Aims

Hip fracture is a common injury in the elderly. Recent studies in orthopaedic access have demonstrated inequities affecting Māori. This study aimed to compare the demographic differences between Māori and NZ Europeans with hip fractures, identify any deficiencies in initial, surgical and post op care and in outcomes.

Background

Continuous post-operative infusion of local anaesthetic solutions has been implicated as the causative factor in many cases of chondrolysis. Recent in-vitro studies have shown that even a single exposure to local anaesthetic can cause apoptosis and mitochondrial dysfunction leading to chondrocyte death. Glucosamine has been shown to have a protective and reparative effect on articular cartilage.

Background

A pedobarograph is a device that records pressures exerted by the foot on contact with the ground. Clinically most publications using pedobarography investigated diabetic foot pressures for prevention of ulcers, and assessing gait and sway. Only limited work was done on the effects of foot surgery on foot pressures. Any comparison between papers is hampered by the absence of available defined normal ranges of foot pressures.

We report a retrospective review of outcome after shoulder hemiarthroplasty for proximal humerus fractures. All patients managed with shoulder hemiarthroplasty for proximal humerus fractures between 1997 and 2008 were included. Clinical notes were reviewed and surviving patients completed postal Oxford Shoulder Score (OSS) questionnaires. Results were analysed to assess whether there was a difference in outcome for those above the age of 70 years. A total of 96 patients were treated during this period. Female to male ratio was 3.36:1 with mean age 72 ± 9.6 (45–93) years at time of fracture. At time of review 30.2% of patients were dead. Two patients were lost to follow-up after discharge. Complete case notes were available in 68 patients. Response rate to the OSS was 67.2%. There were 20 patients below 70 years and 48 patients above 70 years of age. The ASA grade was II in 60% of patients. Mean follow-up was 52 months. There were 2 in hospital post-operative deaths due to medical complications. Mean OSS was 27 (3–47) of a maximum of 48, with no significant difference between groups. Overall complication rate was 27.9%, with no significant difference between groups. Ten year survival was 96.9% overall with no significant difference between groups. There appears to be no significant difference in functional outcome, complication rate, or implant survival between patients below or above the age of 70 years treated with primary hemiarthroplasty for fracture of the proximal humerus. This procedure however carries a high complication rate in this group of patients.

Background

There are several case reports of chondrolysis following joint arthroscopy. Continuous post-operative infusion of local anaesthetic solutions, especially 0.5% Bupivacaine, has been implicated as the causative factor in many of these cases. Recent in vitro studies have shown that even a single exposure of articular cartilage to different local anaesthetic solutions can cause apoptosis and mitochondrial dysfunction in chondrocytes leading to cell death. There is currently no study looking at methods to prevent this toxicity of local anaesthetic solutions to articular cartilage. Glucosamine has a protective and reparative effect on articular cartilage and a Cochrane review in 2007 found that it provides mild benefit in pain and function in patients with arthritis.

Establish the positive predictive value of clinical examination predicted radicular level to MRI.

To identify the value of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) assessment tool in the assessment of patients presenting with radicular symptoms of lumbar spine source.

8 patients attending the ESP Orthopaedic triage service, presenting with radicular pain in which MRI is clinically indicated.

Prospective study on patients attending ESP Orthopaedic triage service

Patients were clinically examined, both parts LANSS score was completed.

Following the assessment a radicular level was selected.

Following MRI the results were compared.

Positive predicted values (PPV) for clinical examination and sensitivity and specificity of a LANSS score>12 was calculated.

LANSS score

MRI report.

PPV of 75% of therapist predicted level being same level or adjacent level to MRI stated level.

66% specificity and 100% sensitivity of patients in study with LANNS>12 having MRI evaluated radicular nerve root compression.

This pilot suggests that clinical examination and the LANSS score is useful in establishing the presence of radicular nerve root compression. This evidence supports the need for further research.

Research literature suggests sub classification of LBP may improve clinical outcome. Audit aim is to evaluate the outcome of treatment pathways according to sub classification.

Patients had standardised assessment and completed Oswestry Disability Index (ODI) and Hospital Anxiety and Depression Scale (HAD) following assessment and on discharge.

Patients were subgrouped into; non specific LBP, radicular pain, LBP with high psychosocial indicators. Patients were allocated to 3 treatment pathways; individual treatment, functional Back class, back care programme.

200 adult patients referred to physiotherapy for low back pain. Exclusion criteria; red flag presentation, patient requiring advice only (n=38).

Pre treatment and post treatment HAD, ODI

Of 162 patients Individual treatment, 87 (40%)Functional Back Class, 41 (19%)

Back Care Programme, 34 (16%).

Each pathway demonstrated a clinically significant change in outcome measures. Patient's achieved an average change of between 11 – 17% dependant on pathway.

This suggests that the sub classification criteria used allowed the correct pathway choice for patients conditions.

To evaluate the patient experience of patients referred to the ESP Orthopaedic Triage Service. To identify the demographic data of the patients

To evaluate patients' expectations and satisfaction of the service

A prospective audit of 50 new patients to the ESP service in Mountain Ash General Hospital and Prince Charles Hospital

The audit was carried out over a 3 month period between December 2008 and February 2009.

Patients were asked to anonymously complete a survey following their appointment. Data was collated independently and analysed with descriptive statistics.

Patients referred to ESP service

Self administered satisfaction survey.

Mean age range 40-59 yrs (range 20 -70yrs). 50% >1 year duration of symptoms.

94% of patient's surveyed rated the service provided as good - excellent. 88% of patient's reported that they were happy to be assessed by the ESP.

96% of patients surveyed agreed they were able to discuss their treatment openly with only 10% preferring to see a Doctor.

The ESP service in Cwm Taff Health board achieves a high level of patient satisfaction.

Background: Dr Foster’s Good Hospital Guide 2005–2006 ranked University Hospitals of Leicester NHS Trust amongst the worst in UK for in-hospital mortality and time to theatre in hip fracture patients. The problem had been recognized in early 2005 and the Fracture Neck of Femur (FNOF) project was launched. This included an increase in trauma coordinators and clinical aides, regular orthogeriatric input, daily hip fracture operating lists, a separate hip fracture ward and a dedicated discharge nurse.

Aim: The aim of this study was to assess the outcome of the FNOF project.

Method: Data on mortality and length of stay was collected from the IM& T department and was cross referenced with the PCT database. Time to theatre data was collected from the trauma coordinators. Study period was five years from January 2003 to December 2007.

