The poor reporting and use of statistical methods in orthopaedic papers has been widely discussed by both clinicians and statisticians. A detailed review of research published in general orthopaedic journals was undertaken to assess the quality of experimental design, statistical analysis and reporting. A representative sample of 100 papers was assessed for compliance to CONSORT and STROBE guidelines and the quality of the statistical reporting was assessed using a validated questionnaire. Overall compliance with CONSORT and STROBE guidelines in our study was 59% and 58% respectively, with very few papers fulfilling all criteria. In 37% of papers patient numbers were inadequately reported; 20% of papers introduced new statistical methods in the ‘results’ section not previously reported in the ‘methods’ section, and 23% of papers reported no measurement of error with the main outcome measure. Taken together, these issues indicate a general lack of statistical rigour and are consistent with similar reviews undertaken in a number of other scientific and clinical research disciplines. It is imperative that the orthopaedic research community strives to improve the quality of reporting; a failure to do so could seriously limit the development of future research

Purpose: Distal humeral fractures are often difficult injuries to treat. We hypothesise that more complex distal humeral fractures have unacceptable functional outcomes due to multi-factorial reasons.

Methods: 42 patients with AO/ASIF type B and C fractures of the distal humerus who were treated with open reduction and internal fixation over a six year period were included in the study. All patients were from a single district general hospital. 37 (88%) were clinically, radiologically, and functionally assessed for this study, with the remainder either lost to follow-up or expired.

Results: There were 21 type B and 16 type C fractures, all managed by open reduction and internal fixation. Various fixation techniques were utilised. These were performed by consultant surgeons in 14 cases and by surgeons in training in 23 cases. Average follow up was 38 months (range 22–54 months). The arc of elbow motion was 94 degrees (range 58–130), with an average extension deficit of 28 degrees (range 20–55) and an average flexion deficit of 32 degrees (range 15–45). The average arc of forearm rotation was 136 degrees (range 45–140), with an average supination of 68 (range 35–85) and an average pronation of 72 (range 45–90). The complications (n=20/37) included superficial skin infection (n=4), ulnar nerve neurapraxia (n=3), non-union of the humerus fracture (n=2), non-union of olecranon osteotomy site (n=1), intra-articular screw placement (n=1), loosened plate (n=1), loose/backed out screw (n=2), fixed flexion deformity (n=4) and mild elbow instability (n=2). Second surgery was performed in 24% (n=9/37), revision of metal work (n=2), bone grafting (n=2), anterior capsulectomy (n=4), and removal of screw (n=1).

Conclusions: Fractures of the distal humerus are often more complex than appreciated, and challenging to treat, with respect to fracture union and functional outcome. A generalist practice appears adequate for achieving bony union, but inadequate for obtaining low complication rates and functional outcomes. Our data suggest that such injuries may constitute a fracture group requiring the acute intervention by centres that have specific sub-specialisation and adequate rehabilitation facilities

Purpose: There are numerous papers from specialist arthroplasty centres outlining results of total knee arthroplasties but little information from outside these major centres. We carried out a review of a fixed bearing total condylar knee replacement used in Dunedin by a variety of surgeons for over 10 years.

Method: All patients who received a Duracon/PCA fixed bearing total knee replacement between 1992 and 1996 were assessed clinically, fluoroscopically and completed an SF12, WOMAC and IKSS questionnaire.

Results: At a mean 9.7 (8–12) years follow up, 126 (69.6%) patients were available for review and 46 (25%) were deceased. The average age was 72 years (52–88) and the primary diagnosis was osteoarthritis in 95% of the cases. There were 34% Charnley Grade A, 37% Grade B and 29% Grade C respectively.

The average IKS Knee score was 72 (23–97) and the functional score was 68 (0–100) with 74% experiencing none or only mild pain. The SF12 assessment revealed a mean physical score of 55 (14–99). Ninety per cent of patients were satisfied with their knee and 89% would have the operation again if required.

There was one operative death (PE), one deep infection, 3 PE’s, 3 DVT’s and 5 superficial infections. An MUA was required in 9 cases.

Eight knees were revised. Using ‘all revisions’ as an end point. The survival rate was 95.3% at 10 years.

Conclusion: These results suggest that knee replacements carried out outside specialist arthroplasty centres perform very well with a survival rate of the implant of 95% at 10 years.

Aim. Assess the incidence of Vitamin D deficiency from a cohort of new referrals to a general Paediatric Orthopaedic outpatient clinic and evaluate the relationship between Vitamin D deficiency and the diagnosis of radiological or biochemical nutritional rickets. Methods. We performed a retrospective case note and biochemistry database review of all new patients seen in an elective Paediatric Orthopaedic clinic in the year 2010, who had Vitamin D levels measured. Radiographs were reviewed by the senior author to determine the presence or absence of radiological rickets. Biochemical rickets was diagnosed if there was deficient Vitamin D (< 20 mcg/ml) and raised PTH. Results. We identified 115 children with a mean age of 10.95 years (95% CI 10.24 to 11.68). There were 63 females, 52 males and 51 were of Asian ethnicity. The mean vitamin D level was 18.27mcg/ml (95% CI 16.13 to 20.41). One hundred and three patients (88%) were found to have sub-optimum vitamin D levels. Although, males and those of Asian origin were more likely to be deficient, this was not statistically significant. Winter/Springtime blood sampling was statistically more likely to show Vitamin D deficiency than in Summer/Autumn. Three Asian female children (2.61%) had radiological rickets. The association between low Vitamin D levels (< 20) and radiological or biochemical rickets had poor positive predictive values PPV. Conclusion. Suboptimal Vitamin D levels are common in children presenting with vague limb or back pain, suggesting ‘growing pains’ might reflect deficiency. Vitamin D levels cannot be used as a screening test for the diagnosis of radiological or biochemical ‘rickets’ due to its poor Positive Predictive Value. Further research into Vitamin D requirement is necessary, particularly in relation to growth and age, as growth is not linear and Vitamin D requirement is likely to vary accordingly

The role of dual consultant operating (DCO) in general orthopaedics has not been researched; where it has shown benefit in other specialties, there is a lack of information on how DCO affects the surgeons themselves. We wanted to explore the potential effects of DCO on stress, as a foundation for further research to guide support for our surgeons. We conducted a survey among orthopaedic consultants around New Zealand, containing questions pertaining to the demographics of respondents, their experience with DCO, what the expected risks and benefits of DCO would be, and provided two high-stress exemplar clinical scenarios where respondents were asked to rate their expected stress level at baseline, with a more junior consultant present, and with a more senior consultant present. We found 99% of respondents had been involved in DCO at some point in their careers, yet only 38% were involved in DCO on at least a monthly basis. Perceived benefits greatly outweighed potential risks: 95% felt DCO would decrease their stress, 91% felt it improved intraoperative decision making, and 89% felt it provided more enjoyment at work and enhanced collegiality. A decrease in perceived stress was seen from baseline with a more junior consultant available and a greater decrease in stress seen with a more senior consultant, particularly in a complex elective setting. All respondents felt there is benefit in DCO and the vast majority feel it has positive effects on stress levels. In a time where burnout is more prevalent, using tools such as DCO could be an effective way to decrease stress, enhance enjoyment and collegiality — challenging some key contributors to burnout — and support mentorship with further skill acquisition. This research provides a good base to pursue further qualitative and quantitative research into the area, with a view to addressing barriers to provision of regular DCO

Introduction. This study aimed to assess the relationship between preparation times and operative procedures for elective orthopaedic surgery. A clearer understanding of these relationships may facilitate list organisation and thereby contribute to improved operating theatre efficiency. Methods. Two years of elective orthopaedic theatre data was retrospectively analysed. The hospital medical information unit provided de- identified data for 2015 and 2016 elective orthopaedic cases, from which were selected seven categories of procedures with sufficient numbers to allow further analysis - primary hip and knee replacement, spinal surgery, shoulder surgery (excluding shoulder replacement), knee surgery, foot and ankle surgery (excluding ankle replacement), Dupuytrens surgery and general orthopaedic surgery. The data analysed included patient age, ASA grade, operation, operation time, and preparation time (calculated as the time from the start of the anaesthetic proceedings to the patient's admission to Recovery, with the operating time [skin incision to skin closure] subtracted). Statistical analysis of the data was undertaken. Results. A total of 1596 procedures performed over the two year period were analysed. Preparation times for the different procedures were assessed, along with the relationship to the procedure complexity. Neither age nor ASA correlated strongly with preparation times. Spine procedures had greater preparation times than hip and knee arthroplasty. Greater uniformity in preparation times for hip and knee arthroplasty was seen across the anaesthetic group than operative times across the surgeon group. Discussion. Preparation times are just one aspect that may be evaluated with regard to theatre utilisation. This study did not address the theatre turn-over time between cases, which includes transfer of the patient from the admitting/pre-operative area into the theatre. Conclusion. Preparation times for elective procedures follow a pattern which may be used to inform list planning, with the potential for greater theatre efficiencies with regard to list utilisation and staff allocation

Introduction. A greater emphasis has been placed on fracture related infection (FRI) orthopaedic practice as a separate entity in recent years. Since the publication of the FRI consensus definition and guidelines, there has been an increase in the published literature on the topic and a move towards considering FRI as separate from general orthopaedic practice and as work that requires a more specialist approach. The aim of this study was to audit current FRI practice in the UK. Materials & Methods. Orthopaedic practice related to FRI in the UK was audited using a semi-structured questionnaire. Respondents were from a range of institutions, specialties and clinical roles to reflect the multi-disciplinary nature of treating FRI. The online tool SurveyMonkey was used to share the survey at the 2022 annual meeting of the British Limb Reconstruction Society. Twenty-one questions were asked in the following domains: scope of practice, theatre and clinic capacity, availability of the multidisciplinary team, renumeration for work and scope of FRI networks. Results. Of the 36 respondents, the majority (64%) worked in a major trauma centre. In the majority of cases, bone infection was managed by the limb reconstruction team (68%) although in most centres the wider team was often also involved including the general on call, the trauma team and the arthroplasty team. When referrals were made elsewhere, this was usually done to known individuals rather than established FRI networks. 80% of respondents said that there was a bone infection MDT in their unit and this usually met weekly. This usually included orthopaedics and microbiology but plastics in only 43% of cases and radiology in only 23% of cases. Most respondents said that the lack of funding and appropriate tariffs were the main barrier to FRI management locally (62%) and nationally (83%). Most respondents (83%) said that bone infection practice should be centralised. The overwhelming majority of this cohort (90%) said that patient outcomes would be improved by cases being managed in dedicated centres. Conclusions. There is variation in practice for the management of bone infection in the UK. This reflects the lack of clear national guidelines and the lack of established networks for management and onward referral. There is agreement that patient outcomes would be improved by more formal networks and specialised centres but also recognition that remuneration is a significant barrier to implementing change. This survey reflects practice in units with an interest in limb reconstruction and bone infection. Further work is needed to evaluate practice across district general hospitals in the UK and to build consensus around best practice and national strategies for improved care

Aims

Informed patient consent is a legal prerequisite endorsed by multiple regulatory institutions including the Royal College of Surgeons and the General Medical Council. It is also recommended that the provision of written information is available and may take the form of a Patient Information Leaflet (PIL) with multiple PILs available from leading orthopaedic institutions. PILs may empower the patient, improve compliance, and improve the patient experience. The national reading age in the United Kingdom is less than 12 years and therefore PILs should be written at a readability level not exceeding 12 years old. We aim to assess the readability of PILs currently provided by United Kingdom orthopaedic institutions.

Three developments in the last 10 to 15 years have made it necessary to review how we ensure rapid access to treatment of patients with disabling low back pain. Firstly, there would appear to be an increase in the numbers of patients seeking medical help for low back pain, whether due to increased patient expectation, or better reporting, or a true increase associated with the increasing sedentary nature of life, is uncertain. Secondly, there is the realisation that amongst the factors that encourage acute back pain to become chronic is being off work, and the sooner a diagnosis and treatment is started the more likely that chronicity will be prevented, so a long waiting time to be seen in a clinic is productive of disability. Thirdly, reorganisation of consultant services has created the spinal surgeon, who in return for being allowed to practice spinal surgery almost exclusively undertakes the load of patients referred with back pain, amongst whom lurk those with a surgically remediable problem. The effect has been that although waiting times for general orthopaedic patients have dropped, as general orthopaedic, or other specialist orthopaedic surgeons no longer see spinal cases, the specialist spinal surgeon is overwhelmed by a large group of patients with back pain for whom there is not a surgical solution. Unfortunately, there is a shortage of spinal surgeons, which is likely in the UK at any rate to get worse. Being overwhelmed with non-surgical back pain interferes with their ability to deal with surgical problems. It also does create a recruitment problem, as back pain is not seen as a rewarding or satisfying problem to treat. Triage is a method of screening patients into groups at an early stage, identifying those who might benefit from surgery, and fast tracking them, identifying those who will benefit from other management and tracking them accordingly. Pioneered in general orthopaedics by Robin Ling in Exeter, it has been developed in the hospital setting somewhat randomly, by dedicated enthusiasts, many of whom will be speaking today. The purpose of this meeting today is to hear about the various systems, their funding and organisation and location, the triage staff used, the investigations used in primary triage and the effect on hospital specialist waiting times, the safety and patient satisfaction. Is a multiplicity of systems best, is one better than another, why have some units achieved no waiting times for MRI, and others six months etc?. In 1994, the Clinical Standards Advisory Group produced two books, An epidemiological Review, largely the work of Gordon Waddell, and a second book on Back Pain, chaired by Professor Michael Rosen with, I suspect, considerable input from Professor Waddell and others. Many of us met them when they toured the country collecting facts about the treatment and management of back pain. It discusses back pain triage, and suggests that it can be done within the average GP Consultation time of 9 minutes. It deals with simple back ache, “red flags”, (we now have “yellow flags” denoting the psycho-social factors) nerve root pain, cauda equina and inflammatory disorders. It is to be noted that chronic back pain, is not alluded to in the diagnostic triage, but it is stated that 90% of simple back ache recovers in six weeks. Their management guidelines emphasise the value of physical therapy (manipulation and active exercises), but it will be noted that they are addressed to a group of patients, 90% of whom will recover in six weeks. Sadly, therefore, the effect of this very sensible document, in ignoring in the triage system the chronic patient, has in many cases directed therapy in general practice towards open access for patients who in any event will improve spontaneously. We must therefore address where triage should be, hospital, or GP level. Certainly a GP gatekeeper will remove the acute back pains that are going to get better soon anyway from attending hospital and in certain units, a separate fast track is provided for acute radicular problems (Acute Sciatic Clinics). Any successful triage system involving chronic back pain must be associated with treatment possibilities, and I shall briefly discuss these, although the main thrust of the afternoon will be the triage organisation itself. The session is designed to allow considerable audience participation, as it is hoped that information, comments and criticisms from the audience will allow us to subsequently produce a booklet, hopefully with support from our Professional Societies, describing what we feel is Best Practice in Back Pain Triage, which we hope, after appropriate circulation, will encourage Trusts and Community Health Groups to develop such units and ensure that back pain patients get a better deal

