There is no consensus regarding the optimum frequency of ultrasound for monitoring the response to Pavlik harness (PH) treatment in developmental dysplasia of hip (DDH). The purpose of our study was to determine if a limited-frequency hip ultrasound (USS) assessment in children undergoing PH treatment for DDH had an adverse effect on treatment outcomes when compared to traditional comprehensive ultrasound monitoring.

This study was a single-center non-inferiority randomized controlled trial. Children aged less than six months of age with dislocated, dislocatable and stable dysplastic hips undergoing a standardized treatment program with a PH were randomized, once stability had been achieved, to our current standard USS monitoring protocol (every clinic visit) or to a limited-frequency ultrasound protocol (USS only until hip stability and then end of treatment). Groups were compared based on alpha angle at the end of treatment, acetabular indices (AI) and IHDI grade on follow up radiographs at one-year post harness and complication rates. The premise was that if there were no differences in these outcomes, either protocol could be deemed safe and effective.

One hundred patients were recruited to the study; after exclusions, 42 patients completed the standard protocol (SP) and 36 completed the limited protocol (LP). There was no significant difference between the mean age between both groups at follow up x-ray (SP: 17.8 months; LP: 16.6 months; p=0.26). There was no difference between the groups in mean alpha angle at the end of treatment (SP: 69°; LP: 68.1°: p=0.25). There was no significant difference in the mean right AI at follow up (SP: 23.1°; LP: 22.0°; p=0.26), nor on the left (SP:23.3°; LP 22.8°; p=0.59). All hips in both groups were IHDI grade 1 at follow up. The only complication was one femoral nerve palsy in the SP group. In addition, the LP group underwent a 60% reduction in USS use once stable.

We found that once dysplastic or dislocated hips were reduced and stable on USS, a limited- frequency ultrasound protocol was not associated with an inferior complication or radiographic outcome profile compared to a standardized PH treatment pathway. Our study supports reducing the frequency of ultrasound assessment during PH treatment of hip dysplasia. Minimizing the need for expensive, time-consuming and in-person health care interventions is critical to reducing health care costs, improving patient experience and assists the move to remote care. Removing the need for USS assessment at every PH check will expand care to centers where USS is not routinely available and will facilitate the establishment of virtual care clinics where clinical examination may be performed remotely.

Aims

There is no consensus regarding optimum timing and frequency of ultrasound (US) for monitoring response to Pavlik harness (PH) treatment in developmental dysplasia of the hip (DDH). The purpose of our study was to determine if a limited-frequency hip US assessment had an adverse effect on treatment outcomes compared to traditional comprehensive US monitoring.

The purpose of this study is the evaluate the net promotor score of arthroscopic subacromial decompression and rotator cuff repair.

The Friends and Family Test, a variant of the Net Promoter Score, was adapted for the National Health Service to evaluate overall patient satisfaction and how likely patients are to recommend an intervention. It ranges from −100 to 100. Positive scores indicate good performance.

This study quantifies the scores in 71 patients at 1 year following arthroscopic sub acromial decompression and rotator cuff repair. All of the procedures were performed by 1 consultant shoulder specialist. The patient filled out a shoulder questionnaire pre-operatively, at 6 months and 1 year.

The score was 72 for subacromial decompression (n = 32) and 85 for rotator cuff repair +/− decompression (n = 39). Oxford shoulder score was also taken and had a rise of 4.3 and 6.9 respectively. Our study indicates that these procedures are highly valued and are recommended by patients according to the Friends and Family Test. The results of the Friends and Family Test correlated well with postoperative functional improvement and satisfaction.

We conclude from this study that a compound score based on the Friends and Family Test is a useful addition to traditional measures of patient satisfaction.

The Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score was developed in 2004 to risk-stratify patients with soft tissue infections using common blood tests when the clinical picture is equivocal. A score ≥ 6 conferred a positive predictive value (PPV) of 92% and negative predictive value of 96% for necrotising fasciitis.

We retrospectively calculated LRINEC scores for Orthopaedic patients admitted to ITU in our hospital with limb soft-tissue infection and confirmed Group-A Streptococcus or Staphylococcus in fluid, blood, tissue or swab culture between 2010–2017 (n=10). Mean age = 57.4 and 60% were female. Half of all patients died during admission. Mean LRINEC score of all patients was 5.3±3.1 (median = 6). Mean score in deceased patients was 4.8±2.8 (scores: 0,5,6,6,7; median = 6); in discharged patients mean = 5.8±3.7 (scores: 0,5,7,7,10; median = 7). 6 patients had a score ≥6, making our PPV 60%. 4 patients had necrotising fasciitis confirmed on histology (LRINEC scores = 0,5,7,10).

Our PPV of 60% is less than the figure obtained in the original paper. 2 patients with a LRINEC score <6 died during admission, including a patient with a score of 0. Furthermore, a patient with necrotising fasciitis confirmed on histology also had a LRINEC score of 0. We conclude that LRINEC scores should not delay surgery when clinical suspicion is high, and should be used as an adjunct to clinical decision-making, rather than a replacement, as patients with low LRINEC scores can also have confirmed necrotising fasciitis and poor outcomes.

Introduction

Training the next generation of surgeon's forms part of routine Consultant practice. Stress causes activation of the Autonomic Nervous System and this can be directly measured using heart rate (HR). Training time is limited with pressures from EWTD and management and efficiency targets. The aim of this study was to assess whether being an orthopaedic trainer is more stressful than performing the surgery.

Introduction

The hierarchical structure of tendon results in a complex mechanical strain environment, with tenocytes experiencing both tension and shear during loading. The mechanotransduction mechanisms involved in sensing these environments is currently unclear. To better understand the effects of shear and tension on cell behaviour, a fibre composite system able to recapitulate the physiological shear-tension ratio found in tendons, was used. Cell attachment within the composite was achieved by using either a collagen type I mimetic peptide, DGEA, or a fibronectin associated peptide, YRGDS, and the gene expression response analysed after loading.

Despite a lack of long-term follow-up, there is an increasing trend towards using femoral heads of large diameter in total hip replacement (THR), partly because of the perceived advantage of lower rates of dislocation. However, increasing the size of the femoral head is not the only way to reduce the rate of dislocation; optimal alignment of the components and repair of the posterior capsule could achieve a similar effect.

In this prospective study of 512 cemented unilateral THRs (Male:Female 230:282) performed between 2004 and 2011, we aimed to determine the rate of dislocation in patients who received a 22 mm head on a 9/10 Morse taper through a posterior approach with capsular repair and using the transverse acetabular ligament (TAL) as a guide for the alignment of the acetabular component. The mean age of the patients at operation was 67 years (35 to 89). The mean follow-up was 2.8 years (0.5 to 6.6). Pre- and post-operative assessment included Oxford hip, Short Form-12 and modified University of California Los Angeles and Merle D’Aubigne scores. The angles of inclination and anteversion of the acetabular components were measured using radiological software. There were four dislocations (0.78%), all of which were anterior.

In conclusion, THR with a 22 mm diameter head performed through a posterior approach with capsular repair and using the TAL as a guide for the alignment of the acetabular component was associated with a low rate of dislocation.

Cite this article: Bone Joint J 2014;96-B:1202–6.