Results: 3636 patients were admitted with a hip fracture in the five year period. The length of stay reduced from 31 days in 2005 to 19 days in 2007 (p< 0.001). The in-hospital mortality reduced from 17.0 % in 2005 to 11.3% in 2007 (p< 0.01). 1 year mortality dropped from 36.9% to 27.3% (p< 0.001). The 30 day and 4 month mortality were also reduced but this was not statistically significant. 85% of patients had surgery within 48 hours in 2007 as compared to 47% in 2005–06.

Conclusions: The FNOF project was successful in reducing In-hospital and 1 year mortality, length of stay and time to theatre. However, the 30 day mortality did not show a significant reduction. In-hospital mortality is not a good comparator of hospital performance as it depends on length of stay; 30 day mortality would be more accurate. The national hip fracture database can be used to obtain accurate data for future studies.

Introduction: Cephalosporins have traditionally been the preferred antimicrobial prophylaxis for 90% of orthopaedic surgeons. With a recent increase in Clos-tridium difficile and MRSA infections, antimicrobial prophylaxis is changing. The aim of this study was to conduct a national survey of current orthopaedic antimicrobial prophylaxis regimes. We wanted to ascertain whether there were any recent changes in these regimes and the reasons for these changes. We also aimed to show any relationship between antimicrobial usage and Clostridium difficile rates.

Methods: Information on prophylaxis regimes and Clostridium difficile rates was requested through a five item questionnaire which was sent to all hospitals in the United Kingdom.

Results: The response rate was 83 %. The top three antimicrobial regimes in trauma and elective orthopaedic surgery were cefuroxime alone (52 %), flucloxacillin plus gentamicin (18 %) and co-amoxiclav alone (8 %). Half of all hospitals had changed antimicrobial regimes and half of these changes were due to Clostridium difficile. The incidence of Clostridium difficile was 70% higher in hospitals using Cefuroxime than hospitals using other antibiotics (0.19% vs. 0.32%)(p < 0.001). Clostridium difficile infection was more common in trauma than elective surgery.

Conclusion: Cefuroxime is still the most commonly used antimicrobial agent but its use has declined mainly due to a surge in Clostridium difficile rates. Reduction in cephalosporin use along with other infection control measures has resulted in a fall in Clostridium difficile infection rates.

Background: Animal studies have shown that 0.9% NaCl causes inhibition of proteoglycan metabolism in articular cartilage yet it continues to be the most commonly used irrigation fluid for arthroscopic surgery. Ringer’s solution and non ionic fluids have been shown to cause less damage. There is currently no such comparison in human articular cartilage. The aim of this study was to assess the effect of different irrigation fluids on arthritic and non arthritic human articular cartilage.

Materials and Methods: Non arthritic cartilage specimens were obtained from femoral heads of hip fracture patients undergoing hemiarthroplasty where there were no radiological or macroscopic signs of osteoarthritis. Arthritic articular cartilage was obtained from tibial plateau of total knee arthroplasty patients or femoral heads with macroscopic signs of osteoarthritis. Cartilage explants were exposed to either 0.9% normal saline or Ringer’s solution, 1.5% Glycine, 10% Mannitol or a control solution of M199 culture medium. 0.5% bupivacaine, which has been shown to be toxic to chondrocytes, was used as a second control solution. The specimens were then incubated in culture medium containing radiolabelled 35-SO4 for 16 hours and uptake was measured as counts per gram per minute.

Results: In non arthritic cartilage, the inhibition of proteoglycan synthesis was 0% with Ringer’s solution (p> 0.05), 3% with Glycine and Mannitol (p> 0.05), 12% with 0.9% NaCl (p> 0.05) and 75% with 0.5% bupivacaine (p< 0.001).

In arthritic cartilage, the inhibition was 15% with Ringer’s solution (p> 0.05), 20% with Mannitol (p> 0.05), 30% with 0.9% NaCl and Glycine (p=0.04) and 85% with 0.5% bupivacaine (p< 0.001).

Conclusion: Normal saline was most harmful to human articular cartilage. Ringer’s solution was the best solution for joint irrigation. We have provided yet more evidence to suggest that 0.5% bupivacaine is severely toxic to articular cartilage.

Background: Ultraclean air (UCA) in the operating theatre has been defined as less than 10 colony forming units (CFU)/m3. Wearing a Body Exhaust Suit (BES) in clear air has been shown to reduce infection from 1.0% to 0.1%. A trial in our unit in 2003 found bacterial air counts of 1 CFU/m3 with Rotecno gowns made from polyester T85392 compared to 0.5 CFU/m3 with BES. The same Rotecno gowns have since been used for arthroplasty surgery in our unit as this difference was not felt to be clinically significant. A new type of gown, manufactured by Gore ltd. was offered to our hospital. These gowns consist of a three layer laminate containing polyester and polytetrafluoroethylene (PTFE) and were advertised as impervious to liquids, bacteria and viruses. Their laboratory results were deemed to be superior to Rotecno gowns on standard testing.

Aim: The aim of this study was to compare bacterial air counts using the existing Rotecno gowns with this new type of occlusive gown made by Gore ltd.

Methods: 56 joint replacements were allocated randomly to either the Rotecno or Gore gowns and also stratified to Total Knee Arthroplasty (TKR), Total Hip Arthroplasty (THA) or Revision THA. Bacterial air counts were measured for the first ten minutes of surgery using a Casella slit sampler which sampled air at 700 lt/min onto a nutrient agar plate. These plates were then incubated for 48 hours at 37 degrees Celcius and colonies were counted.

Results: The new gowns were associated with higher air counts (3.7 CFU/m) than the Rotecno gowns (1.2 CFU/m) (p=0.01). All Rotecno air samples were < 10 CFU/m3 but three of the Gore samples exceeded the clean air standard. The bacterial counts with the Rotecno gowns were the same as those in the 2003 study. TKA was associated with higher air counts than THA or Revision THA (p=0.04).

Conclusions: The new gowns may have been superior on the standard tests but they were not superior at preventing airborne bacterial dispersal. Rotecno gowns made from polyester T85392, although many years old, were still associated with very low air counts. This study highlights the importance of testing new materials in a clinical environment with UCA; in vitro testing alone is not an adequate assessment. This is especially important for TKA which was associated with higher counts.

Background: A good hospital guide published in 2006 identified high in-hospital mortality rates in fracture neck of femur patients at the University Hospitals of Leicester NHS trust. The trust was identified as the worst in the country in terms of the percentage of patients having surgery within the recommended 48 hours from admission. The problem had already been identified and a ‘Fracture Neck of femur project’ was launched in January 2006 to improve outcomes in these patients. This included the introduction of trauma coordinators and clinical aides who prepared patients for surgery, a separate fracture neck of femur ward, a discharge nurse, dedicated hip fracture lists and pre and post operative orthogeriatric input.

