social functioning, mental health, pain experienced and change in health; the greatest improvements seen in role limitation due to emotional problem, social functioning, mental health, pain, and change in health.

Discussion: These results indicate that limb lengthening with the ISKD improves patients’ overall quality of life decreasing post operative pain, improving their social functioning and mental health, overall ISKD lengthening improves how the patients perceive their health and physical disability.

Lumps of the foot present relatively infrequently to the orthopaedic service. There have been very few published studies looking at presenting characteristics or the differential diagnosis of such lesions. We report our experience of foot lumps treated surgically looking at the patient demographics, presenting characteristics, diagnoses encountered and the diagnostic accuracy of the surgeon. All patients who underwent excision or biopsy of a foot lump over a period of 4 years were studied; 101 patients were identified. Average age was 47.3 years (range 14–79); there was a significant female preponderance with 73 females and 28 males (p< 0.0001). Pain was the single most common presenting complaint followed by footwear problems. Only three patients attended because of cosmetic reasons and neurological symptoms were very rare with only one patient complaining of paraesthesia. Certain lesions were more commonly encountered in specific zones of the foot. 32 different histological types were identified, ganglion cysts were the most commonly encountered lesions and there was only one malignant lesion encountered in this study. Only 58 out of the l01 lumps were correctly diagnosed prior to surgery.

We have shown that there are a wide variety of potential diagnoses, which have to be considered when examining a patient with a foot lump. There is a low diagnostic accuracy for foot lumps and therefore surgical excision and histological diagnosis should be sought if there is any uncertainty.

Despite the increase in numbers of the extreme elderly, little data is available regarding their outcome after surgery for fracture of the hip. We performed a prospective study of 50 patients aged 95 years and over who underwent this procedure. Outcome measures included morbidity, mortality, hospital stay, residential and walking status. Comparison was made with a control group of 200 consecutive patients aged less than 95 years who had a similar operation. The mortality at 28 and 120 days was higher (p = 0.005, p = 0.001) in the patients over 95 years. However, the one-year cumulative post-operative mortality was neither significantly different between the two groups (p = 0.229) nor from the standardised mortality rate for the age-matched population (p = 0.445). Predictors of mortality included the ASA grade, the number of comorbid medical conditions and active medical problems on admission. Patients over 95 were unlikely to recover their independence and at a mean follow-up of 29.3 months (12.1 to 48) 96% required permanent institutional care.

In-vitro evidence suggests that wear debris can alter osteoblast function resulting in decreased bone matrix production and negative remodelling balance. FRZB encodes for Secreted Frizzled-Related Protein 3 which may play a role in bone formation and osteoarthritis. This study was undertaken to investigate whether the recently described single nucleotide polymorphisms (SNPs) at positions [+6] and [+109] of the FRZB gene are associated with osteolysis after THA.

Genomic DNA was extracted from 481 North European Caucasians at a mean of 12 years following cemented THA for idiopathic osteoarthritis. The control group consisted of 267 subjects and the osteolysis group 214 subjects. The [+6] and [+109] FRZB SNPs were genotyped using standard techniques.

For the FRZB [+6] SNP, the rare T allele was significantly over-represented in control versus the osteolysis group (χ² test for trend, p=0.02,). The odds ratio for osteolysis associated with carriage of the [+6] T-allele versus the [+6] C-allele was 0.58 (95%CI 0.36 to 0.94), p=0.03. The odds ratio for osteolysis associated with carriage of the [+109] G-allele versus the [+109] C-allele was 0.66 (0.38 to 1.12), p=0.15. A number of covariates have previously been described in this cohort and after adjustment for the effects of these covariates, the odds ratio for osteolysis with carriage of the [+6] T-allele was 0.69 (0.42–1.16).

We found that the FRZB [+6] T-allele is less common in subjects with osteolysis after THA versus controls, suggesting that allelic variants of genes associated with bone formation pathways may have a role in modulating the risk of osteolysis. However its loss of significance after correction for other factors suggests an interaction between this allele and other risk factors in osteolysis.

We performed a prospective audit to assess radiological and clinical sequelae of using injectable calcium sulphate in the management of distal radial fractures.