Percutaneous Achilles tenotomy is an integral part of the Ponseti technique. Though considered as a simple procedure, many authors have reported serious neurovascular complications that include iatrogenic injury to the lesser saphenous vein, the posterior tibial neurovascular bundle, the sural artery and pseudoaneurysm formation. The authors describe the results of their new tenotomy technique, the ‘Posterior to Anterior Controlled’ (PAC) technique in an attempt to eliminate such complications.

This is a prospective study. Infants < 1 year of age with idiopathic clubfoot were taken up for the Ponseti technique of correction. Tenotomy was performed by the ‘PAC’ technique under local anaesthesia if passive dorsiflexion was found to be < 15 degrees. Outcome measures included completeness of the tenotomy (by ultrasonography), improvement in the equinus angle and occurrence of neurovascular complications.

40 clubfeet in 22 patients underwent ‘PAC’ tenotomy. The mean age was 3.5 months. The tenotomy was found to be complete in all cases. The equinus angle improved by an average of 78.5 degrees (range 70–95 degrees), which was statistically significant (p < 0.05, students t test). Mild soakage of the cast with blood was noted in 21 (52.5%) cases. No neurovascular complication was noted. The average follow-up was 12.2 months (range 9–18 months).

The ‘PAC’ tenotomy virtually eliminates the possibility of neurovascular damage, maintains the percutaneous nature of the procedure, is easy to learn and can be performed even by relatively inexperienced surgeons safely and effectively as an office procedure under local anaesthesia.

The quality of femoral stem cementation has been shown to be a useful indicator of long-term survival of the total hip arthroplasty. Barrack's cementation grading is widely used but has certain limitations. It is based upon second-generation cementation technique and has high inter- and intra-observer variability. We introduce a new femoral cementation index based upon lengths of radiological lucency and cement-bone interface on AP and lateral views.

Five observers graded femoral cementation of radiographs of 30 primary hip arthroplasties using Barrack's grading and the new index on two occasions and Inter- & Intra-observer reliability was assessed. We also assessed the correlation between proximal femoral anatomy (calcar-canal ratio) & structural bone quality (using cortical index) with cementation using the new index in 50 patients.

Inter- and intra-observer reliability of the new index showed intraclass correlation coefficient 0.79 and 0.82 respectively and Barrack's grading system showed Kappa value- 0.20 (inter-observer) and 0.55 (intra-observer) reliability.

There was poor correlation between the calcar-canal ratio and the quality of cementation [Pearson's coefficient −0.04 (p< 0.05)]. There was some correlation between the cortical index and the quality of cementation [Pearson's coefficient 0.46 (p < 0.05)].

Our new index is a reliable method of assessing femoral cementation. The anatomy of femoral canal didn't have any significant influence on the quality of cementation achieved as assessed by our new index. The femoral cortical structural quality seemed to have some positive influence on the quality of cementation.

Financial impact and patient satisfaction with four different anticoagulants for hip and knee arthroplasty in patients with a previous history of VTE- A prospective randomised trial

Introduction

Adolescent idiopathic scoliosis (AIS) is the most common paediatric spinal deformity, affecting about 3% of school-aged children worldwide. This disorder occurs in otherwise healthy children who bear no obvious deficiencies in the components of the spinal column itself. The cause of AIS is poorly understood, as is implied by the name. Lesions of the bony composition of the vertebrae, the vertebral endplates, the paraspinous muscles, or the neurological system each have been proposed to explain disease pathogenesis. Progress has been hampered by the absence of an obvious AIS animal model. Consequently we have used genetic studies in human populations to identify factors underlying AIS susceptibility.

The complex inheritance and population frequency of AIS suggest that many genetic factors are involved in this disease. To search comprehensively for such factors we previously undertook the first genome-wide association study (GWAS) of AIS susceptibility in a cohort of 419 families in Texas, USA. We found that chromosome 3 SNPs in the proximity of the CHL1 gene yielded strongest results, which we replicated in additional cohorts (rs10510181 OR 1·49, 95% CI 1·29–173, p=2·58×10–8). CHL1 is of interest because it encodes an axon guidance protein and is functionally related to the ROBO3 gene that causes hereditary gaze palsy with progressive scoliosis (HGPPS), a rare disease marked by severe scoliosis. Here we expanded the study to 702 Texas families.

Objective

Arthroscopic rotator cuff repairs now yield a similar footprint as open procedures with several advantages, including reduced tissue trauma, post-operative pain, swelling, and concern about the deltoid attachment. We present a new simple and reproducible technique for arthroscopic rotator cuff repair.

Introduction

Osteoarthritis (OA) has historically been thought of as a degenerative joint disease, but inflammation and angiogenesis are increasingly being recognised as contributing to the pathogenesis, symptoms and progression of OA. b-dystroglycan (b-DG) is a pivotal element of the transmembrane adhesion molecule involved in cell-extracellular matrix adhesion and angiogenesis. Matrix metalloproteinases (MMPs) are the main enzymes responsible for cartilage extracellular matrix breakdown and are also implicated in both angiogenesis and b-DG degradation in a number of malignancies. We aimed to investigate the expression and localisation of b-DG and MMP-3, -9, and -13 within cartilage, synovium and synovial fluid and establish their roles in the pathogenesis of OA.

Background: Surgery in adolescent idiopathic scoliosis is done mainly for cosmesis and outcomes are reported in terms of radiological measurements (Cobb angle), outcome questionnaires (SRS-22) and back surface measurements (Scoliometer & Quantec). Previous studies have shown correlations between SRS-22 and objective radiological and back surface measures at a point in time (Asher et al 2003 & 2004).

Aim: of the study was to evaluate the association between subjective and objective outcomes in posterior instrumented scoliosis correction.

Patients and Methods: 43 patients with late-onset thoracic idiopathic scoliosis were included in the study with 39 girls and 4 boys with a mean age 13.2 years. Mean pre-operative Cobb angle was 71o. The objective assessment of back surface was done using a scoliometer and the POTSI & Suzuki Hump Sum scores. The subjective assessment was done using the Scoliosis Research Society (SRS)-22 score. The assessments were done pre-operatively and then post-operatively at 8-weeks and one year.

Results: The average percentage improvement in various outcomes after surgery was as follows: Cobb angle (71%), Maximum Angle of Trunk Inclination (Max. ATI) (52 % at 8 weeks and 39 % at 1 year), POTSI (57%), Hump Sum (24%), SRS-Total (14%), SRS-self image (14%). Pre-operatively, there were good inter-correlations (r= 0.4–0.7) between the objective measures (Max. ATI, POTSI and Hump Sum). Significant correlation was found between SRS-22 total versus Cobb angle (p-0.001, r=0.41). No significant correlation was found between the SRS-22 (total & domains) versus the Max. ATI, POTSI or the Hump Sum scores. Post-operatively, good correlation (r=0.6) was again found between the objective measures (Max. ATI, POTSI and Hump Sum) of back surface measurements (absolute and percentage). No significant correlation was found between SRS-22 (domains & total) versus Cobb angle correction, Max. ATI, POTSI, or Hump Sum.