Aim: The aim of this study was to assess the impact of the fracture neck of femur project.

Methods: Data on admissions, time to theatre, length of stay and mortality was collected for 3400 patients admitted with fracture neck of femur between January 2003 and September 2007. Mortality rates, length of stay and time to theatre were compared before and after the introduction of the fracture neck of femur project.

Results: The length of stay reduced from 32 days to 18 days in 2007 (p< 0.01). The in-hospital mortality reduced from 16.6 % in 2003 to 10.7% in 2007 (p< 0.01). 30 day mortality showed a minor reduction from 12.4% in 2003 to 11.4% in 2007 (p=0.6). 95% of patients had surgery within 48 hours as compared to 47% in 2005–06 and 85% in 2006–07.

Conclusions: The high in-hospital mortality rates were reduced. The length of stay was also reduced by effective discharge planning. Measures to reduce time to theatre were highly successful. However, the 30 day mortality did not show a significant reduction. We conclude that in hospital mortality is not a good comparator of hospital performance. 30 day mortality would be more accurate.

Background: Clostridium difficile (C diff) diarrhoea is a growing UK hospital problem. However, it is controversial whether patients die with C diff or of C diff. A series of infection control measures were introduced from August 2006 onwards to reduce the rate of C diff infection and to treat patients suffering from diarrhoea. These included a five-day antibiotic stop policy, a diarrhoea treatment policy, a hand washing campaign, increased investment in environmental cleaning and a change in policy for antimicrobial prophylaxis to coamoxiclav instead of cefuroxime. The aim of this study was to assess the impact of these measures on the incidence of C diff infection and to record the mortality associated with C diff. Fracture neck of femur patients were chosen as they are at particular risk.

Method: We assessed data on orthopaedic admissions in particular fracture neck of femur patients, C diff samples, and mortality up to one year. The incidence of C diff was compared between fracture neck of femur patients and other orthopaedic admissions and also before and since the introduction of the infection control policies. This was followed by a comparison of mortality between C diff positive patients and a control group matched by age, sex, ASA grade and place of residence. Mortality data was at 30days, 6 month and 1 year.

Results: Clostridium difficile was much more common in patients with fracture neck of femur (72 out of 1800, 4%) than in other orthopaedic admissions (51 out of 10000, 0.5%, p < 0.001). The incidence of C diff in patients with fracture neck of femur decreased from 49 of 548 (9%) in the 9 months pre-policy to 28 of 562 (5%, p=0.009) in the 9 months since policy Introduction: In those with C diff, mortality at 30 days and 6 months was 10/49 (20%) and 35/49 (71%) pre-policy and 9/28 (32%) and 20/28 (71%) since policy Introduction: Regardless of policy introduction, the overall mortality in 168 C diff positive patients at 30days, 6 months and 1 year was 31 (19%), 112 (67%) and 117 (70%) whilst that in the 168 matched controls was 19 (11%), 43 (26%) and 48 (29%).

Conclusion: The matched group data indicates that C diff increases mortality. It does not simply colonise the most frail. The percentage of deaths in C diff positive patients was no different after the diarrhoea treatment policy Introduction: The incidence of C diff was reduced by 43% using infection control measures. Our results indicate that the best way to reduce mortality due to C diff is to reduce the incidence, our current treatment policy was ineffective or in other words, ‘prevention was better than cure’. We recommend that similar measures could be introduced in other orthopaedic units in order to reduce the incidence and mortality in fracture neck of femur patients from Clostridium difficile.

We report the 15 year follow-up of displaced intra-articular calcaneal fractures from a randomised controlled trial of conservative versus operative treatment. Of the initial study, 46 patients (82%) were still alive and 26 patients (57%) agreed to review.

The clinical outcomes were not different between operative versus conservative treatment. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale: p = 0.11; Foot Function Index (FFI): p = 0.66; and calcaneal fracture score: p = 0.41. The radiological outcomes also were not different between both groups. Böhler’s angle: p = 0.07; height of calcaneum: p = 0.57; and grade of osteoarthritis of the subtalar joint: p = 0.54. There was no correlation between Böhler’s angle and the outcome measures in either group.

The results of this 15 year follow-up of displaced intra-articular calcaneal fracture randomised controlled trial demonstrate similar findings to those at one year follow-up.

Arthrodesis of the ankle joint gives satisfactory short and medium-term results; however, in the longer term, it frequently leads to sub-talar and mid-tarsal osteoarthritis which is difficult to treat. Use of mobile bearings have significantly improved the results of ankle replacement. This a mid term follow up (1 to 5 years)of Buechel-Pappas ankle replacements performed by the senior author.34 total ankle replacements performed by one surgeon from October 1999 to May 2004 were reviewed retrospectively. Pre and post operative VAS scores, AOFAS scores were evaluated to find patient satisfaction and outcome. Tourniquet time as recorded in operation notes showed the learning curve for the procedure. Males : Females- 1:1.4. Mean age was 65 years (range : 33 to 83). Indication for surgery was primary osteoarthritis in 13, post traumatic arthritis in 14 and rheumatoid arthritis in 8. Average VAS score was 8.2 pre operative and improved to 2.0 at follow-up. AOFAS score improved from 39.1 to 72. Operating time averaged 113 minutes in 1999 and 85 in 2004. Significant complications were medial impingement (8) out of which 3 patients needed further surgery, intra-operative malleolar fractures (medial 4, lateral 1 and posterior 1, all healed successfully) and injury to cutaneous nerves (4) 3 patients had superficial infection which settled with antibiotics, but there were no cases of deep infection. 58 % were very happy, 32.5 % were happy, 9.5 % were not happy with the result. 2 patients had ankle fusion on the opposite side earlier, both were happier with the replaced side. Ankle replacements appear to offer a good alternative to fusion in selected patients. There is a significant risk of minor complications. Medial impingement may need further debridement at a later stage.

Ankle replacements appear to offer a good alternative to fusion in most arthritic conditions. Use of mobile bearings have significantly improved results of ankle replacement. These have a significant minor complication rate including nerve injury, fractures. One of the significant complications noted in our series was medial impingement. 34 Buechel-Pappas total ankle replacements performed by the senior author from October 1999 to May 2004 were reviewed retrospectively. Mean follow up of 2.8 years. 8 patients reported medial impingment symptoms at follow up. 3 patients underwent repeat surgery for this problem. One patient underwent arthroscopic debridement of scar tissue and impinging bone by another surgeon which gave good symptomatic relief. Two other patients had tibialis posterior tendonitis and underwent surgical decompression of the tendon. Both were found to be having degenerative tendons with partial tears. We discuss the findings, literature review and other complications of ankle replacements as well. Whether medial impingement is due to implant design or inherent pathology of ankle has to be studied further. Other implant designs like Agility may treat arthritis in medial and lateral gutters but can still cause soft tissue impingement. Whether these are due to implant design, residual arthritis in medial recess or soft tissue pathology is uncertain. This may be caused by the cylindrical shape of talar component (the physiologic talus has a cone shape with smaller radius on medial side). This has not been proven yet, but has been addressed in newer designs like Salto and Hintegra prostheses.

