Revision anterior cruciate ligament (ACL) reconstruction is a technically demanding procedure, reporting poorer outcomes compared to the primary procedure. Identification of the cause of primary failure and a thorough pre-operative evaluation is required to plan the most appropriate surgical approach. 3D printing technology has become increasingly commonplace in the surgical setting. In particular, patient-specific anatomical models can be used to aid pre-operative planning of complicated procedures. We have conducted a qualitative study to gauge the interest amongst orthopaedic knee surgeons in using a 3D-printed model to plan revision ACL reconstructions.

A tibia and femur model was printed from one patient who is a candidate for the procedure. The binder jetting printing technique was performed, using Visijet PXL Core powder. 12 orthopaedic knee surgeons assessed the usefulness of the 3D-printed model compared to conventional CT images on a likert scale. 6 key steps of preoperative planning were assessed, including the size and location of the tunnel defects, the need for notchplasty, and whether a staged revision was required.

We found that surgeons preferred the 3D-printed model to conventional CT images only, and 83% of them would use such a model for both pre-operative simulation, and as an intra-operative reference. However, there were some variation in the perceived usefulness of the model in several areas assessed. This may reflect differences in individual approach towards planning of the procedure.

Our findings suggest that 3D-printed models could be a versatile pre-operative and intra-operative tool for complicated arthroscopic knee surgery. While 3D printing technology is becoming increasingly accessible and affordable, in-depth cost-effectiveness studies need to be conducted before it can be integrated into clinical. Further study would be needed to determine the clinical utility and economic cost-effectiveness of the 3D-printed model in revision ACL reconstruction.

This work examines the Upper limb (UL) blast-mediated traumatic amputation (TA) significance from recent operations in Afghanistan. It is hypothesized that the presence of an UL amputation at any level is an independent predictor of torso injury.

A joint theatre trauma registry search was performed to determine the number of British casualties with TA and their associated injuries.

UL TA accounted for 15.7% of all amputations; distributed: shoulder disarticulation 2.5%, trans-humeral 30%, elbow disarticulation 10%, trans-radial 20% and hand 37.5%. The presence of an UL amputation was more likely in dismounted casualties (P=0.015) and is a predictor of an increased number of total body regions injured and thoracic injuries (P 0.001 and P 0.026 respectively). An increased Injury Severity Score (ISS) was seen in patients with multiple amputations involving the UL (UL TA present ISS=30, no UL TA ISS=21; P=0.000) and the ISS was not significantly different whether mounted or dismounted (P=0.806).

The presence of an upper limb amputation at any level should insight in the receiving clinician a high index of suspicion of concomitant internal injury; especially thoracic injury. Therefore with regards to blast mediated TA the injury patterns observed reflect a primary and tertiary blast mechanism of injury.

Electron Microscopy and Synchrotron analysis of Heterotopic Ossification (HO) from blast-related amputees' has shown that HO is bone with a disorganised structure and altered remodelling. This research performs mechanical testing of HO to understand its biomechanical properties in an attempt to create an accurate model to predict its morphological appearance. The hypothesis of this work is that HO is mechanically mediated in its formation.

Synchrotron mechanical analysis of HO samples was performed to measure Young's modulus, ultimate strength and density distribution. A novel algorithm based on Wolf's law was implemented in a Finite Element (FE) analysis model of HO to take into account the differing mechanical and biological properties measured and the presence of HO outside the skeletal system.

An HO modeling factor, which considers boundary conditions, and regulates recruitment of the soft tissue into bone formation, results in a re-creatable formation of HO within the soft tissues, comparable to the appearance of HO seen in military amputees. The results and model demonstrates that certain types of HO are under the control of endogenous and exogenous mechanical stimulus. HO can thus be mechanically exploited in the casualty management and rehabilitation process to achieve better clinical outcomes.

