First Metatarsophalangeal joint fusion has been successfully used to treat Hallux rigidus. We have attempted to evaluate commonly used methods of fixation and joint preparation. To the best of our knowledge, this is the single largest comparative study on first MTPJ fusion. We aimed to evaluate the radiological union and revision rates. We included 409 consecutive MTPJ fusions performed in 385 patients. We collected demographic, comorbidities and complication data. We evaluated the radiographs for the status of the union. Logistic regression was used to calculate the Odds ratio (OR) of non-union for the collected variables. Our union rate was 91.4% (34/409). 29.4% of our non-unions were symptomatic (10/34). Hallux valgus showed a statistically significant relation to non-union (Odds ratio 9.33, p-value 0.017). Other potential contributing factors like sex (OR1.9, p-value 0.44), diabetes (OR 0, p-value 0.99), steroid use (OR 2.07, p-value 0.44), inflammatory arthritis (OR 0, p-value 0.99) and smoking (OR 2.69, p-value 0.34) did not attain statistical significance. Further, the methods of fixation like solid screws (OR 0, p-value 0.99), plate (OR 3.6, p-value 0.187) or cannulated screws (OR 0.09, p-value 0.06) showed no correlation with non-union. We compared two techniques of joint preparation and found no significant difference in union rates (Chi-Square 1.0426, p-value 0.30). Our crude cost comparison showed the average saving to the trust per year could be 33,442.50£ by choosing screws over plate. Only Hallux Valgus had a statistically significant relation to non-union. Solid screw could be economically the most viable option and a valid alternative.

Nanoscale topography increases the bioactivity of a material and stimulates specific responses (third generation biomaterial properties) at the molecular level upon first generation (bioinert) or second generation (bioresorbable or bioactive) biomaterials.

We developed a technique (based upon the effects of nanoscale topography) that facilitated the in vitro expansion of bone graft for subsequent implantation and investigated the optimal conditions for growing new mineralised bone in vitro.

Two topographies (nanopits and nanoislands) were embossed into the bioresorbable polymer Polycaprolactone (PCL). Three dimensional cell culture was performed using double-sided embossing of substrates, seeding of both sides, and vertical positioning of substrates. The effect of Hydroxyapatite, and chemical stimulation were also examined.

Human bone marrow was harvested from hip arthroplasty patients, the mesenchymal stem cells culture expanded and used for cellular analysis of substrate bioactivity.

The cell line specificity and osteogenic behaviour was demonstrated through immunohistochemistry, confirmed by real-time PCR and quantitative PCR. Mineralisation was demonstrated using alizarin red staining.

Results showed that the osteoinduction was optimally conferred by the presence of nanotopography, and also by the incorporation of hydroxyapatite (HA) into the PCL. The nanopit topography and HA were both superior to the use of BMP2 in the production of mineralised bone tissue.

The protocol from shim production to bone marrow harvesting and vertical cell culture on nanoembossed HaPCL has been shown to be reproducible and potentially applicable to economical larger scale production.

Allogenic blood is a finite resource, with associated risks. Previous studies have shown intra-operative cell salvage (ICS) can reduce allogenic transfusion rates in orthopaedic surgery. However, recent concerns regarding the efficacy and cost-effectiveness of ICS mean we must continually re-assess its usefulness in current practice. This study was carried out to review the use of ICS, to establish if its use has led to a reduction in patient exposure to post-op allogenic transfusion.

All orthopaedic patients who underwent ICS and re-infusion between 2008–2010 in the Southern General Hospital (SGH) were audited. The Haemoglobin (Hb) drop, volume of blood re-infused and post-op allogenic transfusion rates were recorded. The revision hip group was compared to a similar SGH cohort, who underwent surgery by the same surgeons between 2006–2008, and a pre-2005 control group. The Cell Saver (Haemonetics) machine was used.

The proportion of patients who received a post-op allogenic transfusion fell by 55% in the 2008–2010 ICS cohort compared with the control, and by 40% compared with the previous ICS study group. In both instances, this was accompanied by a statistically significant (p<0.001) reduction in mean number of units transfused per patient.