The majority of diaphyseal forearm fractures in children are treated by closed reduction and plaster immobilisation. There is a small subset of patients where operative treatment is indicated. Recent reports indicate that elastic intramedullary nailing (EIN) is gaining popularity over plate fixation. We report the results of EIN for diaphyseal fractures of the forearm in 44 children aged between 5 and 15 years during a three-year period. The indications were instability (26), redisplacement (14), and open fractures (4). Closed reduction and nailing was carried out in 18 cases. A single bone had to be opened in 16 cases and in 10 cases both bones were opened for achieving reduction. Out of the 39 both bone forearm fractures, 35 patients had stabilisation of both radius and ulna and in 4 cases only a single bone was nailed (Radius 3, Ulna 1).

Union was achieved in all the 44 cases at an average time of 7 weeks with one delayed union. All patients regained full flexion and extension of the elbow and wrist. Pronation was restricted by an average of 20° in 30% patients.

Complications were seen in 10 patients (20%). 4 patients had prominent metal work which required early removal. There was refracture in one case, which was treated by nail removal and re-fixation. Two patients developed post operative compartment syndrome requiring fasciotomy. EIN of the radius alone in a patient with fractures of both the bones of forearm, led to secondary displacement of the ulna. This resulted in ulnar malunion and a symptomatic distal radio-ulnar joint subluxation. This was successfully treated by ulnar osteotomy.

Compared to forearm plating EIN involves minimal scarring, easier removal and less risk of nerve damage. We therefore recommend EIN for the treatment of unstable middle and proximal third forearm fractures.

Arthrodesis of the first metatarsophalangeal joint (MTPJ) has been recommended for various big toe deformities. We present a new technique of internal fixation for achieving dynamic compression at the first metatarso-phalangeal joint arthrodesis using memory compression staples. The memory compression staple is fabricated from equiatomic Nickel-Titanium (Ni-Ti) alloy. This alloy has a property by virtue of which it becomes easily malleable at a low temperature and reverts back to its original shape at a higher temperature. This property is known as the Shape Memory Effect. This principle is employed to provide compression at the arthrodesis site. Thirty feet were operated in 27 patients. There were 24 females and 3 males with a mean age of 61.2 years. Two memory compression staples were used at right angles to each other to achieve compression at the fusion site. The post-operative regime allowed full weight-bearing in a rigid sole shoe. A standard questionnaire was used for the subjective assessment, which included questions regarding level of pain, ambulation and patient satisfaction. Objective assessment was performed by a clinical and a radiological examination. Post-operatively there was a reduction in the pain score from 4.6 to 1.6 (p< 0.0001). Ambulation ability improved from 4 to 2.5 (p< 0.0001). There was 96.7% of radiological fusion with an average fusion time of 8.2 weeks. Patients reported 86.6% excellent to good results. The only significant post-operative complication was a single non-union.

We advocate memory compression staples for the internal fixation of the first metatarsophalangeal joint arthrodesis, which is a low profile implant, does not require post-operative cast immobilisation and has a predictable success rate comparable to previously reported methods.

We matched 78 patients with a loose cemented Charnley Elite Plus total hip replacement (THR) by age, gender, race, prosthesis and time from surgery with 49 patients with a well-fixed stable hip replacement, to determine if poor bone quality predisposes to loosening. Clinical, radiological, biomechanical and bone mineral density indicators of bone quality were assessed.

Patients with loose replacements had more pain, were more likely to have presented with atrophic arthritis and to have a history of fragility fracture, narrower femoral cortices and lower peri-prosthetic or lumbar spine bone mineral density (all t-test, p < 0.01). They also tended to be smokers (chi-squared test, p = 0.08). Vitamin-D deficiency was common, but not significantly different between the two groups (t-test, p = 0.31)

In this series of cemented hip replacements performed between 1994 and 1998, aseptic loosening was associated with poor bone quality. Patients with a THR should be screened for osteoporosis and have regular radiological surveillance.

Background: Aseptic loosening of total joint arthroplasty is characterised by osteolysis caused by osteoclasts and macrophages. Osteolysis occurs by acidification and dissolution of hydroxyapatite crystals then proteolysis of the bone collagen matrix. N-Telopeptide (NTx) and deoxypyridinolone (DPD) represent highly specific markers for bone resorption.

Aim: To investigate whether urinary NTx and DPD generated in-vivo can be used as bone markers in a small animal model of wear debris induced osteolysis.

Materials and Methods: 41 and 38 urinary samples were collected from mice at autopsy four weeks following either the implantation of clinically relevant ceramic particles or sham surgery into their femora and assayed for NTx and DPD respectively. Bone markers were corrected for urinary creatinine.

Results: The mean urinary NTx concentration for mice that underwent the implantation of clinically relevant ceramic particles was 95.0 nM BCE/mM creatinine compared to 85.3 nM BCE/mM creatinine for mice who had sham surgery (p = 0.8, 95%CI: −29.0 to 30.7). The mean urinary DPD concentration for mice that underwent the implantation of clinically relevant ceramic particles was 5.3 nM DPD/mM creatinine compared to 4.0 nM DPD/ mM creatinine for mice who had sham surgery (p = 0.07, 95%CI: −2.8 to 1.4).

Conclusion: The absolute values of NTx and DPD increased in mice that underwent the implantation of clinically relevant ceramic particles compared to sham surgery even though this was not statistically significant. Extending the post operative interval might allow both NTx and DPD to be utilised as bone markers of osteolysis in our small animal model of aseptic loosening.

Introduction: The diagnosis of Achilles tendon rupture must be made promptly and reliably to prevent avoidable morbidity. The calf squeeze test (CST) offers a simple clinical test with high sensitivity. However, in our clinical practice we have noticed a lack of clarity in the medical notes. We believe there is confusion regarding what constitutes a positive CST. Movement of the foot being positive or lack of movement of the foot indicating the test is positive. The purpose of this study was to assess the degree of error and to determine whether this is due to lack of knowledge, an inability to perform or correctly interpret and record the result of the CST. We assessed SHO’s , Registrars and Consultants in the Accident & Emergency and Orthopaedic Departments.

