The Hospital (Trust) guidelines generally recommend 40mg of Low molecular weight heparin (LMWH) twice daily (BD) for all patients over 100kg for those undergoing total hip (THR) and knee replacements (TKR) respectively. British National Formulary (BNF) recommends 40mg of LMWH once daily (OD) for all patients regardless of their overall weight or body mass index (BMI).

We evaluated the outcome of prophylactic LMWH dosage for patients undergoing THR and TKR by monitoring surgery related venous-thromboembolic events up to a minimum of three months after surgery.

A retrospective audit was carried out after obtaining institutional approval and all consecutive elective patients weighing over 100kg and undergoing THR and TKR were included. All patients were followed up for a minimum of 3 months after their operation to investigate the dose of prophylactic LMWH received, and whether they had developed any venous thromboembolic events (VTE) post operatively. This was done using a combination of electronic notes, drug charts and deep venous thrombosis (DVT) or computed tomography pulmonary angiogram (CTPA) reports on the hospital/trust database.

A total of 53 patients underwent elective THR (18) and TKR (35) between the period of March 2017 and September 2017. Forty-four patients received 40 mg OD and 9 patients had 40 mg BD. None of the patients developed a confirmed DVT or pulmonary embolism in the 3 months following surgery regardless of the dose received.

We demonstrate that there is no clinical benefit in having patients over 100kg on twice daily LMWH with the aim of preventing post-op thromboembolic complications. This conclusion is in line with the BNF recommendations for VTE prophylaxis.

The metal backed glenoid component in total shoulder replacement (TSR) has been associated with high revision rates and some authors have suspended the use of this implant.

The aim of this study was to evaluate the medium to long-term outcome of the metal backed glenoid component in rheumatoid patients.

Thirty-nine patients (46 shoulders) with a mean age of 55 years (35–86 years) received a TSR with a screw fixed porous coated metal-back glenoid. Ten were lost or died before 8 years follow-up, of which none were revised. Twenty-nine patients (36 shoulders) were followed up for a mean of 132 months (96–168 months). A Constant score was measured preoperatively and annually from time of surgery, and independently at last follow-up. Radiographs were assessed for lucency, loosening and superior subluxation of the humeral head.

The Constant score improved by 12.9 points (p=< 0.001). Implant survivorship at 10 years was 89%. Five were revised: 3 for pain secondary to superior subluxation, one for infection and one for aseptic loosing. All patients with lucent zones around the glenoid (four) had superior subluxation of the humeral head two to four years prior to their development. Survival rate however at 10 years was reduced, if judged by the development of superior subluxation on radiographs (33%).

The uncemented glenoid performs well in the rheumatoid shoulder, giving pain relief and improved functional outcome. The survivorship is comparable to previously reported studies.

The purpose of this study was to evaluate and assess the sporting and physical activities of patients who have undergone hip resurfacing. One hundred and seventeen patients who underwent hip resurfacing between 2003–2007 were reviewed.

Demographic data such as age, sex and comorbidities were recorded. University of California and Los Angeles (UCLA) activity level ratings and Oxford hip scores were collected pre-and postoperatively for each patient. The sporting and physical activities of all patients were pre-and post-operatively recorded.

The mean age of patients at surgery was 54 yrs and 56 yrs at review. The mean follow up time was 19 months. Following surgery there was a significant improvement in UCLA activity level scores from 4.4 to 6.8 (Wilcoxon Matched-pairs Signed rank test, p< 0.05). Oxford hip scores significantly improved from 43.4 to 17.7 following surgery. Eighty six patients regularly participated in sport before they became symptomatic with significant hip pain, and 75 regularly participated in sports after surgery. In total 87% of patients successfully returned to their regular sporting and physical activities following surgery. Many patients were returning to high impact sports including football, tennis, cricket and squash.

The published medium-term survivorship of the Birmingham hip has given surgeons increasing confidence to use the prosthesis on a younger generation of patients. Our study has demonstrated that hip resurfacing can allow patients to remain extremely active.

The management of osteoarthritis of the hip in young active patients has always been challenging. This can be made more difficult because of the longevity required of the prostheses used and the level of activity they must endure.