The explosive device has successfully been used by terrorists globally, with their effects extending beyond the resulting injuries. Suicide bombings, in particular, are being increasingly deployed due to the devastating effect of a combination of, high lethality and target accuracy. This aim of this study was to analyse the demographics and casualty figures of terrorist bombings worldwide. Analysis of the Global Terrorism Database and a PubMed search (keywords “terrorist”, and/or “suicide”, and/or “bombing”) from 1970 to date was performed. Of 58,095 reported terrorist explosions worldwide, 5.08% were suicide bombings. Incidents per year is increasing (P<0.01). PubMed identified 41 publications reporting 167 incidents. Mean casualty statistics per incidents was 1.14 deaths and 3.45 wounded from non-suicide incidents, and 10.16 and 24.16 from suicide bombings (p<0.05). The Middle East witnessed the most incidents (26.9%), with Europe ranked 4^th in the number of terrorist related explosion (13.2%). Differing injury patterns were seen in open, confined and building collapse incidents. Terrorist bombings continue to be a threat and are increasing in the Middle East and Europe. Suicide bombings are becoming an increased threat with greater casualty figures per incident seen. This data assists in the planning of security, logistics, casualty evacuation and care.

Heterotopic ossification (HO) is the formation of lamellar bone in extra-skeletal soft tissues. Its exact pathogenic mechanism remains elusive. Previous studies demonstrate observation only of HO at the microscopic scale. This study uses scanning electron microscopy (SEM), Back-scatter electron (BSE) imaging and mechanical testing to detail the organic and non-organic elements of HO, compared to normal bone, to guide stem cell and bio-modelling research into HO. Samples analysed were 5 military blast related HO patients, 5 control cadaveric samples (age and sex matched). Samples were imaged using SEM, BSE and the I13 beam Synchrotron x-ray diffraction scanner using validated quantitative and qualitative techniques of measurement. Appearances seen in HO compared to normal bone were characterised by the presence of a hyper-vascular network and high lacunae (osteocyte) counts, two distinct zones of bone mineral density distribution, with a tendency for hypermineralisation with kurtosis of the grey scale plots (mineral content as a weight percentage of Ca²⁺ was calibrated to atomic weight of C, Al and HA). Direction of dependence and collagen orientation in HO suggest isotropic properties. This research demonstrates that HO is bone, however its characteristics suggest a high metabolic turnover and disorganised ultra-structure consistent with an inflammatory origin.

Previous reports of the prevalence of Heterotopic Ossification (HO) in limbs from UK blast-related amputees from Afghanistan, is demonstrated to be 57.1%. With the end of UK military operations in Afghanistan in 2014 the aim of this study is establish the rate of HO, assess causality demographics and ascertain risk factors for the formation of HO during the entire period of operations in Afghanistan. Military databases, case notes and radiographs were scrutinised to quantify and qualify the prevalence and risk factors for the formation of HO. 256 servicemen sustained 398 military trauma related amputations. The overall prevalence of HO was 65.9%. Significant (p<0.05) risks identified for the formation of HO included a blast mechanism of injury, a zone of injury the same as the subsequent amputation, and an increased number of debridements prior to closure. Positive correlation existed between the number of amputations and the presence and grade of HO (p=0.04). HO presents clinical problems to military blast injury patient populations. This study demonstrates that both a blast mechanism of injury and an increased injury load are key factors in the increased prevalence of HO seen in military trauma.

2014 sees the withdrawal of British troops from Afghanistan. It is documented that the conflict is associated with increased survivability form military related trauma attributed to personal protection equipment, improved on the ground medical care and rapid extraction of the casualty. However, the consequence is that of complex trauma patients and in particular trauma-related amputations (TA). With the draw down a complete picture is now possible.

This report quantity's and quality's the extent and nature of TA from Afghanistan by means of a retrospective analysis of an accurate database of TA casualties forms this conflict. This will provide useful information for the resources required for managing these complex patients in the future. Data extracted included number of amputations, locations and level of amputations and date of injury.