Method: Ninety one doctors completed a supervised questionaire. They were asked four questions 1) What tests they chose to diagnose Achilles tendon rupture. 2) How they would perform a CST. 3) What they considered a positive CST to mean . 4) How they would record the diagnosis of a ruptured Achilles tendon.

Results: 92%(84/91) of doctors overall chose to use a CST. 88%(80/91) performed the CST correctly. The CST was interpreted incorrectly by 41%(15/37) and 26%(14/54) of A + E and Orthopaedic doctors respectively. Also 32%(12/37) of A + E and 19%(10/54) of Orthopaedic department doctors mistakenly thought that the diagnosis of an Achilles tendon rupture was consistent with a negative test.

Conclusion: The results suggest that the recording of AT rupture may be inaccurate in as many as 32%(12/37) when patients present to the A + E department. This error is not a result of lack of knowledge or performance of the CST but of interpretation and recording. We would strongly discourage the recording of the CST in terms of a positive or negative result. The result should be described in words, for example ‘No movement of the foot on squeezing the calf muscle.’ We suggest that all SHOs and Registrars who may be called upon to assess patients with suspected Achilles tendon rupture are informed of this source of error.

Background: The commonest cause of long term failure of total joint arthroplasty is aseptic loosening. As a result, many patients will require complex revision surgery that is not only technically challenging but associated with poorer results. Revisions procedures are also associated with higher morbidity and costs.

Aim: To quantify osteolysis in a small animal model of aseptic loosening. This model can then be utilised for screening therapeutic agents to inhibit aseptic loosening.

Materials and Methods: 7 time mated female mice were injected with radioactive calcium 45 on day 14 of gestation. The 52 offsprings were divided into 2 equal groups and subjected to either the implantation of clinically relevant ceramic particles or sham surgery into their femora. The non-operated femora were used as control. Animals were killed 4 weeks following surgery. Femora were retrieved, dissolved and radioactivity measured as outcome (CPM/mg = Counts Per Minute per milligram). A Linear mixed effects model was utilised to examine the difference in outcome between the 2 groups.

Results: The mean scintillation count for sham surgery was 388 CPM/mg compared to 449 CPM/mg in the control femora. The mean scintillation count for ceramic particles was 351 CPM/mg compared to 420 CPM/mg in the control femora. The mean effect on outcome of surgery with ceramic particles relative to sham surgery was estimated at 16.7 CPM/mg (95CI%: 0.9 to 32.5 CPM/mg; p = 0.025).

Conclusion: We have successfully shown that this model can quantify osteolysis. However, the difference detected between sham surgery and ceramic particles was biologically small displaying the inert properties of ceramic. Extending the post surgery interval might show a larger difference between sham surgery and ceramic particles and permit quantitative analysis of therapeutic agents to be screened to inhibit aseptic loosening.

We examined the rates of infection and colonisation by methicillin-resistant Staphylococcus aureus (MRSA) between January 2003 and May 2004 in order to assess the impact of the introduction of an MRSA policy in October 2003, which required all admissions to be screened. Emergency admissions were treated prophylactically and elective beds ring-fenced. A total of 5594 admissions were cross-referenced with 22 810 microbiology results. The morbidity, mortality and cost of managing MRSA-carrying patients, with a proximal fracture of the femur were compared, in relation to age, gender, American Society of Anaesthesiologists grade and residential status, with a group of matched controls who were MRSA-negative.

In 2004, we screened 1795 of 1796 elective admissions and MRSA was found in 23 (1.3%). We also screened 1122 of 1447 trauma admissions and 43 (3.8%) were carrying MRSA. All ten ward transfers were screened and four (40%) were carriers (all p < 0.001). The incidence of MRSA in trauma patients increased by 2.6% per week of inpatient stay (r = 0.97, p < 0.001). MRSA developed in 2.9% of trauma and 0.2% of elective patients during that admission (p < 0.001). The implementation of the MRSA policy reduced the incidence of MRSA infection by 56% in trauma patients (1.57% in 2003 (17 of 1084) to 0.69% in 2004 (10 of 1447), p = 0.035). Infection with MRSA in elective patients was reduced by 70% (0.56% in 2003 (7 of 1257) to 0.17% in 2004 (3 of 1806), p = 0.06). The cost of preventing one MRSA infection was £3200.

Although colonisation by MRSA did not affect the mortality rate, infection by MRSA more than doubled it. Patients with proximal fractures of the femur infected with MRSA remained in hospital for 50 extra days, had 19 more days of vancomycin treatment and 26 more days of vacuum-assisted closure therapy than the matched controls. These additional costs equated to £13 972 per patient.

From this experience we have been able to describe the epidemiology of MRSA, assess the impact of infection-control measures on MRSA infection rates and determine the morbidity, mortality and economic cost of MRSA carriage on trauma and elective orthopaedic wards.

Background Our hospital operates a consultant led rapid review process of X-rays and case notes of patients referred to fracture clinic from Accident & Emergency (A& E) and General Practitioners (GP) on a daily basis. This compares with other centres where patients are reviewed in outpatient fracture clinics soon after injury.

Aim Evaluate effectiveness of consultant led rapid review process compared to standard consultant fracture clinics.

Patients and Methods Prospective study of the rapid review process over 4 weeks of all patients referred to fracture clinic by A& E and GPs. Total number of patients referred per day, time taken to review these patients case notes and X-rays, number of recalls and reason for recall were documented. This was compared to consultant led fracture clinics, which included time taken to review patients.

Results 797 patients were processed through the rapid review over 4 weeks. 53 (6%) patients were recalled, 32 (4%) for a change of management and 21 (2.6%) because of lack of information. The mean number of patients referred per day was 28 taking a mean of 28 minutes; thus the mean time to review one patient was 1.0 minute. The mean number of patients recalled per day was 2. The mean time taken to review a patient in a standard fracture clinic was 11 minutes. Therefore, the total time that would have taken to review 28 patients in the standard fracture clinic would be 308 minutes.

Conclusion A consultant led rapid review process of all patients referred to fracture clinic is a very efficient process. Rapid review process saves clinic time and resources, minimises delays in clinical decision-making and saves the patient an unnecessary visit to the outpatient department.

Background Adhesive capsulitis of the shoulder is a painful condition that results in gradual loss of joint movement. Numerous treatment modalities have been utilised with variable benefits. Because of the risk of brachial plexus injury and fracture, manipulation under anaesthesia is considered with caution.

Aim To determine the rate of manipulation under anaesthesia (MUA) following primary distension arthrogram for adhesive capsulitis of the shoulder.

Patients and Methods The case notes of 40 patients (42 shoulders) between 1998 to 2004 at Glenfield Hospital, Leicester under the care of one consultant with adhesive capsulitis of the shoulder treated with distension arthrogram by using intra-articular injection of local anaesthetic, corticosteroid, contrast media and air were reviewed.