The aim of this study was to compare the functional outcomes and activity levels following hip resurfacing and uncemented THA in young active patients matched for age, gender and activity levels.

A retrospective review of 255 consecutive hip arthroplasties performed in a teaching hospital was carried out. From this series we identified 58 patients who had undergone uncemented THA (Group A) and 58 patients who underwent hip resurfacing (Group B), matched for age, gender and pre-operative activity level.

The mean age of patients within Group A was 58.5 years (34–65) and in Group B was 57.9 years (43–68). Mean pre-operative University of California at Los Angeles (UCLA) score in Group A was 3.4 (1–7) and in Group B was 4.2 (1–8). The mean pre-operative Oxford Hip Score (OHS) was 46.1 (16–60) and 44.4 (31–57) in Groups A and B respectively.

Mean follow-up period was five years (4–7 years). In the hip resurfacing group, the mean UCLA score improved from 4.2 (1–8) to 6.7 (3–10), while in the uncemented THA group this improved from 3.4 (1–7) to 5.8 (3–10). Similarly, the mean OHS improved from 44.4 (31–57) to 16.6 (12–31) in the hip resurfacing group and from 46.1 (16–60) to 18.8 (12–45) in the uncemented THA group.

This study found no statistically significant difference in the levels of function (p= 0.82) or activity pursued (p= 0.60) after surgery between uncemented THA and hip resurfacing in a population of patients matched for age, gender and pre-operative activity levels.

Although there was statistically significant improvement in UCLA and OHS within each group, it was found that no group was better than the other.

This study has shown comparable outcomes with hip resurfacing and uncemented THA in terms of both functional outcomes and activity levels in a group of young active patients. The potential complications unique to hip resurfacing may be avoided by the use of uncemented THA. In addition, uncemented THA has a longer track record.

Background: goal of our study was to predict the size of intramedullary nail using forearm as reference. Intra-medullary nailing has become favoured treatment for femoral shaft fractures. An implant of the correct size is needed to achieve the desired results. Preoperative templating is useful and well established for trauma and elective surgery to ensure availablity of a suitable implant of correct size preoperatively. Various ways have been described to estimate the nail length. Most commonly used is to x-ray the other limb or directly measure the reamer under x-ray. However these methods involve use of x-rays and information is not well-timed. We describe a simple technique, which can be used to predict the length of femur and therefore have the intra medullary nail of appropriate length available.

METHOD: measurements were taken on 100 volunteers from the tip of olecranon to the tip of little finger and tip of greater trochanter to palpable joint line on the lateral side of the knee. Two observers took the measurements on both sides. We used an ordinary plastic tape measure for ease of use and reproducibility.

RESULTS: statistical analysis revealed a very strong correlation (with pearson correlation factor of 1) between the two lengths. Difference between the two means was 0.16 Mm.

CONCLUSION: forearm reference represents maximum nail length required. It provides a useful method of estimation of femoral length. It can be easily applied in clinical practice with a tape measure alone without resort to x-rays and other expensive and possibly harmful means.

Purpose of the study: To assess the survivability of the metal backed glenoid component, to examine its mode of failure and to measure the range of movement, specifically rotation following Total Shoulder Arthroplasty.

Patients and methods: 46 patients (55 shoulders) were prospectively followed up after Biomet biomodular Total Shoulder Arthroplasty using a metal backed glenoid component fixed with screws. 36 patients (43 shoulders) had Rheumatoid arthritis, 9 patients (11 shoulders) had Osteoarthritis and 1 patient had Psoriatic arthritis. Mean age at surgery was 58 years (range 37 to 79 years). Patients were followed up for a minimum of 5 years. Data was collected prospectively for a mean follow up of 84 months. 28 of the 46 patients had more than 10 years follow up. Range of movement including forward flexion and rotation was measured. Data was analysed by 3 independent observers. Intention to treat or revision of component was taken as failure. Paired t test comparison was carried out for statistical analysis.