There are numerous papers from specialist arthroplasty centres outlining results of total knee replacement. This review was performed as there is little information on results in general orthopaedic centres. All patients received a Duracon/PCA replacement between 1992 and 1996. Patients were assessed clinically, fluoroscopically and completed SF12, WOMAC and IKSS questionnaires. At a mean of 6.7 (5–9) years follow up 93 (78%) were available for review. The average age was 70 years (52–88) with 58% being male. The primary diagnosis was osteoarthritis in 94.3%, with 41 %, 38% and 21 % being Charnley grades A, B and C respectively. The average IKS knee score was 71.4 (23–96) and functional score 70 (0–100), with 72.7% experiencing none or only mild pain. The SF12 assessment revealed a mean physical score of 38 (14–63) and mental score of 53 (25–67). There were 88.6% of patients satisfied with their knee and 92% would have the operation again if required. There were no deep infections or PE’s but there were 7 superficial infections and 2 DVT’s. A MUA was required in 8 patients. One patient retains a radiologically loose prosthesis at 8 years but had mild pain with stairs only, a WOMAC functional score of 85 and was happy. There was a best-case survival of 94.4% at 5 years. There were 5 knees revised in 5 patients and no revisions of the deceased patients, all surviving greater than 5 years from surgery. These results suggest that those in general orthopaedic centres are a little less reliable than those in specialist centres. However they are acceptable and patient satisfaction remains high

Introduction: More than 140,000 joint replacements are carried out in England and Wales per annum costing from £4000 to £7000 each (. 1. , . 2. ). Implant costs are relatively fixed but there are considerable variations in length of stay [LOS] following surgery. The National Audit office estimated that a reduction of two days per patient could save the NHS £15.5 million per year (. 2. ). A specialist orthopaedic ward for elective arthroplasty was opened in Bangor in 2008 in an attempt to address these issues. The staff per bed ratio remained the same as in the general orthopaedic wards but beds were “ring fenced” and strict infection control measures protocols were implemented. This audit aimed to assess the effect of the specialist ward on LOS following arthroplasty. Method: Retrospective data on length of stay, demographics and surgical site infections [SSI] were collected for the six months before and six months after the specialist ward was opened. Only primary lower limb arthroplasty data was evaluated and LOS was calculated from day of operation to the day of discharge. Statistical analysis was performed on the length of stay with SPSS software using the two-sample t-test and Mann-Whitley U test. Results: Patients were managed by the same surgical teams in the same theatres but nursed in different ward settings. Group 1 included 222 patients managed in general orthopaedic wards and group 2 included 191 patients, managed in the ring fenced ward. The mean age for total hip replacements was 70.8 in group 1 and 71.2 years in group 2. The mean age for total knee replacements was 70.9 years in group 1 and 69.2 years in group 2. The overall mean LOS for both procedures was 7.61 days (95% CI: 7.14 – 8.07) in group 1 compared with 5.67 days (95% CI: 5.28 – 6.06) group 2. This was statistically significant (p< 0.001). The mode was 7 days in group 1 compared with 4 days in group 2. Three SSIs were noted in group 1 and zero in group 2. Conclusions: This audit demonstrates a two day reduction in LOS for patients managed in a ring fenced ward. The reasons for the reduction are multi factorial but include a trend for reduced SSI. Overall reduced stay frees up resources for other use and may reduce costs. Other units may benefit from similar dedicated wards in response to growing demand for arthroplasty within a system of fixed resources

Background: The Levels of Evidence Rating System is widely believed to categorize studies by quality, with Level I studies representing the highest quality evidence. We aimed to determine the reporting quality of Randomised Controlled Trials (RCTs) published in the most frequently cited general orthopaedic journals. Methods: Two assessors identified orthopaedic journals that reported a level of evidence rating in their abstracts from January 2003 to December 2004 by searching the instructions for authors of the four highest impact general orthopaedic journals. Based upon a priori eligibility criteria, two assessors hand searched all issues of the eligible journal from 2003–2004 for RCTs. The assessors extracted the demographic information and the evidence rating from each included RCT and scored the quality of reporting using the reporting quality assessment tool, which was developed by the Cochrane Bone, Joint and Muscle Trauma Group. Scores were conducted in duplicate, and we reached a consensus for any disagreements. We examined the correlation between the level of evidence rating and the Cochrane reporting quality score. Results: We found that only the Journal of Bone and Joint Surgery–American Volume (JBJS-A) used a level of evidence rating from 2003 to 2004. We identified 938 publications in the JBJS-A from January 2003 to December 2004. Of these publications, 32 (3.4%) were RCTs that fit the inclusion criteria. The 32 RCTs included a total of 3543 patients, with sample sizes ranging from 17 to 514 patients. Despite being labelled as the highest level of evidence (Level 1 and Level II evidence), these studies had low Cochrane reporting quality scores among individual methodological safeguards. The Cochrane reporting quality scores did not differ significantly between Level I and Level II studies. Correlations varied from 0.0 to 0.2 across the 12 items of the Cochrane reporting quality assessment tool (p> 0.05). Among items closely corresponding to the Levels of Evidence Rating System criteria assessors achieved substantial agreement (ICC=0.80, 95%CI:0.60 to 0.90). Conclusions: Our findings suggest that readers should not assume that. 1) studies labelled as Level I have high reporting quality and. 2) Level I studies have better reporting quality than Level II studies. One should address methodological safeguards individually

Objective evaluations of resident performance can be difficult to simulate. A novel competency based surgical OSCE was developed to evaluate surgical skill. The goal of this study was to test the construct validity comparing previously validated Ottawa scores (O-scores) and Orthopaedic in-training evaluation scores (OITE). An OSCE designed to simulate typical general orthopaedic surgical cases was developed to evaluate resident surgical performance. Post-graduate year (PGY) 3–5 trainees have an encounter (interview and physical exam) with a standardized patient and perform a correlating surgery on a cadaver. Examiners evaluate all components of the treatment plan and provide an overall score on the OSCE and also provide an O-score on overall surgical performance. Convergent and divergent validity was assessed comparing OSCE scores to O-scores and OITE scores. SPSS was used for statistical analysis. ANOVA was used to compare PGY averages and Pearson correlation coefficients were calculated to compare OSCE versus O-score and OITE scores. A total of 96 simulated surgical cases were evaluated over a 3 year period for 24 trainees. There was a significant difference in OSCE scores based on year of training. (PGY3 − 6.06/15, PGY4 − 8.16/15 and PGY5 − 11.14/15, p < 0 .001). OSCE and O-scores demonstrated a strong positive correlation of +0.89 while OSCE and OITE scores demonstrated a moderate positive correlation of 0.68. OSCE scores demonstrated strong convergent and moderate divergent correlation. A positive trajectory based on level of training and stronger correlations with established, validated scores supports the construct validity of the novel surgical OSCE

Introduction

Theatre cancellation is unpleasant experience to patient and it is expensive to service provider. There are various causes for cancellation which are avoidable and unavoidable as well. Nationwide, there has been several measures put in place to reduce avoidable theatre cancellations.

We describe retrospective review of 158 cancellations and root cause analysis & solutions in relation to the National standard.

An 83-year-old woman presented with acute weakness in her right hand and wrist extensors and swelling in the proximal right forearm. Nerve conduction studies confirmed compression of posterior introsseous nerve at the level of proximal forearm. MR imaging demonstrated the characteristics of lipoma which extended on the atero-lateral aspect of the right radius neck. The lesion was parosteal lipoma of the proximal radius causing paralysis of the posterior interosseous nerve without sensory deficit. In this case report, posterior inretosseous nerve palsy due to compression of a parostel lipoma was recovered after excision of the lipoma followed by intensive rehabilitation for six month. Surgical excision should be promptly performed to ensure optimal recovery from the nerve paralysis.

Hip resurfacing arthroplasty (HRA) in patients with a varus deformity of the femoral neck-shaft angle (NSA) is associated with poorer outcomes. Our experience has not reflected this. We examined the Oxford Hip Scores (OHS), Harris Hip Scores (HHS) and outcomes of patients with varus hips against a normal cohort to ascertain any significant difference.

We identified 179 patients. Measurement of the femoral neck-shaft angle was undertaken from antero-posterior radiographs pre-operatively. The mean NSA was 128.5 degrees (SD 6.3). Patients with a NSA of less than 122.2 were deemed varus and those above 134.8 valgus. These parameters were consistent with published anatomical studies.

The varus cohort consisted of 23 patients, mean NSA 118.7 (range 113.6-121.5), mean follow-up 49 months (range 13-74). Mean OHS and HHS were 16 and 93.5 respectively. Complications included 2 cases of trochanteric non-union; no femoral neck fractures, early failures or revisions. Normal cohort consisted of 125 patients, mean NSA 128 degrees, mean follow-up 41 months (range 6-76). The OHS and HSS were 18.8, 88.9 respectively. Complications included 5 trochanteric non-unions and 1 revision due to an acetabular fracture following a fall. Statistical analysis demonstrated no statistical difference between the cohorts OHS (p=0.583) or HHS (p=0.139).

Our experience in patients with a varus femoral neck has been positive. Our analysis has demonstrated no statistical difference in hip scores between the cohorts. We have not yet experienced any femoral neck fractures, which we believe is due to the use of the Ganz trochanteric flip and preservation of blood supply.

Choice of implant for patients aged sixty-five years or younger requiring hip arthroplasty is a topic of current debate, those in favor of resurfacing maintain it offers a greater range of motion and activity. We examined the Oxford Hip Score's (OHS) and Duke Activity Status Index (DASI) of patients undergoing either total hip replacement (THR) using an Elite Plus Stem, or hip resurfacing using a Birmingham Hip Resurfacing (BHR).

The THR cohort comprised 34 implants (4 bilateral), 17 men, 17 women, mean age 56.08 years. The resurfacing cohort comprised 27 implants (3 bilateral), 18 men, 9 women, mean age 50.51 years. The mean difference calculated between pre- and post-operative OHS was 22.08 and 25.33 for the THR and resurfacing cohorts respectively. The mean Duke score was 42.3 and 53 for the cohorts respectively.

Using the pre-operative and post-operative change in Oxford Hip Scores, no statistically significant difference was found between the THR and resurfacing cohorts (p = 0.2891). There was a statistically difference found between the THR and resurfacing cohorts with regards to activity using post-operative Duke scores, (p = 0.0047).

This study has emphasized the use of the DASI, a pure activity score, in hip research. In terms of reducing pain, both prostheses appear equally effective. With regards to activity, as evidenced by utilizing a pure activity score, the resurfacing cohort faired better. Our study suggests at one year post-op, young patients with a resurfacing have a greater activity level than those with a THR.

Introduction

One of the common frustrations for staff in hospital clinics is the frequent disruption caused by failure of patients to turn up for their booked appointments. DNA high rates have an enormous impact on the healthcare system in terms of cost and waiting time, significantly adding to delays along the patient pathway. We need to know the most common causes for non attendance and hence modify or put new protocol to deal with this problem.

We investigated the role of Plasma Viscosity (PV), C-reactive protein (CRP) and Frozen Section (FS) in diagnosing prosthetic joint infection. We compared these results with microbiological diagnosis of infection of the tissue samples (three or more samples grown same organisms in culture).

53 patients, average age 67 years (37 – 89) underwent joint revision surgery. 34 patients had hip and 19 patients had knee joint revision arthroplasty, this includes single and multiple stage revision surgeries and excision arthroplasty. Nine (17%) patients had microbiologically proven joint infection. PV had sensitivity of 100%, specificity of 43% and negative predictive value of 100%. CRP had sensitivity of 89 %, specificity of 75% and negative predictive value of 97%. FS (presence of infection being more than 5 neutrophils/hpf) had sensitivity of 56% and specificity of 84%.

We recommend PV and CRP to be used in the investigation of prosthetic joint infection. If both CRP and PV are normal the chance of infection is very low (negative predictive value of 100%). In our series an elevated PV and CRP represented a 50% chance of having a joint infection. The role of frozen section does not appear to be beneficial in the diagnosis of joint

At the Peninsula NHS Treatment Centre in Plymouth some of the surgeons are UK trained and some trained elsewhere in Europe.