Results Capsular disruption into the subscapular bursa was demonstrated in all cases. 15 of 42 (36%) shoulders underwent MUA following distension arthrogram. The average period of pain prior to distension arthrogram for these patients was 42 weeks (range: 7–156). 35 of 40 (88%) patients were pain free following primary distension arthrogram.

One patient experienced a vasovagal episode during the distension arthrogram.

Conclusion Distension arthrogram can be used as a therapeutic procedure for achieving symptomatic pain relief in the early phase of adhesive capsulitis and decreasing the risk of MUA of the shoulder.

Introduction: Activated matrix metalloproteinases (MMPs) are responsible for the osteolytic process in aseptic loosening. Fluvastatin has been shown in previous studies to inhibit MMPs. The purpose of this study was to investigate the potential pharmacological effect of fluvastatin on aseptic loosening.

Materials and methods: A radiolabelled mouse calvaria and human interface membrane cells culture system was used to study the effect of fluvastatin on bone resorption induced by interface membrane cells. The experimental conditions were: 1) test culture consisted of culturing a dead radiolabelled bone disc with cells from human interface membrane in culture medium containing fluvastatin for 14 days 2) control culture consisted of similar culture system without fluvastatin and 3) baseline control culture consisted of bone disc only. The bone discs from each test and control groups comparison were from the same parietal bone to ensure equal amount of radioactive calcium in the bone discs at the start of the experiment. Supernatant were sampled on day 7, 10 & 14 for scintillation counting. The total Ca⁴⁵ remained in the bone discs at the completion of the culture were measured by scintillation counting. Eight sets of experiments were performed in this study. The results were expressed as the ratio of Ca⁴⁵ in the fluvastatin exposed culture over culture containing bone disc only. In the control, the results were expressed as ratio of bone disc exposed to cells over culture containing bone disc only.

Results: In the supernatant Ca⁴⁵, both the fluvastatin and control ratios increased with time confirming bone resorption in both culture. The fluvastatin culture consistently showed a lower ratio compared with control indicating an inhibitory effect. In the fluvastatin culture the mean ratios on day 7, 10 & 14 were 0.79, 1.53 and 2.55. The mean ratios in the control culture were 1.03, 1.81 and 3.20 (n = 8, p = 0.0001 ANOVA, General Linear Model). The mean ratio of total Ca⁴⁵ remaining in the bone disc in the fluvastatin culture was 0.87 and the control was 0.70 (p = 0.01, t test). This implies 55% less bone resorption in the presence of fluvastatin.

Conclusions: In this in vitro study we found fluvastatin has the ability to inhibit osteolysis by cells from interface membrane of aseptically loosened hips. We believe fluvastatin inhibit bone resorption by MMPs inhibition. This may have therapeutic implication in the treatment of patients with aseptic loosening of total joint replacements.

Introduction Rheumatoid arthritis commonly produces disabling forefoot deformities. Surgical interventions include hallux metatarsophalangeal (MTP) joint fusion with lesser toe metatarsal head and/or proximal phalanx base excisions. Here we describe our experience of combining first MTP joint fusion using a plate with Weil metatarsal osteotomies (WMO) of the lesser toes. WMO preserve and reduce lesser MTP joints thus enhancing stability and relocating the plantar fat pads. Plate fusion of the first MTP joint protects against recurrent deformity. Our aim was to assess the outcome of this procedure.

Method Twelve female patients (21 feet) underwent the procedure with no loss to follow up. Informed consent was given and ethics approval obtained. American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scale and visual analogue scale scores were recorded post-operatively only. Pre- and post-operative plain radiographs were compared.

Results Mean age at operation was 62.5 years (range 48–75). Mean follow up was 25.9 months (range 2–54). The mean post-operative AOFAS scale score was 70.6/100 (range 34–90).

The mean hallux valgus angle was reduced from 39.6 degrees to 31.8 degrees and the second MTP angle from 28.3 degrees to 19.4 degrees. Pre-operatively 28% of the lesser toe MTP joints were aligned compared with 83% post-operatively. All of the WMOs fused. Two first MTP joint fusions resulted in non-unions and required successful revision surgery. In five cases metalwork was removed from the hallux because of discomfort. In two cases, metalwork was removed because of superficial wound infection. Infection subsequently resolved after a course of oral antibiotics. Nine patients stated they would recommend the procedure.

Conclusion First MTP joint plate arthrodesis and WMOs of the lesser toes provides good symptomatic relief and restoration of forefoot mechanics. It is a useful procedure in delaying more radical and final surgery for this progressive, destructive disease.

Background: Aseptic loosening of total joint arthroplasty is characterised by osteolysis, which is caused by osteoclasts and macrophages. Collagen cross link molecules N Telopeptides (NTx) are released during osteolysis and represents a highly specific marker for bone resorption. NTx could be a potential marker in the laboratory investigation of aseptic loosening with the advantage of being cheaper and easier to perform compared to present established markers. The aim of this study was to show that NTx generated during osteolysis by cells extracted from human interface membranes of aseptically loosened hips correlates with the established radiolabelled 45Ca bone resorption model.

Methods: Cells from human interface membranes of aseptic loosened hip joints were cultured with dead radiolabelled (45Ca) mice calvaria discs and in the control culture no cells were added to the culture system. Calvaria discs used in each experiment comparison were from the same parietal bone. The supernatant culture medium were extracted on day 3,7,10 & 14 and assayed for NTx and by scintillation counting. On day 14 the remaining culture medium and cells were assayed by scintillation counting and the total remaining 45Ca in the bone were measured.

Results: All results were expressed as the ratio of bone exposed to cells (BC)/bone only (B). Supernatant samples for 45Ca and NTx showed a rise in BC/B ratio with time. These were 0.83, 0.88, 0.97 & 1.08 (p=0.0001) and 1.06, 1.21, 1.41 & 1.40 (p = 0.03) respectively. In the bottom sampling for 45Ca the mean ratio of BC/B was 1.8 (p=0.0001) and the mean BC/B ratio for the remaining 45Ca in the bone at the end of the culture was 0.81 (p=0.0007). There was a strong correlation between 45Ca and NTx (r = 0.88).

Discussion: The initial drop of calcium levels can be explained by calcium uptake by the cells. We believe this is the first time human interface membrane cells have been shown to release NTx during osteolysis in an in vitro model. Replacing 45Ca radilabelled bone with NTx as a marker represents an important step towards simplifying and reducing the cost of an in in vitro model of particle induced osteolysis.

