The poor reporting and use of statistical methods in orthopaedic papers has been widely discussed by both clinicians and statisticians. A detailed review of research published in general orthopaedic journals was undertaken to assess the quality of experimental design, statistical analysis and reporting. A representative sample of 100 papers was assessed for compliance to CONSORT and STROBE guidelines and the quality of the statistical reporting was assessed using a validated questionnaire. Overall compliance with CONSORT and STROBE guidelines in our study was 59% and 58% respectively, with very few papers fulfilling all criteria. In 37% of papers patient numbers were inadequately reported; 20% of papers introduced new statistical methods in the ‘results’ section not previously reported in the ‘methods’ section, and 23% of papers reported no measurement of error with the main outcome measure. Taken together, these issues indicate a general lack of statistical rigour and are consistent with similar reviews undertaken in a number of other scientific and clinical research disciplines. It is imperative that the orthopaedic research community strives to improve the quality of reporting; a failure to do so could seriously limit the development of future research

Purpose: Distal humeral fractures are often difficult injuries to treat. We hypothesise that more complex distal humeral fractures have unacceptable functional outcomes due to multi-factorial reasons.

Methods: 42 patients with AO/ASIF type B and C fractures of the distal humerus who were treated with open reduction and internal fixation over a six year period were included in the study. All patients were from a single district general hospital. 37 (88%) were clinically, radiologically, and functionally assessed for this study, with the remainder either lost to follow-up or expired.

Results: There were 21 type B and 16 type C fractures, all managed by open reduction and internal fixation. Various fixation techniques were utilised. These were performed by consultant surgeons in 14 cases and by surgeons in training in 23 cases. Average follow up was 38 months (range 22–54 months). The arc of elbow motion was 94 degrees (range 58–130), with an average extension deficit of 28 degrees (range 20–55) and an average flexion deficit of 32 degrees (range 15–45). The average arc of forearm rotation was 136 degrees (range 45–140), with an average supination of 68 (range 35–85) and an average pronation of 72 (range 45–90). The complications (n=20/37) included superficial skin infection (n=4), ulnar nerve neurapraxia (n=3), non-union of the humerus fracture (n=2), non-union of olecranon osteotomy site (n=1), intra-articular screw placement (n=1), loosened plate (n=1), loose/backed out screw (n=2), fixed flexion deformity (n=4) and mild elbow instability (n=2). Second surgery was performed in 24% (n=9/37), revision of metal work (n=2), bone grafting (n=2), anterior capsulectomy (n=4), and removal of screw (n=1).

Conclusions: Fractures of the distal humerus are often more complex than appreciated, and challenging to treat, with respect to fracture union and functional outcome. A generalist practice appears adequate for achieving bony union, but inadequate for obtaining low complication rates and functional outcomes. Our data suggest that such injuries may constitute a fracture group requiring the acute intervention by centres that have specific sub-specialisation and adequate rehabilitation facilities

Purpose: There are numerous papers from specialist arthroplasty centres outlining results of total knee arthroplasties but little information from outside these major centres. We carried out a review of a fixed bearing total condylar knee replacement used in Dunedin by a variety of surgeons for over 10 years.

Method: All patients who received a Duracon/PCA fixed bearing total knee replacement between 1992 and 1996 were assessed clinically, fluoroscopically and completed an SF12, WOMAC and IKSS questionnaire.

Results: At a mean 9.7 (8–12) years follow up, 126 (69.6%) patients were available for review and 46 (25%) were deceased. The average age was 72 years (52–88) and the primary diagnosis was osteoarthritis in 95% of the cases. There were 34% Charnley Grade A, 37% Grade B and 29% Grade C respectively.

The average IKS Knee score was 72 (23–97) and the functional score was 68 (0–100) with 74% experiencing none or only mild pain. The SF12 assessment revealed a mean physical score of 55 (14–99). Ninety per cent of patients were satisfied with their knee and 89% would have the operation again if required.

There was one operative death (PE), one deep infection, 3 PE’s, 3 DVT’s and 5 superficial infections. An MUA was required in 9 cases.

Eight knees were revised. Using ‘all revisions’ as an end point. The survival rate was 95.3% at 10 years.

Conclusion: These results suggest that knee replacements carried out outside specialist arthroplasty centres perform very well with a survival rate of the implant of 95% at 10 years.

Aim. Assess the incidence of Vitamin D deficiency from a cohort of new referrals to a general Paediatric Orthopaedic outpatient clinic and evaluate the relationship between Vitamin D deficiency and the diagnosis of radiological or biochemical nutritional rickets. Methods. We performed a retrospective case note and biochemistry database review of all new patients seen in an elective Paediatric Orthopaedic clinic in the year 2010, who had Vitamin D levels measured. Radiographs were reviewed by the senior author to determine the presence or absence of radiological rickets. Biochemical rickets was diagnosed if there was deficient Vitamin D (< 20 mcg/ml) and raised PTH. Results. We identified 115 children with a mean age of 10.95 years (95% CI 10.24 to 11.68). There were 63 females, 52 males and 51 were of Asian ethnicity. The mean vitamin D level was 18.27mcg/ml (95% CI 16.13 to 20.41). One hundred and three patients (88%) were found to have sub-optimum vitamin D levels. Although, males and those of Asian origin were more likely to be deficient, this was not statistically significant. Winter/Springtime blood sampling was statistically more likely to show Vitamin D deficiency than in Summer/Autumn. Three Asian female children (2.61%) had radiological rickets. The association between low Vitamin D levels (< 20) and radiological or biochemical rickets had poor positive predictive values PPV. Conclusion. Suboptimal Vitamin D levels are common in children presenting with vague limb or back pain, suggesting ‘growing pains’ might reflect deficiency. Vitamin D levels cannot be used as a screening test for the diagnosis of radiological or biochemical ‘rickets’ due to its poor Positive Predictive Value. Further research into Vitamin D requirement is necessary, particularly in relation to growth and age, as growth is not linear and Vitamin D requirement is likely to vary accordingly