This paper examines the outcomes of a large series of joint replacements from 2006 to 2008 at a minimum of one year follow up to determine whether the place of orthopaedic specialist training makes any difference to the outcome. The same implants were used by all surgeons and the anaesthetic technique and post-operative management was identical.

1700 patients were interviewed by a structured telephone questionnaire with over 92% follow-up and the results entered into a joint replacement database. Additional data about length of stay and blood transfusion was added.

Results will be presented about length of stay, transfusion requirements, any further treatment or hospital attendance relating to the new joint, reoperation, deep or superficial infection, hip dislocation, VTE and patient satisfaction.

The surgeon's place of orthopaedic training was found to make no difference to the surgical outcome.

Treatment of osteoarthritis is evolving, allowing surgical treatment options at an earlier stage. The interpositional knee device is a recently developed patient specific implant used for the treatment of mild to moderate uni-compartmental osteoarthritis. The benefits over traditional methods of surgical management are: it's less invasive, can be a day procedure and does not limit future options. Young Adults with early uni-compartmental arthritis are suitable. A MRI scan of the patient's knee is reviewed by radiologists to decide if the patient is suitable. A bespoke implant is produced. Prior to insertion an arthroscopy is undertaken to allow proper positioning.

We treated 27 patients with the iForma Conformis interpositional knee implant in South Wales at the Princess of Wales Hospital, Bridgend and the Royal Glamorgan Hospital, Llantrisant since November 2007. The pre- and post-operative WOMAC scores were recorded. The average age was 54.7 years, BMI 32; 10 females and 20 males. The average pre-operative WOMAC score was 42.2 improving to 62.9 post-operatively. 35 implants were used. 7 patients experienced post-operative problems. No dislocations were reported. Average follow-up was 12.6 months.

Our early experience suggests patient selection plays a role in the outcome following surgery. It indicates that this device is a viable and safe alternative to a uni-compartmental knee replacement.

The Oxford unicompartmental knee replacement (UKR) was introduced in 1976 with good results. Mobile bearings in the lateral compartment have been associated with unacceptably high bearing dislocation rates, due to greater movement between the lateral femoral condyle and tibia, and the lateral collateral ligament's laxity in flexion. The new domed implant is designed to counter this with a convex tibial prosthesis and a fully-congruent, bi-concave mobile bearing allowing a full range-of-movement (ROM), minimising dislocation risk and bearing wear.

We present complication rates and clinical outcomes for a consecutive series of our first 20 patients undergoing Oxford domed lateral UKR, between June 2006 and August 2009, with minimum 6-month follow-up. There was one unrelated death (31 months post-UKR) and one postop MI. We had no bearing dislocations, infections or loosening nor other complications. All patients had post-op Oxford Knee Scores; eleven had pre-op scores and demonstrated a significant improvement – mean pre-op 22.75 to post-op 35.45 (p=0.01). All achieved full extension with average ROM 116°, mean change in ROM was –2.6°(p=0.6).

This study adds to previous work in confirming a low level of complications with this new procedure (including the early learning curve), particularly bearing dislocation and demonstrates excellent functional outcomes.

Hip resurfacing arthroplasty (HRA) in patients with a varus deformity of the femoral neck-shaft angle (NSA) has been cited in the literature as contributory factor towards a poorer outcome. Our experience has not reflected this. We examined the outcomes of patients with varus hips against a normal cohort.

Measurement of the femoral neck-shaft angle was undertaken from standard antero-posterior radiographs pre-operatively. The mean NSA was 128.5 degrees (SD 6.3). Patients less than 122.2 were deemed varus and those above 134.8 valgus. These parameters were consistent with the published literature.

The varus cohort consisted of 23 patients, mean NSA 118.7 (range 113.6-121.5), mean follow-up 49 months (range 13-74), mean OHS & HHS, 16 & 93.5 respectively. Complications included 2 cases of trochanteric non-union; no femoral neck fractures or revisions. The normal cohort consisted of 125 patients, mean NSA 128 degrees, mean follow-up 41 months (range 6-76), mean OHS & HSS, 18.8 & 88.9 respectively. Complications included 5 cases of trochanteric non-union and 1 revision. Statistical analysis demonstrated no difference between the cohorts OHS (p=0.583) or HHS (p=0.139).

Our experience in patients with a varus femoral neck has been positive. Our analysis has demonstrated no difference in outcomes between the cohorts.

It costs the NHS £2billion/year to treat 70000 hip fractures. Following hemiarthroplasty a departmental x-ray is standard practice.

During 2009 217 hemiarthroplasties were performed in our unit. 210 had postoperative radiographs (148 departmental, 62 in theatre). All patient demographics were considered and hospital costs accounted for.

Mean patient age was 83 (55-100) years. Mean theatre times were 120 (51-213) minutes in the departmental x-ray group and 128 (74-187) minutes in the theatre imaging group. Hospital stay was decreased from 12.8 (3-41) days in the departmental x-ray group to 11.8 (3-32) days in the theatre imaging group. Orthopaedic beds cost £136/day. Departmental x-rays give a radiation dose of ∼12mGy and costs £48.30, theatre imaging gives ∼0.26mGy with no additional cost given the radiographers previous allocation to the list.

Changing our practice to intra-theatre imaging has improved patient safety, reduced the average inpatient stay and saves our trust approximately £40,000 annually.

An osteoporosis screening service for patients presenting to the fracture clinic in Derriford Hospital Plymouth was established in February 2009. We report on the findings of the first year of patients referred for dual energy X-ray absorptiometry (DEXA) screening.

Patients between 50 and 75 years of age, who sustained a fracture as a result of a fall from standing height or less, who had not previously had a DEXA scan within the last two years, were referred. Patients outside these age limits with other risk factors for osteoporosis were scanned at the discretion of the fracture clinic consultant. Of those patients who were referred, 96% subsequently attended for a scan timed to coincide with their scheduled fracture clinic follow-up appointment.

402 patients were scanned in total, of which 351 were female and 51 were male. The mean patient age was 65. The results for women were as follows: 21% normal, 45% osteopenic, 34% osteoporotic. The results for men were: 19% normal, 43% osteopenic, 38% osteoporotic. The scan results were forwarded to the patient's general practitioner for action as deemed necessary.

These findings support the establishment of this screening service for both men and women.

Last minute cancellations of operations are a major waste of NHS resources. This study identifies the number of late cancellations at our elective orthopaedic centre, the reasons for them, the costs involved, and whether they are avoidable.

Last minute cancellations of operations in a 7-month period from January to July 2009 were examined.

172 cases out of 3330 scheduled operations were cancelled at the last minute (5.2%). Significantly more cancellations occurred during the winter months due to seasonal illness.

The commonest causes for cancellation in descending order of frequency were patient unfit/unwell (n=76, 44.2%), lack of theatre time (n=32, 18.6%), patient self cancelled/DNA (n=20, 11.6%), staff unavailable or sick (n=9, 5.2%), theatre or equipment problem (n=8, 4.7%), operation no longer required (n=8, 4.7%), administrative error (n=7, 4.1%) or no bed available (n=5, 2.9%). In 7 out of the 172 cancelled cases (4.1%) no cause was identified. 59.7% of the cases were potentially avoidable.

3.2% of Patients seen in the specialist pre-operative anaesthetic clinic (POAC) were cancelled at the last minute for being unfit or unwell, compared to 2.2% seen in the routine nurse led clinic. Last minute cancellations cost the hospital over £700,000 in 7 months.

Soft tissue reactions following metal-on-metal arthroplasty of the hip have been under discussion in recent times. The phenomenon has been observed since the advent of arthroplasty, but the particular nature of metal-on-metal (MoM) resurfacing or total hip arthroplasty (THA), and the associated shedding of metal particles in high wear states, appears to excite a more aggressive response. Recent reports suggest involvement of muscle groups on a wide scale, and some cases of neurovascular involvement. It is not known which reactions require widespread muscle excision, and which cases may be adequately addressed by bearing exchange alone. We report three cases of soft tissue reaction (pseudotumour) following MoM hip resurfacing all managed with revision to ceramic-on-ceramic (CoC) THA with minimal soft tissue excision. All patients were female with ages at original operation of 49, 52 and 58 years. Time to revision surgery was 85, 28 and 66 months respectively.

Prosthesis revision resulted in progressive and satisfactory resolution of the pseudotumour. We propose that in the early stages, pseudotumour following MoM hip resurfacing can be adequately managed with revision to ceramic-bearing THA with minimal soft tissue excision, rather than revision with extensive soft tissue debridement that has been recently described.

We analysed the clinical data of 858 consecutive primary total hip and knee replacement patients to establish how age, ASA grade, body mass index and a simplified cognitive score correlate with the length of hospital stay and early complication rates. We further used statistical regression analysis to study how hospital stay and complication rates correlate with different pre-operative grading systems based on combinations of age, ASA grade, body mass index and a cognitive score.

The results indicate that age and ASA grade correlate significantly with both length of hospital stay and complication rates, while body mass index correlated poorly with both. A grading system based on a combination of age and ASA grade (the AA Grade) correlated significantly with both length of hospital stay and complication rates. Adding body mass index or a cognitive score did not significantly add to the correlation.

We discuss the relevance of this simple grading system and how it might contribute to pre-operative risk assessment and peri-operative planning.

Long-term prospective RCT comparing hemiarthroplasty (HEMI) and total hip arthroplasty (THA) for the treatment of intracapsular neck of femur fracture.

81 previously mobile, independent, orientated patients were randomised to receive THA or HEMI after sustaining a displaced neck of femur fracture. Patients were followed up with radiographs, Oxford hip score (OHS), SF-36 scores and their walking distance.

At a mean follow up of 8.7 years, overall mortality following THA was 32.5% compared to 51.2% following HEMI (p=0.09). Following THA, patients died after a mean of 63.6 months compared to 45 months following HEMI (p=0.093). Patients with THA walked further and had better physical function. No HEMIs dislocated but three (7.5%) THAs did. Four (9.8%) HEMI patients were revised to THA, but only one (2.5%) THA required revision. All surviving HEMI patients had acetabular erosion and all surviving THA patients had wear of the cemented polyethylene cup.

Patients with THA have better function in the medium-term and survive longer.

Outcome following wrist fractures is difficult to assess. There are many methods used to assess outcome following distal radius fractures, but may be that simply asking the patient for their level of satisfaction may be enough. We looked at 50 wrist fractures at 12 weeks post injury and compared their level of satisfaction with various respected outcome measures (Gartland and Verley, Sarmiento, Cooney, Patient-Rated Wrist Evaluation, Hand Function Score, and Disability of Arm Shoulder and Hand Score) to determine whether there was a correlation with their level of satisfaction. The aim was to determine which wrist scoring system best correlates with patient satisfaction and functional outcome and which individual variables predict a good outcome. Forty-five females and 5 males with a mean age of 66 years (range 19 to 93 years) were included in the study. Multivariate regression analysis was carried out using SPSS 17.

Patient satisfaction correlated best with the MacDermid, Watts and DASH scores. The variables in these scoring systems that best accounted for hand function were pain, ability to perform household chores or usual occupation, open packets and cut meat.

The McDermid, Watts and DASH scores provide a better measure of patient satisfaction than the Gartland and Verley, Sarmiento and Cooney scores, however they are all time consuming, complicated and may indeed not be necessary.

The four most important questions to ask in the clinic following wrist fractures are about severity of pain, ability to open packets, cut meat and perform household chores or usual occupation. This may provide a simple and more concise means of assessing outcome after distal radial fractures.

We often regard patient satisfaction as the best clinical indicator of outcome in the clinic situation. The aim of this study was to determine which wrist scoring system (Gartland and Verley, Sarmiento, Cooney, Patient-Rated Wrist Evaluation, Hand Function Score, and Disability of Arm Shoulder and Hand Score) best correlates with patient satisfaction and functional outcome and which individual variables predict a good outcome. Forty-five females and 5 males with a mean age of 66 years (range 19 to 93 years) were included in the study. Multivariate regression analysis was carried out using SPSS 13.

Patient satisfaction correlated best with the MacDermid, Watts and DASH scores. The variables in these scoring systems that best accounted for hand function were pain, ability to perform household chores, open packets, cut meat and perform the usual occupation.

The most important questions to ask in the clinic following wrist fractures are about pain, ability to perform household chores, open packets, cut meat and perform the usual occupation. The McDermid, Watts and DASH scores provide a better measure of patient satisfaction than the Gartland and Verley, Sarmiento and Cooney scores, however they are time consuming, complicated and may indeed not be necessary.

Introduction

The goal of arthrodesis around the ankle or of triple (hind foot) arthrodesis is a painless, plantigrade, and stable foot. Stress fracture is a differential diagnosis for pain following an ankle/subtalar arthrodesis. Management of stress fractures following sound ankle/subtalar fusion is extremely difficult as the entire movement tends to occur at the fracture site, hence hampering healing.

Purpose

To evaluate Radiological changes in the lumbosacral spine after insertion of Wallis Ligament for Foraminal Stenosis.

Awareness that minimising tip apex distance (TAD) when inserting a sliding hip screw reduces the risk of screw cut out is important for orthopaedic trainees. The advent of the Picture Archive and Communication System (PACS) has made the accurate measurement of TAD from x-rays and image intensifier films much easier. This study was to determine whether TAD would be reduced if a surgeon knew that his performance was being continually monitored.

31 consecutive cases of sliding hip screw insertion by a single group of surgeons were identified and the TAD measured. The mean TAD was 16.11mm (8.87mm-25.47mm). The same surgeons were then re-educated as to the importance of the TAD and informed that their results would be monitored and discussed. The next 34 consecutive cases were collected prospectively. The mean TAD in these cases was 13.83mm (6.72mm-21.51mm). There was a significant difference between the TAD for the two groups using the two-tailed t-test (p=0.034). There was one implant failure in the pre education group and none in the post education group.