265 casualties sustained 416 amputations. The commonest injury pattern per casualty seen was that of a single amputation. The commonest level of amputation was trans-femoral (TF)(153), followed by 143 trans-tibial (TT)(143. Single amputations associated with TT injuries. TF amputations were commonest in double and triple amputees. The commonest double amputee pattern was TF:TF casualty.

Casualties form this conflict are more likely to have greater number of amputations and higher levels.

With an increasing ageing population and a rise in the number of primary hip arthroplasty, peri-prosthetic fracture (PPF) reconstructive surgery is becoming more commonplace. The Swedish National Hip Registry reported that, in 2002, 5.1% of primary total hip replacements required revision due to PPF. Laboratory studies have indicated that age, bone quality and BMI all contribute to an increased risk of PPF. Osteolysis and aseptic loosening contribute to the formation of loosening zones as described by Gruen, with subsequent increased risk of fracture. The aim of the study was to identify significant risk factors for PPF in patients who have undergone primary total hip replacement (THR).

Logbooks of three Consultant hip surgeons were filtered for patients who had THR-PPF fixation subsequent to trauma. Risk factors evaluated included sex, age, bone density (Singhs index), loosening zones, Vancouver classification, prosthesis stem angle relative to the axis of the femur, and length of time from THR to fracture. A control group of uncomplicated primary THR patients was also scrutinised.

Forty-six PPF were identified representing 2.59% of THR workload. The male: female ratios in both groups were not significantly different (1:1.27 and 1:1.14 respectively). Average age of PPF was 72.1, which was significantly older than the control group (54.7, p>0.05). The commonest type of PPF was Vancouver type B. Whilst stem position in the AP plane was similar in both groups, in lateral views the PPF stem angle demonstrated significant antero-grade leg position compared to the non-PPF group (p.0.05). The PPF group demonstrated a greater number of loosening zones in pre-fracture radiographs compared to the control group (2.59 and 1.39 respectively, p>0.05)

Our workload from PPF reflects that seen in Europe. Age, stem position and the degree of stem loosening appear to contribute to the risk of a peri-prosthetic fracture.

The long term results of closed reduction of the hip for DDH were reviewed to determine if the presence of the ossific nucleus had an effect on outcome.

The clinical and radiological outcome of a single-surgeon series of closed reduction for DDH was assessed in a strictly defined group of 48 hips in 42 patients with an average of 11.1 years follow up.

In 50% of cases, the ossific nucleus was absent. 100% of patients had an excellent or good result (Severin classification) at final follow-up. 8.3% (4 hips) demonstrated evidence of avascular necrosis. Three were Kalamchi & MacEwen Type I and one was type II. Two of the AVN cases did not demonstrate an ossific nucleus at closed reduction, and both developed type I AVN. 6 hips underwent further surgery. The acetabular index and center-edge angle were not significantly different between the affected and unaffected hip at final follow-up.

There was no relationship between the presence or absence of an ossific nucleus at the time of closed reduction and the final outcome.

In this well defined group, closed reduction is safe and provides excellent results in the long-term. The absence of an ossific nucleus is not detrimental to the final outcome.

The Orthopaedic Competence Assessment Project (OCAP) is a validated system for assessment of competence in orthopaedics. OCAP materials are increasingly used in the NHS. Defence Orthopaedic trainees now deploy for 6 weeks on Operation Herrick.

The senior author used OCAP induction and assessment materials with the 3 three trainees assigned to him at the United Kingdom Medical Facility at Camp Bastion, Afghanistan. Mini-CV and ‘Military Trauma’ Knowledge and Procedure Profiles were provided and learning agreements signed at an initial meeting. Interim and final meetings took place to review progress and update Knowledge and Procedure Profiles. Procedure Based assessments (PBAs) were also attempted during the attachments.

