The number of primary Total Knee Arthroplasty (TKA) and primary Total Hip Arthroplasty (THA) procedures carried out in England and Wales is increasing annually. The British Orthopaedic Association guidelines for follow up currently differ for patients with TKA and THA. In THA the BOA recommends that Orthopaedic Data Evaluation Panel (ODEP) 10A rated implants should be followed up in the first year, once at seven years and three yearly thereafter. The BOA guidelines for TKA minimum requirement is radiographs at 5 years and each five years thereafter. Few studies have investigated if early follow up affects patient management following total hip and knee arthroplasty

We carried out a retrospective review of all revision procedures carried out in our institution between April 2010 to April 2013. The medical notes and radiographs for each patient were examined to determine the operative indications and patients symptoms. 92 knee revisions and 143 hip revisions were identified. Additionally we retrospectively reviewed the outcome of 300 one year routine arthroplasty follow up appointments.

The mean time of hip revision was 8.5years (range 0 to 27years) and 5.6years (range 0 to 20years) for knee revisions. The commonest cause for revision was aseptic loosening associated with pain in 49 (53%) of knee revision patients and 89 (63%) of hip revisions. Infection accounted for 26 (28%) knee revisions and 16 (12%) hip revisions. Only 1% of hip and knee revisions was carried out in asymptomatic patients with aseptic loosening.

We did not identify any cases were a patients management was altered at the routine arthroplasty review clinic and none were referred on for further surgical treatment. The findings of our study suggest there is no evidence for a routine one year arthroplasty review and revisions were carried out in asymptomatic patients in 1% of patients.

Myotome values for the upper limb appear to have been established in the early twentieth century based on historical work. Supraclavicular brachial plexus injuries present with a pattern of neurological loss consistent to the nerve roots affected. Recent advances in radiological imaging and intraoperative nerve stimulation have allowed confirmation of the affected nerve roots.

The records of 43 patients with partial injuries to the supraclavicular brachial plexus were reviewed. The injuries covered the full range of injury patterns including those affecting C5, C5-6, C5-7, C5-8, C7-T1 and C8-T1 roots. All cases with upper plexus injuries had surgical exploration of the brachial plexus with the injury pattern being classified on the basis of whether the roots were in continuity, ruptured, or avulsed, and, if seen in continuity, the presence or absence of a response to stimulation. For lower plexus injuries the classification relied on identification of avulsed roots on Magnetic Resonance Imaging. Muscle powers recorded on clinical examination using the MRC grading system.

In upper plexus injuries paralysis of flexor carpi radialis indicated involvement of C7 in addition to C5-6, and paralysis of triceps and pectoralis major suggested loss of C8 function. A major input from T1 was confirmed for flexor digitorum superficialis, flexor digitorum profundus (FDP) to the radial digits, and extensor pollicis longus. C8 was the predominant innervation to the ulnar side of FDP and intrinsic muscles innervated by the ulnar nerve with some contribution from C7.

A revised myotome chart for the upper limb is proposed.

Introduction

Two randomised trials concluded cast type (above or below elbow) makes no significant difference in the re-displacement rate of paediatric forearm fractures involving the distal third of the radius. This has not, however, led to the universal use of below elbow casts. In particular we noted one trial reported significant re-displacement in 40% or more of cases, which was much higher than we would expect.

To review the radiological outcomes and need for re-manipulation of paediatric distal forearm fractures treated with closed manipulation under anaesthesia in our institution, in part for subsequent comparison with published results.

All forearm fractures treated at a specialist children's hospital in one year were reviewed retrospectively. Based on the methodology of one trial, we included all fractures involving the distal third of the radius, with or without an ulna fracture, which underwent closed manipulation. Outcomes were radiological alignment using existing radiographs and need for re-manipulation. Cast type was at the discretion of the treating surgeon. The radiological criteria for re-displacement were based on published methodology.

79 children underwent manipulation, 71 receiving above elbow casts and 8 below elbow casts. Radiologically 21% of injuries treated in an above elbow cast re-displaced (15/71) compared to 38% of those in below elbow plasters (3/8). In 2 cases the re-displacement was treated with re-manipulation.

The preference in our institution was clearly for above elbow casts in this injury pattern. The small number of below elbow casts in our series limits any comparisons. Our rate of re-displacement using above elbow casts was half that of one of the published studies, so the existing literature is not consistent with our experience.

Primary bone tumours of the clavicle are rare. Currently the existing literature is limited to a single case series and case reports or cases. Information regarding the patient's demographics and tumour types is therefore limited.