The role of dual consultant operating (DCO) in general orthopaedics has not been researched; where it has shown benefit in other specialties, there is a lack of information on how DCO affects the surgeons themselves. We wanted to explore the potential effects of DCO on stress, as a foundation for further research to guide support for our surgeons. We conducted a survey among orthopaedic consultants around New Zealand, containing questions pertaining to the demographics of respondents, their experience with DCO, what the expected risks and benefits of DCO would be, and provided two high-stress exemplar clinical scenarios where respondents were asked to rate their expected stress level at baseline, with a more junior consultant present, and with a more senior consultant present. We found 99% of respondents had been involved in DCO at some point in their careers, yet only 38% were involved in DCO on at least a monthly basis. Perceived benefits greatly outweighed potential risks: 95% felt DCO would decrease their stress, 91% felt it improved intraoperative decision making, and 89% felt it provided more enjoyment at work and enhanced collegiality. A decrease in perceived stress was seen from baseline with a more junior consultant available and a greater decrease in stress seen with a more senior consultant, particularly in a complex elective setting. All respondents felt there is benefit in DCO and the vast majority feel it has positive effects on stress levels. In a time where burnout is more prevalent, using tools such as DCO could be an effective way to decrease stress, enhance enjoyment and collegiality — challenging some key contributors to burnout — and support mentorship with further skill acquisition. This research provides a good base to pursue further qualitative and quantitative research into the area, with a view to addressing barriers to provision of regular DCO

Introduction. This study aimed to assess the relationship between preparation times and operative procedures for elective orthopaedic surgery. A clearer understanding of these relationships may facilitate list organisation and thereby contribute to improved operating theatre efficiency. Methods. Two years of elective orthopaedic theatre data was retrospectively analysed. The hospital medical information unit provided de- identified data for 2015 and 2016 elective orthopaedic cases, from which were selected seven categories of procedures with sufficient numbers to allow further analysis - primary hip and knee replacement, spinal surgery, shoulder surgery (excluding shoulder replacement), knee surgery, foot and ankle surgery (excluding ankle replacement), Dupuytrens surgery and general orthopaedic surgery. The data analysed included patient age, ASA grade, operation, operation time, and preparation time (calculated as the time from the start of the anaesthetic proceedings to the patient's admission to Recovery, with the operating time [skin incision to skin closure] subtracted). Statistical analysis of the data was undertaken. Results. A total of 1596 procedures performed over the two year period were analysed. Preparation times for the different procedures were assessed, along with the relationship to the procedure complexity. Neither age nor ASA correlated strongly with preparation times. Spine procedures had greater preparation times than hip and knee arthroplasty. Greater uniformity in preparation times for hip and knee arthroplasty was seen across the anaesthetic group than operative times across the surgeon group. Discussion. Preparation times are just one aspect that may be evaluated with regard to theatre utilisation. This study did not address the theatre turn-over time between cases, which includes transfer of the patient from the admitting/pre-operative area into the theatre. Conclusion. Preparation times for elective procedures follow a pattern which may be used to inform list planning, with the potential for greater theatre efficiencies with regard to list utilisation and staff allocation

Introduction. A greater emphasis has been placed on fracture related infection (FRI) orthopaedic practice as a separate entity in recent years. Since the publication of the FRI consensus definition and guidelines, there has been an increase in the published literature on the topic and a move towards considering FRI as separate from general orthopaedic practice and as work that requires a more specialist approach. The aim of this study was to audit current FRI practice in the UK. Materials & Methods. Orthopaedic practice related to FRI in the UK was audited using a semi-structured questionnaire. Respondents were from a range of institutions, specialties and clinical roles to reflect the multi-disciplinary nature of treating FRI. The online tool SurveyMonkey was used to share the survey at the 2022 annual meeting of the British Limb Reconstruction Society. Twenty-one questions were asked in the following domains: scope of practice, theatre and clinic capacity, availability of the multidisciplinary team, renumeration for work and scope of FRI networks. Results. Of the 36 respondents, the majority (64%) worked in a major trauma centre. In the majority of cases, bone infection was managed by the limb reconstruction team (68%) although in most centres the wider team was often also involved including the general on call, the trauma team and the arthroplasty team. When referrals were made elsewhere, this was usually done to known individuals rather than established FRI networks. 80% of respondents said that there was a bone infection MDT in their unit and this usually met weekly. This usually included orthopaedics and microbiology but plastics in only 43% of cases and radiology in only 23% of cases. Most respondents said that the lack of funding and appropriate tariffs were the main barrier to FRI management locally (62%) and nationally (83%). Most respondents (83%) said that bone infection practice should be centralised. The overwhelming majority of this cohort (90%) said that patient outcomes would be improved by cases being managed in dedicated centres. Conclusions. There is variation in practice for the management of bone infection in the UK. This reflects the lack of clear national guidelines and the lack of established networks for management and onward referral. There is agreement that patient outcomes would be improved by more formal networks and specialised centres but also recognition that remuneration is a significant barrier to implementing change. This survey reflects practice in units with an interest in limb reconstruction and bone infection. Further work is needed to evaluate practice across district general hospitals in the UK and to build consensus around best practice and national strategies for improved care

Aims

Informed patient consent is a legal prerequisite endorsed by multiple regulatory institutions including the Royal College of Surgeons and the General Medical Council. It is also recommended that the provision of written information is available and may take the form of a Patient Information Leaflet (PIL) with multiple PILs available from leading orthopaedic institutions. PILs may empower the patient, improve compliance, and improve the patient experience. The national reading age in the United Kingdom is less than 12 years and therefore PILs should be written at a readability level not exceeding 12 years old. We aim to assess the readability of PILs currently provided by United Kingdom orthopaedic institutions.

