Osteochondral lesions (OCLs) of the talus are a challenging and increasingly recognized problem in chronic ankle pain. Many novel techniques exist to attempt to treat this challenging entity. Difficulties associated with treating OCLs include lesion location, size, chronicity and problems associated with potential graft harvest sites. Matrix associated stem cell transplantation (MAST) is one such treatment described for larger lesions >15mm² or failed alternative therapies. This cohort study describes a 5 year review of the outcomes of talar lesions treated with MAST. A review of all patients treated with MAST by a single surgeon was conducted. Pre-operative radiographs, MRIs and FAOS outcome questionnaire scores were conducted. Intraoperative classification was conducted to correlate with imaging. Post-operative outcomes included FAOS scores, return to sport, revision surgery/failure of treatment and progression to arthritis/fusion surgery. 32 patients were identified in this cohort. There were 10 females, 22 males, with an average age of 35. 01. 73% had returned and continued playing active sport. 23 patients underwent MAST in the setting of a failed previous operative attempt, with just 9 having MAST as a first option. 9 patients out of 32 had a further procedure. Two patients had a further treatment directed at their OCL. Two patients had a fusion, 2 had a cheilectomy at > 4 years for impingement, one had a debridement of their anterolateral gutter, one had debridement for arthrofibrosis, one patient had a re alignment calcaneal osteotomy with debridement of their posterior tibial tendon. MAST has demonstrated positive results in lesions which prove challenging to treat, even in a “failed microfracture” cohort.

Optimal treatment for symptomatic talus Osteochondral Lesions (OCLs) where primary surgical techniques have failed has not been established. Recent advances have focussed on biological repair such as Autologous Chondrocyte Implantation (ACI) however funding for this treatment is limited. Stem cell therapy in the ankle has not been assessed. The purpose of this pilot study was to evaluate the safety and efficacy of stem cell therapy in the treatment of ankle OCLs.

The study was approved by the new procedures committee. Between January 2015 and December 2016, 26 patients, mean age of 36 years (range 16–58 years) with persisting disabling symptoms underwent Complete Cartilage Regeneration (CCR) using stem cells for failed primary treatment for ankle OCLs. Treatment involved iliac crest bone marrow aspiration, centrifugation to obtain bone marrow concentrate (BMC), and then injection of the BMC combined with hyaluronic acid into the OCL. Any necessary additional procedures, e.g. bone grafting or lateral ligament reconstruction were also undertaken. In 18 patients the lesion was on the medial talar dome, in 5 the lateral talar dome, 2 multiple, 1 tibial plafond. The Manchester-Oxford Foot Questionnaire (MOXFQ) was utilised to assess outcome.

Average pre-operative MOXFQ scores were Walking dimension −78, Pain dimension − 65, and Social dimension − 64.2. Average 3 month post-operative MOXFQ scores were Walking − 54.8, Pain − 35.4, Social − 38.9. Average 6 month post-operative MOXFQ scores were Walking − 34.4, Pain − 35.4, Social − 28. Two patients from the beginning of the series had AOFAS scores only which improved from an average of 55 pre-operatively to 76 post-operatively. No early complications were noted.

We conclude that CCR treatment is a safe treatment for talus OCLs in patients who have failed primary treatment. The procedure avoids two-stage surgery of ACI in some patients without large cysts. The early clinical outcome is favourable with no complications noted. Longer term follow-up is required.

Aim: It is widely accepted that surgical skills improve with experience. Part of this experience comes from operating on patients while honing new skills. Total hip arthroplasty is one such procedure. This paper examines outcomes in relation to the primary surgeon

Methodology: All patients who had an Exeter femoral component implanted and 2 years follow-up in the hospital joint register had their X-Ray, outcome scores and complications reviewed. Complications are routinely recorded as part of the joint register and hospital computer discharge system. Radiological outcome measures were taken as recommended by Johnston et al. Procedures were recorded as either performed by consultant surgeon or registrar supervised by consultant surgeon.

Results: Post operative WOMAC scores at six months and 2 years were similar in both groups (Consultant 19.6, registrar 22.32 at 6 months) SF-36 figures were similar at six months (Consultant performed 78.56, consultant supervised 75.39). There was a difference in SF-36 at 2 years (72.77 vs 63.11) but this was not statistically significant. Average abduction angle was lower in consultant supervised than consultant performed procedure. (36.75 vs 47 deg) Barrack cement grading was similar in both groups. Consultant inserted stems were more likely to be in neutral position compared to consultant supervised stems (84% vs 56%)

Conclusion: In both goups the quality of life indexes do show a difference in outcome which relates to the primary surgeon.. However decreased abduction angle may lead to decreased range of motion post operatively and should be addressed intraoperatively.