The aim of this study was to investigate the and also suggest a management protocol for suspected primary bone tumours of the clavicle. We retrospectively reviewed the Scottish Bone Tumour Register from January 1971 to January 2012 and included all primary bone tumours of the clavicle.

We identified only sixteen primary bone tumours over forty one year's highlighting the rarity of these tumours. There were ten benign and six malignant tumours with a mean age of 32 years (Range 4 to 66). The average presentation to orthopaedics after onset of symptoms was two months with five patients presenting following a pathological fracture. Malignant tumour types identified were consistent with previous literature with two cases of Ewing's sarcoma and osteosarcoma and a single case of osteosarcoma post radiotherapy and a single case of chondrosarcoma. Benign tumours were treated effectively with intralesional procedures. Malignant tumours were treated with wide local excision and subtotal or total clavicle excision.

We suggest an investigatory and treatment protocol for patients with a suspected primary bone tumour of the clavicle. This is the largest series of primary bone tumours of the clavicle in the literature.

The surgical management of musculoskeletal tumours is a challenging problem, particularly in pelvic and diaphyseal tumour resection where accurate determination of bony transection points is extremely important to optimise oncologic, functional and reconstructive options. The use of computer assisted navigation in these cases could improve surgical precision.

We resected musculoskeletal tumours in fifteen patients using commercially available computer navigation software (Orthomap 3D). Of the eight pelvic tumours, three underwent biological reconstruction with extra corporeal irradiation; three endoprosthetic replacement (EPR) and two required no bony reconstruction. Four diaphyseal tumours had biological reconstruction. Two patients with proximal femoral sarcoma underwent extra-articular resection and EPR. One soft tissue sarcoma of the adductor compartment involving the femur was resected with EPR.

Histological examination of the resected specimens revealed tumour free margins in all cases. Post-operative radiographs and CT show resection and reconstruction as planned in all cases. Several learning points were identified related to juvenile bony anatomy and intra-operative registration.

The use of computer navigation in musculoskeletal oncology allows integration of local anatomy and tumour extent to identify resection margins accurately. Furthermore, it can aid in reconstruction following tumour resection. Our experience thus far has been encouraging.

Current knowledge regarding upper limb myotomes is based on historic papers. Recent advances in magnetic resonance imaging (MRI) and surgical exploration with intraoperative nerve stimulation now allow accurate identification of nerve root injuries in the brachial plexus. The aim of this study is to identify the myotome values of the upper limb associated with defined supraclvicular brachial plexus injuries.

57 patients with partial supraclavicular brachial plexus injuries were identified from the Scottish brachial plexus database. The average age was 28 years and most injuries secondary to motor cycle accidents or stabbings. The operative and MRI findings for each patient were checked to establish the root injuries and the muscle powers of the upper limb documented.

The main patterns of injuries identified involved (C5,6), (C5,6,7), (C5,6,7,8) and (C8, T1). C5, 6 injuries were associated with loss of shoulder abduction, external rotation and elbow flexion. In 30% of the 16 cases showed some biceps action from the C7 root. C5,6,7 injuries showed a similar pattern of weakness with the additional loss of flexor carpi radialis and weakness but not total paralysis of triceps in 85% of cases. C5,6,7,8 injuries were characterised by loss of pectoralis major, lattisimus dorsi, triceps, wrist extension, finger extension and as well as weakness of the ulnar intrinsic muscles. We identified weakness of the flexor digitorum profundus to the ulnar sided digits in 83% of cases. T1 has a major input to innervation of flexors of the radial digits and thumb, as well as intrinsics.

This is the largest study of myotome values in patients with surgically or radiologically confirmed injuries in the literature and presents information for general orthopaedic surgeons dealing with trauma patients for the differentiation of different patterns of brachial plexus injuries. In addition we have identified new anatomical relationships not previously described in upper limb myotomes.

We report the short term follow up of nineteen consecutive PFC sigma unicompartmental knee replacements carried out in our institution with minimum one year follow up. The PFC Sigma medial unicompartmental knee replacement is a fixed bearing, cemented unicompartmenal knee replacement. There are currently no published reports of follow up for the PFC Sigma medial unicompartmental knee replacement.

Nineteen patients (nineteen knees) underwent PFC sigma medial unicompartmental knee arthroplasty. The pre-operative diagnosis was osteoarthritis in eighteen patients and osteonecrosis in one patient. There were ten males and nine females with a mean age of sixty four years. All patients had clinical and radiological review at one year. All operations were carried out by the two senior authors (BPR and BL).

