Recent NICE guidelines suggest that Total Hip Arthroplasty (THA) be offered to all patients with a displaced intracapsular neck of femur fracture who: are able to walk independently; not cognitively impaired and are medically fit for the anaesthesia and procedure. This is likely to have significant logistical implications for individual departments.

Data from the National Hip Fracture Database was analysed retrospectively between January 2009 and November 2011. The aim was to determine if patients with displaced intracapsular neck of femur fractures admitted to a single tertiary referral orthopaedic trauma unit received a THA if they met NICE criteria. Case notes were then reviewed to obtain outcome and complication rates after surgery.

Five hundred and forty-six patients were admitted with a displaced intracapsular neck of femur fracture over the described time period. Sixty-five patients met the NICE criteria to receive a THA (mean age 74 years, M:F = 16: 49); however, 21 patients had a THA. The other patients received either a cemented Thompson or bipolar hemiarthroplasty. Within the THA cohort there were no episodes of dislocation, venous thromboembolism, significant wound complications or infections that required further surgery. Within the hemiarthroplasty cohort there was 2 mortalities, 2 implant related infections, 1 dislocation and 2 required revision to a THA.

There is evidence to suggest better outcomes in this cohort of patients, in terms pain and function. There is also a forecasted cost saving for departments, largely due to the relative reduction in complications. However, there were many cases (44) in our department, which would have been eligible for a THA, according to the NICE guidelines, who received a hemiarthroplasty. This is likely a reflection of the increased technical demand, and larger logistical difficulties faced by the department. We did note more complications within the hemiarthroplasty group, however, the numbers are too small to address statistical significance, and a longer follow up would be needed to further evaluate this. There is a clear scope for optimisation and improvement of infrastructure to develop time and resources to cope with the increased demand for THA for displaced intracapsular neck of femur fractures, in order to closely adhere to the NICE guidelines.

Surgery for pelvic or acetabular fractures carries a high risk of deep-vein thrombosis (DVT). Reports indicate that fondaparinux is a more effective thromboprophylactic agent than low molecular weight heparin (LMWH) after major orthopaedic surgery. We prospectively evaluated a new protocol for DVT prophylaxis using fondaparinux.

Background: During cemented hip arthroplasty revision removal of all the old cement mantle is a time staking process with multiple disadvantages. In some selected patients cementing revision stem into the old mantle is regarded as a highly attractive option. Contradictory evidence exists whether bond between two cement layers is strong enough, especially in the presence of interfering fluids.

Aim: analysis of the shearing strength of the interface between two layers of polymethylmethacrylate cement in the presence of fluid.

Methods: Cylindrical blocks of polymethylmethacrylate cement represented primary cement mantle. Its flat surface was machined to reproduce smooth old cement mantle surface comparable with that after removal of a highly polished stem (Ra=200nm). A second block was cast against the first and their junction represented the investigated interface. The influence of fluid was examined by injecting liquid onto the ‘primary’ surface prior to casting. Water or 2% water solution of carboxy-methyllcellulose (representing bone marrow viscosity of 400mPas) were used in two volumes: 0.02ml/cm2 (small) or 0.4ml/cm2 (large - surface submerged).

6 variants (control monoblock, dry surface, surface stained with small or large volume of water or highly viscous fluid) containing 7 repeats were exposed to a single shearing stress to failure at the speed of 1mm/min (Autograph AGS, Shimadzu, Japan).

Results were analyzed using 1-way ANOVA with post-hoc analysis (equal N HSD) and power calculations.

Results: Large volume of viscous fluid prevented bonding completely in two cases and significantly weakened the other samples showing mean failure stress of 5.53 MPa (95%CI:1.33–9.73 MPa). This was significantly lower compared with control monoblock (19.8–95% CI: 17.8–21.9 MPa), dry surface variant (16.9–95% CI: 15.9–18.0 MPa) and that stained with small amount of high viscosity fluid (16.01–95% CI: 15.12–17.0 MPa). Interestingly, presence of a large volume of low viscosity fluid (water) did not significantly reduce resistance to shear stress (17.05 – 95% CI:15.67–18.43 MPa).

Similar relations were observed when strain at failure and toughness were analyzed.

