Aim: To compare between the number of steps and instruments required for total knee arthroplasty (TKA) using 3 different techniques. The proposed techniques were conventional technique, conventional technique with patient-specific pin locators and CAOS technique using patient-specific templates (PST). Patients and methods: Zimmer/Nexgen was used as the standard implant and templating system for TKA. A Comparison was done on the number of steps and instruments required for TKA when performed with conventional technique, conventional technique with patient-specific pin locators and CAOS technique with patient-specific templates (PST) used as cutting guides. Results: The essential steps and instruments required for conventional TKA without surgical approach or bone exposure were average 70 steps with 183 different instruments; for conventional technique with patient-specific pin locators, they were average 20 steps with 40 instruments and two templates; for CAOS technique using PST, they were average 10 steps with two templates and 15 accessory instruments. CAOS PST technique required an average of 4 days for preoperative preparation and templates fabrication. Conclusion: CAOS technique using PST could make TKA less complicated in light of essential steps and instrumentation required. Although this technique required accurate preoperative preparation, it could offer less technical errors and shorter operative time compared to conventional TKA techniques. The errors’ rate for each technique was still depending on the surgeon's skills and training; however, CAOS technique with PST required shorter learning curve.

A retrospective review of 57 military patients undergoing ankle arthroscopy between 1999 and 2011 was performed. A case-note review of medical records was undertaken pertaining to military role, ankle injury sustained, mechanism, presenting symptoms and their duration. Arthroscopic findings were compared to findings on radiographs and MRI scans. At first presentation 23 patients had features of arthritis on radiographs. We found MRI was both highly sensitive (97.7%) and specific (93.4%) in detecting osteochondral defects (OCD). 16 of the patients had evidence of osteochondral injury. All OCDs picked up on MRI were confirmed at arthroscopy. Ankle injury may not be a benign injury in military personnel, with over half of these young patients having radiological features of osteoarthritis at presentation. We found MRI an effective tool for identifying occult injuries not seen on radiographs. Lateral ligament injury with associated gutter scarring can be successfully treated with arthroscopic debridement. This suggests pseudoinstability rather than a true mechanical instability as the main cause for patient's symptoms in this cohort.

Introduction

Both intra- and post-operative radiographs are traditionally obtained after instrumented lumbar spinal surgery; however the clinical advantage of routine post operative images has not been demonstrated.

Introduction

Restrictions placed on the working hours of doctors have led to increasing time-pressures on surgical training. Consequently, there has been growing interest in developing new techniques to teach and assess technical skills. The primary aim of this study was to determine whether a novel set of visual parameters assessing visuospatial ability, fine motor dexterity and gaze control could objectively distinguish between varying levels of arthroscopic experience. The secondary aim was to evaluate the correlations between these new parameters and previously established technical skill assessment methods.

Akins original description of his osteotomy did not describe the use of any metal work. Today the osteotomy is most commonly held and fixed with either a staple or screw. We describe the results obtained with a simple suture technique. Methods Data was collected prospectively on 125 patients undergoing an Akin osteotomy. Hallux valgus (HV) and intermetatarsal (IM) angles pre and postoperatively were recorded. Patients were reviewed at 6 week follow up. Cost analysis was also performed comparing different fixation types.

111 of the patients were female and 14 male. The average age at time of surgery was 49 years. 104 cases were in conjunction with hallux valgus correction while 21 cases were for hallux interphalangeus. The mean preoperative HV angle was 33.3 degrees (range 22 to 53), and the IM angle 13.3 degrees (range 9 to 25). At the 6 week follow up all patients had shown signs of radiological union. The postoperative HV angle was 12.4 degrees (range 7 to 17) and the IM angle 6.4 degrees (range 5 to 11). All patients maintained their correction. There were no complications, infections or fixation problems. All patients were satisfied with their surgery and would have it repeated again. The suture technique was the most cost effective method.

We describe a quick, easy, implant free method of fixing the Akin osteotomy. There is no need for metalwork removal and in today's world of austerity and the current climate of widespread budget constraints we describe a cost effective method which is clinically just as effective as methods requiring a staple or screw.