These results suggest that awareness of surveillance improves surgical performance even if the importance of the variable being assessed is already known.

Introduction

It is not uncommon to encounter patients with atypical hip or lower extremity pain, ill-defined clinico-radiological features and concomitant hip and lumbar spine arthritis. It has been hypothesized that an anaesthetic hip arthrogram can help identify the source of pain in these cases. The purpose of this study is to analyze our experience with this technique in order to verify its accuracy.

Sledging related minor and major injuries represent a significant workload at ski-area medical centers across the world. Although safety rules exist, they are seldom obeyed or enforced. We set out to determine the incidence of sledging related injuries, identifying trends and causative factors at a busy New Zealand Ski resort.

All sledging related injuries presenting during a 70-day period were prospectively reviewed. Patient demographics, mechanism, diagnosis, and treatment were recorded. Sixty patients were identified, mean age 10 years, range 4-30 years. Injuries comprised; collisions with sledgers (21), collision with wall (14) and falling from sledge (14). Site of injury included head (36), lower limb (18), spine (9), upper limb (7), and abdomen (2). Fractures included; femur (1), tibia (1), fibula (1), ankle (2), cuboid (1), clavicle (2), scaphoid (1). One 9-year-old patient sustained a serious intracranial haemorrhage, with subsequent permanent neurological sequelae.

Sledging related injuries are mostly minor, however significant major injuries do occur requiring intervention at a secondary center. The potential for serious morbidity is evident. Recommendations supporting safety improvement measures does exist, however most were not implemented by the study cohort examined. The use of basic cycling helmets would seem an appropriate minimum level of protection, and greater sledging safety awareness should be encouraged.

Implant related hypersensitivity is an infrequent complication after total knee replacement. It remains a relatively unpredictable and poorly understood cause of failure of an implant.

We present a report of five patients who presented with persistent hypertrophic synovitis after total knee replacement using a cobalt chrome component. Extensive preoperative and intraoperative attempts ruled out infection as a cause of symptoms. The knees had good ligamentous balance and were well aligned and fixed.

The clinical condition improved after revision to a zirconium femoral and titanium metal backed tibial components. Intraoperative histopathology revealed thickened synovium with a predominantly monocellular (lymphocytic or histiocytic) response.

Where infection has been excluded as a cause of persistent pain and swelling, consideration should be given to metal allergy as a cause of failure in primary knee replacement surgery.

The purposes of this study were to investigate whether twins and multiple births have a higher incidence of Developmental Dysplasia of the Hip (DDH), and whether universal ultrasound scanning would be beneficial in this population.

Manipulation under anaesthetic (MUA) for the treatment of frozen shoulder is well established and effective however timing of surgery remains controversial. Intervention before 9 months has previously been shown to be associated with improved outcome. We test this theory by measuring Oxford Shoulder Score (OSS), re-MUA and subsequent surgery rate.

A retrospective review of a prospectively collected, single surgeon, consecutive patient series revealed 244 primary frozen shoulders treated by MUA within 4 weeks of presentation. The mean duration of antecedent symptoms was 28 weeks (95% CI 4-44 weeks) and time to follow up was 26 days (95% CI 11-41 days). The mean OSS improved by 16 points (2-tailed t test p< 0.001) with a mean follow up OSS of 43 (95% CI 38-48). 195 shoulders were manipulated before 38 weeks (9 months) and had the same mean change in OSS (16) as the 49 shoulders manipulated after 38 weeks. 48 shoulders, including 15 diabetic shoulders required further MUA. 8 shoulders had subsequent surgery. These events were also independent of antecedent symptom duration.

Early MUA does not appear to produce improved outcomes when compared to later intervention but we note does result in an earlier return to function.

Pedicle screw systems are now the commonest method of achieving posterior spinal fixation. Surgical planning in spinal surgery may include measuring pedicle size to guide screw size on WEBPACS. We performed a study to determine whether measuring pedicle size on CT is accurate and reproducible using the WEBPACS ruler tool.

A human cadaveric spine along with 5 geometrical shapes were scanned using a multislice spiral CT scanner with 1mm cuts. The objects and the pedicle diameters for lumbar and thoracic vertebrae in the axial plane were measured independently using the WEBPACS ruler tool by 2 observers (to the nearest 0.1mm). The geometrical shapes and pedicle size on the skeleton were then measured using Vernier callipers by an independent third observer. All measurements were repeated a week later.

The WEBPACS ruler on a CT scan is accurate to within 0.5-0.6mm of the true size of an object. The error for pedicle measurements is marginally higher (0.6-1.0mm) and this may reflect the fact that they are ill defined geometric shapes. Measuring pedicle size on CT for surgical planning may have implications for small pedicles when sizing them up for a good screw.

Aim

To correlate the surgical and MRI findings in acute lateral patellar dislocation and to determine the accuracy of MRI in identifying location of MFPL injury.

Controversy exists whether a single proximal lateral tibia (PLT) locked plate is adequate for bicondylar fractures and whether the use of integral raft screws makes the use of bone graft less important.

57 consecutive patients who underwent reconstruction with a locked PLT plate were retrospectively reviewed. Radiographs were examined for operative reduction and subsequent loss of reduction.

55 patients were followed-up for an average of 27 weeks. Fractures were divided into unicondylar (Group 1, n=33) and bicondylar (Group 2, n=22). Union occurred in all patients, with no revisions or removal of metalwork at final follow-up. In 50 patients (88%), the fracture was reduced to within 2mm of anatomical. Articular surface collapse of >2mm occurred in three patients. Nine patients underwent bone grafting with no difference in outcome. A supplementary medial plate was used in three patients with a separate posteromedial fragment.

Except for a separate posteromedial fragment, the use of a single locked PLT plate for bicondylar fractures allows union to occur without failure. With the use of integral raft screws, the need for bone graft is questionable. The short-term radiological results and complication rate of PLT locked plating is excellent.

The addition of Extended Scope Practitioner (ESP) clinics was proposed to review new Foot and Ankle referrals, to reduce time consultants spend in clinic and free them up for theatre. There would be a cost benefit to the Primary Care Trusts (PCT), a clinic appointment with the consultants cost's around £140 and ESPs around £70.

We prospectively collected data from the ESP clinics for two months in 2009. We looked at the number of patients referred on to the consultants and how many of these needed surgery.

During this period one hundred and forty one patients were booked into ESP clinics, forty three were referred to the consultants, ninety one were managed by the ESPs and seven patients failed to attend. The estimated saving to the PCT during the 2 month period was £6860 which would be £41,160 over a year. Twenty nine of the patients referred to the consultants required surgery giving a 74% conversion rate.

The use of ESPs in Foot and Ankle Clinic reduces the number of new referrals seen by consultants, therefore being cost effective to the PCTs. This also increased the consultant's surgical conversion rate producing a more efficient service.

The treatment of nonunion is challenging providing the surgeon with a variety of different surgical options in order to encourage and achieve bone consolidation. Despite excellent results presented in 2008 of 99% union rates, Judet Osteo-Periosteal Decortication does not seem to be popular at present with bone grafting and distraction osteo-modelling being the favoured option.

Retrospective analysis was performed from December 2002 to December 2008 of 46 cases of osteoperiosteal decortication(Judet technique) for failure of fracture union.

Union was successfully achieved in 39 of the 45 patients(85%) after a mean delay of 10.7 months(range 3-39 months). Thirty patients(65%) achieved union following the decortication procedure without subsequent operations. The mean number of procedures following decortication was 0.6(range 0-4) mostly being performed for metalwork failure. Metal work failure occurred in 13 cases(28%) with the majority occurring in decortications of the femur(n=11,85%). The femur was the location of all persistent non unions in the series. The nonunion scoring system(0-100,Calori et al 2008) means were noticeably worse for the persistent nonunion group(41.67, range 34-46) compared to the union group(29, range 4-52).

Osteoperiosteal decortication remains a highly effective surgical technique in the management of failed fracture union.

Purpose of study

To investigate possible advantages of uncemented over cemented femoral components in hip resurfacing.

Aim

Thromboprophylaxis in total hip replacement (THR) and total knee replacement (TKR) remains controversial, conspicuous by absence of consensus. Because of protracted and variable mobilisation, there is an extended risk of Venous Thromboembolism (VTE). We hypothesised that a combination of low molecular weight heparin and miniwarfarin would minimise the initial and extended risk. Therefore we evolved a protocol of enoxaparin sodium 40 mgs for 5 days starting preoperatively and miniwarfarin 1-2mg for 6 weeks following surgery. We undertook a retrospective study of total hip and knee replacements in a District General Hospital between January 2000 and December 2005 to determine the effectiveness of the protocol.

BACKGROUND

In our institution we use the Winklestabile volar locking plate for operative fixation of distal radius fractures. This study aims to assess subjective and objective outcomes using this method of treatment.

The time at which patients should drive following total hip replacement (THR) is dependant upon recovery and the advice they are given. The Driver Vehicle and Licensing Agency (DVLA) in the United Kingdom does not publish recommendations following THR and insurance companies usually rely on medical instruction. Few studies have been performed previously and have reached different conclusions.

Brake reaction times for patients undergoing primary THR were measured pre-operatively and at four, six and eight weeks after surgery using a vehicle driving simulator at a dedicated testing centre. Patients were prospectively recruited. Ethical approval was granted. Participants included eleven males and nine females, mean age 69 years. Side of surgery, frequency of driving and type of car (automatic or manual) were documented. Patients with postoperative complications were excluded. No adverse events occurred during the study.

Statistical analysis using Friedman's test demonstrated a statistically significant difference (P=0.015) in reaction times across the four time periods. Wilcoxon test demonstrated a highly significant difference between initial and six week mean results (P=0.003), and between four and six week results (P=0.001). No significant difference was found between six and eight weeks.

Our data suggests reaction times improve until week six and significantly between week four to six. Patients making an uncomplicated recovery following primary THR may be considered safe to return to driving from week six onwards. We recommend this is clearly documented in the medical notes, and patients should check with their insurance company prior to recommencement.

Queen Elizabeth the Queen Mother Hospital, Margate, East Kent Hospitals NHS University Trust, UK.

Lower limb mal-alignment due to deformity is a significant cause of early degenerative change and dysfunction. Standard techniques are available to determine the centre of rotation of angulation (CORA) and extent of the deformities. However, distal femoral deformity is difficult to assess because of the difference between anatomic and mechanical axes. We describe a novel technique which accurately determines the CORA and extent of distal femoral deformity.

Using standard leg alignment views of the normal femur, the distal femoral metaphysis and joint line are stylised as a block. A line bisecting the anatomical axis of the proximal femur is then extended distally to intersect the joint. The angle (?) between the joint and the proximal femoral axis, and the position (p) where the extended proximal femoral axis intersects the joint line are calculated. These measurements can then be reproduced on the abnormal distal femur in order to calculate the CORA and extent of deformity, permitting accurate correction.

We examined the utility and reproducibility of the new method using 100 normal femora. We found this technique to be universally robust in a variety of distal femoral deformities.

Knee dislocation is a rare injury in high energy trauma, but it is even rarer in low energy injuries. We present, to our knowledge, the only case in the world literature of knee dislocation following a cricketing injury. The patient was a 46 year old recreational fast bowler who, whilst bowling, slipped on the pitch on the follow through. He sustained an anteromedial knee dislocation which was reduced under intravenous sedation. He also sustained a neuropraxia of the common peroneal nerve with grade 2 weakness of ankle and toe dorsiflexion. Magnetic Resonance Imaging (MRI) confirmed a complete rupture of anterior cruciate ligament (ACL), lateral collateral ligament (LCL) and postero-lateral corner (PLC). Patient underwent surgical reconstruction and repair of his PLC along with repair of LCL with combination of anchor sutures and metal staple within 72 hours of the injury. He was treated in a cast brace. The ACL insufficiency was treated conservatively. Patient made an uneventful recovery and follow up at 3 months revealed a full range of knee movements with asymptomatic ACL laxity

The role of magnetic resonance arthrography (MRA) in the evaluation of patients with femeroacetabular impingement (FAI) to assess femoral head-neck junction asphericity and labral pathology is well established. However, in our experience the presence of acetabular cysts on MRA, which may signify underlying full thickness articular cartilage delamination and progression towards arthropathy, is also an important feature.

We retrospectively reviewed 142 hips (mean age 32 years, 47 men, 95 women), correlating the findings on MRA with those found at the time of open surgical hip debridement to ascertain the prevalence of acetabular cysts and the association with underlying acetabular changes. Fifteen MRA's demonstrated features consistent with underlying acetabular cystic change. At the time of surgery, this was confirmed in eleven cases that demonstrated a full thickness articular chondral flap (carpet lesion) and an underlying acetabular cyst. The sensitivity, specificity, positive predictive value and negative predictive value of MRA in relation to acetabular cysts was 55%, 96.7%, 73.3% and 92.9% respectively.

We believe acetabular cysts on MRA to be a significant finding. Such patients are likely to have an associated full thickness chondral lesion and features of early degenerative change, influencing outcome and prognosis. Our clinical practise has changed to reflect this finding. For those patients with cysts on MRA, we are less likely to offer open debridement and favour arthroscopic intervention followed by arthroplasty when symptoms dictate. We believe hip preservation surgeons should be aware of the significance of acetabular cysts and be prepared to adjust treatment options accordingly.

AIM

To evaluate patient outcomes in surgically managed ankle fractures with respect to fracture pattern, timing of surgery and length of stay.