Conclusions: In all but large volume of viscous fluid variants, the failure occurred away from the interface between two cement layers. Large amount of viscous fluid weakened significantly this interface. If such a viscous fluid can be eliminated by copious water irrigation it is likely that strength of the cement-cement bond will be maintained. In the presence of low viscosity fluids (water, blood) careful use of gun technique is likely to allow for their escape as the cement is advanced within the femoral or the old mantle canal leading to a satisfactory bond. Our observations suggest that cement-in-cement technique seems to be biomechanically acceptable.

Impaction allografting is a bone reconstruction technique currently used in lower limb revision arthroplasty. Demineralisation and addition of osteogenic protein-1 (OP-1) can improve the osteoinductivity of the allograft however recent reports indicate significant allograft resorption when it is combined with OP-1 during impaction. Our hypothesis was that hydroxyapatite (HA) and OP-1 could effectively replace demineralised allograft. The objective was to evaluate human mesenchymal stem cell (h-MSC) proliferation (tritiated thymidine incorporation, total DNA Hoechst 33258 and scanning electron microscopy) and osteogenic differentiation (alkaline phosphatase activity) in human demineralised bone matrix (h-DBM) and HA, with or without OP-1. Cell proliferation on HA+OP-1 was significantly higher compared to HA at all time points (p< 0.05) and to DBM alone (day 1, p=0.042; day 14, p< 0.001). Cell proliferation was higher in DBM+OP-1, at all time points compared to HA+OP-1 but only in absolute values. Cell differentiation was significantly higher in HA+OP-1 compared to HA (p< 0.05) but comparable to DBM alone. Differentiation was significantly higher on DBM+OP-1 at all time points compared to HA (p< 0.05) and to HA+OP-1 (p< 0.05). HA is a potential graft expander in impaction allografting. When combined with OP-1 is comparable to DBM alone and being non absorbable may support the impacted graft in the early stages after the administration of OP-1.

Introduction: Ever since the coding has been introduced in the NHS there has been lot of debate whether the trust is being paid accurately. There is no data available which compares the coding done by the surgeon and the one done by the coding department.

Material and Methods: A prospective study was done on 305 patients in an elective orthopedic hospital over a period of one month. All operations were coded separately by the operating surgeon and the coding department. The procedures included all upper and lower limb procedures other than elective hand, spine and paediatric procedures. The results were compared by an independent assessor in line with the national guidelines and the information originally available to clinical coders.

Results: The results showed a marked difference in reimbursement cost of complex procedures, revisions and co-morbidities as coded by the surgeon who took into consideration additional top ups which were available and these were often missed by the coding department. There was no difference in the primary hip and knee arthroplasty.

Conclusion: There is an increased need for correct coding as this can result in potential income consequences by applied tariffs. With the introduction of acute phase tariffs and marked difference in reimbursement to the trust if correct codes are not applied, there is an increased need for awareness for the coding and the top-ups available for complex procedures.

Comparison of the safety and efficacy of Bilateral Simultaneous Total Hip Arthroplasty (BSTHA) with that of staged (SgTHA) and unilateral (UTHA) was conducted using DerSimonian–Laird heterogeneity meta-analysis. Twenty three citations were eligible for inclusion. A total of 2063 BSTHA patients were identified. Meta-analysis of homogenous data revealed that there were no statistically significant differences between rates of thromboembolic events (p=0.268 and p=0.356) and dislocation (p=0.877) when comparing SgTHA or UTHA versus BSTHA procedures. Systematic analysis of heterogenous data demonstrated that mean length of stay was shorter in BSTHA as compared to SgTHA and UTHA procedure, blood loss was lower in BSTHA in all studies except one, whilst the surgical time was not different between groups. BSTHA was also found to be economically and functionally efficacious.