Conclusion: In this study SRS-22 was found to be responsive to change with surgery, especially the self-image/appearance domain. However the SRS-22 score after surgery and the change in this score did not correlate with the change in objective measures of back surface deformity after surgery.

Introduction: Metastatic spinal disease continues to be a challenge in the management of patients with advanced malignancy. Anterior en bloc spondylectomy and stabilisation, a more extensive procedure, is favoured as it is thought to provide a curative resection and improve the overall outcome (Tomita et al,2002; Wiegel, 1999).

Aim: The aim of this study was to see if there is still a role for extensive posterior decompression (Wide laminectomy and transpedicular decompression) with stabilisation in the treatment of these patients which is the mode of treatment used in our institution and favoured by some others (Bauer, 1997)

Patients and Methods: We retrospectively reviewed a cohort of patients treated in our institute by extensive posterior decompression and stabilisation between 2000 to 2006. We excluded patients having haematological primaries and anterior surgery and those with inadequate data.

Outcome measures used were post operative mortality, Post operative improvement in Frankel score, level of pain perception, level of mobility and ability to perform activities of daily living.

Results: 52 patients had posterior surgery with Colarado instrumentation being used in a majority. There was a slight male preponderance with an average age of 67 years. The mean length of follow up was 12 months.57% patients were dead at last review. 52 % patients showed an improvement in Frankel scores. There was a significant decrease in analgesic requirement post operatively with an improvement in pain scores. Similarly there was an improvement in the ability to perform activities of daily living and the level of mobility. No major surgical complications were noted bar a few superficial wound infections. Revision surgery was done in 6 cases. In 2 it was for a tumour recurrence, for broken rods in 2 and converted to anterior in 2. There were 4 immediate peri operative deaths.

Conclusion: Our results are comparable to Bauer et al, 1997 and other series. Posterior spinal surgery is very much a viable treatment option to treat selected cases with metastatic spinal disease. It avoids all the complications and morbidity of anterior surgery while producing an overall improvement in pain, the quality of life, level of mobility and neurological status.

Background: Total knee replacement remains one of the most common knee surgery practices worldwide. The operative procedure universally requires the use of cutting jigs to resect predetermined amounts of bone irrespective of the preoperative anatomy and morphology of the femur and tibia.

Aims: The aims of this study were to elucidate anatomical morphological differences between ethnicities pre-operatively and to assess whether any change elucidated was preserved post-operatively.

Method: This was a retrospective study comparing the pre and postoperative lateral view X-Rays of TKRs performed. Distances measured from most prominent anterior point to midline and the most prominent posterior point to midline and their ratio was compared between two ethnic groups. Each x-ray measurement was triple checked.

Results: The study groups comprised of 60 Caucasian knees and 40 Asian knees. Preoperatively the mean ratio was 0.55 in Caucasians and 0.44 in Asians, with this difference being statistically significant (p value < 0.005). Post operatively the mean ratio was 0.59 in Caucasians and 0.55 in Asians and this difference was not statistically significant (p value =0.166). These findings were also cross-checked with range of movement measurements post-operatively in the same group of patients. There was no comparable improvement in range of movements (ROM) post-operatively in the Asian group.

Conclusion: We infer that the present TKR cutting jigs are not taking into account the anatomical differences within the knee of Asians individuals. This is converting the post operative distal femurs of this group to become morphologically comparable to the Caucasian knee and this is possibly affecting the kinematics of those knees leading to no significant improvement in the post operative ROM and affecting satisfaction with surgery.

The purpose of this study is to evaluate the effectiveness of current surgical management of pelvic acetabular fractures providing insight into the outcomes of fractures treated operatively using validated scoring systems.

20 Patients were surgically treated over a 2 year period at the Hudders field Royal Infirmary Hospital, United Kingdom. All were operated on by a single surgeon following pelvic and acetabular fractures. The first part of the study consisted of a review of the clinical records and x-rays done by 2 different observers. All the pelvic fractures were classified according to the Young-Burgess classification, and acetabular injuries according to the Letournels classification. The notes were assessed for probability of survival on admission and ‘ISS scoring’. The clinical records were reviewed for post operative complications, a protocol for follow up management, involvement of HDU, and any relevant re-admissions. The second portion of the retrospective study consisted of patient reviews at the clinic, the minimum being 6 months post operatively. Recent x-rays were reviewed for bone healing, heterotrophic ossification and avascular necrosis. The patients wound healing was assessed. Clinical results were recorded using the Oxford Hip score and the SF-36.

The results were analysed whilst ISS scoring varied from 8–32 with most of the patients. All patients had a good reduction and fracture healing. Complications noted were wound infection in 5%, and heterotrophic ossification in 5%. There were no nerve palsys, no DVT or pulmonary embolus, and no patients had avascular necrosis of the femoral head. Most patients had returned to near normal activities, with low pain scores. The Oxford Hip score ranged between 12–25, and the SF-36 score between 80 & 100.

The authors concluded that patients with complex acetabular fractures can be managed effectively in a district hospital set up. Osteoarthrosis of the hip can be avoided if an anatomical reduction is achieved.

Introduction: Peri-prosthetic osteolysis due to wear has been acknowledged as a major challenge to long-term survival of hip arthroplasty and this has led to a search for alternative articular bearing couples. We present our experience with metal-on-metal (Metasul^®) articulation with a minimum patient follow-up of 5 years.

Materials and methods: 193 patients (215 hips) were reviewed; 187 (209 hips) had a follow-up of ≥ 5 years. Hip scores were completed and radiographs performed at follow-up visits and data was entered prospectively into software (orthocom) designed by Sulzer Ltd.. Serial radiographs were reviewed retrospectively along with hospital notes and the database.

Results: mean age was 70 (± 7.46) years (range 47–86 years). Female: male was 143:44. Most common pre-operative diagnoses were: osteoarthritis (147) and intra-capsular hip fracture (22).

Mean pre-operative HHS was 39.7 (±15.7) and the corresponding pain score was 13.4 (±8.49). The average post-operative scores were 89.5, 87.3, 88.4 and 85.8 at 1 year, 3 years, 5 years and final follow-up respectively. The corresponding pain scores were 42.7, 41.98, 42.1 and 41.94. Implant survival for the cohort as a whole was 95.5% at 12 years (ci: 88%–100%). Survivorship for the Weber Metasul cup was 93.4% at 12 years (ci: 82.7%–100%) and for armor cup was 100% at 11 years.

Complications included: dislocations (7), periprosthetic fractures (8), deep infection- early (3) & late (3), aseptic loosening (cup) (2) & heterotopic ossification (9). There were no untoward systemic complications with regards to metal ion release.

Discussion: We believe that second generation metal-on-metal implants (Metasul^®) with improved design and better lubrication show better survival with regards to aseptic loosening and reduction in osteolysis in the medium-term. Concerns regarding metal ion and metal particle release remain theoretical but are kept under constant review.

Introduction More than 2% of the general population is reported to be affected by adhesive capsulitis. The incidence is greater in patients with diabetes than in the general population for both IDDM and NIDDM. This study sought to test the hypotheses that diabetes does not have an effect on outcome and does not contribute to morbidity.