All patients in a 4-month period who were treated with injectable calcium sulphate for distal radial fracture were included in the audit. Initial data was collected on demographics; AO classification and degree of deformity; method of fixation and surgical complications. Follow up consisted of clinical and radiological assessment of fracture healing at standard fracture clinic intervals with a final assessment of subjective functional recovery. 16 patients were included in the audit, all of whom were followed up for a minimum of 8 weeks. We observed a low incidence of secondary displacement, and did not observe the problem of increased pain and erythema that has been observed with other bone graft substitutes.

We conclude that injectable calcium sulphate is a useful adjunct to conventional management of these fractures that is safe, helps maintain fracture reduction and is not associated with product specific complications.

Introduction and Aims: The dilemma to retain or sacrifice the posterior cruciate ligament in a primary total knee arthroplasty continues to be an area of discussion. A randomised clinical trial was performed comparing clinical, radiographic and quality of life outcomes between patients receiving a posterior cruciate sparing versus posterior cruciate substituting knee implants.

Method: A multi-centred, prospective, randomised, blinded, clinical trial was performed to compare posterior cruciate retaining (CR) versus posterior cruciate substitution (PS) in osteoarthritic patients with an intact posterior cruciate ligament, undergoing total knee arthroplasty using the AMK^® (Depuy^®, Warsaw, Indiana) component. One hundred and fifty-two patients were randomised to receive one of the two devices. Patients were evaluated pre-operatively, at three, six, 12 months and annually thereafter. Patient demographics, radiographs, and multiple validated, outcome measures (WOMAC, SF-12, the Knee Society Clinical Rating System, and a stair climbing test) were evaluated. Patients and assessors were blinded to the implant design.

Results: One hundred and fifty-two patients were randomised at three centres; 72 in the CR group and 80 in the PS group. One patient was revised due to instability. Average follow-up was 5.14 years (range 2.97–6.99 years). There were no significant differences in baseline patient demographics between groups. There were no significant differences in outcome measures or radiographic findings. There were no significant differences in the Knee Society Clinical Rating System (CR- 159.18 versus PS- 156.49). There were no differences in knee extension at latest follow-up (CR- 1.02) and (PS- 1.10). There were no differences in knee flexion at latest follow-up (CR-111.00 ) and (PS- 113.61). No differences were noted in the WOMAC and SF-12 scores between the two groups.

Conclusion: In this prospective randomised clinical trial no significant differences involving radiographs and multiple outcome measures could be seen between a cruciate retaining versus a posterior stabilised total knee prostheses at a mean follow-up of 5.14 years. Long-term evaluation is necessary to comment on wear, osteolysis and implant longevity.

Aims: Prosthesis malpositioning and inadequate cement mantles have been shown to adversely affect outcomes in cemented total hip arthroplasty. Although this has been extensively studied and reported for anteroposterior (AP) radiographs, we have found a paucity of literature concerning lateral radiographs which this study addresses. Methods: We analysed radiographs of 100 patients (Group I) with cemented Charnley total hip replacements (52 ßanged, 48 round back) performed through the lateral approach to determine the relationship between stem positioning and cement mantles in both AP and lateral radiographs. The measurements were made by a single observer and the data was analysed using chi squared tests to compare categorical data. Results: The most common stem malpositioning was seen in the lateral radiographs with þfty þve percent of stems directed 4 or more degrees from anterior to posterior (A to P). In contrast on the AP radiographs 18% of stems were directed from medial to lateral (Varus) and 3% of stems were directed from lateral to medial (Valgus) 4 or more degrees. There was no relationship between the different malpositions. Adequate resection of the posterior femoral neck gave better alignment of the stem in the lateral radiograph (p< 0.001). The ßanged stems were signiþcantly more in varus as compared to round back stems (p< 0.01). Cement mantles were most often deþcient in Gruen zone 12. There was a strong association between sagittal malpositioning and deþcient zones 12 and 9 (p< 0.001). Conclusions: This study demonstrates that sagittal mal-positioning of the stem is most important and surgical technique has a signiþcant inßuence on the same.