The mean length of admission was 2.7 days (Range 2–5). There have been no infective or thromboembolic complications to date. The mean oxford scores improved from 41 (Range 26–52) pre-operatively to 18 (15–27) at one year follow-up. The mean range of motion improved from 115 degrees of flexion preoperatively to 125 degrees. All radiographs were satisfactory at one year follow up with no evidence of loosening.

We report the promising early results of a new medial unicompartmental knee replacement with at least one year follow up. No early complications or infections were identified in our cohort of patients.

To collate and present epidemiological data collected by Scottish National Brachial Injury Service over the past decade.

The Brachial Plexus Injury Service is based at the Victoria Infirmary, Glasgow and has been a designated National Service since 2004. It provides an integrated multidisciplinary service for traumatic brachial plexus injury and plexus tumours. The Service maintains an active archive recording details of all clinical referrals and procedures conducted by the Service over the past decade. The data presented here was derived from analysis of this database and information contained in the National Brachial Plexus Injury Service Annual Report 2010/11 & 2011/12.

Data shows that there has been a steady rate in the number of referrals to the Service, particularly since 2004, with an average of 50 cases referred per annum. Of these, approximately 25% required formal surgical exploration for traumatic injury and a further 10% required surgery for brachial plexus tumour removal. The vast majority of referred cases are treated non-operatively, with appropriate support from specialist physiotherapy and occupational therapy. Referrals to the Service appear well distributed from around Scotland. However, data from 2011 shows that Greater Glasgow & Clyde is the greatest individual source of referrals and subsequent hospital admissions for surgical treatment. The commonest mechanism of brachial plexus injury appears to be secondary to falls and motorcycle RTA. Using the Disabilities of the Arm, Shoulder and Hand (DASH) Score, improved functional outcomes have been demonstrated consistently in patients who have undergone surgery for brachial plexus injuries within the Service.

Over the past decade, the Brachial Plexus Injury Service has had a steady patient referral record from across the Scotland, particularly Glasgow. Data indicates that there is an on-going clinical need for provision of the service with improved outcomes and reduced functional disability in patients treated by the service. It is envisaged that data from the Service will also act as a useful planning model for the provision of UK national services in the future.

Background

The surgical management of musculoskeletal tumours is a challenging problem, particularly in pelvic and diaphyseal tumour resection where accurate determination of bony transection points is extremely important to optimise oncologic, functional and reconstructive options. The use of computer assisted navigation in these cases could improve surgical precision.

Arthordesis of small joints of the foot is a commonly performed procedure in orthopaedics. A variety of fixation devices have been used for this purpose. Nickel-Titanium Memory compression staples for arthrodesis have been used in our institute since June 2003. We report the results of the procedure over a period of 7years involving 252 feet in 232 consecutive patients who underwent arthrodesis or an osteotomy fixation using compression staples. The patients were evaluated to determine the period of immobilization in cast and the time to radiographic joint fusion.

The emphasis of this study was to validate the safety of the implant for fusion of small joints of the foot, as well as to determine whether there is a demonstrable trend in time to fusion and period of immobilization required.

The average time to fusion was 7.2 weeks, the average period of immobilisation was 6.5 weeks. Successful union was achieved in 98% cases. We report the follow up results, finer technical aspects of the procedure and pitfalls to avoid whilst performing the fusions.

Introduction

Bony tumours of the foot account for approximately 3% of all osseous tumours. However, literature regarding os calcis and talar tumours comprises individual case reports, short case series or literature reviews with no recent large series.

Introduction

Total knee arthroplasty is an established and successful operation. In up to 10% of patients who undergo total knee arthroplasty continue to complain of pain [1]. Recently computerised tomography (CT) has been used to assess the rotational profile of both the tibial and femoral components in painful total knee arthroplasty.

The purpose of this study was to determine if the use of a new 4 Dimensional CT scan aids the clinician in defining the size and area of the scapular bone to be removed arthroscopically in patients with Snapping Scapular Syndrome.

From January 2009 – January 2011 nine consecutive patients with Snapping Scapular Syndrome were included. In six patients, (mean age 21±5 years, range 15–27) conservative treatment failed. These patients were positioned prone and demonstrated their snapping motion during the 7 seconds duration of the scan. The 4D CT machine scans 16 cm volumes in 0.3 seconds. It also scans motion, allowing a 3D reconstruction of the scapulothoracic joint, its’ movements and the dynamic area of impingement of the scapula on the surrounding structures. This scan has already improved arthroscopic removal of the supero-medial angle of the scapula.

