Weight-bearing is a known stimulus for bone remodelling and a reduction in weight-bearing is associated with reduced bone mineral density (BMD) in affected limbs post lower limb fracture. This study investigated short and long-term precision of a method for measuring relative left/right weight-bearing using two sets of identical calibrated scales. The effect of imbalance on BMD at the hip and on lower limb lean tissue mass (LLTM) was also assessed.

46 postmenopausal women, with no history of leg or ankle fracture, were measured three times whilst standing astride two scales (Seca, Germany). 34 of the participants were re-measured after 6 months by the same method. Bilateral hip and total body dual x-ray absorptiometry measurements were performed using a GE Lunar Prodigy (Bedford, MA). Precision errors in weight-bearing measures were calculated using the root mean square coefficient of variation (RMSCV%). The correlations at the first visit between left/right differences in weight-bearing and differences in BMD and LLTM were calculated.

The short-term RMSCV% for left and right weights were 4.20% and 4.25% respectively and the long-term RMSCV% were 6.91% and 6.90%. Differences in left/right weight-bearing ranged from 0 to 24% (SD 8.63%) at visit 1 and 0 to 30% (SD 10.71%) at visit 2. Using data from visit 1, the relationship between hip BMD differences and left/right weight-bearing differences were investigated, with no significant correlations found. However, a weak, but statistically significant correlation of r=0.35 (p=0.02) was found for differences in LLTM and left/right weight-bearing differences.

In conclusion, left/right weight-bearing measured using two scales is a precise method for evaluating differences in weight-bearing in the short and long-term. Differences in left/right weight-bearing in this population varied by up to 30%. Participants showed a high degree of consistency in their long-term balance in a natural standing posture. Inequalities in left/right weight-bearing did not correlate significantly with BMD at the hip, but demonstrated a weak but statistically significant correlation with lean tissue mass.

Introduction: There has been a substantial increase of Clostidium Difficile (C.difficile) in Europe over the last decade. This increased incidence of C.difficile has been attributed in part to the prophylactic use of antibiotics during orthopaedic and trauma surgery. The consequences of a C.difficile infection can be an increase in mortality, length of stay and cost of medical care. The mortality associated with C.difficile has been quoted to be up to 25% in frail elderly people and the cost of treating a single case of C. difficile infection has been estimated at 4500 Euros (£4000).

The antibiotic prophylaxis for orthopaedic and trauma patients undergoing metal work implantation was changed in our unit to specifically reduce the incidence of C.difficile. The aim of this study was to determine whether this change did reduce the incidence of post-operative C.difficile infections presenting on the orthopaedic ward. The secondary aim was to ensure that the change in prophylaxis did not increase the incidence of deep wound infections.

Method: The old prophylactic protocol involved a dose of Cefuroxime at induction, followed by two further doses post-operatively. The new protocol was a single dose of Gentamicin and Flucloxacillin or a single dose of Gentamicin and Teicoplanin (if MRSA positive or penicillin allergy) at induction. The incidence of C.difficile infection and deep wound infection were recorded for a six month period prior to the protocol change and for a six month period once the new antibiotic protocol had been established. Patients included into the study were those undergoing a primary arthroplasty of the knee or hip and patients undergoing metalwork implantation for a proximal femoral fracture.

Results: 1566 patients were included in the study. The overall rate of C.difficle infection reduced form 3.7% to 1.3% (p less than 0.005) after the prophylactic antibiotic protocol was changed. This was most marked in the trauma patients from 8% to 3% (p less than 0.05). There was no significant difference in the incidence of deep wound infections for the trauma patients (p equals 0.5) or the elective patients (p equals 0.7).

Conclusion: The change in antibiotic prophylaxis did significantly reduce the incidence of C.difficile in patients undergoing metalwork implantation and did not change the rate of deep wound infections.

Antero-posterior (AP) pelvis and lateral x-rays are routinely prescribed for the positional diagnosis of proximal femoral fractures, however; the usefulness of the lateral x-ray has not been previously presented in the literature. In addition, the clinical advantage of internally rotated AP views has also not been tested. This study aims to define the value of the lateral x-ray, and the internally rotated AP view, in the assessment and treatment planning of proximal femoral fractures.

X-rays from 359 consecutive patients with proximal femoral fractures were divided into: ‘un-positioned’ AP (greater trochanter overlying the lateral femoral neck), clear neck AP (internally rotated to show the lateral femoral neck), and lateral views. Three blinded reviewers independently assessed the x-rays in sequence and noted the positional diagnosis and displacement. This was then compared with the intra-operative diagnosis used as gold standard.

