The Global Conservative Anatomic Prosthesis (Global CAP) is an uncemented press fit humeral resurfacing implant developed by DePuy. We report a single surgeon series of Global CAP prostheses implanted in Norwich.

103 procedures were carried out between 2006 and 2011, in 93 patients. Mean age was 72 years (range 43 to 90). Patients were followed up for a mean 8 months (range 0 to 56). Pre-operative Oxford shoulder scores were recorded in a preadmission clinic and an Oxford score questionnaire was sent to patients post-operatively in December 2011. The mean score preoperatively was 19, rising to 28 postoperatively.

Two patients developed rotator cuff tears and have been revised to reverse polarity arthroplasty. One is pending revision for a cuff tear.

This prosthesis shows promise at this early stage for compensated glenohumeral arthritis when a bone preserving procedure is desirable.

Historically the management of distal radial fracture has been often inadequate. It can be difficult to internally fix complex distal radial fractures with conventional plates. The fracture often collapses with metalwork failure. Literature suggests that malunion may lead to painful wrist with loss of function. In recent years fixed angle locking plate has been advocated for treatment of complex distal radius fracture. Our aim was to assess to assess the effectiveness of the volar locking plate (DePuy) in maintaining fracture reduction in distal radial fractures.

Radiographs of 170 distal radius fractures treated by the DVR plate were analysed. Fractures were classified according to the Melone and AO classifications. The post injury, intra-operative, 6 weeks postoperative and final postoperative radiographs were reviewed to obtain measurements for radial height, radial slope and volar inclination. The measurements were correlated with fracture pattern, locking screw length, presence or absence of radial styloid screw and plate placement in relation to the wrist joint. The results were analysed statistically using Wilcoxon signed rank test.

Radiologically there was minor loss of radial height, slope and volar inclination but this was not statistically significant. There was a statistically significant correlation between complexity of fracture and loss of radiological parameters. There was no statistically significant correlation between loss of radiological parameters and screw length, plate placement or presence or absence of radial styloid screw.

The DVR volar locking plate appears to maintain a satisfactory reduction of the fracture except for some complex fractures with dorsal comminution in which case dorsoradial plates may be preferable.

To investigate whether radioscapholunate arthrodesis [RSLA] can provide functional wrist movement with satisfactory pain relief. 19 patients with radio-carpal arthritis underwent RSLA. There were 3 diagnostic groups [post-traumatic osteoarthritis, rheumatoid arthritis and Kienbock’s disease].

The total flexion-extension range decreased. There was a decrease in pain post-operatively. Grip strength increased in Kienbock’s but fell-in patients with osteoarthritis. 95% of patients were satisfied with their result.

The normal ‘functional’ arc is 35 degrees. Pain was reduced in all of our patients, whilst maintaining the functional arc. With only one failure and no complications, we feel the procedure is safe and reliable.

Introduction The close proximity of the cutaneous and major nerves around the elbow have caused orthopaedic surgeons to feel uncomfortable about the prospect of performing basic and advanced elbow arthroscopy. The aim of this study was to review the proximity of the nerves with arthroscopic vision in a cadaveric model and selected clinical cases.

Methods Open exploration of the major nerves in the elbow was performed in alcohol preserved cadaveric specimens. Arthroscopic assessment of the elbow joint was performed before and after the capsule adjacent to the nerve was excised. The arthroscopic assessment of the major nerves in these specimens provided an excellent way to visualise the nerves.

Results The radial nerve was found to be in contact with the anterior capsule of the joint and was at great risk with portal placement, lateral sided procedures including synovectomy, radial head excision, capsulotmy and capsulectomy. The medial nerve was protected by the brachialis muscle. The ulnar nerve was also at risk in the medial gutter.

Conclusions The close proximity of the major nerves to the elbow joint places them at risk, with elbow arthroscopy. The radial and ulnar nerves are particularly close and their exact position can be dissected free with arthroscopic techniques.