The scan showed in one case not only snapping of the superior medial angle of the scapula on the 2nd rib, but also extra bone impinging on the 3rd rib. Another case showed no real impingement but movement of the 2nd and 3rd rib by a tethering structure and a third case demonstrated impingement of the lateral third of the clavicle on the 2nd rib.

The images provided by this new 4D CT scan offer greater pre-operative insight on the pathology in each individual patient with Snapping Scapular Syndrome. Therefore, we feel that it is a valuable addition to the assessment and treatment of these patients.

The purpose of this study was to determine the motion pattern of the Acromio-Clavicular (AC) joint in a normal shoulder with the use of the new 4 Dimensional CT scan.

From April 2010 till January 2011 fourteen healthy volunteers (4 female, 10 male)(mean age 42±11 years) with no previous history of shoulder complaints participated in this study. The 4D CT machine scans motion, allowing a 3D reconstruction of the shoulder joint and its movements. Patients were positioned supine with their arm elevated 90° in the sagittal plane. During the 7 seconds duration of the scan they adducted their arm at that level and then elevated their arm upwards resisted by the gantry for 4 seconds, in this way simulating the clinical Bell-van Riet test for AC pathology.

In the transverse plane the mean AC joint space measured in the neutral position is 1.8±0.5 mm. While adducting the arm the AC joint narrows 0.0±0.4 mm (with a positive value being narrowing and a negative value widening). On resisted elevation the joint space is narrowed 0.2±0.6 mm. The mean antero-posterior (AP) translation in this same plane is 0.2±2.2 mm on adduction (with a positive value being posterior translation of the clavicle and a negative value anterior translation) and 0.4±2.9 mm on resisted elevation.

The new 4D CT scan demonstrates that the AC joint in a normal shoulder mainly translates in an AP direction, rather than being narrowed or widened, when the arm is adducted (with or without resisted active elevation).

Total knee arthroplasty (TKA) is an established and successful operation. However patient satisfaction rates vary from 81 to 89% 1,2,3. Pain following TKA is a significant factor in patient dissatisfaction 1. Many causes for pain following total knee arthroplasty have been identified 4 but rates of unexplained pain vary from 4 to 13.1% 5,6. Recently computerised tomography (CT) has been used to assess the rotational profile of both the tibial and femoral components in painful TKA

We reviewed 57 patients with an unexplained painful following TKA and compared these to a matched control group of 60 patients with TKA. Datum gathered from case notes and radiographs using a prospective database to identify patients. The CT information recorded was limb alignment, tibial component rotation, and femoral component rotation and combined rotation.

The two matched cohorts of patients had similar demographics. A significant difference in tibial, femoral and combined component rotation was identified between the groups. The following mean rotations were identified for the painful and control groups respectively. Tibial rotation was 3.46 degrees internal rotation (IR) compared to 2.50 degrees external rotation (ER)(p=0.001). Femoral rotation was 2.30 IR compared to 0.36 ER(p=0.02). Combined rotation was 7.08 IR compared to 2.85 ER(p=0.001).

This is the largest study presently in the literature. We have identified significant internal rotation in a patient cohort with unexplained painful TKA when compared to a matched control group. Internal rotation of the tibial component, femoral component and combined rotation was identified as a factor in unexplained pain following TKA.

Introduction

Bony tumours of foot account for approximately 3% of osseous tumours. However, literature regarding calcaneal tumours comprises individual case reports, short case series or literature reviews, with last large case series in 1973. Literature on bony tumours of the talus is limited to case reports only.

Bony tumours of the foot account for approximately 3% of all osseous tumours. However, literature regarding os calcis tumours comprises individual case reports, short case series or literature reviews, with the last large case series in 1973.

We retrospectively reviewed the medical notes and imaging for all patients with calcaneal tumours recorded in the Scottish Bone Tumour Registry since the 1940's. Demographics, presentation, investigation, histology, management and outcome were reviewed.

38 calcaneal tumours were identified. Male to female ratio 2:1, mean age at presentation 30 with heel pain and swelling, average length of symptoms 9 months. 4 cases present with pathological fracture. 24 tumours benign including 6 unicameral bone cysts, 3 chondroblastoma, 3 PVNS with calcaneal erosion, and a wide variety of individual lesions. 13 malignant tumours comprising 6 osteosarcoma, 5 chondrosarcoma and 2 Ewings sarcoma. 1 metastatic carcinoma.