Rheumatology and Musculoskeletal Sciences, NIHR Biomedical Research Unit, University of Oxford and the Nuffield Orthopaedic Hospital, Oxford

Purpose

The purpose was to determine if the use of cold irrigation fluid in routine knee arthroscopy leads to a reduction in post operative pain.

Introduction

Total knee arthroplasty (TKA) accounts for 84% of all knee replacement surgery in the UK (NJR 2009) despite published epidemiological data showing that single compartment disease is most prevalent. We investigated this incompatibility further by describing the compartmental pattern and stage of cartilage loss of all patients with osteoarthritis (OA) presenting to a specialist knee clinic over one year.

The purpose of this prospective audit was to assess the efficacy of local infiltration analgesia in relieving postoperative pain following knee replacement surgery.

Methods and materials: Data was collected on 61 consecutive patients undergoing knee replacement. They formed 2 groups. Patients in Group I (n=33) had 30 mls of Bupivacaine 0.5%, Ketoralac 30 mg, 0.75ml of adrenaline 1:1000 concentration made up to100mls with normal saline while patients in Group II (n=28) had either patient controlled analgesia (PCA) or regional nerve blocks. The group I patients had the local analgesia cocktail infiltrated into the soft tissues before wound closure. Majority of these patients had spinal anaesthesia supplemented with sedation while some had general anaesthesia supplemented with regional nerve blocks. All the patients were prescribed morphine as rescue analgesia and patacetamol/co-codamol and/or naproxene as supplemental analgesia. Pain was assessed with Numerical Rating Scale (NRS 0 – 10) at 1 hr, 3 hr, 6 hr and 8 hrs post-operatively.

Results: The two groups were well matched for age, sex, ASA grade and body mass index. Pain control was generally satisfactory for group I (NRS range 0 – 2) compared to group II (NRS range 0 – 7). Most patients did not require morphine for post-operative pain control in group I (18/27 pts) while additional analgesics were not needed until 6 hours in this group. They were able to mobilise with assistance earlier compared to the other group. Moreover the pain levels as assessed by pain scores were lower with group I patients compared to group II patients. The nursing level of intensity was lower in group I patients as monitoring of PCA was not required compared to group II patients.

Conclusion: Local infiltration analgesia is practical, simple and safe procedure with good efficacy in relieving pain after knee surgery. Moreover monitoring levels are reduced relieving nursing staff to concentrate on other duties.

It is unclear which length of thread may be most advantageous for the internal fixation of an intracapsular fracture with cancellous screws. We have compared the 16mm versus the 32mm threads on cancellous screws within a randomised trial for 432 patients. All fractures were fixed with three screws and patients followed-up for a minimum of one year from injury.

The characteristics of the patients in the two groups was similar with a mean age of 76 years. 23% were male. The most common complication encountered was non-union of the fracture which for undisplaced fractures occurred in 7/107(6.5%) of short threaded screws versus 11/133(8.3%) of long threaded screws. For displaced fractures the figures were 29/104(27.9%) versus 24/89(27.0%). Other complications for the short versus long threaded group were avascular necrosis (two cases versus five cases) and fracture below the implant (two cases in each group). Elective removal of the screws for discomfort was undertaken in five and three cases respectively. None of these differences between groups was statistically significant. In summary there is no difference in fracture healing complications related to the length of the screw threads.

Background: Guidelines for the management of Low Back Pain (LBP) consistently recommend that the initial assessment focuses on the detection of serious spinal pathologies. In 1994 the UK Clinical Standards Advisory Group introduced the concept of “red flags”. One of these red flags is the first presentation of LBP in people over the age of 55 years. The aim of this study was to investigate the incidence of serious spinal pathologies in patients presenting with new onset of LBP over the age of 55 years.

Method/Results: This was a prospective analysis of all patients presenting to a secondary care spinal triage service over a 3 year period (2005–2008). During the study period, in excess of 3000 patients were seen. Of these, a total of 70 patients presented with a first onset of LBP aged over 55 years and had no other red flags. Analysis of this group of patients revealed 2 serious spinal pathologies. Both of which were osteoporotic vertebral compression fractures. Both patients were over age 75. In addition 1 patient had severe central lumbar canal stenosis. Therefore, 2.3% of patients presented with the first onset of LBP > 55 years, of which 2.9% has serious pathology. Patients > 55 years with cancer or infection had other red flags in addition.