ICS has been shown to be effective in reducing rates and volume of post-op allogenic transfusion in patients undergoing revision hip surgery at the SGH. ICS has been used with increasing efficiency over time.

Introduction

Both the RANK/RANKL system and the endocannabinoid system have roles in bone remodelling. Activation of CB1 receptors on sympathetic nerve terminals in trabecular bone modulates bone remodelling by attenuating adrenergic inhibition over bone formation. CB2 receptors are involved in the local control of bone cell differentiation and function. Osteoblastic CB2 receptor activation negatively regulates RANKL mRNA expression indicating an interaction between the two systems and that efficient bone remodelling requires a balance between these two systems. The aim of the study was to establish the presence of the different components of the endocannabinoid system and the RANK/RANKL signalling pathway in human bone and osteoclast culture.

Introduction: We investigated the use of suture repair for tuberosities in hemiarthroplasty for 4 part fractures, by examining cadaveric repairs after repetitive loading tests.

Sutures are the most popular repair tool currently. However tuberosity “disappearance” with this is common; and touted as the prime cause for failure. In some studies biochemical lysis has been suggested to explain this. The aim of this study was to analyse the mode of failure.

Materials and Methods: Tests were carried out in line with UK HTA regulations. Eight fresh frozen cadaver shoulders were stripped of all soft tissue except the rotator cuff. A 4 part fracture was then created by osteotomising the tuberosities. A standard hemiarthroplasty implant was cemented in at the native height and retroversion. A tuberosity repair with Ethibond 5 sutures, employed transverse cerclage sutures; and vertical figure of eight repairs, from the cuff to a shaft drill hole.

The repairs were subjected to cyclical tension on the cuff musculature, and simultaneous gleno-humeral motion; using a test process we have described separately. During the entire process the repair site was videoed

At the end of 8000 cycles the tuberosities were probed with a forceps, to record any movement in vertical, horizontal and axial planes. The humeral shaft was also rotated to check for dissociation between tuberosities and shaft.

Results: Uniform failure of the hold on the tuberosities occurred by 8000 cycles. Defining failure as movement of any tuberosity more than 3mm, failure rate was 100% (exact 95% confidence interval 65.2 – 100% due to sample size). Movements of at least 1cm were commonly observed. The sutures were loose but never snapped. Failure mechanisms involved digging of the sutures into the tendon, cutting of the sutures through bone, loss of cancellous supporting structure, and migration of the sutures. Failure occurred early in what we considered to the parallel of 1 to 2 weeks of rehabilitation.

Conclusion: Suture repair of tuberosities has a high chance of failure if the cuff can not be prevented from contracting. We believe failure is early and mechanical, rather than by lysis or biochemical means. More effective alternatives to suture techniques would be desirable.

Introduction: The upper edge of pectoralis major tendon insertion (PMTI) on the humerus is touted as a reference to restore humeral height, to be used in hemi-arthroplasty for proximal humeral fracture. The aim of the study was to verify the reliability of reference and ease of its use in routine practice.

Materials and Methods: Tests were carried out in line with UK HTA regulations.

21 fresh frozen shoulders were stripped of all tissues except the rotator cuff and the PMTI. In each specimen the tuberosities were osteotomised, and the humeral head dislocated. The top margin of the PMTI was sought and marked. A flat object was held on the top of the humeral head perpendicular to the shaft and the vertical height from upper edge of PMTI to this object was measured.

Results: The 21 measurements (12 right +9 left) had a mean height of 5.98cm (95% CI: 5.64 – 6.31cm). The range of heights was 5 to 7.3 cm for all shoulders and also for right and left sides separately. Eighteen of these 21 shoulders were a pair i.e. right and left of 9 cadavers. The average height for 12 right shoulders was 5.91cm and for the left side average height was 6.05cm. The heights for a pair matched within 0.5 cm only in four pairs (8 shoulders) and exactly in only two pairs (4 shoulders) of specimens. The maximum difference in heights for one pair of shoulders from the same cadaver was as large as 1.4 cm. In comparison to previous studies our measurements were significantly greater than 5.6 cm (P = 0.029). Furthermore, there were 4 measurements of at least 7cm (19.0%, 95%CI: 5.4 – 41.9%).