Materials and methods Data were collected retrospectively by reviewing medical records from 1996 to 2005. A total of 148 case notes were evaluated to identify patients with a diagnosis of frozen shoulder who underwent MUA ± arthroscopy ± release. Twenty-two patients (22 shoulders), 12 of whom had diabetes, agreed to participate and were included. The diabetic and non-diabetic groups were broadly comparable with respect to demographic characteristics. Invited patients were asked to assess current physical function and symptoms by completing a shortened version of the DASH outcome measure questionnaire prior to attending the clinic and a further questionnaire detailing pre-op symptoms. Physical function was assessed and calculated using the Constant score system.

Results The median pre-operative DASH score was 72.73 in the diabetic group and 71.00 in the non-diabetic group (difference 2.3%). The median post-operative DASH score was 27.27 in the diabetic group and 28.86 in the non-diabetic group (difference 5.51%). The median postoperative Constant score was 60.00 in the diabetic group and 59.50 in the non-diabetic group (difference 0.83%).

Conclusion The pre- and post-operative DASH results and post-operative Constant score showed little difference between diabetic and non-diabetic patients. While giving due cognisance to the small number of patients included and the retrospective design of the study, the results support the hypothesis that diabetes does not have an effect on outcome following MUA or arthroscopy for adhesive capsulitis and does not contribute to morbidity.

Introduction: Osteoarthritis (OA) has historically been thought of as a degenerative joint disease, but inflammation and angiogenesis are increasingly being recognised as contributing to the pathogenesis, symptoms and progression of OA. β-dystroglycan (β-DG) is a pivotal element of the transmembrane adhesion molecule involved in cell-extracellular matrix adhesion and angiogenesis. Matrix metalloproteinases (MMPs) are the main enzymes responsible for cartilage extracellular matrix breakdown and are also implicated in both angiogenesis and β-DG degradation in a number of malignancies. We aimed to investigate the expression and localisation of β-DG and MMP-3, -9, and -13 within cartilage, synovium and synovial fluid and establish their roles in the pathogenesis of OA.

Methods: Following ethical committee approval, cartilage, synovium and synovial fluid were obtained from the hip joints of 5 osteoarthritic (patients undergoing total hip replacement) and 5 control hip joints (patients undergoing hemiarthroplasty for femoral neck fracture). The samples were analysed for β-DG expression using Western Blotting and for the distribution of β-DG, MMP-3, -9, and -13 using immunohistochemistry on paraffin embedded tissue.

Results: Whilst no significant expression of β-DG was found in cartilage or synovial fluid, β-DG was expressed in the smooth muscle of both normal and osteoarthritic synovial blood vessels. Moreover, β-DG was expressed in endothelium of blood vessels of OA synovium, but not in the normal endothelium. In the endothelium of osteoarthritic synovial blood vessels, β-DG co-localised with MMP −3 and −9.

Discussion: Our results demonstrate that β-DG does not act as a cell adhesion molecule binding chondrocytes to the ECM. However, specific immunolocalisation of β-DG within endothelium of inflamed OA blood vessels suggests that β-DG may play a role in angiogenesis associated with OA. Its co-localisation with MMP-3 and −9, previously reported to also have pro-angiogenic roles, may be linked. Further research is required to understand these roles more fully.

Introduction: There has been a renewed interest in metal-on-metal articulation in hip joint Arthroplasty. The reason for having metal-on-metal articulation is to reduce the volume of wear particles that are produced with THR. The outcome of reduced particle formation will hopefully be reduced osteolysis.

Methods: We reviewed the results of 139 primary hip arthroplasties (130 patients) performed using Metasul articulation and cemented Weber cup. Six patients were lost to follow-up leaving 133 hips (124 patients) for review with at least 5-year follow-up. The acetabular socket was the cemented Weber cup and Bone grafting of the acetabulum and application of a reinforcement ring was done where necessary. Cemented CF-30 femoral stem was used in all patients but one (PFMR). The study was conducted retrospectively based on the information collected from hospital notes and Orthocom database. Immediate post-operative films were seen to measure the cup and stem inclination and quality of cementing using the Barracks grading system.

Results: There were 102 females and 22 males in the cohort. Mean age was 73 years (SD-7.46, range 58–86). Left to right hip ratio was 52:81. Most common Pre-operative diagnosis was Osteoarthritis (103) followed by Intracapsular fracture neck of femur (20). The average follow-up was 7.23 years (range 5–10.9). Mean pre-operative Harris hip score was 42.09 and mean post-operative hip scores were 90.01, 86.84, 87.42 and 84.63 at 1-year, 3-year, 5-year and final follow-up with the corresponding pain scores were 42.9, 41.84, 41.56 and 41.56 respectively. Only two hips were revised for aseptic loosening of the cup with a 93.4% implant survivorship at 12 years. There was no case of aseptic stem loosening. No untoward systemic effects were noted in the cohort.

Discussion: We believe that in our study Metasul metal-on-metal articulation has shown satisfactory results with regards to aseptic loosening and reduction in osteolysis in medium-term.

Introduction: Osteoarthritis has historically been thought of as a degenerative joint disease, but inflam-mation and angiogenesis are increasingly being recognised as contributing to the pathogenesis, symptoms and progression of osteoarthritis. Beta-dystroglycan is a pivotal element of the transmembrane adhesion molecule involved in cell-extracellular matrix adhesion and angiogenesis. Matrix metalloproteinases are the main enzymes responsible for cartilage extracellular matrix breakdown and are also implicated in both angiogen-esis and beta-dystroglycan degradation in a number of malignancies. We aimed to investigate the expression and localisation of beta-dystroglycan and matrix metal-loproteinase 3, 9, and 13 within cartilage, synovium and synovial fluid and establish their roles in the pathogenesis of osteoarthritis.

Methods: Following ethical committee approval, cartilage, synovium and synovial fluid were obtained from the hip joints of 5 osteoarthritic (patients undergoing total hip replacement) and 5 control hip joints (patients undergoing hemiarthroplasty for femoral neck fracture). The samples were analysed for beta-dystroglycan expression using Western Blotting and for the distribution of beta-dystroglycan, matrix metalloproteinase 3, 9, and 13 using immunohistochemistry on paraffin embedded tissue.

Results: Whilst no significant expression of beta-dystro-glycan was found in cartilage or synovial fluid, beta-dys-troglycan was expressed in the smooth muscle of both normal and osteoarthritic synovial blood vessels. Moreover, beta-dystroglycan was expressed in endothelium of blood vessels of osteoarthritic synovium, but not in the normal endothelium. In the endothelium of osteo-arthritic synovial blood vessels, beta-dystroglycan co-localised with matrix metalloproteinase 3 and 9. Discussion: Our results demonstrate that beta-dystro-glycan does not act as a cell adhesion molecule binding chondrocytes to the extracellular matrix. However, specific immunolocalisation of beta-dystroglycan within endothelium of inflamed osteoarthritic blood vessels suggests that beta-dystroglycan may play a role in angiogenesis associated with osteoarthritis. Its co-localisation with matrix metalloproteinase 3 and 9, previously reported to also have pro-angiogenic roles, may be linked. Further research is required to understand these roles more fully.