Three developments in the last 10 to 15 years have made it necessary to review how we ensure rapid access to treatment of patients with disabling low back pain. Firstly, there would appear to be an increase in the numbers of patients seeking medical help for low back pain, whether due to increased patient expectation, or better reporting, or a true increase associated with the increasing sedentary nature of life, is uncertain. Secondly, there is the realisation that amongst the factors that encourage acute back pain to become chronic is being off work, and the sooner a diagnosis and treatment is started the more likely that chronicity will be prevented, so a long waiting time to be seen in a clinic is productive of disability. Thirdly, reorganisation of consultant services has created the spinal surgeon, who in return for being allowed to practice spinal surgery almost exclusively undertakes the load of patients referred with back pain, amongst whom lurk those with a surgically remediable problem. The effect has been that although waiting times for general orthopaedic patients have dropped, as general orthopaedic, or other specialist orthopaedic surgeons no longer see spinal cases, the specialist spinal surgeon is overwhelmed by a large group of patients with back pain for whom there is not a surgical solution. Unfortunately, there is a shortage of spinal surgeons, which is likely in the UK at any rate to get worse. Being overwhelmed with non-surgical back pain interferes with their ability to deal with surgical problems. It also does create a recruitment problem, as back pain is not seen as a rewarding or satisfying problem to treat. Triage is a method of screening patients into groups at an early stage, identifying those who might benefit from surgery, and fast tracking them, identifying those who will benefit from other management and tracking them accordingly. Pioneered in general orthopaedics by Robin Ling in Exeter, it has been developed in the hospital setting somewhat randomly, by dedicated enthusiasts, many of whom will be speaking today. The purpose of this meeting today is to hear about the various systems, their funding and organisation and location, the triage staff used, the investigations used in primary triage and the effect on hospital specialist waiting times, the safety and patient satisfaction. Is a multiplicity of systems best, is one better than another, why have some units achieved no waiting times for MRI, and others six months etc?. In 1994, the Clinical Standards Advisory Group produced two books, An epidemiological Review, largely the work of Gordon Waddell, and a second book on Back Pain, chaired by Professor Michael Rosen with, I suspect, considerable input from Professor Waddell and others. Many of us met them when they toured the country collecting facts about the treatment and management of back pain. It discusses back pain triage, and suggests that it can be done within the average GP Consultation time of 9 minutes. It deals with simple back ache, “red flags”, (we now have “yellow flags” denoting the psycho-social factors) nerve root pain, cauda equina and inflammatory disorders. It is to be noted that chronic back pain, is not alluded to in the diagnostic triage, but it is stated that 90% of simple back ache recovers in six weeks. Their management guidelines emphasise the value of physical therapy (manipulation and active exercises), but it will be noted that they are addressed to a group of patients, 90% of whom will recover in six weeks. Sadly, therefore, the effect of this very sensible document, in ignoring in the triage system the chronic patient, has in many cases directed therapy in general practice towards open access for patients who in any event will improve spontaneously. We must therefore address where triage should be, hospital, or GP level. Certainly a GP gatekeeper will remove the acute back pains that are going to get better soon anyway from attending hospital and in certain units, a separate fast track is provided for acute radicular problems (Acute Sciatic Clinics). Any successful triage system involving chronic back pain must be associated with treatment possibilities, and I shall briefly discuss these, although the main thrust of the afternoon will be the triage organisation itself. The session is designed to allow considerable audience participation, as it is hoped that information, comments and criticisms from the audience will allow us to subsequently produce a booklet, hopefully with support from our Professional Societies, describing what we feel is Best Practice in Back Pain Triage, which we hope, after appropriate circulation, will encourage Trusts and Community Health Groups to develop such units and ensure that back pain patients get a better deal

There are numerous papers from specialist arthroplasty centres outlining results of total knee replacement. This review was performed as there is little information on results in general orthopaedic centres. All patients received a Duracon/PCA replacement between 1992 and 1996. Patients were assessed clinically, fluoroscopically and completed SF12, WOMAC and IKSS questionnaires. At a mean of 6.7 (5–9) years follow up 93 (78%) were available for review. The average age was 70 years (52–88) with 58% being male. The primary diagnosis was osteoarthritis in 94.3%, with 41 %, 38% and 21 % being Charnley grades A, B and C respectively. The average IKS knee score was 71.4 (23–96) and functional score 70 (0–100), with 72.7% experiencing none or only mild pain. The SF12 assessment revealed a mean physical score of 38 (14–63) and mental score of 53 (25–67). There were 88.6% of patients satisfied with their knee and 92% would have the operation again if required. There were no deep infections or PE’s but there were 7 superficial infections and 2 DVT’s. A MUA was required in 8 patients. One patient retains a radiologically loose prosthesis at 8 years but had mild pain with stairs only, a WOMAC functional score of 85 and was happy. There was a best-case survival of 94.4% at 5 years. There were 5 knees revised in 5 patients and no revisions of the deceased patients, all surviving greater than 5 years from surgery. These results suggest that those in general orthopaedic centres are a little less reliable than those in specialist centres. However they are acceptable and patient satisfaction remains high

Introduction: More than 140,000 joint replacements are carried out in England and Wales per annum costing from £4000 to £7000 each (. 1. , . 2. ). Implant costs are relatively fixed but there are considerable variations in length of stay [LOS] following surgery. The National Audit office estimated that a reduction of two days per patient could save the NHS £15.5 million per year (. 2. ). A specialist orthopaedic ward for elective arthroplasty was opened in Bangor in 2008 in an attempt to address these issues. The staff per bed ratio remained the same as in the general orthopaedic wards but beds were “ring fenced” and strict infection control measures protocols were implemented. This audit aimed to assess the effect of the specialist ward on LOS following arthroplasty. Method: Retrospective data on length of stay, demographics and surgical site infections [SSI] were collected for the six months before and six months after the specialist ward was opened. Only primary lower limb arthroplasty data was evaluated and LOS was calculated from day of operation to the day of discharge. Statistical analysis was performed on the length of stay with SPSS software using the two-sample t-test and Mann-Whitley U test. Results: Patients were managed by the same surgical teams in the same theatres but nursed in different ward settings. Group 1 included 222 patients managed in general orthopaedic wards and group 2 included 191 patients, managed in the ring fenced ward. The mean age for total hip replacements was 70.8 in group 1 and 71.2 years in group 2. The mean age for total knee replacements was 70.9 years in group 1 and 69.2 years in group 2. The overall mean LOS for both procedures was 7.61 days (95% CI: 7.14 – 8.07) in group 1 compared with 5.67 days (95% CI: 5.28 – 6.06) group 2. This was statistically significant (p< 0.001). The mode was 7 days in group 1 compared with 4 days in group 2. Three SSIs were noted in group 1 and zero in group 2. Conclusions: This audit demonstrates a two day reduction in LOS for patients managed in a ring fenced ward. The reasons for the reduction are multi factorial but include a trend for reduced SSI. Overall reduced stay frees up resources for other use and may reduce costs. Other units may benefit from similar dedicated wards in response to growing demand for arthroplasty within a system of fixed resources