We have developed a list of 281 competencies deemed to be of importance in the training of orthopaedic surgeons. A stratified, randomised selection of non-university orthopaedic surgeons rated each individual item on a scale 1 to 4 of increasing importance. Summary statistics across all respondents were given. The mean scores and . sd. s were computed. Secondary analyses were computed in general orthopaedics, paediatrics, trauma and adult reconstruction. Of the 156 orthopaedic surgeons approached 131 (84%) responded to the questionnaire. They rated 240 of the 281 items greater than 3.0 suggesting that competence in these was necessary by completion of training. Complex procedures were rated to be less important. The structure, delivery and implementation of the curriculum needs further study. Learning activities are ‘driven’ by the evaluation of competencies and thus competency-based learning may soon be in the forefront of training programmes

The global economy has been facing a financial crisis. Healthcare costs are spiraling, and there is a projected £30 billion health funding gap by 2020 in the UK. 1. This has prompted a drive for efficiency in healthcare provision in the UK, and in 2012, the Health and Social Care Act was introduced, heralding a fundamental change to the structure of the National Health Service, especially in the way that healthcare is funded in England. 2. What is happening in the UK is a reflection of a global problem. Rationing of healthcare is a topic of much discussion; as unless spending is capped, providing healthcare will become unsustainable. Who decides how money is spent, and which services should be rationed? . In this article we aim to discuss the impact that rationing may have on orthopaedic surgery, and we will discuss our own experiences of attempts to ration local services. 3. We also seek to inform and educate the general orthopaedic community on this topic

Problem drinking was found to be likely in 21% of inpatients in a general orthopaedic and fracture service, and in 42% of outpatients attending the fracture clinics. The questionnaire showed that the problem was most common among young men, particularly among outpatients. Previous hospital admissions were more frequent in this group. Many of the health problems associated with the chronic abuse of alcohol are directly relevant to orthopaedic practice. Early intervention may be highly successful, and it is recommended that screening for problem drinking be considered in orthopaedic and fracture services

We present a study of 67 Oxford bicompartmental total knee replacements performed at a district general hospital. In this general orthopaedic unit, 57 of the knees (85%) had significant relief of pain with a mean flexion range of 95 degrees and a mean flexion deformity of only 9 degrees. There was a noticeable difference between osteoarthritic and rheumatoid knees. Poor results could be directly related to an avoidable postoperative complication. The results of this independent assessment may be compared favourably with the previously published series from the specialist centre at which the prosthesis was designed

Adverse events (AEs) following spine surgery are very common. It is important to monitor the incidence of AEs to ensure that appropriate practices are implemented to minimise AEs and improve patient outcomes. The Spine Adverse Events Severity System (SAVES) is a validated AE recording tool specifically designed for spine surgery and the Orthopaedic Surgical Adverse Events Severity System (OrthoSAVES) is a similar tool intended for general orthopaedic surgery. The main objective was to prospectively collect AE data from spine surgery patients using SAVES and OrthoSAVES and compare their viability and applicability for use. The longterm objective is to enhance patient safety by tracking AEs with a view towards potentially changing future healthcare practices to eliminate the risk factors for AEs. For a 10-week period in June-September 2015, three spine surgeons used SAVES to record AEs experienced by any elective spine surgery patients. In addition, a trained independent clinical reviewer with access to electronic records, medical charts, and allied health professionals (e.g. nurses, physioterhapists) used SAVES and OrthoSAVES to record AEs for the same patients. At discharge, the SAVES forms from the surgeons and SAVES and OrthoSAVES forms from the independent reviewer were collected and all AEs were recorded in a database. In 48 patients, the independent reviewer recorded a total of 45 AEs (4 intra-operative, 41 post-operative), compared to the surgeons who recorded a total of 8 AEs (2 intra-operative, 6 post-operative) (P2) were recorded by both the independent reviewer and surgeons. OrthoSAVES had the capacity to directly record 3 additional AEs that had to be included in the “Other” section on SAVES. SAVES and OrthoSAVES are valuable tools for recording AEs. Use of SAVES and OrthoSAVES has the potential to enhance patient care and safety by ensuring AEs are followed by the surgeon during their in-hospital stay and prior to discharge. Independent reviewers are more effective at capturing AEs following spine surgery, and thus, could be recruited in order to capture more AEs and maximise different complication diagnoses in alignment with proposed diagnosis-based funding models. The next step is to analyse AE data identified by the hospital discharge abstract to determine whether retrospective administrative coding can adequately record AEs compared to prospectively-collected AE data with SAVES/OrthoSAVES

Introduction: Outcome reporting following THR constitute a significant proportion of orthopaedic publications. Publication bias in the form of underreporting of studies showing non satisfactory or negative results is a well recognised problem in other specialities. We tried to find out the magnitude of this problem in orthopaedics publications dealing with THR. Method and materials: We reviewed all publications on THR in the year 2004 in three general orthopaedic journals namely JBJS (BR), JBJS (Am), CORR. Of the 1034 original articles published in these three journals more than 400 articles were concerned with total hip replacement. Results and Discussion: In this study we found only 6% of the published articles were showing non significant or negative results. This raises concerns about evidence based approach in THR and the need for preventive measures like registering all clinical trials and change in the attitude of editorial board

Since1986 we have monitored the actual diagnosis of all cases referred to our Unit with the diagnosis of ‘possible primary malignant bone tumour’. We have excluded all patients referred with a known diagnosis of either a benign condition or known to have bone metastases. In most cases the suspected diagnosis was based on X-rays alone, sometimes supported by further imaging. Method. Retrospective review of a prospective database that was started in 1986 identifying the actual diagnosis. Results. There were 5922 patients with a confirmed diagnosis over the 23 year time period of this study. 2205 (37%) were found to have a primary malignant bone sarcoma and 1309 (22%) had a benign bone tumour. 992 patients had a general orthopaedic condition (e.g. geode or a vascular necrosis) whilst 303 (5%) had a haematological malignancy and 289 (4.9%) infection. 533 patients (9%) had metastases. There was a similar pattern of frequency of all diagnoses except for metastatic disease and haematologic malignancy at different ages. The incidence of metastases increased from the age of 35 onwards. Discussion. Analysis of this data has led to an algorithm for investigating ‘worrying’ bones that should lead to earlier diagnosis whilst avoiding unnecessary investigations

Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus without vascular deficit, were managed by elevated, straight-arm traction for a mean of 22 days. The final outcome was assessed using clinical (flexion-extension arc, carrying angle and residual rotational deformity) and radiographic (metaphyseal-diaphyseal angle and humerocapitellar angle) criteria. Excellent results were achieved in 71 (63%) patients, 33 (29%) had good results, 5 (4.4%) fair, and 3 (2.6%) poor. All patients with fair or poor outcomes were older than ten years of age. Elevated, straight-arm traction is safe and effective in children younger than ten years. It can be effectively used in an environment that can provide ordinary paediatric medical care and general orthopaedic expertise. The outcomes compare with supracondylar fractures treated surgically in specialist centres

Aims: A retrospective study was done to examine the rate of failure. Methods: The most recent evaluation consisted of a medical papers and a radiographic examination. Between 1992 and 2000 in general orthopaedic unit 222 patients with an acute femoral neck fracture were managed by 180 primary prosthetic replacements and 42 cannulated screws internal fixations (25 percutaneosly and 17 open technique). The patients treated with cannulated screws had a mean age of 63,5 years (range,42 to 88 years) at the time of operation and were followed-up on average for 42 months (range, 12 to 102 months). There were 13 type B1 and 29 type B3 according to AO classification system. Results: Four patients had died early postoperatively (less than 6 months). Femoral neck fracture healed in 24 patients (57%). Osteonecrosis developed in 5 patients (12%). Redisplacement of the fracture and non-union were found in 16 patients (38%). Revision operation was done in 13 patients (10 total arthroplasties, 2 hemiar-throplasties and 1 corrective osteotomy). Conclusions: An acute subcapital desplaced fracture of the femoral neck still remains the so-colled “Unsolved fracture”

To study the surgical outcome of multi-fragmentary, un-reconstructable radial head fractures managed acutely by a radial head prosthetic replacement, we retrospectively reviewed nineteen radial head fractures that were treated acutely with a radial head replacement, over a four-year period in three district general hospitals. Nineteen patients were clinically and radiologically assessed for this study. Functional assessment was performed with the Mayo elbow performance score (MEPS). No patient achieved full functional range of motion. The average range of flexion was 110° (range 80° to 120°), average extension deficit of 35° (range 30° to 45°), average pronation was 35° (range 0° to 65°), and average supination was 50° (range 30° to 85°). Complications included implant removal due to loosening (n=1), elbow stiffness (n=2), and instability (n=1), the latter case requiring a revision of the radial head prosthesis. Some degree of persistent discomfort was noticed in all cases. Five patients were tolerant of the final functional outcome. The average Mayo elbow score was 68/100 (range 55 to 80). One patient had an intra-operative fracture of the radial metaphysis during insertion of the implant. Conclusions. Radial head replacement in general orthopaedic, low volume practice failed to achieve satisfactory results. Contrary to popular belief, it is a technically demanding operation, for which surveillance should be continued for a minimum of one year. Strict indications for prosthetic replacement should be followed and implant selection has yet to be proven to make a significant positive contribution. Our review highlights the need for a stricter adherence to indications; surgery should not be under-estimated and devolved to trainees, and our understanding of the radial axis of the elbow and forearm remains relatively rudimentary

Reduction and K-wiring is the most popular form of treating displaced supracondylar fractures of the humerus. Complications including redisplacement of the fracture, cubitus varus, iatrogenic nerve injuries and pin tract infection have been reported following surgery. For successful outcome with K-wiring of supracondylar fractures, strict adherence to protocols and surgical expertise are necessary. We have treated these fractures in straight arm traction since 1995, and the purpose of this study was to audit our practice. Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus, without neurovascular deficit, were managed by straight arm traction for a mean duration of 22 days. Final outcome was assessed using clinical (flex-ion-extension arc, carrying angle and residual rotational deformity) and radiographical (metaphyseal-diaphyseal angle and Humero-Capitellar angle) criteria. Our outcomes were compared with those of the recent large studies reporting results of surgical treatment. 71 (63%) patients had excellent, 33 (29%) patients good, 5 (4.4%) patients fair, and 3 (2.6%) patients poor outcome. All patients with fair or poor outcomes were older than 10 years. Elevated straight-arm traction is safe and effective in children younger than 10 years. It can be effectively used in an environment that has provision of paediatric medical care and general orthopaedic expertise with outcomes comparable to those fractures treated surgically in specialist centres

Chris Hani Baragwanath Hospital is situated in the South Western part of Johannesburg and is one of the largest acute hospitals in the world, serving a population of more than 3.5 million people. The hospital has a total of 2964 beds of which 232 beds are orthopaedic, including paediatric orthopaedics. The orthopaedic division at this tertiary level hospital comprises six units, namely; Upper Limb Trauma, Lower Limb Trauma, Spine Unit, Paediatric Orthopaedics, Sports and General Orthopaedics, and Arthroplasty/Tumour & Sepsis Unit. This review seeks to elicit the total number of patients seen with orthopaedic conditions and the spectrum thereof in and around Soweto. This is the first review of its kind done at The Chris Hani Baragwanath Hospital, Orthopaedic division, to date. Purpose:. The purpose of this audit is to identify the orthopaedic related health events that occur within the Soweto population being serviced by the Chris Hani Baragwanath Hospital, and in doing so be used as a tool to improve orthopaedic related patient care and outcomes in public health services. Method:. A retrospective review was conducted for a period of one year. This included all orthopaedic admissions, theatre cases performed, and outpatient assessments. Statistics were taken from registers incorporating OPD, Wards, Casualty and theatre. Results of the study:. For the period of the review there were more than 3000 orthopaedic admissions from the emergency unit. Theatre records show that approximately 4000 orthopaedic theatre cases were performed at Chris Hani Baragwanath Hospital. This consisted of more than 75 different types of operative procedures. The majority were hand procedures and the bulk of elective procedures were for total hip replacements. There were more than 28000 patients reviewed at the outpatients department for the year being reviewed. Conclusion:. This analysis outlines the spectrum of orthopaedics seen at Chris Hani Baragwanath Hospital, ranging from admissions to theatre cases performed. The result of which can be used to improve the quality of patient care, reduce elective procedure waiting lists, as well as be used as a tool for future research

The Constant score is widely used as a measure of assessing outcome from surgery. The pre and post-operative Scores are usually compared to assess outcome. The expected Scores for an age-matched population however are not known. Patients attending fracture and general orthopaedic clinics with lower limb problems only were assessed. Age, handedness, occupation and Constant Score results were recorded. The score for differing sections of the Constant score were reviewed and analysed in combination with the above parameters. The overall Constant Score decreased with age, as one would expect. However the decrease in the strength measurement was out of all proportion to that of the remainder of the Score-79% of total strength in the under 40 year age group compared with 11.2% of total strength in the over 80 year age group. This compared with a percentage of 97.8% for the remainder of the Score in the under 40 year group compared to 70.4% in the over 80 year age group. If one is using the Constant Score as a measure of surgical outcome one should be aware of the expected age-matched figures and in particular the poor strength measurements in the older populations. We suggest that a more useful measurement would be one without strength and just score out of 75