We have investigated nine patients with cemented Furlong (JRI, London, UK) titanium hip replacements who presented with early pain despite a well-fixed, aseptic prosthesis. All were followed up clinically and radiologically at regular intervals. Pain was located in the thigh and was worse at night. Radiographs showed cortical hypertrophy of the femur around the tip of the stem. Eight of the nine patients subsequently required single-stage revision using an uncemented prosthesis, which relieved the pain. At revision, the pH of the tip of the stem was found to be highly acidic with macroscopic evidence of corrosion consisting of multiple layers of titanium oxides when studied by X-ray dispersive analysis. Cemented titanium implants have a potential for crevice corrosion leading to cortical hypertrophy and intractable pain.

Studies comparing the biomechanical properties of different meniscal repair systems are limited, and most have simply investigated load to failure. Meniscal tissue is highly anisotropic, and far weaker under tension in the radial direction. Loading to failure using high radially orientated loads may, therefore, not be the most physiologically relevant in-vitro test for repair of circumferential tears, and determining increases in gapping across repair sites under cyclical loading at lower loads may be of greater importance. This study aimed to determine the load to failure for 4 different meniscal repair techniques, and to assess gapping across repairs under cyclical loading.

Bovine menisci were divided vertically, 5mm from the peripheral edge to simulate a circumferential tear, and then repaired using 1 of 4 techniques: vertical loop sutures using 2-0 PDS, bioabsorbable Meniscal Arrows (Atlantech), T-Fix Suture Bars (Acufex) or Meniscal Fasteners (Mitek). 9 specimens were tested in each group using an Instron 5565 materials testing machine with Merlin control software to determine load to failure. A further 9 specimens in each group were tested by cyclical loading between 5N and 10N at 20mm/min for 25 cycles. Gapping across the repairs under cyclical loading was measured using a digital micrometer and a Differential Voltage Reluctance Transducer.

The peak load to failure values for each repair method did not appear to fit a Gaussian distribution, but were skewed to the left due to some samples failing at lower loads than the main cluster. Results were analysed using the Kruskal-Wallis test, with Dunn’s multiple comparison post test. The results for gapping across the repairs from the cyclical testing all appeared to fit the Gaussian distribution, and these were analysed by Analysis of Variance, with Tukey’s multiple comparison post test. All analysis was performed using Prism (Graph-pad) Software.

The mean loads to failure for each of the repair groups were: Sutures 72.7 N, T-Fix 49.1 N, Fasteners 40.8 N, and Arrows 34.2 N. The load to failure was significantly greater with the Suture group compared to the Arrows (p< 0.01) or the Fasteners (p< 0.05). The mean gapping across the repairs for each of the repair groups after 25 loading cycles were: Sutures 3.29mm, Arrows 2.18mm,Fasteners 3.99mm,andT-Fix 3.47mm.The mean gapping was significantly less for the Arrows compared to the Sutures (p< 0.05), the Fasteners (p< 0.01), or the T-Fix (p< 0.05).

The results confirm that meniscal repair by suturing gives the highest load to failure, but show that Arrows give superior hold under lower loads, with the least gapping across repairs under cyclical loading by this testing protocol.

Skeletal tuberculosis is an indolent disease whose diagnosis is often delayed. Evidence of pulmonary tuberculosis is present in less than 50% of cases. We present our experience from a small inner city district hospital of the difficulties managing patients with skeletal tuberculosis.

During the period 1988 to 1998 a total of 38 patients with tuberculous osteomyelitis confirmed microbiologically by tissue culture or histologically on material gained at biopsy presented to our inner city hospital serving 250 000 patients.

Two groups of patients were identified in our series. There was an acute group that tended to affect the appendicular skeleton and who responded to local treatment plus chemotherapy with restoration of normal function. In contrast the second group, who were difficult to diagnose, had axial skeleton involvement, deteriorated before treatment and had a poor outcome despite treatment. Failure of admitting medical teams to examine the axial skeleton in their confused patients led to a delay in diagnosis of skeletal tuberculosis in this second group with profound consequences.