Conclusion: In isolation the first onset of LBP over the age > 55 accounts for a small percentage of this secondary care population, of which 2.9% had vertebral compression fractures. Further research into the clinical value of this independent red flag or its added value in combination with other red flags is recommended.

Two of the major complications of total hip and knee arthroplasty is periprosthetic infection and aseptic loosening. The serum marker Procalcitonin (PCT) has been shown to be a sensitive indicator of bacterial infection, but very little is known of its behaviour in Orthopaedic practice. The diagnosis of periprosthetic infection still remains a difficult diagnosis.

A prospective study over 6 months of 59 patients undergoing either primary total hip or knee arthroplasty was performed, which included 32 hips. The mean age was 70 years. There were no exclusion criteria. Serum blood samples for PCT, CRP, ESR and WCC were taken pre- operatively and on days 1, 3 and 5 post- operatively. Patient records were reviewed after their routine 6 week follow- up. There was no clinical suspicion of infection at this stage, or during their hospital stay.

Fifty patients (85%) had PCT concentrations within the normal range (< 0.5ng/ml) on all 4 days, and only 5 recorded a value > 1.0ng/ml. Only 1 patient had an elevated level on day 5. The other markers all showed sporadic elevation over the 3 post- operative days

The usefulness of PCT in diagnosing surgical infection has been frequently researched in cardio- thoracic and abdominal surgery. However, there is debate as to what cut- off value should represent infection, ranging from 1– 10ng/ml. This is largely because the natural acute phase response caused by these operations elevates PCT levels. This study convincingly shows that PCT, unlike the routine inflammatory markers, is not significantly stimulated by primary hip and knee arthroplasty. This would imply that PCT may be useful in diagnosing periprosthetic infection. A large multicentre study involving patients undergoing revision surgery would help validate this assumption.

Purpose of the study: To see if there are any differences in pain relief and complications with intraarticular Knee injection of synthetic and avian Hyaluronic acid products.

Summary: After following the inclusion and exclusion criteria, 130 patients were randomly allocated two groups, receiving either synthetic or avian Hyaluronic acid injections. Patients were explained about the study and consent was sought. They were given Western Ontario and McMaster University [WOMAC] questionnaires to be filled before, 48 hours, 6 weeks and 3 months after the injections. They were examined at 6 weeks, 3 and 6 months post injections.

124 of these patients promptly responded. 68 patients had natural product and 56 patients had synthetic product.

In the natural injection group of 68 patients, 57 had pain relief at 3 months and 20 of these continued to have relief at 6 months.

In the synthetic injection group of 56 patients, 48 had pain relief at 3 months and 28 of these continued to have relief at 6 months.

No complications were noted in either of the groups.

Difference of WOMAC scores were done at 6weeks and 3 months for each group. The p value of this difference of scores was 0.12 at 6 weeks and 0.92 at 3 months showing no significant difference. The 95% confidence intervals [avian vs synthetic] at 6weeks were −0.8 to 7.2 and at 3 months were −3.8 to 4.2. The p value of clinical examination at 6 months was 0.043 showing significance.

Conclusion: Synthetic injections are significantly more effective, economical and equally safe as avian injections.

Study Design: Prospective Cohort Study.

Summary of Background Data: It has previously been suggested that fulcrum bending radiographs (Cheung et al Luk 1997) and traction radiography under anaesthetic (Davis et al 2003) predict the flexibility and correction obtained following surgery better than conventional supine bending radiographs.

Objective: To compare fulcrum bending radiographs and traction radiographs for the prediction of surgical correction of idiopathic scoliosis.

Subjects: The study was based on 16 patients with a diagnosis of idiopathic scoliosis who underwent corrective surgery.

Outcome measures: The Cobb angle of the major curve was compared on the standing AP and fulcrum bending radiograph taken in the pre-op assessment clinic, the traction film undertaken under anaesthetic immediately prior to surgery and the first post operative standing radiograph taken. The post operative correction of the major curve was analysed using regression techniques and adjusted for the base line curve angle of the major curve.