Background: The Levels of Evidence Rating System is widely believed to categorize studies by quality, with Level I studies representing the highest quality evidence. We aimed to determine the reporting quality of Randomised Controlled Trials (RCTs) published in the most frequently cited general orthopaedic journals. Methods: Two assessors identified orthopaedic journals that reported a level of evidence rating in their abstracts from January 2003 to December 2004 by searching the instructions for authors of the four highest impact general orthopaedic journals. Based upon a priori eligibility criteria, two assessors hand searched all issues of the eligible journal from 2003–2004 for RCTs. The assessors extracted the demographic information and the evidence rating from each included RCT and scored the quality of reporting using the reporting quality assessment tool, which was developed by the Cochrane Bone, Joint and Muscle Trauma Group. Scores were conducted in duplicate, and we reached a consensus for any disagreements. We examined the correlation between the level of evidence rating and the Cochrane reporting quality score. Results: We found that only the Journal of Bone and Joint Surgery–American Volume (JBJS-A) used a level of evidence rating from 2003 to 2004. We identified 938 publications in the JBJS-A from January 2003 to December 2004. Of these publications, 32 (3.4%) were RCTs that fit the inclusion criteria. The 32 RCTs included a total of 3543 patients, with sample sizes ranging from 17 to 514 patients. Despite being labelled as the highest level of evidence (Level 1 and Level II evidence), these studies had low Cochrane reporting quality scores among individual methodological safeguards. The Cochrane reporting quality scores did not differ significantly between Level I and Level II studies. Correlations varied from 0.0 to 0.2 across the 12 items of the Cochrane reporting quality assessment tool (p> 0.05). Among items closely corresponding to the Levels of Evidence Rating System criteria assessors achieved substantial agreement (ICC=0.80, 95%CI:0.60 to 0.90). Conclusions: Our findings suggest that readers should not assume that. 1) studies labelled as Level I have high reporting quality and. 2) Level I studies have better reporting quality than Level II studies. One should address methodological safeguards individually

Objective evaluations of resident performance can be difficult to simulate. A novel competency based surgical OSCE was developed to evaluate surgical skill. The goal of this study was to test the construct validity comparing previously validated Ottawa scores (O-scores) and Orthopaedic in-training evaluation scores (OITE). An OSCE designed to simulate typical general orthopaedic surgical cases was developed to evaluate resident surgical performance. Post-graduate year (PGY) 3–5 trainees have an encounter (interview and physical exam) with a standardized patient and perform a correlating surgery on a cadaver. Examiners evaluate all components of the treatment plan and provide an overall score on the OSCE and also provide an O-score on overall surgical performance. Convergent and divergent validity was assessed comparing OSCE scores to O-scores and OITE scores. SPSS was used for statistical analysis. ANOVA was used to compare PGY averages and Pearson correlation coefficients were calculated to compare OSCE versus O-score and OITE scores. A total of 96 simulated surgical cases were evaluated over a 3 year period for 24 trainees. There was a significant difference in OSCE scores based on year of training. (PGY3 − 6.06/15, PGY4 − 8.16/15 and PGY5 − 11.14/15, p < 0 .001). OSCE and O-scores demonstrated a strong positive correlation of +0.89 while OSCE and OITE scores demonstrated a moderate positive correlation of 0.68. OSCE scores demonstrated strong convergent and moderate divergent correlation. A positive trajectory based on level of training and stronger correlations with established, validated scores supports the construct validity of the novel surgical OSCE

Introduction

Theatre cancellation is unpleasant experience to patient and it is expensive to service provider. There are various causes for cancellation which are avoidable and unavoidable as well. Nationwide, there has been several measures put in place to reduce avoidable theatre cancellations.

We describe retrospective review of 158 cancellations and root cause analysis & solutions in relation to the National standard.

An 83-year-old woman presented with acute weakness in her right hand and wrist extensors and swelling in the proximal right forearm. Nerve conduction studies confirmed compression of posterior introsseous nerve at the level of proximal forearm. MR imaging demonstrated the characteristics of lipoma which extended on the atero-lateral aspect of the right radius neck. The lesion was parosteal lipoma of the proximal radius causing paralysis of the posterior interosseous nerve without sensory deficit. In this case report, posterior inretosseous nerve palsy due to compression of a parostel lipoma was recovered after excision of the lipoma followed by intensive rehabilitation for six month. Surgical excision should be promptly performed to ensure optimal recovery from the nerve paralysis.

Hip resurfacing arthroplasty (HRA) in patients with a varus deformity of the femoral neck-shaft angle (NSA) is associated with poorer outcomes. Our experience has not reflected this. We examined the Oxford Hip Scores (OHS), Harris Hip Scores (HHS) and outcomes of patients with varus hips against a normal cohort to ascertain any significant difference.

We identified 179 patients. Measurement of the femoral neck-shaft angle was undertaken from antero-posterior radiographs pre-operatively. The mean NSA was 128.5 degrees (SD 6.3). Patients with a NSA of less than 122.2 were deemed varus and those above 134.8 valgus. These parameters were consistent with published anatomical studies.

The varus cohort consisted of 23 patients, mean NSA 118.7 (range 113.6-121.5), mean follow-up 49 months (range 13-74). Mean OHS and HHS were 16 and 93.5 respectively. Complications included 2 cases of trochanteric non-union; no femoral neck fractures, early failures or revisions. Normal cohort consisted of 125 patients, mean NSA 128 degrees, mean follow-up 41 months (range 6-76). The OHS and HSS were 18.8, 88.9 respectively. Complications included 5 trochanteric non-unions and 1 revision due to an acetabular fracture following a fall. Statistical analysis demonstrated no statistical difference between the cohorts OHS (p=0.583) or HHS (p=0.139).

Our experience in patients with a varus femoral neck has been positive. Our analysis has demonstrated no statistical difference in hip scores between the cohorts. We have not yet experienced any femoral neck fractures, which we believe is due to the use of the Ganz trochanteric flip and preservation of blood supply.

Choice of implant for patients aged sixty-five years or younger requiring hip arthroplasty is a topic of current debate, those in favor of resurfacing maintain it offers a greater range of motion and activity. We examined the Oxford Hip Score's (OHS) and Duke Activity Status Index (DASI) of patients undergoing either total hip replacement (THR) using an Elite Plus Stem, or hip resurfacing using a Birmingham Hip Resurfacing (BHR).

The THR cohort comprised 34 implants (4 bilateral), 17 men, 17 women, mean age 56.08 years. The resurfacing cohort comprised 27 implants (3 bilateral), 18 men, 9 women, mean age 50.51 years. The mean difference calculated between pre- and post-operative OHS was 22.08 and 25.33 for the THR and resurfacing cohorts respectively. The mean Duke score was 42.3 and 53 for the cohorts respectively.

Using the pre-operative and post-operative change in Oxford Hip Scores, no statistically significant difference was found between the THR and resurfacing cohorts (p = 0.2891). There was a statistically difference found between the THR and resurfacing cohorts with regards to activity using post-operative Duke scores, (p = 0.0047).