Afghanistan was ideal for training due to a significant trauma caseload, close one-on-one supervision and no working time directives. The use of induction and assessment materials with which trainer and trainees were already familiar gave structure and focus to training on deployment and allows the benefit of the deployment to be demonstrated.

Coronal alignment is an important factor in long-term survival of TKA. Many implant systems are available and most aim to produce a posterior slope on the tibial component to reproduce the 7⁰ seen in the normal tibia. We hypothesized that resecting the tibial plateau with a posterior slope can introduce error in coronal plane alignment in TKA.

We used a standard saw-bones model in conjunction with a computer navigation system that is available for use in TKA (Stryker Orthopaedics). The normal protocol for preliminary referencing was followed; care was taken to identify tibial landmarks (tibial plateau reference point, true sagittal plane and transmalleolar axis). We then used a standard extramedullary alignment jig (Scorpio TKR System, Stryker Orthopaedics) with cutting blocks designed to give 0, 3, 5 and 7 degrees of posterior slope and varied the position of the alignment jig.

Variations included:

Medial rotation of the cutting block,

In all experiments, there was a greater deviation from ideal coronal alignment as the slope on the tibial cut was increased. The greatest influence was with external rotation of the distal part of the jig, which produced 3⁰ of varus at only 15⁰ of external rotation with a 7⁰ slope. Medialisation of the proximal reference point worsened this to 4.5⁰ of varus.

We have quantified the degree of coronal malalignment that can occur for different posterior slopes during tibial resection for TKA. We recommend either using a minimal slope or navigation to ensure correct implant positioning.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

Background: Coronal alignment is important in long-term survival of TKA. Many systems are available; most aim to produce a posterior slope on the tibial component in order to reproduce the 7⁰ seen in the normal tibia. Some are designed to produce a bone cut with 7⁰ of slope whereas others combine the slope of the bone cut with an in-built slope on the polyethylene insert. We have investigated the theory that resecting the tibial plateau with a posterior slope can introduce error in coronal plane alignment in TKA.

Methods: We used a standard saw-bones model in conjunction with a computer navigation system that is available for use in TKA (Stryker Orthopaedics). The normal protocol for preliminary referencing was followed; care was taken to identify tibial landmarks (tibial plateau reference point, true sagittal plane and transmalleolar axis). We then used a standard extra-medullary alignment jig (Scorpio TKR System, Stryker Orthopaedics) with cutting blocks designed to give 0, 3, 5 and 7 degrees of posterior slope and varied the position of the alignment jig. Variations included:

Medial rotation of the cutting block

Results: In all experiments, there was a greater deviation from ideal coronal alignment as the slope on the tibial cut was increased. The greatest influence was from external rotation of the distal part of the jig which produced 3⁰ of varus at only 15⁰ of external rotation with a 7⁰ slope. Medialisation of the proximal reference point worsened this to 4.5⁰ of varus.

Conclusions: We have quantified the degree of coronal malalignment that can occur for different posterior slopes during tibial resection for TKA. We recommend either using a minimal slope or navigation to ensure correct implant positioning.

Leucocytes are white blood cells that help the body fight against bacteria, viruses and tumour cells. However, the activity of leucocytes has been implicated in other clinically important inflammatory conditions such as ischaemic heart disease, stroke, and during cardio-aortic and orthopaedic surgery.

The main objectives of this study was to optimise methods for the isolation of leucocyte subpopulations (neutrophils and monocytes), and to assess in vitro the effects of PMA and fMLP on markers of leucocyte adhesion (CD11b, CD62L) and activation (intracellular hydrogen peroxide) (n=10). Leucocyte subpopulations were labelled by incubation with fluorescein isothiocya-nate (FITC) conjugated anti-human CD11b and CD62L antibodies. The cell surface expression of these labelled adhesion molecules were measured by flow cytometry. Intracellular production of hydrogen peroxide by neutrophils and monocytes was measured by flow cytometry, using the fluorochrome dichloroflurorescin diacetate (DCFH-DA). These were visualised by Immunofluorescence microscopy.