Results: One failure was noted in the Osteoarthritis group at 8 years follow up. Superior head migration and eccentric wear of polyethylene liner was noted in an otherwise well fixed glenoid component. Range of external rotation improved from a mean of 18.2 to 38.2 degrees. This improvement was statistically significant (p=0.01, 95% CI= 6.3 to 35.2). The range of forward flexion improved significantly from a mean of 80.5 to 110 degrees (p= .01, 95% CI= −42.6 to −5.9)

3 failures were noted in the Rheumatoid group. 2 patients needed revision to hemiarthroplasty within 4 years of surgery for rotator cuff insufficiency with superior head migration but without loosening of glenoid. One other shoulder was revised at 11 years for glenoid component loosening with a worn out polyethylene liner. All 3 failures occurred in patients more than 60 years of age. Rheumatoid patients under 60 had a significant improvement in the range of external rotation from a mean of 24.2 to 30.6 degrees (p= 0.03, 95% CI = −21.4 to −1.1). The range of forward flexion improved from a mean of 71.2 to 73.3 degrees which was not statistically significant (p=.767). Rheumatoid patients over 60 years of age did not have a statistically significant improvement in the range of external rotation( p= 0.712) or in their range of forward flexion (p=.757).

Conclusion: Contrary to recent literature, in this study the metal backed glenoid component performed well in the medium to long term following Total Shoulder Arthroplasty particularly in patients with Osteoarthritis and in younger patients suffering with Rheumatoid arthritis.

We reviewed 13 patients with a complex fracture-dislocation of the proximal interphalangeal joint of a finger and one patient with a complex fracture-dislocation of the interphalangeal joint of thumb. We had treated these injuries using a pins and rubbers traction system which had been modified to avoid friction of the pins against the bone during mobilisation of the joint in order to minimise the risk of osteolysis. A Michigan hand outcome questionnaire was used for subjective assessment. The active range of movement (AROM) of the proximal and distal interphalangeal joints and the grip strength were used for objective assessment.

The mean follow-up was 34 months (12 to 49). The mean normalised Michigan hand outcome score was 84. The mean AROM of the proximal interphalangeal joint was 85° and that of the distal interphalangeal joint 48°. The mean grip strength was 92% of the uninvolved hand.

Twelve patients have returned to their original occupations. There has been no radiological osteolysis or clinical osteomyelitis. This modified traction system has given acceptable results with a low rate of complications. It is light, cheap, effective and easy to apply.

Introduction: We have previously demonstrated significantly elevated IgG titres (ELISA) to a glycolipid antigen found in the cell wall of most gram positive bacteria in patients with discogenic radiculitis (sciatica).

This raised the possibility that the inflammation associated with disc protrusion might be initiated or accelerated by the presence of bacteria.

Aim of the study: To confirm whether bacteria were present in the disc material harvested at the time of discectomy. To determine whether the presence of bacteria correlated with elevation of Anti Lipid S antibody levels. To compare these results with Antibody levels and disc specimens from patients undergoing surgery for indications other than radiculitis.

Methods: This was a prospective study. Recognising the frequency of contamination in clean wound culture stringent aseptic precautions were taken. Disc material was harvested from 108 microdiscectomy patients with sciatica.

Disc material was also obtained from 11 patients undergoing discectomy for other indications (trauma, tumour scoliosis). Serology was obtained for all these patients.

Results: In the microdiscectomy group 50/112 (45%) had positive cultures after seven days incubation, of which 15 (30%) had positive serology. Thirty-one patients had Propionibacteria, nine Coagulase negative Staphylococci (CNS), six Propionibacteria and CNS, one Corynebacterium and three mixed growth.

Sixty-two (55%) patients had negative cultures and all except one had negative serology. There was a significant difference between patients with positive serology and culture compared with those with negative serology and culture (Fischer exact test P< 0.01). In some patients organisms were visible on microscopy prior to culture.

Thirteen of those with postive cultures and 25 of those with negative cultures had had one or more epidural injections prior to surgery. Epidural injection was not found to be significantly associated with postive culture.

None of the patients undergoing surgery for other indications had positive serology or positive cultures.

Conclusion: A significant proportion of patients with discogenic radiculitis have positive cultures with low virulence Gram positive organisms (predominantly Propionibacteria) and in a proportion a corresponding appropriate antibody response.