This study has emphasized the use of the DASI, a pure activity score, in hip research. In terms of reducing pain, both prostheses appear equally effective. With regards to activity, as evidenced by utilizing a pure activity score, the resurfacing cohort faired better. Our study suggests at one year post-op, young patients with a resurfacing have a greater activity level than those with a THR.

Introduction

One of the common frustrations for staff in hospital clinics is the frequent disruption caused by failure of patients to turn up for their booked appointments. DNA high rates have an enormous impact on the healthcare system in terms of cost and waiting time, significantly adding to delays along the patient pathway. We need to know the most common causes for non attendance and hence modify or put new protocol to deal with this problem.

We investigated the role of Plasma Viscosity (PV), C-reactive protein (CRP) and Frozen Section (FS) in diagnosing prosthetic joint infection. We compared these results with microbiological diagnosis of infection of the tissue samples (three or more samples grown same organisms in culture).

53 patients, average age 67 years (37 – 89) underwent joint revision surgery. 34 patients had hip and 19 patients had knee joint revision arthroplasty, this includes single and multiple stage revision surgeries and excision arthroplasty. Nine (17%) patients had microbiologically proven joint infection. PV had sensitivity of 100%, specificity of 43% and negative predictive value of 100%. CRP had sensitivity of 89 %, specificity of 75% and negative predictive value of 97%. FS (presence of infection being more than 5 neutrophils/hpf) had sensitivity of 56% and specificity of 84%.

We recommend PV and CRP to be used in the investigation of prosthetic joint infection. If both CRP and PV are normal the chance of infection is very low (negative predictive value of 100%). In our series an elevated PV and CRP represented a 50% chance of having a joint infection. The role of frozen section does not appear to be beneficial in the diagnosis of joint

At the Peninsula NHS Treatment Centre in Plymouth some of the surgeons are UK trained and some trained elsewhere in Europe.

This paper examines the outcomes of a large series of joint replacements from 2006 to 2008 at a minimum of one year follow up to determine whether the place of orthopaedic specialist training makes any difference to the outcome. The same implants were used by all surgeons and the anaesthetic technique and post-operative management was identical.

1700 patients were interviewed by a structured telephone questionnaire with over 92% follow-up and the results entered into a joint replacement database. Additional data about length of stay and blood transfusion was added.

Results will be presented about length of stay, transfusion requirements, any further treatment or hospital attendance relating to the new joint, reoperation, deep or superficial infection, hip dislocation, VTE and patient satisfaction.

The surgeon's place of orthopaedic training was found to make no difference to the surgical outcome.

Treatment of osteoarthritis is evolving, allowing surgical treatment options at an earlier stage. The interpositional knee device is a recently developed patient specific implant used for the treatment of mild to moderate uni-compartmental osteoarthritis. The benefits over traditional methods of surgical management are: it's less invasive, can be a day procedure and does not limit future options. Young Adults with early uni-compartmental arthritis are suitable. A MRI scan of the patient's knee is reviewed by radiologists to decide if the patient is suitable. A bespoke implant is produced. Prior to insertion an arthroscopy is undertaken to allow proper positioning.

We treated 27 patients with the iForma Conformis interpositional knee implant in South Wales at the Princess of Wales Hospital, Bridgend and the Royal Glamorgan Hospital, Llantrisant since November 2007. The pre- and post-operative WOMAC scores were recorded. The average age was 54.7 years, BMI 32; 10 females and 20 males. The average pre-operative WOMAC score was 42.2 improving to 62.9 post-operatively. 35 implants were used. 7 patients experienced post-operative problems. No dislocations were reported. Average follow-up was 12.6 months.

Our early experience suggests patient selection plays a role in the outcome following surgery. It indicates that this device is a viable and safe alternative to a uni-compartmental knee replacement.

The Oxford unicompartmental knee replacement (UKR) was introduced in 1976 with good results. Mobile bearings in the lateral compartment have been associated with unacceptably high bearing dislocation rates, due to greater movement between the lateral femoral condyle and tibia, and the lateral collateral ligament's laxity in flexion. The new domed implant is designed to counter this with a convex tibial prosthesis and a fully-congruent, bi-concave mobile bearing allowing a full range-of-movement (ROM), minimising dislocation risk and bearing wear.

We present complication rates and clinical outcomes for a consecutive series of our first 20 patients undergoing Oxford domed lateral UKR, between June 2006 and August 2009, with minimum 6-month follow-up. There was one unrelated death (31 months post-UKR) and one postop MI. We had no bearing dislocations, infections or loosening nor other complications. All patients had post-op Oxford Knee Scores; eleven had pre-op scores and demonstrated a significant improvement – mean pre-op 22.75 to post-op 35.45 (p=0.01). All achieved full extension with average ROM 116°, mean change in ROM was –2.6°(p=0.6).

This study adds to previous work in confirming a low level of complications with this new procedure (including the early learning curve), particularly bearing dislocation and demonstrates excellent functional outcomes.

Hip resurfacing arthroplasty (HRA) in patients with a varus deformity of the femoral neck-shaft angle (NSA) has been cited in the literature as contributory factor towards a poorer outcome. Our experience has not reflected this. We examined the outcomes of patients with varus hips against a normal cohort.

Measurement of the femoral neck-shaft angle was undertaken from standard antero-posterior radiographs pre-operatively. The mean NSA was 128.5 degrees (SD 6.3). Patients less than 122.2 were deemed varus and those above 134.8 valgus. These parameters were consistent with the published literature.

The varus cohort consisted of 23 patients, mean NSA 118.7 (range 113.6-121.5), mean follow-up 49 months (range 13-74), mean OHS & HHS, 16 & 93.5 respectively. Complications included 2 cases of trochanteric non-union; no femoral neck fractures or revisions. The normal cohort consisted of 125 patients, mean NSA 128 degrees, mean follow-up 41 months (range 6-76), mean OHS & HSS, 18.8 & 88.9 respectively. Complications included 5 cases of trochanteric non-union and 1 revision. Statistical analysis demonstrated no difference between the cohorts OHS (p=0.583) or HHS (p=0.139).

Our experience in patients with a varus femoral neck has been positive. Our analysis has demonstrated no difference in outcomes between the cohorts.

It costs the NHS £2billion/year to treat 70000 hip fractures. Following hemiarthroplasty a departmental x-ray is standard practice.

During 2009 217 hemiarthroplasties were performed in our unit. 210 had postoperative radiographs (148 departmental, 62 in theatre). All patient demographics were considered and hospital costs accounted for.