Aims: There are no large published studies examining the complication rates associated with use of Kirschner wires in þxation of a wide variety of paediatric fractures. The aim of this study is to analyse the outcomes of fracture þxation using K-wire in upper limb fractures in children and to critically assess the incidence and type of complications. Methods: This study is a retrospective review of a consecutive series of 107 fractures in 105 paediatric trauma cases treated with K-wire in between 01.09.99 to 10.09.01. Results: The fractures were fractures around Wrist (47%) and around elbow (45%). 66 (61.68%) were performed by closed percutaneous technique, 27 (25.23%) by open method and in 14 (13.08%) combined approach was used. Around there were 13 cases with over-granulation at wound site, 6 cases of Soft tissue infection, 2 cases with tendinitis, 1 case of Osteo-myelitis and 1 case with hyper-sensitive scar. 3 cases found to have postoperative neurapraxia and 1 case with axonotmesis. Metal migration was detected in 4 cases and 14 cases found to have shown wire loosening. 10 fractures have lost position in postoperative period out of which 2 cases were reoperated for Re K-wire, 1 had undergone Re-MUA and 7 left for remodelling. Conclusions: K-wires are versatile but are not inherently benign. We conclude that best results could be achieved if total life of K-wire can be restricted to 3–4 weeks. We recommend one should explain all these risks and complications during consenting for K-wiring procedures.

Between June 1988 and December 1997, 332 babies with 546 dysplastic hips were treated in the Pavlik harness for primary Developmental Dysplasia (DDH) as a product of the Southampton selective screening program. Each was managed by a strict protocol including ultrasonic monitoring of treatment within the harness. The group was prospectively studied over a mean duration of 6. 5 years (SD=2. 7y) with 89. 1% follow-up. The Acetabular Index (AI) and Centre-Edge angle of Wiberg (CEA) were measured on annual radiographs to determine the natural history of hip development following treatment in the Pavilik harness. These were compared to published normal values.

We observed a failed reduction rate of 15. 2% of all complete hip dislocations; these required alternative surgical treatment. The development of those hips of infants successfully treated in the harness showed no significant difference from the normal values of Acetabular Index for female left hips, after eighteen months of age. Of those dysplastic hips that were successfully reduced in the harness; 2. 4% exhibited persisting significant late dysplasia (CEA< 20°) and 0.2% demonstrated persistent severe late dysplasia (CEA< 15 °) All such cases could be identified at sixty months. Dysplasia was clinically deemed sufficient to merit innominate osteotomy in 0. 9% dysplastic hips treated. Avascular necrosis was noted in 1% of hips treated in the harness.

We conclude that using our protocol, successful initial treatment of DDH with the Pavlik harness appears to revert the natural history of hip development to that of the normal population. We recommend that regular radiographic surveillance up to 60 months of age constitutes safe and effective practice.

Aseptic loosening of total joint arthroplasty is characterised by osteolysis that is caused by osteoclasts and macrophages. The mechanism of bone resorption is by acidification, dissolution of hydroxyapatite crystals then proteolysis of the bone collagen matrix. The collagen cross-link molecules are cleaved by osteoclasts exposing the N terminal of the cross-link protein - N Telo-peptides (NTx). This represents a highly specific marker for bone resorption. Previously described bone resorption models include radiolabelled animal bones which require the use of animals and radioactive materials or thin dentine slice resorption pits which are only semi-quantitative and technically difficult to produce. NTx could be a potential osteolysis marker in the laboratory investigation of aseptic loosening with the advantage of being cheaper and easier to perform compared to present established marker and also does not require animals or radioactive materials. The aim of this study was to show that NTx generated during osteolysis by cells extracted from human interface membranes of aseptically loosened hips correlates with the established radiolabelled ⁴⁵Ca bone resorption model.

Cells from human interface membranes of aseptic loosened hip joints were extracted from the tissue following enzyme digestion. These cells were cultured with dead radiolabelled (⁴⁵Ca) mice calvaria discs in the presence of 1,25 dihydroxyvitamin D₃, hydrocortisone, RANKL and M-CSF. In the control culture no cells were added to the culture system. Calvaria discs used for each experiment comparison were from the same parietal bone. The supernatant culture medium were extracted on day 3, 7, 10 and 14 and assayed for NTx and by scintillation counting. On day 14 the remaining culture medium and cells were assayed by scintillation counting. The remaining bone samples were decalcified and the total remaining ⁴⁵Ca in the bone was measured.

All results were expressed as the ratio of bone exposed to cells (BC)/bone only (B). Supernatant samples for ⁴⁵Ca showed a rise in BC/B ratio with time 0.83, 0.88, 0.97 and 1.08 (p= 0.0001). Supernatant samples for NTx also showed a rise with time 1.06, 1.21, 1.41 and 1.40 (p=0.03). In the bottom sampling for ⁴⁵Ca the mean ratio of BC/B was1.8 (p=0.0001) and the BC/B ratio for the remaining radioactivity in the bone at the end of the culture was 0.81(p=0.0007). There was a strong correlation between ⁴⁵Ca and NTx (r= 0.9).

The absolute values of ⁴⁵ Ca dropped initially due to the uptake of calcium by the cells and this explains our previously unsuccessful attempt to use non radioactive calcium as a marker of bone destruction. We believe this is the first time human interface membrane cells have been shown to release NTx during osteolysis in an in vitro model. Replacing ⁴⁵Ca radiolabelled bone with NTx as a marker represents an important step towards simplifying and reducing the cost of an in vitro model of particle induced osteolysis

Introduction: Deep infection remains a major complication of joint arthroplasty. Major randomised controlled trials to determine the most effective antibiotic prophylaxis are difficult to construct and interpret. In a conventional theatre most orthopaedic intraoperative wound contamination arrives by the airborne route.

Aim: To use a unique method to compare antibiotics against these airborne bacteria.

Method: Seven antibiotics were tested; Cephradine, Cefuroxime, Cefotaxime, Flucloxacillin, Amoxycillin, Co-amoxyclav and Imipenem. They were incorporated into blood agar at concentrations equivalent to serum levels. Plates were then inoculated with airborne theatre bacteria using a multiple synchronous collection technique. After incubation, the percentage kills were calculated for each antibiotic.

Results: At concentrations equivalent to serum levels one hour following an intravenous dose all of the antibiotics proved highly effective, with kill rates greater than 95%. Imipenem and Co-amoxiclav significantly outperformed the other antibiotics with kill rates of 99.6% and 99.4% respectively. At trough levels the antibiotics achieved kill rates from 61% to 97.6%.