We reviewed the outcome of 146 Insall-Burstein II total knee replacements carried out in 121 patients over a period of nearly four years in a general orthopaedic unit. At a mean follow-up of ten years, 94 knees in 78 patients were available for review. Six patients (7 knees) were lost to follow-up and 37 (45 knees) had died. The clinical outcome using the scoring system of the Hospital for Special Surgery (HSS) was excellent or good in 79% of patients, fair in 14% and poor in 7%. The mean preoperative HSS score was 31, improving to 79 at the latest review. Using the newer rating system of the Knee Society, the mean score at ten years was 87 and the mean functional score 56. The arc of flexion improved from a mean preoperative value of 88° to 100°. The 18 patients who had had a previous high tibial osteotomy were analysed separately and were found to have benefited equally from the operation. Nine prostheses were revised, giving a cumulative survival rate of 92.3% at ten years. Radiological evaluation of 104 radiographs showed radiolucent lines around ten tibial components, none of which required revision. Anterior knee pain was a significant problem

Background: With the foreseeable increase in demand for revision hip surgery, it is likely that orthopaedic surgeons working in district general orthopaedic units will undertake an increasing number of secondary procedures. This article set out to determine whether a single orthopaedic surgeon, working in a district general hospital, could achieve results comparable to those obtained by surgeons working in specialised tertiary referral centres. Patients and methods: Complete records and serial radiographs of 72 patients (76 hips) having revision total hip arthroplasty by a single surgeon and follow-up of at least 1 year, were reviewed by an independent observer. Results: The mean follow-up period was 4 years. Indications for revision were aseptic loosening (N=51), sepsis (N=16), fracture (N=3), dislocation (N=2), and other (N=4). Complete cement removal was achieved in 97% of acetabular components revised and 88% of femoral components revised. There were no documented complications in 68% of revised hip prostheses. The complications of the remaining cases comprised trochanteric bursitis (9%), dislocation (10%), thromboembolism (5%), periprosthetic fracture (1%) and infection of the revised prosthesis (1%). None of the cases studied died as a direct result of surgery. All radiographic parameters measured were improved by revision of the prostheses. Conclusions: Orthopaedic surgeons working in district general hospitals performing 5 to 10 revision hip arthroplasties per year can achieve results comparable to those of surgeons working in specialised units

Aims: Outside of specialist centres, follow up data on knee arthroplasties beyond 3 years is seldom available. We have devised a simple and cost effective tool to enable the average District general Orthopaedic department to assess their long-term outcomes following knee replacements. Methods: 130 patients underwent a total knee arthroplasty in 1997 at Bolton. A simple questionnaire (which could be completed in person or over the telephone) was dispatched to all of the 115 patients still alive. Questions referred to the patientñs satisfaction with their operation, their mobility, visual analogue score for their pain and any complications that had occurred. Results: Within two weeks there were 95(83%) meaningful returns and a further 8(7%) were completed over the telephone. 12(10%) were lost to follow up. Of the 103 questionnaires completed 80(78%) patients were completely satisþed with their joint. 23(22%) patients experienced problems Ð 13 had signiþcant pain (greater than 50% on VAS), 5 thromboembolisms, 4 infections (2 joint, 2 wound) and 1 complained of a shorter leg. Conclusions: With this questionnaire we have quickly and cheaply identiþed our 5-year status for knee arthroplasty. We thus propose it is a useful audit tool for a department such as ours. In addition it may have the potential to identify those patients who would beneþt from hospital review at þve years and thus could be recalled

Introduction: Aim of this study was to provide survivor-ship analysis of the cementless Zweymüller, then Alloclassic flat-wedge femoral titanium alloy taper used in primary THA. Material and Methods: Of 1128 consecutive 1ary THAs (paired with a grit-basted threaded cup in 93%) performed over the 01/1986–12/2008 period and prospectively followed-up, 31 were all-cemented (2.7%), 74 were hybrid reconstructions (6.6%) and 1023 were fully cementless (90.7%). A total of 1034 cementless tapers (72 “Hochgezogen” and 962 “Alloclassic-SL” implants) were implanted. Results: Considering the unavoidable learning curve, first author complication rates (526 consecutive 1ary THAs) were acceptable with fracture ; femur, 0.5%: greater-trochanter, 0.8% ; subsidence > 2mm, 3.4% ; varus position 14.3% ; and osteolysis, 0.9%. Of the 1034 uncemented tapers, 19 were revised for: deep infection (7), recurrent dislocation (4), intra-operative or late fractures (4), unexplained pain (3, none loose at revision) and 1 for aseptic loosening (due to metallic head sleeve impingement). Overall femoral revision burden was 1.8% (< 0.1% per year) and survivorship with revision “for any reason” and “for aseptic loosening” was 94.2% and 99.5% % at 17 years, respectively. Currently, main reason for revision is related to osteolysis due to wear of conventional polyethylene liners. Conclusion. In a general orthopaedic population and in a regular setting, the Alloclassic SL-stem, our everyday femoral component, was forgiving and reliable for more than 20 years. We can reasonably expect an outstanding outcome in the future due to improved surgical skill, hard bearings (Metasul, 1994), slimmer neck and “Offset” options (2004)

During the development and early use of the First Generation of Universal Total Knee Replacement Instruments, those instruments supplied with the PCA knee and also available for use with the Kinematic and Total Condylar knees, David Hungerford and I noticed our imperfection in balancing some varus and valgus deformed total knee patients. We decided to start ligament tightening procedures to address this problem. I became impressed with the potential difficulty of simply grasping the medial capsular ligamentous sleeve and pulling it distally on the proximal tibia so that it could be stapled in place. I thought that use of a suture and then incorporation of that suture with a staple or screw could enhance the fixation. The tissue we were working with and are now talking about is rather thin, 1mm to 2mm, flat and broad with longitudinal fibers running in a caudad-cephalad direction. I wanted some way to grab these longitudinal fibers and exert a distal pull without having the suture material pull through. This suggested the use of a locking loop, analogous to what I had seen in my training when locking stitches were commonly used on different layers of wound closure. I developed in my head the picture of a row of locking loops and then saw the cross-over to the other side which revealed the entire structure with trailing tails. At this writing, I am uncertain of the year, but I am thinking it was 1982. Soon after that I illustrated it with OR suture thru paper and then began using it in surgery. I felt that publication would require studies of relative pull-out strength, and we added an injection study to look at possible influence of the tissue vascularity. For tensile strength we used #5 Ethibond in bovine xenograft material, stapled and sewn to wood. In summary, different from individual stitches or stapling without stitching, The K-stitch fails at the suture material and not by pulling the tissue. This statement is true when the suture reasonably matches the heft or thickness and strength of the soft tissue. Otherwise one is dealing with suture that is overpoweringly stronger than the tissues being fixed or held. Clearly this stitch has found common application in Achilles tendon repair and a wide variety of other applications. My own most common use is with re-attachment of the gluteus minimus tendon after an anterolateral total hip exposure. I imagine that this suture is used or at least known by all orthopaedic surgeons with one exception, spine surgeons. I just do not see an application in their surgery. However, some of the younger ones will know it from their general orthopaedic training. A video is shown of the technique and it is emphasised that the suture need not be used so that it loops the edge of a tendon. It may just as easily and helpfully be used on a broader surface as shown

Faced with the challenge of managing war trauma in Afghanistan (1984–86), within limited resources and compromised conditions, we started managing open fractures with the pin and plaster method. With time a new External Fixation System evolved, which helped save hundreds of limbs and lives. Encouraged with the results, this system was used in the civilian practice, in India. There were further improvements in the design and refinements in technique. Subsequently biomechanical studies were conducted in Liverpool. The Fixator has been used at other centers in India and the UK with good results. This paper describes evolution of the model, and its use in 116 patients by a single surgeon between February 1987 and July 1990. It has been used on every limb segment and indications included open fractures, infected non-unions, arthrodesis, osteotomy, etc. Analysis of results in 41 open tibial fractures showed 97.3% united at an average of 21.4 weeks. Delayed union occurred in 5.2 %. There was no malunion and pin tract infection was 6.3%. The system has proved to be simple yet versatile, cheap, easy to use, and an effective alternative to more costly and complex designs. It has been used as a modular system for varieties of conditions encountered in general orthopedic practice. Customized configurations can be produced and rigidity of fixation can also be altered in the same configuration, to meet biomechanical and biological demands in each patient. With advent of newer techniques during last decade, the use of ExFix in our practice has been more selective and judicious

Introduction and Aims: To evaluate the results of radial head replacement in the primary management of radial head fractures. The recommended indications for prosthetic radial head replacement include unreconstructable Mason 3 fractures associated with ligament disruption or axial forearm instability. Method: We retrospectively reviewed all radial head fractures that were treated with a radial head replacement, over a four-year period, in two district general hospitals. All seven patients were finally assessed specifically for this study, either in person or by telephone/ postal questionnaire, with final radiographs obtained for this study. Results: Routine clinical follow-up was three months, following which the patient was discharged. No patient achieved full functional range of motion. The average range of flexion was 110 degrees (range 80 to 120 degrees), average extension deficit of 35 degrees (range 30 to 45 degrees), average pronation was 35 degrees (range 0 to 65 degrees), and average supination was 50 degrees (range 30 to 85 degrees). Three patients required implant removal due to loosening (1/3), elbow stiffness (2/3), and instability (1/3), the latter case requiring a revision of the radial head prosthesis. Persistent discomfort was noticed in all cases. Four patients were tolerant of the final functional outcome, although the average Mayo elbow score was 78/100 (range 55 to 80). Conclusion: Radial head replacement in general orthopaedic, low volume, practice failed to achieve satisfactory results. Contrary to popular belief, it is a technically demanding operation, for which surveillance should be continued for a minimum of one year. Strict indications for prosthetic replacement should be followed and implant selection has yet to be proven to make a significant positive contribution

Purpose- To study the surgical outcome of multi-fragmentary, un-reconstructable radial head fractures managed acutely by a radial head prosthetic replacement. Materials- We retrospectively reviewed fifteen radial head fractures that were treated acutely with a radial head replacement, over a four-year period, in three district general hospitals. Fifteen patients were clinically and radiologically assessed for this study. Functional assessment was performed with the Mayo elbow performance score (MEPS). Results- No patient achieved full functional range of motion. The average range of flexion was 110° (range 80° to 120°), average extension deficit of 35° (range 30° to 45°), average pronation was 35° (range 0° to 65°), and average supination was 50° (range 30° to 85°). Complications included implant removal due to loosening (n=1), elbow stiffness (n=2), and instability (n=1), the latter case requiring a revision of the radial head prosthesis. Some degree of persistent discomfort was noticed in all cases. Five patients were tolerant of the final functional outcome. The average Mayo elbow score was 68/100 (range 55 to 80). One patient had an intra-operative fracture of the radial metaphysis during insertion of the implant. Conclusions- Radial head replacement in general orthopaedic, low volume, practice failed to achieve satisfactory results. Contrary to popular belief, it is a technically demanding operation, for which surveillance should be continued for a minimum of one year. Strict indications for prosthetic replacement should be followed and implant selection has yet to be proven to make a significant positive contribution. Our review highlights the need for a stricter adherence to indications, surgery should not be under-estimated and devolved to trainees, and our understanding of the radial axis of the elbow and forearm remains relatively rudimentary

It has been recently suggested that hyponatraemia may be a cause of significant iatrogenic harm in orthopaedic patients. In an attempt to test this theory, this observational study was done to establish the incidence of post-operative hyponatraemia following hip fracture and evaluate its correlation with outcome. An observational study was carried out on 213 consecutive hip fracture patients. 201 patients completed the requirements of the study (Male-45, Female-156). Mean age was 80 years. Serum sodium concentrations were recorded during the first week of admission. Hyponatraemia defined as significant (Na < 130mmol/L) was identified in 9% at admission and 18% during first week of stay. Incidence of severe hyponatraemia was 3%. There were no acute complications of hyponatraemia in these patients. 78% of hyponatraemia patients had received 5% Dextrose infusion during the postoperative period as their main intravenous fluid. All hyponatraemic patients had their sodium levels restored to normal during their stay. Long term outcome measures used were mortality, change in residential status, walking ability and use of walking aids at 4 months following fracture. There was 20% mortality at 4 months in the hyponatraemic group and it was 30% in the normal serum sodium group. However this difference was not statistically significant. Hyponatraemia did not significantly influence deterioration in residential status (p< 0. 05), walking independence (p< 0. 05) or increase of walking aids (p< 0. 05). In hip fracture patients, hyponatraemia whilst common was not associated with a poor outcome and at the same time we did not find any evidence of lapse in the recognition and treatment of hyponatraemia in a general orthopaedic ward. However emphasis should be made to junior medical staff to avoid iatrogenic hyponatraemia by following a proper postoperative fluid regime

Minimally invasive hip replacement surgery has become the catch cry of the past 18 months. The technique of two incision surgery has been touted as allowing safe insertion of hip replacement components and early discharge of patients in comparison to standard procedures. The early results and technique developed by the author are discussed with specific reference to early complications and early radiographic and clinical results. After extensive cadaveric dissection and anatomical study, a comparison was made of the existing exposures used in two incision surgery including pitfalls and benefits. Following initial study, a two incision approach has been used on forty patients initially chosen as being suitable for the procedure based upon age, weight, and suitability for cementless hip replacement. Data relating to surgical time, hospital stay, post op complications and radiographic and clinical results have been prospectively analysed. Early clinical results have been very favourable, including no increase in complication, and earlier discharge and recovery from surgery. The results are being validated by a randomised prospective international study, but the ability to discharge patients within 24 hours of surgery does not appear to be a viable option and possibly not a safe option considering the concerns relating to recovery from anaesthesia and post operative postural hypotension. A radiographic assessment has revealed accurate placement of implants compared to an historic group using conventional exposure. Clinical scores have been better at six weeks and three months compared to mini incision and standard incision patients. Further research and experience is required for this technique to be fully applicable and available to the general orthopaedic population. Technically the procedure is more challenging and does require adequate instruction and does have a significant learning curve. However, the early clinical results do support earlier discharge and more rapid recovery compared to standard hip replacement surgery