Mean patient age was 83 (55-100) years. Mean theatre times were 120 (51-213) minutes in the departmental x-ray group and 128 (74-187) minutes in the theatre imaging group. Hospital stay was decreased from 12.8 (3-41) days in the departmental x-ray group to 11.8 (3-32) days in the theatre imaging group. Orthopaedic beds cost £136/day. Departmental x-rays give a radiation dose of ∼12mGy and costs £48.30, theatre imaging gives ∼0.26mGy with no additional cost given the radiographers previous allocation to the list.

Changing our practice to intra-theatre imaging has improved patient safety, reduced the average inpatient stay and saves our trust approximately £40,000 annually.

An osteoporosis screening service for patients presenting to the fracture clinic in Derriford Hospital Plymouth was established in February 2009. We report on the findings of the first year of patients referred for dual energy X-ray absorptiometry (DEXA) screening.

Patients between 50 and 75 years of age, who sustained a fracture as a result of a fall from standing height or less, who had not previously had a DEXA scan within the last two years, were referred. Patients outside these age limits with other risk factors for osteoporosis were scanned at the discretion of the fracture clinic consultant. Of those patients who were referred, 96% subsequently attended for a scan timed to coincide with their scheduled fracture clinic follow-up appointment.

402 patients were scanned in total, of which 351 were female and 51 were male. The mean patient age was 65. The results for women were as follows: 21% normal, 45% osteopenic, 34% osteoporotic. The results for men were: 19% normal, 43% osteopenic, 38% osteoporotic. The scan results were forwarded to the patient's general practitioner for action as deemed necessary.

These findings support the establishment of this screening service for both men and women.

Last minute cancellations of operations are a major waste of NHS resources. This study identifies the number of late cancellations at our elective orthopaedic centre, the reasons for them, the costs involved, and whether they are avoidable.

Last minute cancellations of operations in a 7-month period from January to July 2009 were examined.

172 cases out of 3330 scheduled operations were cancelled at the last minute (5.2%). Significantly more cancellations occurred during the winter months due to seasonal illness.

The commonest causes for cancellation in descending order of frequency were patient unfit/unwell (n=76, 44.2%), lack of theatre time (n=32, 18.6%), patient self cancelled/DNA (n=20, 11.6%), staff unavailable or sick (n=9, 5.2%), theatre or equipment problem (n=8, 4.7%), operation no longer required (n=8, 4.7%), administrative error (n=7, 4.1%) or no bed available (n=5, 2.9%). In 7 out of the 172 cancelled cases (4.1%) no cause was identified. 59.7% of the cases were potentially avoidable.

3.2% of Patients seen in the specialist pre-operative anaesthetic clinic (POAC) were cancelled at the last minute for being unfit or unwell, compared to 2.2% seen in the routine nurse led clinic. Last minute cancellations cost the hospital over £700,000 in 7 months.

Soft tissue reactions following metal-on-metal arthroplasty of the hip have been under discussion in recent times. The phenomenon has been observed since the advent of arthroplasty, but the particular nature of metal-on-metal (MoM) resurfacing or total hip arthroplasty (THA), and the associated shedding of metal particles in high wear states, appears to excite a more aggressive response. Recent reports suggest involvement of muscle groups on a wide scale, and some cases of neurovascular involvement. It is not known which reactions require widespread muscle excision, and which cases may be adequately addressed by bearing exchange alone. We report three cases of soft tissue reaction (pseudotumour) following MoM hip resurfacing all managed with revision to ceramic-on-ceramic (CoC) THA with minimal soft tissue excision. All patients were female with ages at original operation of 49, 52 and 58 years. Time to revision surgery was 85, 28 and 66 months respectively.

Prosthesis revision resulted in progressive and satisfactory resolution of the pseudotumour. We propose that in the early stages, pseudotumour following MoM hip resurfacing can be adequately managed with revision to ceramic-bearing THA with minimal soft tissue excision, rather than revision with extensive soft tissue debridement that has been recently described.

We analysed the clinical data of 858 consecutive primary total hip and knee replacement patients to establish how age, ASA grade, body mass index and a simplified cognitive score correlate with the length of hospital stay and early complication rates. We further used statistical regression analysis to study how hospital stay and complication rates correlate with different pre-operative grading systems based on combinations of age, ASA grade, body mass index and a cognitive score.

The results indicate that age and ASA grade correlate significantly with both length of hospital stay and complication rates, while body mass index correlated poorly with both. A grading system based on a combination of age and ASA grade (the AA Grade) correlated significantly with both length of hospital stay and complication rates. Adding body mass index or a cognitive score did not significantly add to the correlation.

We discuss the relevance of this simple grading system and how it might contribute to pre-operative risk assessment and peri-operative planning.

Long-term prospective RCT comparing hemiarthroplasty (HEMI) and total hip arthroplasty (THA) for the treatment of intracapsular neck of femur fracture.

81 previously mobile, independent, orientated patients were randomised to receive THA or HEMI after sustaining a displaced neck of femur fracture. Patients were followed up with radiographs, Oxford hip score (OHS), SF-36 scores and their walking distance.

At a mean follow up of 8.7 years, overall mortality following THA was 32.5% compared to 51.2% following HEMI (p=0.09). Following THA, patients died after a mean of 63.6 months compared to 45 months following HEMI (p=0.093). Patients with THA walked further and had better physical function. No HEMIs dislocated but three (7.5%) THAs did. Four (9.8%) HEMI patients were revised to THA, but only one (2.5%) THA required revision. All surviving HEMI patients had acetabular erosion and all surviving THA patients had wear of the cemented polyethylene cup.

Patients with THA have better function in the medium-term and survive longer.

Outcome following wrist fractures is difficult to assess. There are many methods used to assess outcome following distal radius fractures, but may be that simply asking the patient for their level of satisfaction may be enough. We looked at 50 wrist fractures at 12 weeks post injury and compared their level of satisfaction with various respected outcome measures (Gartland and Verley, Sarmiento, Cooney, Patient-Rated Wrist Evaluation, Hand Function Score, and Disability of Arm Shoulder and Hand Score) to determine whether there was a correlation with their level of satisfaction. The aim was to determine which wrist scoring system best correlates with patient satisfaction and functional outcome and which individual variables predict a good outcome. Forty-five females and 5 males with a mean age of 66 years (range 19 to 93 years) were included in the study. Multivariate regression analysis was carried out using SPSS 17.

Patient satisfaction correlated best with the MacDermid, Watts and DASH scores. The variables in these scoring systems that best accounted for hand function were pain, ability to perform household chores or usual occupation, open packets and cut meat.