Conclusion: Proximal humeral fracture treatment is a clinical challenge. In these fractures, usually all the ‘bony’ landmarks are lost. In these circumstances an anatomical landmark is needed to navigate from, and the upper edge of PMTI serves as a reference in restoring the height.

We found the average values for height to be larger than previously reported. Additionally the notion that the contra-lateral side can be used to calculate the height as a percentage of the length, accepting an error of +/− 0.5cm; was not corroborated. In 3 cases of the 9 pairs available a difference of 14, 7 and 6mm was seen. Lastly in certain cases a flimsy layer of fascia curved superiorly at the top margin, and we were in doubt as to whether to take this fascial extension as the top margin; in one case this flimsy layer also had muscular tissue attached. Though use of the fixed value had on our testing, a wider range than reported, we feel that PMTI is a useful landmark in these operations.

Revision total hip replacement is often associated with significant blood loss and subsequent transfusion. Intra-operative cell salvage is one approach to minimising this allogenic transfusion.

We carried out a retrospective study of 158 consecutive revision THRs carried out by one surgeon between June 2003 and September 2006 in the Southern General Hospital, Glasgow.

In the study group (79 patients, operated upon after October 2005) Intra-operative cell salvage was routinely used for all cases. In the control group (79 patients, operated upon before October 2005) Intra-operative cell salvage was not available.

Data was collected on transfusion of salvaged blood, transfusion of allogenic blood, operation type, indication for surgery, complications and length of hospital stay.

Results showed a 53% reduction (p=0.002) in the number of units of allogenic blood transfused in the study group compared with the control group. (1.59 units per case compared with 3.41 units).

In the study group 51% of patients received allogenic blood transfusion, compared with 68% of patients in the control group, a relative reduction of 17% (p=0.02).

There was no difference between the two groups regarding haemoglobin drop and length of hospital stay. Data regarding complications yielded no significant results due to small cohort size.

We conclude that intra-operative cell salvage leads to a significant reduction in allogenic blood transfusion with subsequent implications upon cost, resource management, and patient safety and should be used for all patients undergoing revision hip arthroplasty.

The Trent Arthroplasty Audit Group has been prospectively collecting data on primary knee arthroplasty since 1990 and revision procedures since 1992. Details of 27 000 primary and 1300 revision knee arthroplasties have been registered. In 2001 hospitals in Wales joined the group, increasing the catchment population to 8 million (14% of the UK population). The register has enabled evaluation of changes in the demography and surgical practice of knee arthroplasty in the Trent region over the past 13 years.

Over this period there has been a steady increase in the number of arthroplasties registered, from 1330 cases in 1990 to 2855 in 2002. Whilst there has been a slight increase in the proportion of men undergoing surgery, the age distribution remains consistent (mean age 69 years). PFC/Sigma is currently the most commonly used prosthesis in the region.

Since 1990 the number of patients registered with rheumatoid arthritis has fallen by almost 50%. During this period there has also been a slight decrease in the proportion of uncemented joints and a decline in the number of bilateral simultaneous procedures taking place.

The ratio of primary to revision knee arthroplasty has not changed significantly since 1992 but there is some evidence of specialisation of revision knee surgery. There has been no significant change in patient satisfaction rates since the start of the registry, with 80% of patients reporting that they are satisfied with their joint replacement at 1 year.

Conclusion: It is reasonable to assume that these findings reflect practice across the UK as a whole, given the diversity of hospitals contributing and the large population base of the Trent & Wales register.

Introduction and Aims: To assess the 10-year outcome of knee arthroplasty surgery in a generalist setting, across a single UK health region.

Method: The Trent Arthroplasy Audit Group has been collecting prospective data on primary knee replacements since 1990. 4677 primary knee replacements were performed in the period 1990–92. A validated self-administered questionnaire, including a EuroQol health evaluation questionnaire, was mailed to all surviving patients. The mean age at the time of surgery was 70 years.