Introduction: Aseptic loosening is the major cause of implant failure. In cemented hip Arthroplasty it is well known that the acetabular side fails earlier due to lysis caused by wear particles. This is the rationale for Hybrid hip Arthroplasty. It might be advantageous to use a bearing which has a low wear rate. The purpose of this study is present the medium term results of this Uncemented cup with a metal-on-metal bearing.

Methods: We reviewed the results of 119 hips (101 patients) who had the Uncemented Fitmore® cup (Sulzer/Zimmer Orthopaedics, Inc). In 66 out of the 101 patients the femoral component used was CF-30® (Sulzer/Zimmer Orthopaedics, Inc) used with cement. In 35 patients Thrust plate prosthesis TPP® (Sulzer/Zimmer Orthopaedics, Inc) was used. This is a bolt type device which is fixed on to the neck; the femoral canal is not violated. Of the 101 patients, 90(108 hips) were available for study. All had minimum of 5 years follow-up.

Results: Mean follow-up of the 90 patients is 87.4 months (range 60 – 129 months). The mean pre-op Harris hip score is 38.2. The mean post-op Harris hip score is 89.6 at the last follow up. Taking aseptic loosening as the end point the survival rate of the Fitmore cup is 100% at 11 years. Four cups were revised for other causes.

Discussion: Histological studies of retrieved metal-on-metal implants have always shown low volume of inflammatory tissue. Wear rate of metal-on-metal hips is 60–100 times lower than metal-on-polyethylene hips. In the medium to long term Uncemented cups fare better than cemented cups. It might be advantageous to use an Uncemented cup with a metal-on-metal bearing. This follow-up study which has a 100% survival rate at 11 years proves that.

The purpose of this study was to demonstrate the beneficial effects of elbow arthrolysis.

This was a prospective study on 88 patients with post-traumatic elbow stiffness with a mean follow-up of 51 months (1 year - 11 years), who had failed to improve their range of movement at a mimimum period of 6 months after their injury. All patients had an open arthrolysis. Post-operatively patients received continuous passive movement (CPM) for 48 to 72 hours. This was facilitated by good analgesia afforded by a continuous brachial plexus block. All patients received no physiotherapy thereafter and were advised to actively mobilise their elbow. ROM was assessed using a goniometer and function assessed using the Mayo elbow performance index.

The ROM improved from a mean of 56 degrees pre-operatively to 106 degrees post-operatively. This improvement in ROM was reflected in the improvement of pre-operative flexion from 107 to 138 degrees and improvement of extension from 60 to 31 degrees. Function improved from a mean of 65 to 85 on the Mayo elbow performance score. 95% of the patients were satisfied with the outcome. Complications included ulnar nerve paraesthesia in 3 patients, 1 triceps avulsion and 1 superficial infection. 3 patients required a manipulation of the elbow in the postoperative period. This was performed within 2 weeks of the operation. There were no cases of elbow instability or heterotopic ossification in this series.

Conclusion: Open elbow arthrolysis combined with continuous brachial plexus block and CPM in the postoperative period is a safe, reliable and durable procedure for improving ROM and function in patients with post-traumatic elbow stiffness.

Osteoporosis and fragility fractures in men constitute a considerable burden in healthcare. We have reviewed 2035 men aged over 50 years with 2142 fractures to clarify the epidemiology of these injuries and their underlying risk factors. The prevalence of osteoporosis ranged between 17.5% in fractures of the ankle and 57.8% in those of the hip. The main risk factors associated with osteoporosis were smoking (47.4%), alcohol excess (36.2%), body mass index < 21 (12.8%) and a family history of osteoporosis (8.4%). Immobility, smoking, self-reported alcohol excess, a low body mass index, age ≥72 and loss in height were significantly more common among men with fractures of the hip than in those with fractures elsewhere.

We present a retrospective study of 25 patients treated by open arthrolysis of the elbow for post-traumatic stiffness. The mean follow-up was for 7.8 years (5 to 10.8). The range of movement of the elbow, pain scores and functional outcomes were recorded pre- and postoperatively. An improvement in the mean range of movement from 55° (0° to 95°) to 105° (55° to 135°) was obtained in our patients at one year. This improvement was maintained over the mean follow-up period of 7.8 years (5 to 10.8). Improvement in pain, function and patient satisfaction was recorded in 23 of the 25 patients at final follow-up.

On the basis of this study, we believe that the results of open arthrolysis for post-traumatic stiffness of the elbow are durable over the medium term.

Introduction: Slipped Upper Femoral Epiphysis (SUFE) is very rare in children less than 10 years of age but may be more common with increasing obesity in children. There are concerns with the presentation of SUFE in this age group regarding bilateral slips and prophylactic pinning, fixation with multiple pins to preserve growth, and complications.

Methods: We identified 12 cases of SUFE in 8 patients who presented aged less than 10 years to our institution between 1997 and 2004. Case note and radiographic review were carried out.

Results: There were 5 boys and 3 girls in this group, with an average follow-up of 48 months (6 – 90 months). Bilateral SUFE was present in 4 patients (50%). Only 3 slips were unstable. One child was found to be hypothyroid and another had oculocutaneous albinism. The remaining children had normal genetic and endocrine profiles. Six children were above the 90th centile for weight. The severity of slip was mild in 9 hips and moderate in 3 hips.

Multiple threaded pins were used in 10 hips and a cannulated screw in 2 hips.

Complications include revision surgery due to loss of fixation in 3 hips and a superficial wound infection. There were no cases of avascular necrosis and chondrolysis.

Discussion: Gross obesity is the commonest predisposing factor. The high incidence of bilateral involvement is an indication for prophylactic pinning. Multiple threaded pins may need to be revised if the fixation is lost as the child grows. These should be left proud of the lateral femoral cortex to facilitate removal, although at the risk of producing a windscreen wiper effect.

Introduction: The aim of this paper was to test the hypothesis that for hips affected with Legg-Calve-Perthes’ (LCP) disease under the age of 8 years, surgery does not affect the outcome.

Methods: We performed a retrospective paired study of patients, who were diagnosed with LCP disease before the age of 8 years, to compare the radiological results after treatment between conservatively and surgicallytreated groups. One patient was selected from each group to create the pairs for this study. Each pair was strictly matched for gender, body mass index, age at onset, and stage at the first visit, Catterall and Herring grading and radiological at-risk signs. Each pair was assessed by comparing the values of five radiological measurements.

Results: From a cohort of 345 hips diagnosed with LCP disease 14 pairs (28 hips) fitted the criteria. The radiological measurements, which showed a statistically better result in the surgical groups, were Mose’s method (p = 0.019), the Acetabular-Head Index (p = 0.034). There were no statistical differences in the Slope of the Acetabular Roof (p = 0.37), Articulotrochanteric distance (p = 0.17) and Stulberg grading (p = 0.2). 5 pairs had a better Stulberg result in the operative group. Three of these 5 pairs were less than 6.5 years at the time of their surgical procedure. Three pairs had a better Stulberg result in the conservative group. Six pairs had no difference between the groups.

Discussion: We conclude that surgical treatment can improve the sphericity of the femoral head and provide greater acetabular cover than conservative treatment in hips of patients less than 8 years at the onset of LCP disease. However, the Stulberg grading was not affected. Our study supports the hypothesis that for hips affected with LCP disease under the age of 8 years, surgery does not affect the outcome.