Introduction. Our clinic has started to use MAZOR's Spine-Assist(r) robotic device in routine spinal surgery practice since 2006. The use of this system is diverse and now applicable for Vertebroplasty, Biopsy procedures and different techniques of Spinal fusion. During this time our clinic performed near 150 robotic assisted surgeries. Amongst its benefits the system allows the reduction of the duration of fluoroscopic exposure in the OR, better accuracy due to computerized assisted planning and navigation, avoidance of human caused complications and a less traumatic procedure for the patient. On the other hand, the duration of the procedure is prolonged, the wound is subdued to a longer exposure in cases of the open surgery, and the operational cost is higher and requires a good trained medical staff. Materials and Methods. In the last 2 years we have performed 56 robotic assisted Vertebroplasty procedures (research group). At the same time we have performed 44 non assisted Vertebroplasty procedures. There was a significant difference in the fluoroscopic time and subsequent exposure time to radiation between the groups: in the research group we used only an average of 3 seconds of staff fluoroscopic exposure (an average of 5 fluoroscopic images) compared to an average of 11 seconds of exposure (an average of 24 fluoroscopic images). Furthermore, we have successfully inserted more than 400 pedical screws with less than 1mm accuracy from planning, out which only 8 were misplaced. Subsequently we have also performed 16 biopsies, which were effective as CT based biopsies. The average duration of a surgical procedure without the use of the system in 1 level fusion was 82 min. With the use of the system the average time was 106 min. The operational cost with the use of the system was about 1,000 ∊ more expensive. Furthermore, the use of the system required performing of an additional CT scan with 1 mm slices, which caused an additional exposure to patient radiation. Results. Robotic assisted spinal surgery is a new and safe approach aiming to dramatically shorten the duration of fluoroscopic exposure of the staff and surgeon thus reducing the exposure to radiogenic dose. This novel procedure, promotes a better accuracy with regard to Vertebroplasty, Spinal fusion, insertion of Pedical Screws and also for biopsies procedures. We continue to broaden the usage of the robotic assisted device to other fields of spinal surgery and to general orthopaedic surgery. However, we have to resolve some issues such as cost, operation time and less fluoroscopic exposure for the patient

Introduction: Lumbar disc disease comprises of a heavy portion of the workload in spinal as well as general orthopaedic clinic. It is well accepted that nerve root tension signs such as straight leg raise (SLR) & Lasegue’s test are sensitive at diagnosing nerve root impingement secondary to lumbar disc degeneration. In isolation, however, they lack specificity & have a poor positive predictive value (PPV). This can lead to uncertainty in clinical diagnosis. Our study proves that a structured approach to clinical examination with cumulative nerve root tension signs (RTS) significantly increases the tests’ specificity and PPV, therefore giving clinicians more confidence in their diagnosis. Methods: Prospective review of 1303 patients seen in one Orthopaedic consultant’s spinal clinic from 2004 until 2008. Data was collected using a standardized proforma. Pattern of pain as well as RTS (SLR, Lasegue, bowstring and crossover) were recorded and cross-referenced with subsequent MRI findings. In our dataset a positive MRI result was one in which the demonstrated disc lesion and nerve impingement corresponded with patient symptoms. Patients included were all those presenting with lower back and/or neuropathic leg pain. Patients had to be excluded from series due to incomplete datasets & missing MRI scans. Results: N = 858. Our results showed that as we progressed from 1 RTS up to 4 RTS there was a significant increase in the PPV : 1RTS PPV = 0.333 (CI 0.25 – 0.43), 2RTS PPV = 0.78 (CI 0.69 – 0.86), 3RTS PPV 0.87 (CI 0.81 – 0.91), 4RTS PPV 0.93 (CI 0.66 – 0.99). There was also significant increases in specificity compared with 1RTS: 1RTS 0.75 (CI 0.70 – 0.8), 2RTS 0.94 (CI 0.91 – 0.96), 3RTS 0.92 (CI 0.89 – 0.95), 4RTS 0.99 (CI 0.98 – 0.99). Discussion: This study shows that combining root tension signs as part of a structured assessment leads to a significant cumulative increase in the PPV and specificity of the diagnosis of nerve root impingement. Hence proving the importance of clinical examination. This method of sequential, cumulative RTS has not previously been documented in the literature

Patellofemoral problems represent a significant source of morbidity following total knee arthroplasty (TKA). Patellofemoral biomechanics and contact stress following TKA depends (among other factors) upon the position of the patella relative to the tibiofemoral joint. Patellar height may be altered either by changes in the tibio-femoral joint level (pseudo patella baja/alta) or by a change in patella tendon length (true patella baja/alta). The purpose of this study is to examine the latter. Two previous studies have described patella tendon shortening following TKA but both have significant limitations and produced differing results. The aim of this study was to identify the incidence of true patella tendon shortening following TKA for the treatment of osteoarthritis (OA). All patients undergoing primary TKA for OA in 2001 and 2002 were identified. Cases were excluded if they had rheumatoid arthritis, had undergone previous open knee surgery, suffered a significant post-op complication, or had less than 1 year radiological follow up. Case notes and radiographs of 50 knees in 34 patients were reviewed. The Insall-Salvati ratio was measured on immediate pre-op, initial post-op, and final follow-up lateral knee radiographs. Differences between mean pre and post-op ratios were compared using a paired t-test. There were 19 women and 15 men aged 47 to 84 (mean 70.4) years. The mean pre-op Insall-Salvati ratio was 0.99. The initial post-op ratio was unchanged (p=0.06). After a minimum of 1 year the mean ratio remained 1.0 (p=0.09). In no knee was there a significant change in patella tendon length. In this study we found no evidence of patella tendon shortening. Two other studies have identified shortening in one third to two thirds of knees. The methodology of these studies is however open to criticism. The patients in neither study are representative of general orthopaedic practice; the surgical technique in one was unorthodox and the radiological measurement method in the other not validated. This work therefore represents the first study of patella tendon length following TKA using a validated radiological index in a representative osteoarthritic population. In conclusion, TKA in this group of patients with osteoarthritis, employing a standard surgical technique was not associated with postoperative patella tendon shortening or true patella baja

Aim: To study the management and survival outcome of patients with metastatic long bone deposits referred to a general orthopaedic unit at a district general hospital. Methods and materials: 43 patients with pathological or impending long bone fractures were identified between 1998 and 2001. Details of primary tumor, bony metastatic involvement and management were recorded. Additional data was collected regarding prophylactic versus therapeutic treatment, oncological input, time to death and Mirel’s score, where relevant. Results: The most common areas of long bone metastases were found to be proximal femur 29/43 (67%) and humeral shaft 11/43 (26%). Proximal femoral lesions included subcapital, intertrochanteric and subtrochanteric lesions. Operative stabilisation was carried out in 27/43 (63%), and involved intramedullary fixation (10/27; 37%), extramedullary fixation (15/27; 56%), and arthroplasty (2/27; 7%). Of the initial 43 patients, 14 (33%) presented with impending fractures, with Mirel’s scores ranging from 7 to 11 (average 9). The duration of pre-existing pain in the in the fracture group varied from 3 days to 6 months (average 55 days). None of these patients received oncological input during this time period. Of these 15 patients, 12 subsequently required surgery. Patient survival times in the operated group averaged 3 months (2 days to 9 months) – with the exception of one patient who survived for 36 months. This compared equally with survival times for the unoperated group. Only 2/43 patients received preoperative oncology input. In the postoperative group (27 patients), 16 (59%) received radiotherapy. Of the remaining 11 patients, 9 (33%) did not receive radiotherapy due to significant postoperative complications and died within 8 weeks. Discussion: The main aims of surgery in patients with metastatic bony disease are pain relief, and preservation of stability and function. In view of the low life expectancy, preoperative oncology input is important in determining patient longevity and in deciding if surgery is beneficial. All patients should be considered for postoperative radiotherapy once the wound has healed. This multi disciplinary approach can be difficult to achieve in the setting of a district general hospital where oncology services are limited

The issue of preservation or sacrifice of the posterior cruciate ligament in total knee arthroplasty remains unresolved. We report the results of 200 consecutive total knee arthroplasties performed at our hospital under the direction of the senior author. Pre-operatively, patients were randomly chosen to receive either a Kinemax (posterior cruciate retaining) or a Press-Fit-Condylar (posterior cruciate sacrificing) prosthesis. We implanted 97 Kinemax and 103 Press-Fit-Condylar prostheses which were prospectively followed-up by clinical and radiographic assessment. Review at mean follow-up of 2.7 years showed a satisfactory clinical result in both groups [Surace, et al., 1994]. We present the results of our further review, with maximum follow-up of over nine years (mean: 5.9 years). Revision of the implant has been performed in five knees (three Kinemax and two Press-Fit-Condylar). The polythene spacer had to be replaced in one patient with a Press-Fit-Condylar implant. Patients were assessed with the Hospital for Special Surgery Knee Score and radiologically assessed with the Knee Society Roentgenographic Evaluation and Scoring System. Pre-operative demographics and disease states of the patients were similar, with an average Hospital for Special Surgery Knee Score of 63. At the latest assessment the average knee score was good (85). Remarkably, the mean knee score for the posterior cruciate sacrifice and the PCL groups remains similar (mean: 85). Radiographic evaluation demonstrated that the prosthetic components of both groups were in comparable alignment. The posterior cruciate ligament retained (Kinemax) patient group showed a mean 5.9 degrees of the valgus angle at the knee. The angle in the posterior cruciate ligament sacrifice (PFC implant) group was 6.2 degrees. Evaluation of the radiolucent depths below the femoral, tibial and any patella component showed a mean total depth of 1.5 mm (pcl retaining) and 1.7 mm (pcl sacrificing). Our study presents a quantitative perspective of the results of total knee replacement with proven implant systems and performed in a general orthopaedic unit by both consultants and surgeons in training. The Kinemax (Howmedica) and Press-Fit-Condylar (DePuy Johnson and Johnson) implant systems have both previously demonstrated good results and continue to be available with little subsequent modification. To our knowledge, there have been no other large prospectively randomised studies of posterior cruciate ligament preservation or sacrifice in total knee replacement

Purpose: With the growing risk of nosocomial infections, one might expect to see a reinforcement of septic isolation wards in orthopaedics and traumatology units. The question is however being revisited because of several factors. 1st: General Orthopaedics Units are practically the only hospital units caring for a minority of septic patients with often resistant germs and a majority of non-septic patients in the same setting. 2nd: The growing number of single-patient rooms procures confidence (whether justified or not). 3rd: Hygiene specialists are particularly wary of occult carriers of resistant bacteria and apply a single set of protective measures for all patients. 4th: Economic performance is given priority. Material and methods: We studied 1) the current situation in Orthopaedic units in University Hospitals in France and 2) the statistics from the Besançon University Hospital Hygiene Unit and from data in the literature. Results: 1) Interrogation of the 71 University Orthopaedics Units in France revealed that: 11 units have strict isolation wards; 40 have incomplete isolation wards; 20 make no distinction between septic and non-septic patients. 2) According to the Hygiene Unit statistics, the epidemiological load of S. aureus meti-R (SAMR), strains often implicated in orthopaedic infection, is much higher in the University Hospital polyvalent wards than in the Orthopaedic septic ward. Contamination between septic patients is low. Furthermore, hand-borne and airborne contamination are not controlled in wards other than septic wards. Data in the literature are not in agreement concerning this new trend in prevention by isolation. Discussion: a) One argument retained by all is that septic wards have an advantage in terms of efficacy and concentration of preventive measures. b) The growing workload in mixed units hinders strict application of preventive measures. c) A large number of temporary personnel (trainees, temporary employees, personnel untrained in sepsis prevention) are present in polyvalent units. d) Standardisation of preventive measures leads to an average level of prevention which lengthens the duration of care for non-septic patients and simplifies care for septic patients. e) The financial argument is impertinent compared with the consequences of contamination. Furthermore, a departmental structure would allow common use of the septic ward. Conclusion : Septic isolation wards (or a septic department) should be preserved. The orthopaedic surgeon, as a responsible actor in the fight against nosocomial infections, should in concert with the consulting hygienist, oppose purely administrative decisions

We report the effect of introducing a dedicated Ponseti service on the five-year treatment outcomes of children with idiopathic clubfoot. Between 2002 and 2004, 100 feet (66 children; 50 boys and 16 girls) were treated in a general paediatric orthopaedic clinic. Of these, 96 feet (96%) responded to initial casting, 85 requiring a tenotomy of the tendo-Achillis. Recurrent deformity occurred in 38 feet and was successfully treated in 22 by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, The remaining 16 required an extensive surgical release. . Between 2005 and 2006, 72 feet (53 children; 33 boys and 20 girls) were treated in a dedicated multidisciplinary Ponseti clinic. All responded to initial casting: 60 feet (83.3%) required a tenotomy of the tendo-Achillis. Recurrent deformity developed in 14, 11 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The other three required an extensive surgical release. . Statistical analysis showed that children treated in the dedicated Ponseti clinic had a lower rate of recurrence (p = 0.068) and a lower rate of surgical release (p = 0.01) than those treated in the general clinic. This study shows that a dedicated Ponseti clinic, run by a well-trained multidisciplinary team, can improve the outcome of idiopathic clubfoot deformity. Cite this article: Bone Joint J 2014;96-B:1424–6