Aim: We have reviewed the patients treated in our institution with vertical shear fractures of the pelvis and report on our treatment protocol and long term functional outcome. Methods: Between Jan 1993 and Jan 2002 patients with vertical shear fractures were identiþed. Data such as age, sex, aetiology, associated injuries, ISS, resuscitation requirements, transfusion requirements, ICU/HDU stay, treatment, urological injuries, systemic complications, neurological injury and mortality were recorded and analysed. Functional outcome assessment was performed using the following generic tools: Euro-qol 5D (EQ), SF36 v2 (Short form), SMFA, Majeed score and VAS. Results: Out of 380 pelvic ring injuries we identiþed 31 vertical shear fractures in 29 consecutive patients (4 female). The median ISS Score was 22. Motorcycle accidents were responsible for 27%. Injuries were identiþed in the chest (12 patients), abdomen (8 patients) and extremities (14 patients). Urethral injury was present in 9 patients. Ruptured viscus was identiþed in 3 cases. At presentation neurologic deþcit was present in 9 cases. Posterior ring was stabilised in 3(0–13) days. Systemic complications developed in 6 patients Ð ARDS in 4 patients and sepsis in 2 (6%). The mean follow up was 39 months. Functional outcome using the Majeed score revealed that 1/3 of the patients did fair. TheSF-36 v2 analysis, EQ 5-D revealed a moderate functional outcome. The SMFA and the visual analogue score also revealed similar outcomes. Conclusions: Prompt resuscitation and early temporarily stabilisation of the pelvic ring is essential. Sound reconstruction of the pelvic ring is not always associated with good results probably due to the extensive pelvic ßoor trauma as seen in this series of patients. Younger individuals seem to have a relatively better outcome when compared to the older age group.

The purpose of this study was to investigate the validity of exchange intramedullary nailing for the treatment of infected tibial non-union.

14 (10 male) patients with tibial fractures were treated in our institution with exchange nailing for infected tibial non-union. The mean age of the patients was 34.3 years (range 18–60) and the mean ISS was 17.5 (range 9–57). Seven fractures were originally open (grade IIIb). All patients had clinical and radiological evidence of non-union and in each case there was clinical and microbiological evidence of intramedullary infection. Following initial stabilisation, all the patients subsequently had an exchange intramedullary nail performed together with debridement and antibiotics. The mean time between original nailing and exchange nailing was 28 weeks. Antibiotics were then continued for a minimal period of 6 weeks, or longer as the clinical situation warranted. The average length of follow-up was 24 months following exchange nailing.

There were 7 positive cultures of MRSA, 4 of staph. aureus and in 3 cases multiple bacteria were grown from the samples. No further treatment was required following exchange nailing in 5/14 (35.7%) cases. 4 patients required further soft tissue debridement and a free flap to secure union. Of the remaining 5 patients, 1 required dynamisation, another required incision and drainage of peri-fracture abscess, the third patient needed iliac crest bone grafting which eventually resulted in union. The penultimate patient had numerous operations after the exchange nailing before finally uniting with bone morphogenic protein. Unfortunately the last patient developed overwhelming sepsis which necessitated below knee amputation. Overall, the mean time to union was 11.3 months (4–24).

In this series of patients the success rate of exchange nailing for septic tibial pseudarthrosis was 78.5% (11/14). We believe that exchange tibial nailing remains an effective method of treatment in the presence of deep bone sepsis.

We assessed patellofemoral joint function by combining the measurement of maximal isometric extensor torque at the knee with clinical and radiological measurements in order to calculate the patellofemoral contact force. Eighteen volunteers established the normal ranges of results and the reliability of the system. Of the 39 patients with a variety of knee problems, 29 had anterior knee pain, and all had a subsequent arthroscopy. Patients with anterior knee pain and lesions in the patellar cartilage had significantly reduced isometric contact forces, but those with normal patellofemoral cartilage had normal contact forces. Our method may be useful in providing an objective assessment of anterior knee pain and a quantitative means of monitoring its treatment.

The use of an osteocutaneous free fibular graft as a single-stage reconstructive procedure for composite tissue loss is increasingly common. Detailed anatomical study in cadavers of the blood supply to the graft demonstrates cutaneous arteries arising from the peroneal artery and then passing along the posterior surface of the lateral intermuscular septum. These vessels pierce the crural fascia and then ramify to supply the skin. Knowledge of the vascular anatomy of the skin overlying the fibula is essential to the success of the graft.