Stickler’s syndrome, also called Hereditary Progressive Arthro-Ophthalmopathy, is an autosomal dominant connective tissue disorder with strong expressivity, characterised by ocular, orofacial, skeletal, cardiac, and auditory features.

We describe a case of valgus slipped capital femoral epiphysis in a 13 year-old boy with Stickler’s syndrome. He presented at routine rheumatology clinic follow-up with a 1-month history of progressively worsening right hip pain, which radiated to the knee. He underwent insitu cannulated screw fixation of the right slipped capital femoral epiphysis.

Joint pains are a common manifestation in Stickler’s syndrome and this might delay the diagnosis of slipped capital femoral epiphysis. Valgus slipped capital femoral epiphysis is a rare entity. Obesity and the increased femoral anteversion are predisposing factors. Insitu fixation with a single cannulated screw is the treatment of choice.

Introduction: The aim of this paper was to present a profile of Legg-Calve-Perthes’ (LCP) disease and test the hypothesis of an association between LCP disease and poverty.

Methods: We examined demographic data on a group of 240 children (263 hips) presenting with LCP disease in Greater Glasgow, where the mean deprivation scores are substantially greater than in the rest of Scotland, to see if this association applies or whether other clues to the aetiology of LCP could be divined.

Results: There were 197 males and 43 females. The majority presented in the sclerosis phase with much smaller numbers in the other phases. 70 % (184 cases of LCP) were Catterall grades 3 or 4. 16.25% had a family history of LCP. Bone age in our series is heavily skewed towards the lower centiles. The number of siblings in the family averaged 1.9, with 13 % being an only child. The maternal age at birth of the index child showed no preponderance to older age. Maternal smoking during and after pregnancy was noted in 55 %, which compares with 52% reported in the population of Greater Glasgow in general. Bone age in our series was heavily skewed towards the lower centiles. Birth weight showed a definite shift to the left, height a weaker shift to the left. 25 % of the children in our series are in social class IV and V, although this accounts for more than 50 % of the population of the Greater Glasgow.

Discussion: There is no significant evidence of a preponderance of LCP disease in the most deprived groups (p=0.9). The aetiology of LCP disease is likely to be multifactorial and may include a genetic or deprivation influence causing low bone age, hyperactivity and a high pain threshold.

Introduction There has been increasing interest and enthusiasm among both surgeons and patients for small incision for total hip joint replacement (THR). We conducted a prospective study to compare the early postoperative recovery following the two different incisions.

Materials and Methods 40 patients were prospectively randomised (20 patients in each group) by use of envelopes to undergo either conventional or minimal incision (MI) approach for THR between Sept. 2003 and Aug. 2004. Patients with BMI (body mass index) ≤ 30 were considered suitable for randomisation. Conventional incision was 12 cm standard posterolateral in all cases and minimal incision was defined as within 2 cm of the diameter of the contralateral uninvolved femoral head. Minimal incision was made over the posterior aspect of the greater trochanter. All procedures were performed by the senior author. The patients were assessed for operative time, blood loss, haematological parameters, wound healing, ease of mobilisation, post-operative pain, hospital stay and complications. The patients, and assessors (physiotherapists and nurses on ward) were unaware of the treatment group.

Results Average age was 66.95 years for MI group and 68.55 for conventional group (p-0.501). Average BMI for MI and conventional group was 26.5 & 24.4 respectively (p-0.029). Average pre-operative Oxford hip score was 41.75 for conventional group and 42.15 for MI group (p-0.87). There was no statistically significant difference as regards the operating times (p-0.207); post-operative day the patients were mobilised with zimmer frame (p-0.71); drop in hemoglobin (p-0.197) and hematocrit (p-0.208) or the need for blood transfusion (p-0.56). However there was a statistically significant difference in the two groups as regards post-operative pain (on a 10 point visual analogue scale) and the number of postoperative days the patient was fit for discharge. Average pain score on day 1 was 4.05 for MI group and 6.25 for conventional group (p-0.0089) with similar difference on day 2 and the day of discharge. Patients in MI group were fit for discharge on an average 1.65 days earlier than those in conventional group (p-0.042). There was no superficial or deep wound infection, dislocation or per-operative fracture in either group. Transient sciatic nerve neuropraxia occurred in one patient in the minimal incision group which recovered within 6 weeks.

Conclusion Minimal incision posterior approach for total hip replacement may be useful in decreasing the post-operative pain and duration of hospital stay. However the incidence of complications is an area of concern and needs to be studied on a larger study group.

Introduction The aim of the study was to review the results of total hip arthroplasty (THA) in relatively fit and mobile patients with Garden 3 and 4 fractures of the neck of femur.

Materials and methods 37 patients who underwent THA for displaced fractures of neck of femur between 1995 to 2001 were reviewed. Only those patients with 3 years or more follow-up were reviewed.

Results Average age was 67.7 years (37–80 years) with Male:Female ratio 5:32. Fracture involved left hip in 12 and right hip in 15 patients. Average Modified Barthel index before the fracture was 18.5 (13–20) and average Waterlow score was 12 (5–19). Majority were ASA grade II (22 patients). All patients were operated by the senior author. 31 hips were cemented, 1 uncemented and 5 hybrids. Canulated CF-30 (Sulzer, Switzerland) femoral stem was most commonly used (32 patients) and the acetabular component was Weber Metasul cup in most cases (33 patients).33 hips had metal-on-metal bearing surface and the rest had metal-on-polyethylene. Average hospital stay was 12.6 days; majority (33) of the patients were discharged home and the rest needed additional rehabilitation. Average post-operative drop in Hb was 2.63 and14 patients needed blood transfusion. Average transfusion was 0.86 units per patient. Average follow-up was 5.8 years (3–9.5 years). Complications included: wound leakage (5), minor wound dehiscence (1), DVT (3), pulmonary embolism (1), dislocation (1), per-operative femur fracture (1), peri-prosthetic fracture (2), stem loosening (1). 3 hips (8%) were revised (loosening 1, peri-prosthetic fractures 2). Average harris hip score at follow-up was 92 (66–100).

Conclusion In relatively fit, young and mobile patients, we recommend total hip replacement as the primary treatment since it promises better function and pain relief and avoids the drawbacks of internal fixation and hemiarthroplasty.

Introduction The aim of this study was to assess the comparability of telephone questionnaire interviews with outpatient attendance for assessing hip function after Total Hip Replacement (THR).

Materials and Methods 100 patients attending the orthopaedic clinic for follow-up after undergoing THR were recruited to this study. A modified Harris Hip Score (HHS) was used as the questionnaire. This modified score assessed pain and function with 8 variables and had a maximum score of 91. The score thus obtained was multiplied by a factor of 1.1 to derive a score out of 100. Patients attending follow-up clinics were contacted by telephone between 1–2 weeks prior to their scheduled appointment and the questionnaire was completed. The questionnaires thus completed were compared to those completed in the clinic.

Results The mean HHS obtained with the telephone interview was 85.22 as compared to 86.11 obtained at direct interview with a Pearson’s correlation coefficient of (0.906) and p-value for the difference of (0.111). Out of a total of 800 variables assessed 725 (90.37%) had the same scores by the two methods and only 75 (9.67%) showed a discrepancy. Only 3 patients had a significant difference (more than 20 points) between the two methods.