Introduction. The Western Infirmary/Gartnavel General Hospital orthopaedic department is geographically located next to the Beatson Oncology Centre, a specialist regional oncology unit. Pathological femoral fractures are the commonest reason for surgical intervention in patients referred from the Beatson and we have used them as a model to establish the demographic data, referral patterns, treatment results, and survival characteristics in such a group of patients. Methods. We have collected prospective data for the last 4 years on referrals from patients under the care of oncology services. Results. 52 patients with 53 pathological fractures and 2 impending pathological fractures of the femur during a 4 year period have been treated with a surgical intervention. The surgery included locked reconstruction femoral nailing, long stem hemiarthroplasty with distal locking and proximal femoral replacement with or without acetabular augmentation/reconstruction. 34 patients were female, 18 were male reflecting the most common primary diagnosis of breast carcinoma (30 patients). The mean age was 64 years (range 31 to 82). Post-operative complications include one death at 48 hours, 4 pulmonary emboli, a symptomatic DVT and one sciatic nerve palsy. No dislocations have occurred and there have been no implant failures at a mean of 1.2 years (range 2-26 months). We present survival characteristics based on primary tumour type and indicators of poor prognosis. Discussion. The benefits of timely orthopaedic intervention in patients with pathological fractures is well established and this study provides further insight to aid informed decisions and provides information on surgical provision required

Immobilisation is known to be a risk factor for thromboembolic events and the management of ankle fractures often involves immobilisation of the fracture in a below knee cast. Recent literature has found a 5% rate of subclinical deep vein thrombosis (DVT) and suggested thromboembolic prophylaxis is not required. This study involved all adult patients with isolated ankle fractures presenting to a district general hospital orthopaedic department over a 6 month period. This included patients undergoing internal fixation as well as non-operative management. A 3 to 7 month follow-up was performed to assess the incidence of clinical DVT or pulmonary embolism (PE) proven using Doppler imaging, venogram, and computed tomography pulmonary angiography. 119 patients met the entry criteria and, of these, 3 patients developed DVT and 2 patients presented with pulmonary embolus. 15 patients in the study were taking aspirin (75–300 mg daily) during their cast immobilisation and 1 patient was taking warfarin. None of these patients developed a thromboembolic complication. 4.8% of patients not taking aspirin or warfarin experienced a thromboembolic complication. This study demonstrates a relatively high incidence of symptomatic thromboembolism following ankle fractures in the absence of prophylaxis. Previous studies have found aspirin to be an effective method of prophylaxis following hip fractures and total hip arthroplasty. We recommend that thromboembolism prophylaxis is necessary following ankle fractures and suggest that aspirin may be an economical option. Larger studies are needed to evaluate the role of aspirin in this setting

Aim. To compare outcomes for children treated for idiopathic clubfeet with the Ponseti regimen before (2002–2004) and after (2005–2006) implementation of a dedicated Ponseti service. Method. A retrospective analysis of outcomes for all patients with idiopathic clubfeet treated in the 2 years before and after implementation of a dedicated Ponseti service was undertaken. Results were statistically analysed using Fisher's exact t-test. Results. In the original cohort treated between 2002–2004, with an ad-hoc service where children were treated in general paediatric orthopaedic clinics by a number of different consultants, 100 feet in 66 children were treated. 96 feet (96%) responded to initial casting. 85 feet (85%) required tendo-achilles tenotomy. 31 feet had a recurrence within the first 2 years (16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, the remaining 15 requiring extensive soft tissue release). Between 2005–2006, with a dedicated Ponseti service, 72 feet in 53 children were treated. 72 (100%) responded to initial casting. 60 feet (83.3%) required tendo-achilles tenotomy. Relapse of the initial deformity occurred within 2 years in 11 feet – 4 children required repeat serial casting, 3 feet required tendon of tibialis anterior transfer, 3 required repeat tenotomy of tendo-achilles and one foot required extensive soft tissue release. Conclusion. Our results have shown that a dedicated Ponseti service leads to improved outcomes in the treatment of idiopathic clubfeet. We have shown a statistically significant reduction of recurrence (p=0.02) and extensive soft tissue release (0.002) in those children treated in a specialist service compared to an earlier ad hoc treatment programme

Introduction: Image Intensifier screening is commonly utilised in orthopaedic theatres. There has been concern regarding the cumulative radiation dose to surgeons and theatre personnel. The mini C-arm intensifier has been reported to scatter less radiation and have a reduced radiation dose to patient and theatre staff. Material and Methods: 2 month prospective survey of usage of radiographer-operated large intensifier and surgeon-operated mini C-arm image intensifier in a district general hospital orthopaedic theatre department. Results: 153 cases required image intensifier screening. 63% used the large intensifier and 37% the mini c-arm intensifier. The complication rate for the large intensifier was 16%. There were delays in 11% of cases using the large intensifier. The total radiographer attendance time was 123 hours. For the mini C-arm intensifier there were no complications or delays. The minimum radiographer time saved by using this machine was 21.9 hours. Conclusion: The mini C-arm intensifier has saved 15% of the radiographer workload with its current pattern of usage in our department. There have been no complications or delays as a result of its usage in theatres. Other departments are encouraged to consider acquisition of such a machine to facilitate theatre throughput and reduce demands on the radiology department

Purpose: An audit was undertaken to evaluate the patients’ experience of foot surgery at the great Western Hospital in 2004 following the appointment of a podiatric surgeon to the orthopaedic department. Method: The first 100 patients that were operated on by the podiatric surgeon (Group 1) were matched by OPCS code to a randomly selected patient cohort that had been operated on by orthopaedic surgeons (Group 2). All patients were at a minimum of 6 months post-surgery (range 6–10 months Gp. 1, 11–20 months Gp. 2). The audit department sent out an anonymous questionnaire relating to the patients’ experience both before and after their surgery as well as current levels of satisfaction with the outcome of their surgery. Results: The response rate was 64% in Gp.1 and 68% in Gp.2. The patients’ overall satisfaction with the result of their foot surgery was determined using a Likert scale and the results can be seen in Table 1. Patients in the podiatric surgical group were significantly more satisfied with the result of their foot surgery than those in the orthopaedic group (p< 0.008; Mann Whitney U test). Similar statistically significant differences were also seen between the two groups relating to patient satisfaction with their pre and post-operative consultations and information concerning their proposed surgery and its outcome. Conclusion: The results of this audit suggest that the satisfaction of patients following foot surgery can rise significantly following the appointment of a podiatric surgeon to a general hospital orthopaedic department

Satisfactory military orthopaedic service provision in the UK suffers significantly from a lack of basic resources, notably overall consultant numbers and host trust support. The waiting time to see an appropriate consultant (uniformed or contracted) can be as long as nine months. Many of these referrals from the primary care sector do not, in fact, need to see a consultant. Appropriately trained individuals such as; GP’s with special interests, Nurse Practitioners and Extended Scope Practitioners may all have a role to play in patient management. Military Physiotherapists are uniquely qualified to deal with these referrals. They can provide military input, advice on grading, order appropriate investigations (including MRI scans and X-rays) and give guidance on further management and arrange follow-on treatment. Although popular in spinal assessment clinics, we are unaware of this facility being formally used in a general military orthopaedic setting. We have now reviewed the results of our first 100 patients. The average waiting time to first appointment was 2 weeks. 75 patients were dealt with solely by the screening clinic. 21 MRI scans, were ordered. Only 25 patients required review by the orthopaedic team. 7 patients required surgery. Our conclusion is that such clinics represent a clinically beneficial and cost-effective screening tool at the primary/secondary care interface. A high patient satisfaction at the short waiting times and outcomes was also noted

Purpose. Clinical coding is used to record information from patient admissions in the form of coded data used for monitoring the provision of health services and trends, research, audit and NHS financial planning. Method. A sample of 105 cases admitted to Southampton General paediatric orthopaedic department from 2006-9 was used. 31 admissions were grouped using HRG4 and the remaining 74 using HRG3.5. Accuracy of coding was calculated by establishing correct discharge coding and comparing them with coding records. The correct codes were run through HRG 3.5 and 4 payment groupers and their outcomes were compared financially to the HRG codes these admissions were actually grouped under. Results. There were 800 interventions which should have been coded over 148 patient episodes. Of these 442 (55%) were not coded, 189 (24%) were coded inappropriately and 169 (21%) were coded correctly. The HRG3.5 group was coded 18% correctly, the HRG4 29% correctly. However, 70% of the HRG4 and 49% of the HRG 3.5 group were inaccurately grouped. The resulting deficit was a £54,352 (HRG4-£36,711, HRG3.5-£17,641) an average of £507 per patient stay. A conservative estimate of 150 ward admissions monthly means a projected loss of £912,600 per annum. The fractured radius and ulna group (one of the most common causes of admission) suffered greatest financial losses. Additional losses come from paediatric/orthopaedic top-ups (63% and 14% respectively) as only one can be applied to each HRG. Conclusion. The implementation of HRG4 means accuracy is crucial as smaller inaccuracies result in bigger costing discrepancies than with HRG 3.5. Financial losses are larger with paediatric orthopaedics from inadequate top-ups. This system of Payment by Estimates not Results is only acceptable if financial underestimates are balanced with financial overestimates. These results strongly suggest this is not happening

Aims: A retrospective review of all periacetabular osteotomies (PAO) performed at a general elective orthopaedic Hospital over a 7-year period. To assess the clinical, functional and radiographic outcome associated with PAO when introduced as a new procedure to a non-super-specialised regional centre. Methods: A retrospective review of 85 PAOs performed on 79 patients at Cappagh Hospital between 1/4/1998 and 1/4/2005. The medical records and radiographic images of all patients were reviewed. Clinical follow-up evaluations were also performed. Results: 85 PAOs were performed on 79 patients. Mean age at time of surgery was 22.9 years (range, 14–41 years) with an increased preponderance of females (F:M=10:1) and right sided hip involvement (R:L=1.1:1). The mean Merle D’Aubigne and Postel hip score increased from 12.4 (range 9–14) preoperatively to 16 (range 11–18) postoperatively (P< 0.0001). The average lateral center edge angle increased from 5° preoperatively to 26° postoperatively (P< 0.0001). The anterior center edge angle averaged 6.6° preoperatively and improved to 34.4° postoperatively (P < 0.0001). The acetabular index angle decreased from an average of 24.8° preoperatively to 8.4° postoperatively (P< 0.0001). At clinical follow-up, 77% of patients had no/mild pain, 30% of patients had a limp and 64% of patients were unlimited in physical activity. Conclusions: The short term results in this group of patients treated with PAO show reliable radiographic correction of deformity and improved clinical scores. We suggest that PAO may safely be carried out at a non-super-specialized institution provided the surgeons have sufficient experience and patients are selected appropriately

The December 2022 Oncology Roundup³⁶⁰ looks at: Is high-dose radiation therapy associated with early revision with a cemented endoprosthesis?; Neoadjuvant chemotherapy and endoprosthetic reconstruction for lower extremity sarcomas: does timing impact complication rates?; Late amputation after treatment for lower extremity sarcoma; Osteosarcoma prediagnosed as another tumour: a report from the Cooperative Osteosarcoma Study Group; The influence of site on the incidence and diagnosis of solitary central cartilage tumours of the femur: a 21st century perspective.

Aims

Multiligament knee injuries (MLKI) are devastating injuries that can result in significant morbidity and time away from sport. There remains considerable variation in strategies employed for investigation, indications for operative intervention, outcome reporting, and rehabilitation following these injuries. At present no study has yet provided a comprehensive overview evaluating the extent, range, and overall summary of the published literature pertaining to MLKI. Our aim is to perform a methodologically rigorous scoping review, mapping the literature evaluating the diagnosis and management of MLKI.

The April 2023 Knee Roundup³⁶⁰ looks at: Does bariatric surgery reduce complications after total knee arthroplasty?; Mid-flexion stability in total knee arthroplasties implanted with kinematic alignment: posterior-stabilized versus medial-stabilized implants; Inflammatory response in robotic-arm-assisted versus conventional jig-based total knee arthroplasty; Journey II bicruciate stabilized (JII-BCS) and GENESIS II total knee arthroplasty: the CAPAbility, blinded, randomized controlled trial; Lifetime risk of revision and patient factors; Platelet-rich plasma use for hip and knee osteoarthritis in the USA; Where have the knee revisions gone?; Tibial component rotation in total knee arthroplasty: CT-based study of 1,351 tibiae.

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Can you treat type IIA supracondylar humerus fractures conservatively?; Bone bruising and anterior cruciate ligament injury in paediatrics; Participation and motor abilities after treatment with the Ponseti method; Does fellowship training help with paediatric supracondylar fractures?; Supracondylar elbow fracture management (Supra Man): a national trainee collaborative evaluation of practice; Magnetically controlled growing rods in early-onset scoliosis; Weightbearing restrictions and weight gain in children with Perthes’ disease?; Injuries and child abuse increase during the pandemic over 12,942 emergency admissions.

The December 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: A comprehensive nonoperative treatment protocol for developmental dysplasia of the hip in infants; How common are refractures in childhood?; Femoral nailing for paediatric femoral shaft fracture in children aged eight to ten years; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Paediatric patients with an extremity bone tumour: a secondary analysis of the PARITY trial data; Split tibial tendon transfers in cerebral palsy equinovarus foot deformities; Liposomal bupivacaine nerve block: an answer to opioid use?; Correction with distal femoral transphyseal screws in hemiepiphysiodesis for coronal-plane knee deformity.

Aims

Within healthcare, several measures are used to quantify and compare the severity of health conditions. Two common measures are disability weight (DW), a context-independent value representing severity of a health state, and utility weight (UW), a context-dependent measure of health-related quality of life. Neither of these measures have previously been determined for developmental dysplasia of the hip (DDH). The aim of this study is to determine the DW and country-specific UWs for DDH.