During this study, methods of isolating leucocyte subpopulations from whole blood were optimised. This ensured that these cells were isolated with consistently high yields, purity and with no changes in cellular function. Following incubation with PMA and fMLP, neutrophils and monocytes displayed an increase in CD11b cell surface expression; a decrease in CD62L cell surface expression; and increased leucocyte activation. Leucocyte activation was represented by the intracellular production of hydrogen peroxide.

In conclusion this study confirms that both PMA and fMLP have an intrinsic effect on markers of leucocyte function. These findings are in agreement with previous studies performed.

Introduction: The search continues for ideal markers and methods of monitoring cartilage degeneration. Various cartilage components, whole or fragmented, have been measured in synovial fluids. A common problem in quantitating these markers is often the unknown dilution of synovial fluid which can occur in obtaining the samples. In this study we have used urea (ratio in synovial fluid:serum) as a method to correct for the dilution of synovial fluid, and hence to quantify enzyme levels in patients with a spectrum of cartilage degradation, in addition to identifying aggrecan degradation products, many of them for the first time in such samples.

Methods: Forty synovial fluid samples were obtained from 4 groups of individuals (10 in each):

normal,

Levels of matrix metalloproteinases (MMPs) 2 and 3 and the inhibitor, TIMP 1, were measured in the fluids via ELISA assays. Urea levels were measured in blood and synovial fluids and enzymes and their inhibitors were normalized according to the ratio of serum:SF urea, to account for the dilution factor of the SF (Kraus et al 2001). Western blotting was used to identify the presence of aggrecan components (chondroitin-4-sulphate: 2B6 antibody; C-6-S: 3B3 and C-0-S: 1B5; keratan sulphate: BKS-1; the G1 domain: 7D1; interglobular domain: 6B4) and also enzyme degradation products of MMPs (BC14) and aggrecanases (BC3; BC-13).

Results: MMPs 2 and 3 and TIMP 1 were all significantly increased in the synovial fluids from OA patients compared to normals (P< 0.01, 0.001 and 0.01 respectively) and MMP3 was greater in the grade IV chondral and osteochondral defect groups than the normals (P< 0.01). Western blotting demonstrated fragmented aggrecan components with a range of molecular weights. Aggrecanase activity was seen in the OA and grade IV chondral damage groups but not in the osteochondral or normal groups, whereas MMP activity was seen in all 3 groups showing cartilage damage but not in the normals.

Conclusion: Dilution of the synovial fluid, either due to inflammation or joint lavage, is often a problem in quantitating metabolites and markers in joint cavities. This pilot study of a limited number of samples from well characterized patient groups indicates that using urea concentrations in synovial fluid relative to serum provides a mechanism to overcome this. It confirms elevated enzyme activity, both aggrecanase and MMPs, in the joints of patients with degenerate cartilage, compared to normals.

Aim: To present and highlight a remote complication following deep x-ray radiotherapy to Ilium.

Background: Radiotherapy is one the options to treat malignancy. Surrounding normal tissue can be affected by super-imposed infection, radiation-induced tumors, and other complications of radiation therapy. Timing of radiation changes varies in the different organs. Acute radiation pneumonitis is generally seen approximately 2 months after completion of radiotherapy, but radiation pericarditis not until 6–9 months after therapy. Radiation-induced sarcomas do not develop on average until 10–15 years after radiation therapy.

Case report: A 39-year old presented to an oral surgeon 29 years ago with a submandibular swelling that was gradually increasing in size. Excision biopsy revealed Follicular, Large cell, Non-Hogdkin’s Lymphoma. Lymphogram showed positive nodes in pelvic and para-aoric regions. She was treated with chemotherapy initially. She developed left SI joint pain 2 years later and was treated with radiotherapy. The lymphoma later became chemotherapy resistant and the patient was treated with whole body irradiation. She was in remission since 26 years. She started having discomfort in the left hip region far past 5 years and was reviewed. A recent MRI scan revealed avascular necrosis of the femoral head with little collapse. Changes in the ilium and muscle wasting around the left iliac wing were noted, which were consistent with post radiation osteonecrosis.

