Alcohol-based cutaneous disinfectant use is well established in the surgical environment. However, during scrubbing, volatile alcohols are inspired into the pulmonary system. With the recent reduction in the national drink driving limit, even low levels of detected breath alcohol can have legal implications. This study aimed to determine the extent to which passive inhalation of alcohol-based surgical hand disinfectant affects estimated percentage blood alcohol concentration (%BAC) on breathalyser testing.

Over a one week period (September 2015), 24 theatre team members (13 surgeons, 6 scrub staff and 5 anaesthetists) were prospectively recruited. The mean cohort age was 43.7 years (50% female). Participants were instructed to scrub for 90 seconds with an alcohol-based hand disinfectant comprising of the active ingredients (per 100g): propan-1-ol 30.0g, propan-2-ol 45.0g and mecetroniumetilsulphate 0.2g. Estimated %BAC was recorded immediately before and after scrubbing, and every five minutes thereafter until levels returned to 0.00%BAC. Results ≥ 0.05%BAC were deemed above the Scottish legal driving limit.

All participants exceeded the 0.05%BAC threshold on immediate post scrub testing. The mean peak %BAC was 0.12% (± 0.05) with a maximum BAC documented at ≥0.20% in four subjects. In all participants, the %BAC descended to zero over a period ranging from 10–30 minutes with a mean time to zero of 16.7 (± 4.8) minutes.

Following the use of alcohol-based surgical hand disinfectant, estimated blood alcohol concentrations detected on breath sampling can rise up to four times the Scottish driving limit which may have legal and professional ramifications.

Introduction

We report the results of a prospective study of 1349 patients undergoing 1509 total knee replacements, identifying factors increasing the risk of infection.

Introduction: With an aging population, the number of hemiarthroplasties and Total Hip Replacements is on a rise. Though uncommon, one of the serious postoperative complications is periprosthetic fracture of femur. Dall Miles cable plate system is widely used for fixation of these fractures.

Patient and Methods: We present a series of of 19 patients who underwent Dall Miles cable plate fixation for periprosthetic fracture over a hemiarthroplasty or a total hip replacement during the last 5 years, reporting clinical and radiological outcome measures.

Results: Female to male ratio was 2:1. The average age was 77.33 (range from 55 to 93). Eight patients had the periprosthetic fracture after hemiarthroplasty while 11 had it after Total Hip Replacement. These two group were completely different in terms of their fitness, activities and expectations. Twelve were Vancouver B 1, 7 were Vancouver C. Five were initially managed with two plates, the remainder had one plate only.

Patients were followed up at an average of 3.1 years (range 3.2 months to 5.1 years). Three patients had died at the time of our follow up due to unrelated medical problems. One patient had deep infection that required revision and 1 had superficial infection that healed with antibiotics. 1 patient underwent revision to a THR for hip pain.

Of those managed with a single plate, 3 patients had plate/cable failure and underwent revision DM plating with 2 plates and cables along with allogenic bone grafting; all of these healed well. All of these patients had periprosthetic # following a THR.

Five patients managed initially with 2 DM plates healed without any complications.

Discussion: Even in this small series, we feel it is evident that Dall Miles plating using a single plate has a high incidence of plate failure (3 of 13). Orthogonal plating has been widely used in past for fixation of complex fractures and nonunions. We feel there is a distinct advantage of using two plates of uneven lengths to improve chances of healing, preventing implant failure and reducing stress riser effect. We advocate primary fixation of periprosthetic fractures of proximal femur over THR using 2 Dall Miles cable plates and bone graft. We would like to present our results and discuss this complex topic further.

Objective: To evaluate the impact of soft tissue release on range of movement following total knee replacement.

Methods: Sixty four patients underwent PFC sigma total knee replacement through a medial arthrotomy. Range of active movement was measured preoperatively, and maximal flexion was measured after implantation, using the drop test while the patient was under anaesthetic. Soft tissue release was graded from 1 to 5, depending on the structures released.

Range of movement was correlated with extent of soft tissue release, to see if release had any impact on increase in range of movement.

Results: All patients had an improvement in range of movement following surgery. Post operative range of movement correlated strongly with preoperative ROM.

Patients requiring extensive releases tended to have less preoperative ROM, but the gain was independent of medial release. Those requiring extensive posterior release had poorer preoperative movement, and significantly less improvement.

In those requiring an extensive medial release, a posterior release improved gain in ROM.