The addition of a lateral x-ray to an AP view significantly increased the rate of the correct diagnosis made by the reviewers when compared to an AP view alone, in intracapsular fractures only (p < 0.013), but not for extracapsular fractures (p = 0.27).

The use of clear neck AP views did not increase the rate of correctly diagnosing the type of fracture when compared to unpositioned AP views. This applies for both intracapsular (p = 0.57), and extracapsular fractures (p < 0.823).

Although orthopaedic rote dictates that every fracture should be visualised in two views, this study has shown with that for the majority of hip fractures one view is adequate and safe. The lateral x-ray is only required for intracapsular fractures that appear undisplaced on the AP view and should not be performed routinely. Specially positioned AP views are not required and should be avoided due to the unnecessary pain caused and the needless cost.

Introduction: The Polarus nail is used in the treatment of displaced surgical neck of humerus fractures, but has been reported to have a high hardware complication rate. A recent change to 5.3 mm “non-toggling” proximal locking screws has been introduced in an attempt to minimise these complications.

The aims of this study were to determine union rates and hardware complications, and to assess whether the “non-toggle” proximal locking option prevented screw back-out.

Methods: We performed a retrospective review of case notes and radiographs of consecutive patients treated with the 150 mm length Polarus nail for acute displaced surgical neck of humerus fractures at our unit between 1st May 2002 and 29th February 2008. All patients were followed up until fracture union.

Results: Forty-nine patients were treated with the Polarus nail during the study period. Eleven patients were lost to follow-up before fracture union, so were excluded. Median age of the patients was 72 years (range: 31 to 94 years). Mean time to surgery was 10.7 days (range: two to 25 days).

Thirty-six fractures (95%) went on to unite following treatment with the Polarus nail. Of the two fractures that failed to unite one had an infective non-union and the other developed avascular necrosis with non-union of the surgical neck.

Twelve patients (32%) developed post-operative hardware complications. In nine (24%) there was backing out of the proximal locking screws, but only two patients had symptoms requiring screw removal. In five patients (13%) the nail was prominent proximally, causing impingement. In one patient (3%) the proximal screws penetrated the gleno-humeral joint, although this was asymptomatic.

There was backing-out in six of the 21 patients (29%) in which the standard 5.0 mm proximal locking screws were used. This compared with three out of 14 patients (21%) in which the 5.3 mm “non-toggling” screws were used. The difference in the rate of screw backing-out between the two groups was significant (P = 0.0474, Fisher’s Exact test). In three patients a mixture of 5.0 and 5.3 mm screws was used.

Discussion: The Polarus nail provides a stable fixation to union when used for the treatment of displaced surgical neck of humerus fractures. It is associated with a high hardware complication rate (32%), however, this is asymptomatic in the majority of cases (60%). The 5.3 mm “non-toggle” proximal locking option was found to reduce the rate of screw back-out compared with the standard 5.0 mm screw. We recommend the use of this “non-toggling” screw option for proximal locking.

Introduction: Mönckeberg sclerosis or medial artery calcification (MAC) is a well known phenomenon associated with the diabetic and other altered blood parameters. However its consequence within the foot and specifically the 1st dorsal metatarsal artery has not previously been studied.

Materials and Methods: Nearly 1000 foot x-rays were studied over a nine month period in a busy District General Hospital to identify the prevalence of first dorsal metatarsal artery calcification. The electronic medical notes for all the patients were reviewed to confirm which patients were known to be diabetic. The patients with positive findings were then identified and their HbA1c, creatinine, and previous foot interventions recorded.

Results: 1.4% of the population studied had medial artery calcification of the 1st dorsal metatarsal artery. 93% were known diabetics and 100% had impaired glucose tolerance (a glucose plasma concentration of > 7.8mmol/l two hours post glucose loading). 79% have required previous podiatric care for foot ulceration and 64% had required surgical intervention for their diabetic feet. MAC has a high positive predictive value (92.9% (95% CI 69.2–98.7)) for diabetes, with a good specificity (99.9% (95%CI 99.4–100)) and low false positive rate (0.1% (05%CI 0.0–0.6)).

Discussion: Medial artery calcification in the first dorsal metatarsal artery is characteristic of impaired glucose metabolism, and if seen on routine x-ray should be an indication for screening of the patient. It should also be considered as a foot at risk sign in the established diabetic due to the high incidence of foot ulceration and need for surgical intervention in this group.

