Introduction

The rising incidence of metastatic bone disease (MBD) in the UK poses a significant management problem. Poorly defined levels of service provision have meant that improvements in patient prognosis have been mediocre at best. For that reason the British Orthopaedic Association (BOA) in conjunction with the British Orthopaedic Oncology Society (BOOS) issued guidelines in 2002 on good practice in the management of MBD. Despite the availability of these standards, there is very little robust data available for audit. The aim of this study was to conduct a regional survey of how these guidelines are being used in the management of MBD.

Introduction

Rupture of the anterior cruciate ligament (ACL) is a common injury and often presents with a typical injury pattern. Historic literature has shown that the accuracy of diagnosis of ACL ruptures is poor at the initial medical consultation despite the history of injury strongly suggesting an ACL injury. The aims of this study were to determine: if the accuracy of diagnosis of ACL ruptures at initial presentation has improved over the last decade; grade of medical staff at initial and subsequent consultations; the mechanism of injury; and the subsequent delay in diagnosis and definitive treatment.

Background: Neglected ruptures of the tendoachilles pose a difficult surgical problem. Intervening scar tissue has to be excised which cannot be repaired by end-to-end anastamosis. Several techniques for reconstruction of chronic ruptures have been described. The flexor hallucis longus (FHL) tendon transfer is considered advantageous over other tendon transfers. One disadvantage of FHL is it has limited excursion. There are no data to determine the optimal positioning of the FHL tendon to the calcaneum.

Materials and Methods: Two computer programmes (MSC.visualNastran Desktop 2002™ and Solid Edge® V19 were used to generate a human ankle joint model. This model is able to reproduce dorsi- and plantarflexion. Different attachment points of FHL tendon transfer to the calcaneum were investigated.

Results: The lowest muscle force to produce plantarflexion (single stance heel rise) was 1355N. Plantarflexion increased for a more anterior attachment point. The maximal plantarflexion was 33.4° for anterior attachment and 24.4° for posterior attachment. There was no significant difference in these figures when the attachment point was moved to either a medial or lateral position.

Clinical relevance: Optimal FHL tendon transfer positioning is a compromise between achieving plantarflexion for normal physiological function versus the force generating capacity and limited excursion of FHL. A more posterior attachment point is advantageous in terms of power. The range of motion is 10° less than when attachment is more anterior, the arc of motion (24.4°) is still physiological. We recommend that FHL is transferred to the calcaneum in a posterior position.

Introduction: Rupture of the anterior cruciate ligament (ACL) is a common injury and often presents with a typical injury pattern. Historic literature has shown that the accuracy of diagnosis of ACL ruptures is poor at the initial medical consultation despite the history of injury strongly suggesting an ACL injury. The aims of this study were to determine: if the accuracy of diagnosis of ACL ruptures at initial presentation has improved over the last decade; grade of medical staff at initial and subsequent consultations; the mechanism of injury; and the subsequent delay in diagnosis and definitive treatment.

Materials and Methods: One hundred and thirty two consecutive patients who underwent ACL reconstruction between January 2005 and January 2009 were analysed using prospective collected data. The mean age of the patients was 29 years (12–57). Sixteen patients were excluded due to chronic ACL injury (15).

Results: One hundred and sixteen patients (117 ACL ruptures) were included in the analysis. A typical injury pattern was documented in 87 (75%) of cases. The most common sporting activities associated with an ACL injury were football (35.3%), skiing (21.6%), rugby (10.3%) and other (32.8%). The vast majority of patients (68.1%) sought medical attention within 1 week from time of injury. The diagnosis of an ACL rupture was made in 33 cases (28%) at the initial medical consultation. The diagnosis was made in 13 (11%) of cases with the use of MRI and 6 (5%) cases at arthroscopy. The most common diagnoses made in cases of failed ACL rupture diagnosis were medial meniscal tear (10.3%), medial collateral ligament injury (7.8%) and none (33.6%). The mean time to diagnosis was 21 weeks (0–192) and the mean time to ACL reconstruction was 44 weeks (1–240).

Conclusions: Despite a typical mechanism of injury leading to ACL rupture the rate of initial diagnosis remains poor. This often leads to an unnecessary delay in diagnosis and subsequent treatment. Possible reasons for this are discussed.

Background: We have noted a concerning number of early failures (as defined by revision) for Preservation medial mobile-bearing uni-compartmental knee replacements (UKR’s) implanted in our hospital. This study retrospectively reviewed the postoperative radiographs to see if these were as a result of surgical technical failure.

Methods: Between 2003 and 2004, 43 medial mobile-bearing Preservation UKR’s were implanted into 39 patients. The average age of the patients at the time of the index procedure was 61.4 years (range, 46–85), (20 males). The immediate post-operative radiographs were reviewed by 2 independent orthopaedic consultants and a registrar, who were blinded to the patient outcomes, using the radiographic criteria used for the Oxford UKR. We however, particularly tried to identify any medio-lateral offset between femoral and tibial components due to the constrained nature of the prosthesis. A compound error score for all other technical errors was also calculated for each patient.

Results: Six (13.9%) of 43 knees were revised (5 for persistent pain, 1 for tibial component subsidence). Technical errors were few and no correlation was found between post-operative radiographic appearances and the subsequent need for revision. The mean compound error score (maximum value 18) was 4.5 (range, 2–9) in the revision cases and in the non revised cases 3.2 (range, 0–8).

Conclusions: We believe this study gives credence to the opinion that the DePuy Preservation mobile-bearing implant has design faults and is over-constrained leading to early failures in some cases.