Conclusion The study shows that there is no significant difference between scores obtained by telephone interview or direct interview using a modified HHS. Telephone interview is an important adjuvant tool for patient follow-up after THR and a useful adjunct to lifelong review.

It has been reported that there is an association between Perthes’ disease and poverty. We examined the demographic data of a group of 240 children (263 hips) who presented with Perthes’ disease in Greater Glasgow, where the mean deprivation scores are substantially greater than in the rest of Scotland, to see if this association applied and whether other clues to the aetiology of Perthes’ disease could be found. There were 197 boys and 43 girls; 39 (16.25%) had a family history of Perthes’ disease. Bone age in this series was heavily skewed towards the lower percentiles. The mean number of siblings was 1.9, with 31 (12.9%) being an only child. Maternal age at the birth of the first child showed no preponderance of older mothers. Maternal smoking during and after pregnancy was noted in 132 (55%), which compared with the 52% reported in the population of Greater Glasgow in general. Of the children in our series, 60 (25%) were in social class IV and V. However, this applies to more than half of the population of Greater Glasgow. There was no significant evidence of a preponderance of Perthes’ disease in the most deprived groups. The aetiology of Perthes’ disease is likely to be multifactorial and may include a genetic or deprivation influence resulting in delayed bone age.

Introduction and Aims: The aim of this study was to assess the results of open elbow arthrolysis for post-traumatic stiffness.

Method: This is a prospective study of 89 patients (M: F 53:36) with a mean age of 34 years. All patients had open elbow arthrolysis followed by continuous passive motion (CPM) for 72 hours. CPM was facilitated by analgesia in the form of a continuous brachial plexus block. After CPM patients were advised to actively mobilise their elbow. The minimum follow-up was one year. (Mean follow-up 47 months). Range of movement (ROM) was recorded using a goniometer; function was assessed using the mayo score and pain using the visual analogue score.

Results: ROM improved from 60.9 to 104.2 degrees, flexion improved from 119.8 to 136.3 and extension improved from 58.9 to 32.1 degrees. Pain improved from 4.8 to 3.1 and the Mayo score improved from 60 to 85. In the sub-group of 25 patients with severe stiffness (pre-operative arc < 50 degrees), ROM improved from 29.6 to 89 degrees. Flexion improved from 99.2 to 132.2 degrees, extension improved 70 to 43.2 degrees. Pain improved from 5.6 to 4.0 and the Mayo score improved from 40 to 75. In the sub-group of 29 patients with a minimum follow-up of five years, ROM improved from 57.7 to 104.3 degrees at the year one post-operative assessment. ROM was maintained at their last follow-up, measuring 108.6 degrees. The pain score improved from 4.3 to 2.8 and was at 2.7 at their last follow-up. The Mayo score improved from 65 to 85 at year one, which was maintained at their last follow-up.

Conclusion: Open elbow arthrolysis for post-traumatic stiffness of the elbow is a durable procedure for improving ROM and function. Moreover the results of elbow arthrolysis are not influenced by the degree of pre-operative stiffness.

Introduction and Aims: Use of non-steroidals (NSAIDs) and additional factors such as advanced age, anticoagulants and co-morbid diseases, commonly found in patients with arthritis, increases the risk of upper gastrointestinal (UGI) bleeding. Our aim was to assess the incidence of peri-operative UGI bleeding in patients having hip and knee replacements for arthritis.

Method: A single centre, retrospective study was conducted on 100 consecutive hip replacements and 100 consecutive knee replacements performed at Victoria Infirmary, Glasgow, between 1998 and 2000.

Results: The mean age was 74 (41–86). Sixty-three percent of our patients were female. Seventeen percent of the patients had a previous history of UGI problems, of which only 50% were on gastro-protective medication. Fifty-four percent of the patients were on NSAIDs and all patients received anticoagulants (78 aspirin, 122 clexane) peri-operatively. Nine patients (4.5%) had UGI bleeding in the post-operative period. Five patients had endoscopies, which revealed bleeding from gastric ulcers (three), duodenal ulcer (one) and barretts oesophagus (one). Four patients, who had one episode of UGI bleeding, did not have endoscopies. All the nine patients with UGI bleeding were patients who had been on NSAIDs and anticoagulants (six clexane, three aspirin). These nine patients were from the group of patients who were not on any gastro-protective medication. Five of these patients requiring a hospital stay of more than two weeks.

Conclusion: We believe that the incidence of UGI bleeding in patients undergoing hip and knee replacements is underestimated. We propose gastro protective agents in the peri-operative period for patients on NSAIDs.

Introduction and Aims: The aim of this paper was to assess the 10 to 15-year clinical and radiographic results of uncemented LCS meniscal-bearing total knee replacements used to revise failed uni-compartmental knee replacements.

Method: Eleven (5 M: 6 F) cementless LCS meniscal-bearing total knee replacements were implanted in patients who had failed uni-compartmental knee replacements for medial compartment osteoarthritis. Mean time interval between the uni-compartmental knee replacement and the LCS total knee replacement was 18 months (12–72 months). Minimum follow-up of all patients reviewed was 10 years (mean 12.9 years). Average age of patients at the time of surgery was 60.1 years (47–74 years). Clinical and radiographic analysis was performed. American knee society pain and function scores were determined and Kaplan-Meier survivorship analysis was conducted. Failure was defined as revision due to any cause.

Results: At the time of the 10 to 15-year follow-up, all 11 patients were alive and were all reviewed. Four patients (three males, one female) had a revision of their LCS total knee replacement. The average time to revision of the LCS total knee replacement was 26 months (1–60 months). The average knee society pain and function scores were 80 and 45 at the final follow-up evaluation. The average range of movement was 95 degrees (80–100 degrees). The survival rate of 60% (95 % confidence interval) was noted at 12 years.

Conclusion: After 10 to 14 years of follow-up, the cementless LCS meniscal bearing total knee replacement for a previously failed uni-compartmental knee replacement was found to have a 37% revision rate.

We analysed the long-term clinical and radiological results of 63 uncemented Low Contact Stress total knee replacements in 47 patients with rheumatoid arthritis. At a mean follow-up of 12.9 years (10 to 16), 36 patients (49 knees) were still alive; three patients (five knees) were lost to follow-up. Revision was necessary in three knees (4.8%) and the rate of infection was 3.2%. The mean clinical and functional Knee Society scores were 90 (30 to 98) and 59 (25 to 90), respectively, at final follow-up and the mean active range of movement was 104° (55° to 120°). The survival rate was 94% at 16 years but 85.5% of patients lost to follow-up were considered as failures. Radiological evidence of impending failure was noted in one knee.

Total hip arthroplasty (THA) patients often require peri-operative blood transfusion. Variables that predict transfusion requirement may allow us to target cross-matching of individual patients.

153 patients underwent primary unilateral THA for osteoarthritis or rheumatoid arthritis during 2002 in our institution. 75 casenotes from these subjects were reviewed. Age, sex, diagnosis, weight, height, pre-operative haemoglobin (Hb) and haematocrit (Hct), anticoagulation type and timing were recorded, along with post-operative Hb and timing and quantity of any blood transfusion. Potential predictors of transfusion were examined using logistic regression analysis. ROC analysis was used to compare the relative predictive value of significant variables.