Conclusion: The prevalence of MAC seen on routine foot x-rays has been demonstrated in a large cohort of patients. The specificity and positive predictive value for diabetes has been calculated and the prevalence of these patients requiring surgical or specialist podiatric care recorded.

Introduction: Fractures of the tuberosity heal well irrespective of the treatment instituted. Fractures distal to the tuberosity have a high incidence of delayed union and non-union. This could be due to disruption of the vascular supply that enters the bone at the metaphyseal-diaphyseal region. It has also been reported that in these injuries, stress fractures occur at a different anatomic site that is more distal to acute fractures.

We present one of the largest reported series of such fractures in which we have explored the above statements.

Materials & Methods: A retrospective review of 300 closed fractures of the base of the fifth metatarsal- 268 were tuberosity fractures (group 1) and 32 were fractures distal to the tuberosity (group 2).

The patients were followed up in the outpatients clinic for a mean period of 2 months (group 1) and 16 months (group 2).

The distance of the fracture site from the proximal tip of the metatarsal was measured on the radiographs.

Results:

All group 1 fractures healed well following symptomatic management and none required surgical intervention.

Conclusion:

A standardized classification is important because there is great variability in the types of fractures and appropriate treatment.

The aim of this work was to define the tensile material properties of the glenoid labrum. Previous SEM studies of the labrum have observed three definitive layers, with a densely packed circumferentially orientated collagen core layer. The glenoid labrum from ten cadaveric shoulders were dissected out and divided into eight equal sections. Each section was cut to produce specimens from the core layer using a microtome and a specifically designed cryo-clamp resulting in uniform specimens with dimensions of 1mm x 1mm x 8mm. All of the tensile testing was performed within a controlled-environment unit of 38°C and 100% relative humidity. Each specimen was precycled to a quasi-static state to alleviate the effects of deep-freezing, prior to final testing. The elastic modulus was calculated for each specimen before and after a 5-minute period of stress relaxation and before failure initiation. The mean age of the specimens was 61 years (range 47–70). Load to failure was 2.7N (1.0–7.0). The mean modulus was 10.2MPa (3.0–22.3) before stress relaxation, 18.0MPa (5.8–36.7) immediately after stress relaxation and 22.3MPa (8.4–66.4) before failure initiation. The 1 and 2 o’clock specimens had lower moduli than the 4 and 5 o’clock specimens (p=0.01). These results can aid in explaining the differing pathologies encountered around the circumference of the labrum. The high moduli at the 4 and 5 o’clock positions may reflect the ability of this portion of the labrum to accommodate forces and thus resist anteroinferior subluxation. The lower moduli at the 1 and 2 o’clock positions suggest that this portion of the labrum is less apt to accommodate tension; this might explain the higher incidence of labral foramen observed in this area and the anatomical variant of the Buford complex.

Purpose: Many different rotator cuff repairs have been advocated in previous publications without experimental evidence. Our aim was to mechanically test the static tensile properties and cyclical loading to failure of a single row lateral anchor repair and a double row medial and lateral anchor repair.

Method: Fresh frozen cadaveric shoulders were mounted on a rig and a mini-open deltoid split used to visualise the supraspinatus. A standardised full thickness incision of 2 cms was made with a scalpel across the supraspinatus tendon. After the deltoid was repaired and specimens randomised, an arthroscopic rotator cuff repair was performed by the two senior authors in which the medial border of the tear was apposed to the lateral border using either a double or single row technique with a ‘Twinfix AB’ suture anchor. Once the repair had been performed, the gross specimens were dissected down to the rotator cuff musculature and the repair inspected. Those with associated cuff pathology were excluded from the experiment. Specimens were then mounted on a custom made rig to statically load each tendon simulating physiological loading of a repaired cuff defect in a post-operative 300 abducted position. The increase in tear size was then measured against time for 1 hour or to a point at which the mean tendon gap formation exceeded 5mm. Each specimen was then transferred to an Instron tensile testing machine to cyclically load to failure the supraspinatus musculotendinous unit. Each specimen was freeze clamped proximally in a specially designed clamp, whilst the humeral shaft was mounted at an angle of 300 of abduction.

Results: The two groups had a distinct difference in tensile properties with the single row fixation developing a 5mm gap in under 30 minutes. After 1 hour, the gap formed in the double row specimens was less than 5mm. In cyclical loading, the single row failed at a lower load compared with the double row. In some double row specimens the tendon failed mid substance above 250N, rather than at the anchor-suture or suture-tendon interface.

Conclusions: Our results suggest that the double row mattress technique has superior loading properties when tested with a simulated physiological load comparative to the normal post-operative setting.