Tumours of the calcaneus frequently are delayed in diagnosis due to their rarity and lack of clinician familiarity. They are more common in men and have a 1 in 3 risk of malignancy, covering a wide variety of lesions. Outcome is dependent on early diagnosis, timely surgery and most importantly neo-adjuvant chemotherapy. Diagnosis is often made on plain radiograph but MRI is the gold standard.

We present the largest case series of calcaneal tumours, from our experience with the Scottish Bone Tumour Registry. Despite their rarity clinicians should maintain a high index of suspicion as accurate and timely diagnosis is important to management and outcome.

Total knee arthroplasty is an established and successful operation. In up to 13% of patients who undergo total knee arthroplasty continue to complain of pain. Recently computerised tomography (CT) has been used to assess the rotational profile of both the tibial and femoral components in painful total knee arthroplasty.

We reviewed 56 painful total knee replacements and compared these to 56 matched patients with pain free total knee replacements. Patients with infection, aseptic loosening, revision arthroplasties and gross coronal malalignment were excluded. Datum gathered from case notes and radiographs using a prospective orthopaedic database to identify patients. The age, sex, preoperative and postoperative Oxford scores, visual analogue scores and treatments recorded. The CT information recorded was limb alignment, tibial component rotation, femoral component rotation and combined rotation.

The two cohorts of patients had similar demographics. The mean limb alignments were 1.7 degrees varus and 0.01 degrees valgus in the painful and control groups respectively. A significant difference in tibial component rotation was identified between the groups with 3.2 degrees of internal rotation in the painful group compared to 0.5 degrees of external rotation in the control group (p=0.001). A significant difference in femoral component rotation was identified between the groups with 3.8 degrees of internal rotation in the painful group compared to 1.1 degrees of external rotation in the control group (p=0.001). A significant difference in the combined component rotation was identified between the groups with 6.8 degrees of internal rotation in the painful group compared to 1.7 degrees of external rotation in the control group (p=0.001).

We have identified significant internal rotation in a patient cohort with painful total knee arthroplasty when compared to a control group with internal rotation of the tibial component, femoral component and combined rotation. This is the largest comparison series currently in the literature.

Primary bone tumours of the talus are rare. Currently the existing literature is limited to a single case series and case reports or cases described in series of foot tumours. Information regarding the patient's demographics and tumour types is therefore limited.

The aim of this study was to investigate these questions and also suggest a management protocol for suspected primary bone tumours of the talus. We retrospectively reviewed the Scottish Bone Tumour Register from January 1954 to May 2010 and included all primary bone tumours of the talus. We identified only twenty three bone tumours over fifty six years highlighting the rarity of these tumours. There were twenty benign and three malignant tumours with a mean age of twenty eight years. A delay in presentation was common with a mean time from onset of symptoms to diagnosis of ten months. Tumour types identified were consistent with previous literature. We identified cases of desmoplastic fibroma and intraosseous lipodystrophy described for the first time.

We suggest an investigatory and treatment protocol for patients with a suspected primary bone tumour of the talus. This is the largest series of primary bone tumours of the talus in the literature.

Forearm fractures are a common paediatric injury. This study was aimed to describe the epidemiological of paediatric forearm fractures in the urban population of Glasgow.

We reviewed of all the forearm fracture treated by the orthopaedic service in Yorkhill Children's Hospital in 2008. Datum gathered from case notes and radiographs using the prospective orthopaedic database to identify patients with forearm fractures. The age, sex, side and type of fracture, the timing and mechanism of the injury and treatment were documented for the 436 fractures. Census data were used to derive absolute age-specific incidences.

Distinction was made between torus and other types of fractures. Torus fractures require no specific orthopaedic treatment and were segregated out. For the remaining 314 fractures, the age and sex distribution, seasonal variation of fractures and treatments for each type of fracture were examined. The incidence of forearm fractures in our population is 411 fractures per 100,000 population per year. An increased number of fractures occurred during the months of May and August. A fall from less than one metre was the commonest mechanism of injury, sporting injuries were the second commonest with football the most common sport associated.

This study identifies some features which are in good agreement with studies from elsewhere in Britain, such as incidence and seasonality. However, there are also interesting differences – such as the Glasgow peak incidence for forearm fractures being at age 8, with a marked decline by 12 years. Furthermore, our findings have been extended to consideration of type of intervention, and likelihood of successful treatment.