Results: The results were presented as an estimate of the parameter coefficient in the model associated with 95% confidence intervals. The median pre-operative Cobb angle of the major curve was 69 degrees, on the fulcrum bending film was 47 degrees, on the traction film was 30 degrees, and on the first post operative film was 30 degrees. There was no evidence to suggest that the fulcrum Cobb had an effect on the post operative correction of the major curve. There was however evidence to suggest that the traction Cobb angle had an effect on the post operative correction of the major curve (parameter estimate 0.87) 95% CI (0.174, 1.399), T value = 2.83, P = 0.016.

Conclusion: Traction radiographs under anaesthetic better predict the surgical correction obtained in adolescent idiopathic scoliosis compared to fulcrum bending radiographs. These two techniques have not been directly compared before.

Aims: To report medium term results of Beuchal Pappas total ankle replacement carried out at Corbett hospital. Methods: We report a series of 15 patients who underwent this procedure at the Corbett hospital in Dudley between February 95 and March 01. One patient died of an unrelated cause and 14 were followed for an average of 4 years. All patients received the New Jersey total ankle replacement performed by one senior consultant orthopaedic surgeon (SA). The patients were invited to attend a special follow up clinic for clinical and radiological review. The Kitioka ankle scoring system was used to assess outcome. Results: The average age was 64 years. There were 8 women and 6 men. The preoperative diagnosis was advanced post-traumatic arthritis in all patients. Two underwent revision of tibial component- one at 3 years post operative for septic loosening, and the other at 2 years post operative for aseptic loosening. One patient required open washout 7 months post operative for deep infection. The average ankle score in the group was 79. All patients replied in the afþr-mative when asked if they would undergo the operation again. Conclusions: We feel that in carefully selected patients ankle replacement gives satisfactory outcome and can be safely performed in a district general hospital setting. Careful preoperative counselling regarding risks of loosening and infection is essential.

Introduction: 4525 THRs and 1071 TKRs were performed in the eight-health board region of Ireland in the year 2001. The demand continues to increase and long waiting lists for surgery are common. In September 2002, 3258 public patients were waiting for orthopaedic surgery and many of these are joint replacement procedures.

We have developed a system of assessment and reassessment and for the patients who are on the waiting list for hi p and knee arthroplasty. We have evaluated the changes in hip and knee scores in cohort of patients while waiting for surgery.

Method: 153 patients who waited I excess of 6 months for surgery were assessed. Changes in Harris Hip Score and American Knee Society Score while waiting were analyzed. The range of scores for HHS is from 0 (severely disabled) to 100 (normal), and similarly for AKSS is 0 to 200, depending on the symptoms, disabilities and physical findings of the patient.

Result: Out of 153 patients for arthroplasty 105 (68.62%) were waiting for the THR and 48 (31.37%) were waiting for the TKR. Patients for THR (n=105) ranged in age from 30–90 years, with a mean age of 60 years. The average initial hip score was 63.70 and the average hip score in assessment clinic was 53.00 so the average scores deteriorated in score of 24.42 on reassessment.

Conclusion: Above result shows that there is significant deterioration in both hip (10.7) and knee (24.42) scores in patients waiting for hip and knee replacement over a six-month period. This emphasises the importance of regular review and reassessment of waiting list to allow reprioritisation according to changing clinical needs.

Experimentally produced fractures in long bones studied by light and electron microscopic histochemistry were found to heal by a process of enchondral calcification. There was intense proliferation in the cells of the cambium layer of the periosteum, with differentiation to chondroblasts and osteoblasts, suggesting that this layer was the primary tissue responsible for development of the callus. Cytoplasmic processes of the hypertrophic chondrocytes appeared to bud and produce matrix vesicles. Alkaline phosphatase activity was detected along the plasma membrane of the hypertrophic chondrocytes and around the matrix vesicles, before any signs of mineral deposition. Calcification took place by deposition of hydroxyapatite crystals in and around these matrix vesicles which frequently showed alkaline phosphatase activity. It is suggested that there is a close functional association between alkaline phosphatase activity and calcification in the process of fracture healing, which is another type of enchondral calcification mediated by matrix vesicles.