This lady noticed a recent change in the gait and examination revealed positive trendelenberg test and a lurching gait. Latest radiographs have shown a fracture of the left iliac crest. The patient did not request any surgical intervention and was reassured with explanation.

Conclusion: Post radiation osteonecrosis can cause complications as late as 26 years following deep x-ray radiotherapy.

Aims: Outpatient clinic follow-up of patients after knee arthroscopy is routine practice in many orthopaedic units. It can be inconvenient and expensive for patients and may be unnecessary.The aim of our study was to compare oupatient follow-up with telephone follow-up after knee arthroscopy in a prospective randomised trial

Patients and method: Over a four-month period, 50 patients (mean age 41 years) were included in our study. Each patient underwent a day-case knee arthroscopy as previously planned. After surgery, each patient was randomised to either attend for an outpatient clinic follow-up after two weeks or to receive a telephone follow-up after two weeks from operation. All patients were assessed after four weeks from surgery by an independent assessor who was blinded to the type of follow-up each patient had received. No patients in the study were lost to follow-up.

Results: No significant difference was found in patient satisfaction scores between the outpatient and telephone groups (mean 7.78 vs mean 7.92). However, 81% patients in the telephone group and 57% patients in the clinic group (p< 0.01) preferred telephone follow-up if they were to undergo another knee arthroscopy. There was a significant increase in patello-femoral problems in those preferring outpatient follow-up (64%) compared to telephone follow-up (24%), p< 0.05. No difference in complication rates between the two groups was found.

Conclusion: Telephone follow-up provides a satisfactory and safe alternative to outpatient follow-up after knee arthroscopy. It is preferred by the majority of patients and could relieve pressure on outpatient resources.

We have investigated whether the thigh tourniquet used during total knee replacement (TKR) influenced the development of postoperative wound hypoxia and was a cause of delayed wound healing.

We allocated randomly 31 patients (31 TKRs) to one of three groups: 1) no tourniquet; 2) tourniquet inflated at low pressure (about 225 mmHg); and 3) tourniquet inflated to high pressure of about 350 mmHg. Wound oxygenation was measured using transcutaneous oxygen electrodes.

In the first week after surgery, patients with a tourniquet inflated to a high pressure had greater wound hypoxia than those with a low pressure. Those without a tourniquet also had wound hypoxia, but the degree and duration were less pronounced than in either of the groups with a tourniquet.

Use of a tourniquet during TKR can increase postoperative wound hypoxia, especially when inflated to high pressures. Our findings may be relevant to wound healing and the development of wound infection.

We have compared the findings of MRI with those of hip arthroscopy in 23 hips in young adults with hip pain. Large deep cartilage deficiencies on the acetabulum or femoral head, the percentage of femoral head cover, and the presence of marginal osteophytes seen on MRI correlated well with those seen at arthroscopy, but chondral softening, fibrillation, or partial-thickness defects less than 1 cm in diameter were less consistently detected by MRI. Osteochondral loose bodies and labral tears were not well demonstrated by MRI, but were readily identified and treated at arthroscopy. Arthroscopy of the hip is a useful investigation for hip pain in young adults especially when standard non-invasive MRI fails to provide a clear diagnosis.

Computerised tomography of the lumbar spine was performed on 22 patients with clinical evidence of prolapse of an intervertebral disc and normal or equivocal radiculograms. Of 11 patients with positive scans who had an operation the presence of pathology was confirmed in 10. Although CT scanning is always helpful in diagnosing disc disorders, where facilities are scarce (as in Great Britain) it is best employed in patients with negative or non-contributory radiculography.