Background: Relatively little is known about the risk factors for carpal tunnel syndrome (CTS) in the community. Previous studies have generally assessed smaller numbers of patients in specialist clinics, or in particular occupations. Therefore, we have performed a case-control study using the West Midlands General Practice Research Database.

Methods: Our cases were all patients with a recorded diagnosis of CTS; four controls per case were individually matched by age, sex and general practice. Information on constitutional, hormonal and musculoskeletal factors was extracted and analysed by conditional logistic regression.

Results: Our dataset included 3,391 cases; 2,444 (72%) were female, mean age at diagnosis was 45.8 years: and 13,564 matched controls. Multivariate analysis showed that the risk factors associated with CTS were previous wrist fracture (OR = 2.29, 95% CI: 1.67–3.12), rheumatoid arthritis (OR = 2.23, 95% CI: 1.57–3.17), osteoarthritis (OR = 1.89, 95% CI: 1.65–2.17), BMI (BMI 30–40, OR = 2.06, 95% CI: 1.79–2.38), diabetes (OR = 1.51, 95% CI: 1.24–1.84), the use of insulin (OR = 1.52, 95% CI: 1.06–2.18), sulphonylureas (OR = 1.45, 95% CI: 1.07–1.97), metformin (OR = 1.20, 95% CI: 0.84–1.72) and thyroxine (OR = 1.36, 95% CI: 1.08–1.70). Smoking habit, hormone replacement therapy, the combined oral contraceptive pill and oral corticosteroids were not associated with CTS.

Conclusions: Rheumatoid arthritis, wrist fracture, osteoarthritis, and an increased Body Mass Index were the most important risk factors for CTS that we identiþed. The combined oral contraceptive, hormone replacement therapy, prednisolone and smoking are not associated with CTS.

Background: Presently the aetiology of this common condition remains unclear. Previous research suggests that diabetes or epilepsy might increase the prevalence of the condition, but the evidence is inconsistent.

Methods: Our cases were all patients diagnosed with Dupuytren’s Disease, with two controls per case individually matched by age, sex, and general practice. Information on all diagnoses of diabetes and diabetic medication, and epilepsy and anti-epileptics was extracted. All analysis was adjusted for consulting behaviour to reduce ascertainment bias.

Results: There were 821 cases (1,642 controls), 588 (72%) of which were males. Mean age at diagnosis was 62 years. Prevalence = 0.2%. Diabetes was significantly associated with Dupuytren’s (OR 1.82). Insulin use was strongly associated with Dupuytren’s (OR = 4.33), as was metformin (OR = 3.67); the association was also present for sulphonlyureas (OR = 1.89). There was no association with epilepsy and Dupuytren’s (OR = 1.05). None of the treatments for epilepsy were associated with Dupuytren’s disease.

Conclusion:Diabetes is a significant risk factor for Dupuytren’s Disease. There is an increased risk for treated diabetes rather than diet controlled diabetes. Epilepsy and anti-epileptic medication are not associated with Dupuytren’s Disease. Ascertainment bias may explain the association observed in previous studies.

We set up a trial to test whether the KT1000 arthrometer would give consistent measurements of anteroposterior laxity when used by the same and different examiners on the knees of the same subjects on the same day. The results showed substantial inter- and intra-examiner variation in the measurements both of absolute displacement in single knees and of side-to-side differences between pairs of knees. This casts doubt on the reliability of the instrument when used to compare the results of different techniques for reconstructing injured cruciate ligaments.

The place and effectiveness of surgery for acromioclavicular dislocation is disputed. We have reviewed 29 patients all treated by an operation which holds the clavicle down to the coracoid process. This was effective in both acute and late cases, with rapid return to work, a low incidence of complications and no requirement for secondary procedures. We consider it to be the method of choice when operation is indicated.

The pathogenesis of slipped upper femoral epiphysis is unknown but the condition has been linked with various endocrine disorders. Nine patients with slipped epiphyses in association with primary juvenile hypothyroidism are presented. In all patients, slipping occurred or symptoms developed in the affected hip before the hypothyroidism was diagnosed. A generalised pathology was suggested by the absence of trauma (8 patients), by bilateral slipping (6 patients), and by obesity and short stature in all patients. All cases had delayed skeletal maturation and characteristic metaphysial changes were seen on their radiographs. The clinical diagnosis of juvenile hypothyroidism can be difficult but it merits consideration in patients who have a slipped upper femoral epiphysis in association with short stature, obesity, delay in skeletal maturity, or any one of these.