The McDermid, Watts and DASH scores provide a better measure of patient satisfaction than the Gartland and Verley, Sarmiento and Cooney scores, however they are all time consuming, complicated and may indeed not be necessary.

The four most important questions to ask in the clinic following wrist fractures are about severity of pain, ability to open packets, cut meat and perform household chores or usual occupation. This may provide a simple and more concise means of assessing outcome after distal radial fractures.

We often regard patient satisfaction as the best clinical indicator of outcome in the clinic situation. The aim of this study was to determine which wrist scoring system (Gartland and Verley, Sarmiento, Cooney, Patient-Rated Wrist Evaluation, Hand Function Score, and Disability of Arm Shoulder and Hand Score) best correlates with patient satisfaction and functional outcome and which individual variables predict a good outcome. Forty-five females and 5 males with a mean age of 66 years (range 19 to 93 years) were included in the study. Multivariate regression analysis was carried out using SPSS 13.

Patient satisfaction correlated best with the MacDermid, Watts and DASH scores. The variables in these scoring systems that best accounted for hand function were pain, ability to perform household chores, open packets, cut meat and perform the usual occupation.

The most important questions to ask in the clinic following wrist fractures are about pain, ability to perform household chores, open packets, cut meat and perform the usual occupation. The McDermid, Watts and DASH scores provide a better measure of patient satisfaction than the Gartland and Verley, Sarmiento and Cooney scores, however they are time consuming, complicated and may indeed not be necessary.

Introduction

The goal of arthrodesis around the ankle or of triple (hind foot) arthrodesis is a painless, plantigrade, and stable foot. Stress fracture is a differential diagnosis for pain following an ankle/subtalar arthrodesis. Management of stress fractures following sound ankle/subtalar fusion is extremely difficult as the entire movement tends to occur at the fracture site, hence hampering healing.

Purpose

To evaluate Radiological changes in the lumbosacral spine after insertion of Wallis Ligament for Foraminal Stenosis.

Awareness that minimising tip apex distance (TAD) when inserting a sliding hip screw reduces the risk of screw cut out is important for orthopaedic trainees. The advent of the Picture Archive and Communication System (PACS) has made the accurate measurement of TAD from x-rays and image intensifier films much easier. This study was to determine whether TAD would be reduced if a surgeon knew that his performance was being continually monitored.

31 consecutive cases of sliding hip screw insertion by a single group of surgeons were identified and the TAD measured. The mean TAD was 16.11mm (8.87mm-25.47mm). The same surgeons were then re-educated as to the importance of the TAD and informed that their results would be monitored and discussed. The next 34 consecutive cases were collected prospectively. The mean TAD in these cases was 13.83mm (6.72mm-21.51mm). There was a significant difference between the TAD for the two groups using the two-tailed t-test (p=0.034). There was one implant failure in the pre education group and none in the post education group.

These results suggest that awareness of surveillance improves surgical performance even if the importance of the variable being assessed is already known.

Introduction

It is not uncommon to encounter patients with atypical hip or lower extremity pain, ill-defined clinico-radiological features and concomitant hip and lumbar spine arthritis. It has been hypothesized that an anaesthetic hip arthrogram can help identify the source of pain in these cases. The purpose of this study is to analyze our experience with this technique in order to verify its accuracy.

Sledging related minor and major injuries represent a significant workload at ski-area medical centers across the world. Although safety rules exist, they are seldom obeyed or enforced. We set out to determine the incidence of sledging related injuries, identifying trends and causative factors at a busy New Zealand Ski resort.

All sledging related injuries presenting during a 70-day period were prospectively reviewed. Patient demographics, mechanism, diagnosis, and treatment were recorded. Sixty patients were identified, mean age 10 years, range 4-30 years. Injuries comprised; collisions with sledgers (21), collision with wall (14) and falling from sledge (14). Site of injury included head (36), lower limb (18), spine (9), upper limb (7), and abdomen (2). Fractures included; femur (1), tibia (1), fibula (1), ankle (2), cuboid (1), clavicle (2), scaphoid (1). One 9-year-old patient sustained a serious intracranial haemorrhage, with subsequent permanent neurological sequelae.

Sledging related injuries are mostly minor, however significant major injuries do occur requiring intervention at a secondary center. The potential for serious morbidity is evident. Recommendations supporting safety improvement measures does exist, however most were not implemented by the study cohort examined. The use of basic cycling helmets would seem an appropriate minimum level of protection, and greater sledging safety awareness should be encouraged.

Implant related hypersensitivity is an infrequent complication after total knee replacement. It remains a relatively unpredictable and poorly understood cause of failure of an implant.

We present a report of five patients who presented with persistent hypertrophic synovitis after total knee replacement using a cobalt chrome component. Extensive preoperative and intraoperative attempts ruled out infection as a cause of symptoms. The knees had good ligamentous balance and were well aligned and fixed.

The clinical condition improved after revision to a zirconium femoral and titanium metal backed tibial components. Intraoperative histopathology revealed thickened synovium with a predominantly monocellular (lymphocytic or histiocytic) response.

Where infection has been excluded as a cause of persistent pain and swelling, consideration should be given to metal allergy as a cause of failure in primary knee replacement surgery.

The purposes of this study were to investigate whether twins and multiple births have a higher incidence of Developmental Dysplasia of the Hip (DDH), and whether universal ultrasound scanning would be beneficial in this population.

Manipulation under anaesthetic (MUA) for the treatment of frozen shoulder is well established and effective however timing of surgery remains controversial. Intervention before 9 months has previously been shown to be associated with improved outcome. We test this theory by measuring Oxford Shoulder Score (OSS), re-MUA and subsequent surgery rate.

A retrospective review of a prospectively collected, single surgeon, consecutive patient series revealed 244 primary frozen shoulders treated by MUA within 4 weeks of presentation. The mean duration of antecedent symptoms was 28 weeks (95% CI 4-44 weeks) and time to follow up was 26 days (95% CI 11-41 days). The mean OSS improved by 16 points (2-tailed t test p< 0.001) with a mean follow up OSS of 43 (95% CI 38-48). 195 shoulders were manipulated before 38 weeks (9 months) and had the same mean change in OSS (16) as the 49 shoulders manipulated after 38 weeks. 48 shoulders, including 15 diabetic shoulders required further MUA. 8 shoulders had subsequent surgery. These events were also independent of antecedent symptom duration.

Early MUA does not appear to produce improved outcomes when compared to later intervention but we note does result in an earlier return to function.