Conclusion: Postoperative ROM following TKR is independent of extent of medial release. In patients requiring extensive medial release, a posterior release improves gain in movement.

Introduction: Between 1 and 4 per 1000 births worldwide are affected by clubfoot. Clubfoot etiology is unclear, but both genetic and environmental factors are thought to be involved. Low folate status in pregnant women has been implicated in several congenital malformations and folate metabolism may be affected by polymorphisms in the MTHFR gene.

Methods: Using a case-parent triad design, we investigated whether the MTHFR C677T polymorphism, and maternal peri-conceptional folic acid supplement use, influenced risk of isolated clubfoot. 375 case-parent triads took part.

Results: Among children there was a significant trend of decreasing clubfoot risk with increasing number of Talleles: relative risk (RR ) CT vs CC=0.75 (95% CI: 0.57,0.97); RR TT vs CC=0.57 (95% CI: 0.37,0.91); p trend=0.006. This association was not modified by maternal folic acid use.

Conclusion: Maternal MTHFR genotype did not influence risk of clubfoot in the offspring overall, although a possible interaction with folic acid use was found. This is the first report of a specific genetic polymorphism associated with clubfoot. The direction of the association is intriguing and suggests DNA synthesis may be relevant in clubfoot development. However, clubfoot mechanisms are poorly understood and the folate metabolism pathway is complex. Further research is needed to elucidate these relationships.

Background: Congenital talipes equinovarus (CTEV) is a common developmental disorder of the foot, affecting between 1 and 4.5 babies per 1000 live births. The etiology is not well elucidated. While both genetic and environmental factors are implicated, no specific genes have been identified and little is known about environmental risk factors.

Methods: We conducted a case-control study of idiopathic congenital talipes equinovarus (ICTEV) in the United Kingdom. 194 cases and 60 controls were recruited. Pedigrees were obtained for 162 cases.

Results: The rank of the index pregnancy, maternal education and cesarean delivery were significantly associated with ICTEV risk in a multivariate model. There were suggestions that maternal use of folic acid supplements in the three months before the pregnancy decreased ICTEV risk, and that parental smoking during the pregnancy increased risk. One quarter of pedigrees showed a family history of CTEV, and autosomal dominant inheritance was suggested in some of these.

Conclusion: Uterine restriction did not appear to have a strong influence on ICTEV development in our study. Large population-based studies are needed to clarify the etiology of this common developmental disorder.

Objective: To evaluate the impact of soft tissue release on range of movement following total knee replacement.

Methods: Sixty four patients underwent next-gen (Zimmer) posterior stabilising total knee replacement through a medial arthrotomy. Range of active movement was measured preoperatively, and maximal flex-ion was measured after implantation, using the drop test while the patient was under anaesthetic. Soft tissue release was graded from 1 to 5, depending on the structures released.

Range of movement (ROM) was correlated with extent of soft tissue release, to see if release had any impact on increase in range of movement.

Results: All patients had an improvement in range of movement following surgery. Post operative range of movement correlated strongly with preoperative ROM. Patients requiring extensive releases tended to have less preoperative ROM, but the gain was independent of medial release. Those requiring extensive posterior release had poorer preoperative movement, and significantly less improvement.

In those requiring an extensive medial release, a posterior release improved gain in ROM.

Conclusion: Postoperative ROM following TKR is independent of extent of medial release. In patients requiring extensive medial release, a posterior release improves gain in movement.

Introduction: Patients following resurfacing frequently remark about the natural feel of the resurfaced hip joint in contrast to those with total hip arthroplasty. Possible reasons for this include the larger femoral head size, conservation of bone and superior biomechanics of the implant with more accurate restoration of femoral offset, leg length and femoral anteversion.

Our aim was to assess femoral offset and leg length following hip resurfacing and hybrid THR (uncemented acetabulum) performed by the same surgeon.

Methods: A consecutive group of patients were identified (35 resurfacing and 25 hybrid). AP pelvis radiographs were evalulated, films with evidence of malrotation or inadequate imaging of the femur were excluded, leaving 21 resurfacing and 15 hybrid. Comparison was made between the pre-op and post-op films together with the contralateral hip on the same film. Patients with hip dysplasia or significant pathology in the contralateral hip were excluded. Magnification of the films was measured by comparison of the templated diameter of the implanted femoral head and the acutal diameter of the implant. To allow comparison between pre-op films a measurement was taken between the obturaror foraminae.