Results: Thirty-nine percent of the patients had died by 10 years. Responses were received from 87% of patients. Eighty-two percent of patients had been satisfied with the result of their knee replacement. Twenty-one percent of patients felt that it was not as good as they had been led to believe before surgery. Forty percent of patients had had problems with their knee in the 10 years since surgery. Twenty-one percent had had some form of surgical intervention. Eighty-two percent of patients were taking medication to alleviate pain in their replaced knee.

Eighteen percent complained of constant pain in this knee. When the pain occurred it was described as being severe in 16% and moderate in 40%. Most patients were on prescribed medication, but had not been referred to a surgeon to identify if there was a problem with their implant. The revision rate, for all causes at 10 years was 13%.

Conclusion: The results of knee arthroplasty at 10 years are disappointing. Patients’ responses indicate that previously successful knees are becoming painful. At the present time there appears to be inadequate long-term follow-up/re-referral of patients and surgeons have a high threshold for revision surgery. More detailed clinical examination is planned for this group of patients.

Introduction and Aims: To audit the practice and evaluate the outcomes of knee arthroplasty surgery in a general setting in the UK.

Method: The Trent & Wales Arthroplasty Audit group collects prospective data on all knee replacements performed within these UK health regions (population eight million). All patients are sent a validated, self-administered questionnaire to assess outcomes. Data has been collected on 27,500 primary and 1400 revision knee procedures.

Results: In the period from 1990 to 2002 there has been a marked decrease in the proportion of knees being replaced for rheumatoid arthritis (21% to 5%). More arthroplasties are being performed in men (35% to 46%). There has been an increase in knee arthroplasty in patients aged 85+ yrs (2.1% to 3.7%), but a decrease in patients aged 55yrs and under (8.6% to 5.3%). Uncemented implants are used less frequently (7.7% to 4.4%). Unicompartmental knee are implanted more frequently (2.8% to 4.1%). In 2002, 10% of the joints implanted had mobile bearings, 8% were PCL sacrificing, 28% had the patella resurfaced, 0.4% were patellofemoral replacements.

The percentage of patients satisfied with their arthroplasty one-year post-surgery has not improved over the 13 years. (O.A 81%, R.A 87.5% , trauma 63%). The incidence of reoperation (for all causes) in the first year is 1.2% (0.5% infection). The incidence of revision for implant failure appears to be increasing. Outcome data for revision surgery is being collected at present.

Conclusion: Over the past 13 years there has been a marked increase in knee arthroplasty surgery and significant demographic trends. However, validated outcome measures have not shown an improvement of outcome over this period.

The Trent Arthroplasty Audit Group (TAAG) has been prospectively collecting data on primary knee arthroplasty since 1990 and revision procedures since 1992. To date details of 27 000 primary and 1300 revision knee arthroplasties, from both teaching and district general hospitals in the Trent region, have been contributed.

This provides us with a unique opportunity to look at the outcome of total knee arthroplasty across an English region, at 10 or more years of follow-up.

A questionnaire was designed, with assistance from the department of epidemiology and public health, including both generic (EuroQol) and knee specific questions. Patients who underwent primary knee arthroplasty from 1990–92 were included in the study (4420 patients). Surviving patients (65%) were traced using the NHSIA patient tracing service and the questionnaire was administered by post with a response rate was 55%.

The mean length of follow-up was 11 years 7 months and the mean age at the time of follow-up was 78 years. The vast majority (86%) of patients were satisfied with their joint replacement. Although 52 % took prescribed analgesia for pain in their knee, 22% still complained of pain often or all the time. 18% felt their knee totally or greatly interfered with their usual activities. 14% of patients reported re-operation on their knee, of which 11% were revision procedures.

This suggests that a significant number of patients experience pain and/or disability at 10 or more years following knee replacement. Since most GPs have a high threshold for re-referral in this group of patients, it is likely that the degree of morbidity has previously been underestimated in the orthopaedic community.