Impaction allografting is a bone tissue engineering technique currently used in lower limb reconstruction orthopaedic surgery. Our hypothesis was that biological optimisation can be achieved by demineralisation and addition of osteogenic protein-1(OP-1) to the allograft. The objective of our in vitro study was to evaluate human mesenchymal stem cell (MSC) proliferation (Alamar Blue assay, titrated thymidine assay, total DNA Hoechst 33258 and scanning electron microscopy) and osteogenic differentiation (alkaline phosphatase assay) in two types of impacted carrier, namely demineralised bone matrix (DBM) and insoluble collagenous bone matrix (ICBM), with or without OP-1. The objective in vivo was to compare the osteogenic potential of impacted DBM with or without OP-1, with that of impacted fresh frozen allograft (FFA), again with or without OP-1. DBM+OP-1 optimized osteoinduction and significantly improved (p< 0.05) proliferation and differentiation in comparison to the majority of all other graft preparation in vitro. In addition DBM+OP-1 was significantly superior, with regard to osteogenesis, compared to the impacted FFA alone (p< 0.001), FFA+OP-1 (p=0.01) and DBM alone (p=0.02) in vivo. We propose that partial demineralisation and addition of OP-1 provides a good method for improving the osteoinductive properties of fresh allograft currently used in the impaction grafting technique.

Pin placement into the medial calcaneus places a number of structures at risk of damage. Research evidence suggests that the greatest risk of posterior pin placement is to the medial calcaneal branch of the tibial nerve. By using palpable anatomical landmarks, we attempted to redefine the safe zone taking into account possible variations. The medial heel region of twenty-four cadavers was dissected to find the major structures at risk. The inferior tip of the medial malleolus (point A), insertion point of tendo calcaneus (point B), navicular tuberosity (point C) and the medial process of the calcaneal tuberosity (point D) were all selected as anatomic landmarks from which to measure the identified structures using digital electronic calipers. The commonest variation in origins of medial calcaneal nerves was found to be one arising before the bifurcation of the tibial nerve along with one arising from the medial plantar nerve (10/24). The safest zone for percutaneous pin placement has been calculated as beyond two-thirds of the distances AB, CD, AD and CB. More posterior pin placement reduces the risk of damage to the medial calcaneal nerve and its branches, although the risk remains and blunt dissection before pin placement is recommended.

Without thromboprophalaxis, the recorded incidence of deep venous thrombosis (DVT) in pelvic fracture varies between 35% and 61%. The incidence of pulmonary embolism (PE) is reported to be 2–10% and death subsequently occurs in 0.5–4% of patients. With preventative measures the incidence of clinically significant DVT has been reported as low as 0.5%. The primary aim of this study is to look into the efficacy of Enoxaparin in preventing clinically significant DVT and PE in patients with pelvic and acetabular fracture. The secondary aim is to investigate the effect of prolonged pre-operative exposure to Enoxaparin on operative and post-operative bleeding. Sixty-four patients with pelvic and acetabular fractures were reviewed retrospectively between 2000–2005. Patients with coagulopathies were excluded. 40mg Enoxaparin was administered daily following haemodynamic evaluation and continued thereafter until discharge. Blood loss was measured using 3 indicators: volume of blood transfused, difference in pre and post operative Hb, and amount of blood collected in surgical drains. The incidence of clinically significant DVT was 2.9% (2 cases). There was no confirmed incidence of PE. 47% of patients were operated on within a week of admission (Group A), 40% within 1–2 weeks (Group B) and 13% in over 2 weeks (Group C). The group with the most prolonged pre-operative exposure to Enoxaparin: Group C, required the least transfused blood (A: 4.8units, B: 2.0units C: 1.3units), bled the least into drains (A:310ml, B:253ml and C:212ml) and had the smallest post-operative fall in Hb (A:2.2, B:2.0, C:1.9). The low incidence of clinically detectable DVT in the study confirms that Enoxaparin is an effective method for reducing the incidence of significant thrombotic events. Prolonged pre-operative administration of Enoxaparin does not pre-dispose patients to an increased risk of operative and post-operative bleeding.

Sacral insufficiency fractures are traditionally treated with bed rest and analgesia. The importance of early rehabilitation is generally appreciated; but pain frequently delays this, resulting in prolonged hospital stay and the risk of complications related to immobility. We describe three women with sacral insufficiency fractures who were treated with percutaneous sacroiliac screws and followed up for a mean of 18 months (12 to 24). They had immediate pain relief, uncomplicated rehabilitation and uneventful healing.