Pedicle screw systems are now the commonest method of achieving posterior spinal fixation. Surgical planning in spinal surgery may include measuring pedicle size to guide screw size on WEBPACS. We performed a study to determine whether measuring pedicle size on CT is accurate and reproducible using the WEBPACS ruler tool.

A human cadaveric spine along with 5 geometrical shapes were scanned using a multislice spiral CT scanner with 1mm cuts. The objects and the pedicle diameters for lumbar and thoracic vertebrae in the axial plane were measured independently using the WEBPACS ruler tool by 2 observers (to the nearest 0.1mm). The geometrical shapes and pedicle size on the skeleton were then measured using Vernier callipers by an independent third observer. All measurements were repeated a week later.

The WEBPACS ruler on a CT scan is accurate to within 0.5-0.6mm of the true size of an object. The error for pedicle measurements is marginally higher (0.6-1.0mm) and this may reflect the fact that they are ill defined geometric shapes. Measuring pedicle size on CT for surgical planning may have implications for small pedicles when sizing them up for a good screw.

Aim

To correlate the surgical and MRI findings in acute lateral patellar dislocation and to determine the accuracy of MRI in identifying location of MFPL injury.

Controversy exists whether a single proximal lateral tibia (PLT) locked plate is adequate for bicondylar fractures and whether the use of integral raft screws makes the use of bone graft less important.

57 consecutive patients who underwent reconstruction with a locked PLT plate were retrospectively reviewed. Radiographs were examined for operative reduction and subsequent loss of reduction.

55 patients were followed-up for an average of 27 weeks. Fractures were divided into unicondylar (Group 1, n=33) and bicondylar (Group 2, n=22). Union occurred in all patients, with no revisions or removal of metalwork at final follow-up. In 50 patients (88%), the fracture was reduced to within 2mm of anatomical. Articular surface collapse of >2mm occurred in three patients. Nine patients underwent bone grafting with no difference in outcome. A supplementary medial plate was used in three patients with a separate posteromedial fragment.

Except for a separate posteromedial fragment, the use of a single locked PLT plate for bicondylar fractures allows union to occur without failure. With the use of integral raft screws, the need for bone graft is questionable. The short-term radiological results and complication rate of PLT locked plating is excellent.

The addition of Extended Scope Practitioner (ESP) clinics was proposed to review new Foot and Ankle referrals, to reduce time consultants spend in clinic and free them up for theatre. There would be a cost benefit to the Primary Care Trusts (PCT), a clinic appointment with the consultants cost's around £140 and ESPs around £70.

We prospectively collected data from the ESP clinics for two months in 2009. We looked at the number of patients referred on to the consultants and how many of these needed surgery.

During this period one hundred and forty one patients were booked into ESP clinics, forty three were referred to the consultants, ninety one were managed by the ESPs and seven patients failed to attend. The estimated saving to the PCT during the 2 month period was £6860 which would be £41,160 over a year. Twenty nine of the patients referred to the consultants required surgery giving a 74% conversion rate.

The use of ESPs in Foot and Ankle Clinic reduces the number of new referrals seen by consultants, therefore being cost effective to the PCTs. This also increased the consultant's surgical conversion rate producing a more efficient service.

The treatment of nonunion is challenging providing the surgeon with a variety of different surgical options in order to encourage and achieve bone consolidation. Despite excellent results presented in 2008 of 99% union rates, Judet Osteo-Periosteal Decortication does not seem to be popular at present with bone grafting and distraction osteo-modelling being the favoured option.

Retrospective analysis was performed from December 2002 to December 2008 of 46 cases of osteoperiosteal decortication(Judet technique) for failure of fracture union.

Union was successfully achieved in 39 of the 45 patients(85%) after a mean delay of 10.7 months(range 3-39 months). Thirty patients(65%) achieved union following the decortication procedure without subsequent operations. The mean number of procedures following decortication was 0.6(range 0-4) mostly being performed for metalwork failure. Metal work failure occurred in 13 cases(28%) with the majority occurring in decortications of the femur(n=11,85%). The femur was the location of all persistent non unions in the series. The nonunion scoring system(0-100,Calori et al 2008) means were noticeably worse for the persistent nonunion group(41.67, range 34-46) compared to the union group(29, range 4-52).

Osteoperiosteal decortication remains a highly effective surgical technique in the management of failed fracture union.

Purpose of study

To investigate possible advantages of uncemented over cemented femoral components in hip resurfacing.

Aim

Thromboprophylaxis in total hip replacement (THR) and total knee replacement (TKR) remains controversial, conspicuous by absence of consensus. Because of protracted and variable mobilisation, there is an extended risk of Venous Thromboembolism (VTE). We hypothesised that a combination of low molecular weight heparin and miniwarfarin would minimise the initial and extended risk. Therefore we evolved a protocol of enoxaparin sodium 40 mgs for 5 days starting preoperatively and miniwarfarin 1-2mg for 6 weeks following surgery. We undertook a retrospective study of total hip and knee replacements in a District General Hospital between January 2000 and December 2005 to determine the effectiveness of the protocol.

BACKGROUND

In our institution we use the Winklestabile volar locking plate for operative fixation of distal radius fractures. This study aims to assess subjective and objective outcomes using this method of treatment.

The time at which patients should drive following total hip replacement (THR) is dependant upon recovery and the advice they are given. The Driver Vehicle and Licensing Agency (DVLA) in the United Kingdom does not publish recommendations following THR and insurance companies usually rely on medical instruction. Few studies have been performed previously and have reached different conclusions.

Brake reaction times for patients undergoing primary THR were measured pre-operatively and at four, six and eight weeks after surgery using a vehicle driving simulator at a dedicated testing centre. Patients were prospectively recruited. Ethical approval was granted. Participants included eleven males and nine females, mean age 69 years. Side of surgery, frequency of driving and type of car (automatic or manual) were documented. Patients with postoperative complications were excluded. No adverse events occurred during the study.

Statistical analysis using Friedman's test demonstrated a statistically significant difference (P=0.015) in reaction times across the four time periods. Wilcoxon test demonstrated a highly significant difference between initial and six week mean results (P=0.003), and between four and six week results (P=0.001). No significant difference was found between six and eight weeks.

Our data suggests reaction times improve until week six and significantly between week four to six. Patients making an uncomplicated recovery following primary THR may be considered safe to return to driving from week six onwards. We recommend this is clearly documented in the medical notes, and patients should check with their insurance company prior to recommencement.