Ten patients, who underwent treatment for complex fracture-dislocation of the proximal interphalangeal joint of finger and one patient for that of the interphalangeal joint of thumb with a modified pins and rubbers traction system, were reviewed to evaluate the clinical and functional results. Two patients had open fracture-dislocation, 5 had pilon fractures and 4 had fracture-dislocations. The system was modified to avoid rotation of the pins in the bone during joint mobilization, thus minimizing the risk of osteolysis due to friction of pins over the bone.

Michigan hand scoring system was used for subjective assessment and range of motion at proximal and distal interphalangeal joints and grip strength for objective assessment. Average follow-up was 18 months (range 3 months to 28 months). The average normalised Michigan hand score was 86. Based on Michigan scores, overall hand function was rated excellent in 8 patients, good in 2 and poor in 1. Eight patients have returned to their original jobs. The average arc of flexion in the proximal interphalangeal joint was 85 degrees and in the distal interphalangeal joint it was 47 degrees. The average grip strength was 95 percent of the uninvolved side. Two patients developed minor pin site infection, which did not necessitate pin removal or any alteration in the treatment regime. There have been no cases of osteolysis, osteitis or osteomyelitis. This modification of pins and rubbers traction system has given very acceptable results with a low complication rate. It is light, cheap, effective and easy to apply.

This study assessed the role of Ilizarov technique, using soft tissue distraction, in correction of radial club hand deformities.

Five patients (6 deformities) with grade IV radial hemimelia (radial aplasia) were studied. There were three boys and two girls aged 2 to 8 years. One boy had bilateral involvement with TAR syndrome. One girl had bilateral involvement with VATER syndrome. One other boy had unilateral involvement with Holt Oram syndrome. The thumb was absent in three cases and hypoplastic in one case. The preoperative deformity measured 95 degrees (range 60–105 degrees). This was corrected using gradual soft tissue distraction with an Ilizarov fixator. Complete correction of the hand deformity was achieved over a period of 4–6 weeks. In two hands, rebalancing tendon transfers were performed in order to try and maintain correction. Following frame removal in both these patients, the deformity recurred despite splintage. Subsequently, four hands were treated with tendon transfers along with wrist stabilisation using intramedullary K-wires. The correction was maintained in all these cases.

It is concluded that the Ilizarov technique can be used to achieve complete correction of radial club hand deformity but that correction can only be maintained by intramedullary stabilisation. The technique is well tolerated by patients and is more physiological when compared to the conventional treatment with wrist centralisation.

Introduction: We have previously demonstrated significantly elevated IgG titres (ELISA) to a glycolipid antigen found in the cell wall of most gram positive bacteria in patients with discogenic radiculitis (sciatica).

This raised the possibility that the inflammation associated with disc protrusion might be initiated or accelerated by the presence of bacteria.

Aim of the Study: To confirm whether bacteria were present in disc material harvested at the time of discectomy. To determine whether the presence of bacteria correlated with elevation of Anti Lipid S antibody levels. To compare these results with Antibody levels and disc specimens from patients undergoing surgery for indications other than radiculitis.

Methods: This was a prospective study. Recognising the frequency of contamination in clean wound culture, stringent aseptic precautions were taken. Disc material was harvested from 62 microdiscectomy patients with sciatica. Disc material was also obtained from three patients undergoing decompression but without radiculitis and from three patients undergoing anterior correction of scoliosis. Serology was obtained for all these patients.

Results: In the Microdiscectomy group, 27/62 (43%) had positive cultures after seven days incubation, of which nine (33%) had positive serology. 22 patients had Propionibacteria, three Coagulase negative Staphylococci, one Corynebacterium and one mixed growth. Thirty five (56.4%) patients had negative cultures and all except one had negative serology. There was a significant difference between patients with positive serology and culture compared with those with negative serology and culture (Fischer exact test P< 0.001). In some patients organisms were visible on microscopy prior to culture.

Ten of those with positive cultures and fourteen of those with negative cultures had had one or more epidural injections prior to surgery. Epidural injection was not found to be significantly associated with positive culture.

None of the patients undergoing surgery for other indications had positive serology or positive cultures.

Conclusion: A significant proportion of patients with discogenic radiculitis have positive cultures with low virulence Gram positive organisms (predominantly Propionibacteria) and in a proportion, a corresponding appropriate antibody response.