Mean (±SD) age at surgery was 67±11 years (53% females). Mean pre-operative Hb was 13.8±1.4g/dl, mean post-operative Hb was 10.2±1.0g/dl. 27 patients (36%) needed a transfusion; the most frequently given volume was 2 units and the mean number of units given was 0.85. The most common reason for transfusion was an asymptomatic low Hb (< 8.0g/dl). Pre-operative Hb and Hct were predictive of post-operative transfusion (logistic regression analysis P< 0.01). Age, gender, diagnosis and anticoagulation were not predictive. Using ROC analysis the optimal ‘cut-off’ value of pre-op Hb as a predictor was 12.7 g/dl, giving a sensitivity of 41% and a specificity of 88% for blood transfusion requirement. The optimal ‘cut-off’ for Hct was 0.41, sensitivity 74% and specificity 61%. There was no significant difference in the overall predictive value between these variables (comparison of area under ROC curves, P> 0.05).

In summary, subjects with a pre-operative Hb< 12.7 or Hct < 0.41 are more likely to require a blood transfusion after unilateral primary THA than those with an Hb or Hct above these values. In treatment centres where cross-matched blood is not available at short notice on demand, pre-operative cross-match of patients with blood counts below these values may be appropriate.

Introduction: The aim of this study was to assess the feasibility of telephone questionnaire interviews for assessing hip function after Total Hip Replacement (THR).

Methods: 100 patients attending the orthopaedic clinic for follow-up after undergoing THR were recruited to this study. A modified Harris Hip Score (HHS) was used as the questionnaire. This modified score assessed pain and function with 8 variables and had a maximum score of 91. The score thus obtained was multiplied by a factor of 1.1 to derive a score out of 100. Patients attending follow-up clinics were contacted by telephone between 1–2 weeks prior to their scheduled appointment and the questionnaire was completed. The questionnaires thus completed were compared to those completed in the clinic.

Results: The mean HHS obtained with the telephone interview was 85.22 as compared to 86.11 obtained at direct interview with a Pearson’s correlation coefficient of (0.906) and p-value for the difference of (0.111). Out of a total of 800 variables assessed 725 (90.37%) had the same scores by the two methods and only 75 (9.67%) showed a discrepancy. Only 3 patients had a difference of > 20 points between the two methods.

Conclusion: The study shows that there is no significant difference between scores obtained by telephone interview or direct interview using a modified HHS.

Telephone interview is an important tool for patient follow-up after THR and a useful adjunct to life-long review.

The posterior capsule is variously incised and excised during total hip replacement (THR). There is no consensus on the direction of the capsulotomy and the need to repair the posterior capsule. The objective of this study was to determine the orientation of the collagen fibres and nerves in the posterior hip capsule in patients undergoing THR.

Specimens from five patients with osteoarthrosis of the hip (with no fixed deformity) were obtained and fixed in 10% neutral buffered formalin. Sutures were placed to mark the head and trochanteric end before excising. A standard posterior approach was used. The samples were examined and reported by a pathologist. Samples were processed overnight in a VIP5 automatic tissue processor and embedded in paraffin wax, preserving the location of the suture sites on embedding. Sections were cut at 5 Ïm and routinely stained with haematoxylin and eosin. The van Gieson stain was used for collagen fibres. Nerve fibres were highlighted using immunohistochemistry for S100 protein and blood vessels using an antibody to CD34.

The collagen bundles seen were predominantly parallel to the axis of the specimen. Dispersed within the collagen bundles were small vascular leashes that were parallel with the collagen fibres. The S100 staining revealed that these were neurovascular leashes, with small nerves running alongside the vessels and the collagen. Nerves that separate from the vessels were likely to serve proprioceptive and nociceptive functions.

The direction of the capsulotomy during THR by posterior approach has been traditionally perpendicular to the direction of the capsular fibres. However, if possible, capsulotomy along the orientation of the collagen fibres may be advantageous. As this study demonstrates, it will result in less damage to the capsular collagen fibres, blood vessels and nerves resulting in better capsular repair and healing, and better conservation of pro-prioceptive and nociceptive functions.

Introduction: Over the last decade there have been a series of papers, with a follow-up of less than 5 years, demonstrating the beneþcial effects of elbow arthrolysis. There are doubts about the durability of this procedure as most patients develop early arthritis of the elbow joint as a consequence of their injury, which, in theory, could reduce the range of movement in the joint. Aim: The aim of this study was to assess whether the improvement in the range of movement of the elbow achieved through arthrolysis changed in the postoperative period. Methods: This is a prospective study of 25 patients who had arthrolysis of the elbow performed to improve posttraumatic stiffness. All these patients had a minimum follow up period of 5 years. (Mean followup 8.2 years). Range of movement at the elbow was recorded using a goniometer. Functional outcomes and pain were also assessed at each of these visits using the Mayo elbow score and the visual analogue score. Results: Range of movement improved from 55 degrees preoperatively to 105 degrees postoperatively at 1 year and this improvement was maintained at their last followup. Similarly, the Mayo elbow score and visual analogue score also improved following an elbow arthrolysis and again this improvement was maintained at their last followup. Conclusions: Based on the results of this study, we believe that elbow arthrolysis for post traumatic stiffness of the elbow is a durable procedure.

All known shoulder surgeons in Scotland have made a voluntary registration of shoulder replacements since 1996. Information regarding diagnostic and demographic characteristics of the patients, rotator cuff status and type of procedure performed were collated.

20 surgeons have contributed to the register, performing a varied number of shoulder arthroplasties (2 to 79). By five years the total number of shoulder replacements performed was 451. 23. 2 % of patients were male and 76. 8% female. 397 patients had a hemiarthroplasty and 54 (12 %) had a total shoulder replacement. 204/451 (45 %) humeral components used were cemented. In comparison 48/54 (89%) glenoid components used were cemented.

The most common condition requiring shoulder arthroplasty was inflammatory arthritis (184 cases), followed by trauma (128 cases), of which 60 % were for acute trauma and 40 % for old trauma. The remainder consisted of osteoarthritis (87 cases), avascular necrosis (27 cases), and others (25 cases). The consultant in 425 cases and the trainee in 26 cases performed the operation. In 85/451 (18. 9%) of the cases, associated procedures were performed which included cuff repair (26 cases), coracoacromial ligament excision (43 cases), coracoid osteotomy (14 cases) and acromioclavicular joint excision (2 cases). There were 24 intra-operative complications and 9 patients had a revision.

Comparison with figures from the Information and statistics division in Scotland however indicated that our register collected only 53 % of all the arthroplasties performed. In addition it was noted that 30 % of shoulder replacements were performed by surgeons who performed three or fewer shoulder replacements a year.

In an age of clinical governance we believe that a register can provide detailed and accurate information. It is useful for demonstrating current practice and can highlight future changes in practice.

This register supports the need for a national register and surveillance of shoulder replacements. However, in addition to the voluntary data registration, it is proposed that dedicated data collection staff are employed to coordinate the data collection process.