All health professionals will be encountering skeletal tuberculosis more frequently with the recent resurgence of pulmonary tuberculosis. They may have little experience with the management of this condition and may overlook the diagnosis with consequent catastrophic results. A high index of suspicion is required for prompt diagnosis with early referral to an orthopaedic surgeon improving outcome.

Survival in the wake of hindquarter amputation and oncological treatment is improving; the hindquarter amputee population is increasing. Some amputees function well others do not.

To assess quality of life and function of hindquarter amputees.

21 amputees (10 females and 11 males) consented to take part in the study. Ethics approval was sought. Assessment was performed using postal questionnaires; SF36 for quality of life; TESS (Toronto Extremity Salvage Score) for physical function and mobility; IEFF( International Index for Erectile Function) for male sexual function; a prosthetics questionnaire to assess prosthetic use.

Mean age of the group was 55 with the mean survival of 7 years post amputation.

Quality of life results were compared to normal subjects and patients for long tern illness. Amputees had a significant reduction in quality of life concerning physical function and pain. Social function, mental health and energy levels were equivalent to patients with long term illness.

The mean TESS result was 56.9 with females having a mean score of 61.7 and male of 48. 50% of the group considered themselves as severely to completely disabled; 50% considered themselves moderately disabled. Five were in full time employment.

Six males responded to the sexual function questionnaire. Impotence was universally experienced.

Only five amputees used their prosthesis regularly. All amputees have experienced and 20 continue to experience phantom pain.

This study illustrates that hindquarter amputees have poor physical function and a low quality of life. Phantom pain is universally experienced. Male amputees experience impotence. Addressing these areas would improve the life of current and future hindquarter amputees.

Aims: To determine load to failure for four different meniscal repair techniques, and to assess gapping across repairs under cyclical loading.

Background: Studies comparing the biomechanical properties of different meniscal repair systems are limited, and most have simply investigated load to failure. Meniscal tissue is highly anisotropic, and far weaker under tension in the radial direction. Load to failure using high loads may, therefore, not be the most physiologically relevant in-vitro test for repair of circumferential tears, and measuring increases in gapping across repair sites under cyclical loading at lower loads may be of greater importance.

Methods: Bovine menisci were divided vertically, 5mm from the peripheral edge to simulate a circumferential tear, and then repaired using one to four techniques: vertical loop sutures using 1 -PDS, bioabsorbable Meniscal Arrows (Atlantech), Meniscal Fasteners (Mitek) or T-Fix Suture Bars (Acufex). Nine specimens were tested in each group using an Instron 5500 materials testing machine to determine load to failure. A further nine specimens in each group were tested by cyclic loading between 5N and 10N at 20mm/min for 25 cycles, using a digital micrometer to measure initial gapping, and a Differential Variable Reluctance Transducer to measure the progressive increase in gapping across the repair site during the cyclical loading. Data was analysed by ANOVA and Tukey’s multiple comparison post test using Prism (GraphPad) software.

Results: The mean loads to failure (with s.d.) in Newtons were: Sutures 72.7 (22.0), Arrows 34.2 (15.4), Fasteners 40.8 (13.4), and T-Fix 49.1 (13.8). The load to failure was significantly greater with the Sutures compared to the Arrows (p< 0.001), the Fasteners (p< 0.001) or the T-Fix (p< 0.05).

The mean gapping across the repairs after 25 load cycles (with s.d.) in millimetres was: Sutures 3.3 (1.0), Arrows 2.2 (0.9), Fasteners 4.0 (0.6) and TFix 3.5 (0.7). The mean gapping was significantly less for the Arrows compared to the Sutures (p< 0.05), the Fasteners (p< 0.01), or the T-Fix (p< 0.05).

Conclusions: These results confirm that meniscal repair by suturing gives the highest load to failure, but show that Arrows give superior hold with the least increase in gapping across a repair under cyclical loading by this test protocol.