All films were analysed by the same investigator using the technique described by Jolles et al (J Arthroplasty 2002). A horizontal line was drawn between the base of the teardrop on both sides, and perpendicular lines drawn from the back of the teardrops. The anatomical femoral axis was drawn and femoral offset measured from this. The centre of rotation of the femoral head was determined by templating and the acetabular offset obtained.

Distance from tip of the greater trochanter to the centre of the femoral head in the axis of the femur was determined on pre and post-op films, as this shows little variation with rotation of the femur. Leg length was measured from the horizontal line to the tip of the greater trochanter together with the angle between the femoral axis and the horizontal to correct for abduction of the hip.

Results: Mean total femoral offset compared to the contralateral side was −1.3mm (SD 5.3) and −3.2mm (SD 6.5) for the resurfacing and hybrid groups respectively. No significant difference was detected in leg length or other measurements.

Discussion and Conclusion: No significant differences were demonstrated between femoral offset or leg length in the resurfacing and hybrid arthroplasty groups. This study does not support the hypothesis that resurfacing produces more accurate restoration of hip biomechanics than hybrid total hip arthroplasty.

Resurfacing arthroplasty of the hip is being performed more frequently in the United Kingdom. The majority of these patients are younger than 55 years of age, and in this group the key benefits include conservation of femoral bone stock and the potential reduction in the rate of dislocation afforded by the larger resurfacing head. Early aseptic loosening is well recognised in patients younger than 55 years of age, and proponents of resurfacing believe that the improved wear characteristics of the metal-on-metal bearing may improve the long-term survival of this implant. There has been some concern, however, that resurfacing may not be conservative of acetabular bone.

We compared a series of 33 consecutive patients who had a hybrid total hip arthroplasty with an uncemented acetabular component and a cemented femoral implant, with 35 patients undergoing a Birmingham hip resurfacing arthroplasty. We compared the diameter of the implanted acetabulum in both groups and, because they were not directly comparable, we corrected for patient size by measuring the diameter of the contralateral femoral head. The data were analysed using unpaired t-tests and analysis of covariance.

There was a significantly larger acetabulum in the Birmingham arthroplasty group (mean diameter 56.6 mm vs 52.0 mm; p < 0.001). However, this group had a significantly larger femoral head diameter on the contralateral side (p = 0.03). Analysis of covariance revealed a significant difference between the mean size of the acetabular component implanted in the two operations. The greatest difference in the size of acetabulum was in those patients with a larger diameter of the femoral head. This study shows that more bone is removed from the acetabulum in hip resurfacing than during hybrid total hip arthroplasty, a difference which is most marked in larger patients.

Hip resurfacing is being performed more frequently in the United Kingdom. The possible benefits include more accurate restoration of leg length, femoral offset and femoral anteversion than occurs after total hip arthroplasty (THA).

We compared anteroposterior radiographs from 26 patients who had undergone hybrid THA (uncemented cup/cemented stem), with 28 who had undergone Birmingham Hip Resurfacing arthroplasty (BHR). We measured the femoral offset, femoral length, acetabular offset and acetabular height with reference to the normal contralateral hip. The data were analysed by paired t-tests.

There was a significant reduction in femoral offset (p = 0.0004) and increase in length (p = 0.001) in the BHR group. In the THA group, there was a significant reduction in acetabular offset (p = 0.0003), but femoral offset and overall hip length were restored accurately. We conclude that hip resurfacing does not restore hip mechanics as accurately as THA.

Aim: Congenital Talipes Equinovarus (CTEV) is managed in a variety of ways, with little agreement on how best to assess outcome. Some authors advocate patient based subjective assessments, while others use a variety of objective measures. Without agreement, it is impossible to evaluate different management methods. We have therefore evaluated a number of objective parameters compared to a subjective assessment following management of CTEV. Methods: 216 children and their families consented to participate in the study. The children had been managed in a number of hospitals across Scotland, and in a variety of ways. Outcome was assessed by a researcher not involved in the management of the children. Subjective assessment consisted of a postal questionnaire. Objective assessment consisted of a number of anthropometric measures. Results: A strong correlation was seen between subjective assessment, and several objective outcome measures including foot length discrepancy, calf muscle wasting, and range of movement at the ankle. Conclusions: Objective assessment using several parameters correlates well with subjective assessment. Using these objective measures, it is possible to evaluate and compare different management protocols in CTEV.