Discussion: Future randomised controlled trials comparing antibiotics in the setting of an already low infection rate are inappropriate. This technique for comparing antibiotic prophylaxis is quick, inexpensive and repeatable. The superiority of Imipenem is not unexpected, given its broad spectrum against both gram positive and negative, aerobic and anaerobic bacteria. Of more interest is the effectiveness of Co-amoxiclav over the presently favoured Cefuroxime.

The ossific nucleus in Developmental Dysplasia of the Hip. A study of relative ossific nuceus size in hips treated in the Pavlik harness and its predictive value in treatment outcome.

Purpose

To assess the value of measuring relative ossific nucleus (ON) size difference in Developmental Dysplasia of the hip (DDH) as a potential predictor of outcome of hips treated in the Pavlik Harness.

Study Design

Prospective study of all unilateral cases (n=68) of DDH identified in Southampton by dynamic ultrasound and treated in a Pavlik harness studying changes in relative ON size and acetabular indices over a mean follow up period of 3.6 years.

Results

All cases responding to the Pavlik harness showed a progressive correction of ON size difference. Initial ON size difference was not associated with any difference in acetabular index at the date of last follow-up. Ultrasound grading of dysplasia did not affect the rate of normalisation of ON size difference.

Conclusion and clinical relevance

In patients responding to treatment of DDH in a Pavlik harness, ON size difference was not found to be a useful prognostic indicator of outcome.

Between June 1988 and December 1997, we treated 332 babies with 546 dysplastic hips in a Pavlik harness for primary developmental dysplasia of the hip as detected by the selective screening programme in Southampton. Each was managed by a strict protocol including ultrasonic monitoring of treatment in the harness. The group was prospectively studied during a mean period of 6.5 ± 2.7 years with follow-up of 89.9%. The acetabular index (AI) and centre-edge angle of Wiberg (CEA) were measured on annual radiographs to determine the development of the hip after treatment and were compared with published normal values.

The harness failed to reduce 18 hips in 16 patients (15.2% of dislocations, 3.3% of DDH). These required surgical treatment. The development of those hips which were successfully treated in the harness showed no significant difference from the normal values of the AI for the left hips of girls after 18 months of age. Of those dysplastic hips which were successfully reduced in the harness, 2.4% showed persistent significant late dysplasia (CEA < 20°) and 0.2% persistent severe late dysplasia (CEA < 15°). All could be identified by an abnormal CEA (< 20°) at five years of age, and many from the progression of the AI by 18 months. Dysplasia was considered to be sufficient to require innominate osteotomy in five (0.9%). Avascular necrosis was noted in 1% of hips treated in the harness.

We conclude that, using our protocol, successful initial treatment of DDH with the Pavlik harness appears to restore the natural development of the hip to normal. We suggest that regular radiological surveillance up to five years of age is a safe and effective practice.

We report 22 patients (19 women and three men) of mean age 20.8 years who had painful snapping sensations in the groin. Most were able to reproduce the click by extending the affected hip from a flexed, abducted and externally rotated position and most were tender in the adductor triangle. Plain radiographs and an arthrogram were normal. A clinical diagnosis of subluxation of the iliopsoas tendon was made. Conservative management failed in 14 patients, two of whom had bilateral pain. All 14 had surgical release of the iliopsoas tendon through a medial approach. At follow-up (mean 17 months) the click had resolved in ten hips, was occasional but painless in five and unchanged in one. The syndrome of a painful 'snapping' psoas may result in disproportionately disabling symptoms. It may be diagnosed on clinical grounds and effectively treated, when severe, by release of the iliopsoas tendon.

Between 1989 and 1992 we admitted 426 children with an irritable hip, 363 (85.2%) once and 63 (14.8%) on 143 occasions. We assessed the records retrospectively to determine whether the groups differed and in particular whether recurrence was followed by pathological sequelae. We identified no feature which distinguished between them at either presentation. The use of bone isotope scans was greatly increased in recurrent cases, without clinical benefit. No relationship between recurrence and subsequent abnormality was identified, with 22 (42%) of the recurrences taking place in the opposite hip. The only difference was a higher incidence of 'psychosocial factors' recorded in the notes of children who presented on more than two occasions. The incidence of recurrent irritable hip is larger than previously indicated and in the presence of normal radiographs and low-grade clinical signs, more detailed investigation on subsequent admission is unlikely to be helpful.

We modelled a 'clean' surgical wound lightly contaminated with airborne bacteria, using agar, ovine muscle and ovine adipose tissue. This was used to assess the effect on bacteria of ultraviolet C light (UVC) 1200 mu W/cm2, hydrogen peroxide 3%, povidone-iodine 1% and 10%, chlorhexidine 0.05%, pulsed jet lavage with UVC and syringe and needle lavage with chlorhexidine 0.05%. All the agents were effective on agar, but mixing with blood or plasma neutralised hydrogen peroxide and povidone-iodine 1%. All the agents were less effective on tissue specimens than on agar, but were more effective on adipose tissue than on muscle. All the antiseptics except chlorhexidine were less effective when blood or plasma was added to muscle specimens before disinfection. UVC after pulsed jet lavage had an additive effect. Syringe and needle lavage with chlorhexidine 0.05% was the most effective method tested; it reduced colony counts by 99.8% and warrants clinical investigation.

We studied the effects of nine techniques of bone surface preparation on cement penetration and shear strength at the cement-bone interface in a standard model of bovine cancellous bone. In unprepared bone the mean penetration was 0.2 mm and the mean shear strength of the interface was 1.9 MPa, less than that of the underlying bone. Brushing with surface irrigation gave mean penetrations of 0.6 to 1.4 mm and mean shear strengths of 1.5 to 9.9 MPa. In 50% of specimens the interface was weaker than the underlying bone. The use of pressurised lavage resulted in mean penetrations of 4.8 to 7.9 mm and mean shear strengths of 26.5 to 36.1 MPa, which were greater than those of the cancellous bone in all specimens. Pressurised lavage was equally effective alone or in combination with brushing, and its efficacy was not altered by using pulsed or continuous jets, or by changing the temperature of the solution from 21 degrees C to 37 degrees C.

Computerised arthrotomography was performed on 33 patients four to six weeks after acute primary anterior dislocation of the shoulder. Seventeen patients were under, and 16 over 50 years of age. Damage to the anterior glenoidal labrum was seen in all the younger patients and in 75% of the older ones. A large redundant capsular pouch, seen in the older patients, was present in 35% of the younger ones, and a posterior humeral head defect was seen in 82% of the younger patients and only 50% of the older. Associated fractures were more common in the older patients, and a tear of the rotator cuff was demonstrated in 63% of the older patients and in none of the younger ones.

Sixty-nine heels in 42 patients with prominence of the calcaneus sufficient to cause symptoms were operated upon after conservative treatment had failed. At review the overall results of operation were found to be poor.