Aims: The distal radius fracture model prototype has been produced as a means for teaching reduction of a distal radius fracture. In this study we aim to test the repeatability and reproducibility of the force required to correct the shortening of the radius. In addition a questionnaire was carried out to assess face validity

Methods and materials: The distal radius fracture model prototype has been designed and manufactured to simulate reduction of a dorsally displaced, radially angulated, shortened fracture of the distal radius. We designed a mounting rig for the model and used a Hounsfield tensometer to measure the degree of movement of the distal fracture fragment when various degrees of force were applied. Force was applied to reproduce correction of radial shortening. Reproducibility was tested by resetting of the tensioning device at the rear of the model. The questionnaire was constructed using a series of 5 point, verbally anchored Likert items.

Results: Mean force required for reduction was 191.4 N (Newton) (range 189.4 – 193.4N). Standard deviation for repeated measurement was 1.65 N. Graphs of force versus extension showed one consistent point of slippage which could be explained by movement in the spring tensioner for distal radial displacement. On repeated testing the model tensioning device also showed good reproducibility of results. The results for face validity showed that most people rated the model as having an appearance consistent with that of a fractured distal radius (median score for appearance 4.7, tactile propertied 4.7) but that the biomechanical properties of the reduction were not scored as highy (median score 3.9) The median score when asked about the usefulness of the model for teaching junior staff was high (4.52)

Conclusions: This prototype produces repeatable performance parameters on reduction of the fracture. Overall experience with the prototype is good but it requires further refinement.

Introduction: With the advent of harder wearing metal alloys such as cobalt chrome the technique of hip surface replacement has been resurrected. It is becoming an increasingly popular especially with the younger patient with end-stage hip arthritis. In this study we seek to demonstrate this procedure’s short term success rate for Cappagh and to demonstrate the new Joint Registry in action which has been collating data for the last 2 years.

Methods: The Bluespiers online database was used to identify 200 consecutive primary hip resurfacing performed in Cappagh National Orthopaedic Hospital between January 1st 2006 and January 31st 2008. Patients completed a WOMAC 3.1 Osteoarthritis assessment and SF-36 General Health survey before their operation and at their 1st Joint Registry Clinic Review, typically between five and 9 months post-operatively.

Findings: 200 hip resurfacing procedures by 7 surgeons were identified between January 1st 2006 and January 31st 2008. The mean patient age was 55 years(range, 23 to 81 years). 48 (32%) were female and 152 (68%) were male. Two post-operative femoral neck fractures were recorded which were converted to THR.

We used the SF-36 score as a surrogate marker of overall subjective health and quality of life. The average preoperative SF-36 score was 50.93 (5 to 94.4). The average SF-36 score at 1st Joint Review Clinic visit was 77.55 (23.77–100). This demonstrates an average improvement of 24.44 (−17.69 to 59.75)

As a measure of arthritis severity we will use the WOMAC 3.0 score as a surrogate. The average preoperative WOMAC score was 52.95 (4–92) and the average WOMAC score at 1st Joint Registry Review was 16.11 (0–75). This demonstrates an average decrease in WOMAC score of 34.46 (−29 to 83)

Discussion: Hip surface replacement in Cappagh as recorded by the Joint registry has good success in treating hip arthritis with good improvement of quality of life. We would hope to demonstrate with the joint registry continuing long-term success of this treatment.

Objective: Appendicular soft tissue tumours are rare. They represent less than 1% of all malignancy in Ireland. Consequently they are considered to difficult to diagnose and often require several opinions and investigations before a definitive diagnosis is arrived at. Mistakes in this process have been documented to result in the unnecessary loss of limb and life. The Bone and Soft Tissue Service in Cappagh National Orthopaedic Hospital treats a significant proportion of the tertiary referrals in this field. We looked at the referrals to the service of a newly appointed surgeon with an interest in this field.

Method: We prospectively reviewed the charts of all patients (26) with a soft tissue tumour referred to the senior author in his first year of practice and excluded all patients (1) who had an established and treatment instigated by an Orthopaedic Tumour specialist. Where information was not available in the chart the patients GP was contacted for further information.

Results: The most common presenting complaint was swelling (100%), only 3(12%) of the patients complained of pain. The mean time between observation of symptoms and seeking medical advice was 5.2 months (range 3–12 months). All the patients first sought attention from a GP. The mean number of doctors seen prior to presentation was 2 (range 1–4). 21 (84%) patients presented with MRI imaging.8 out of 20 (40%) secondary referrals had histological diagnosis on presentation however 3 of these were incidental findings from surgery performed without malignancy suspicion. Therefore only 5 out of 17 (29%) referrals for management of suspected malignancy had undergone biopsy at the referring institution. A mosaic of histological diagnoses was found, in proportion to previous epidemiological studies. 21 (84%) of the patients went on to have excisional surgery, one had amputation.

Conclusion: Although 40% of secondary referrals had undergone invasive procedures prior to presentation, only 29% had undergone intentional biopsy with a pre-operative suspicion for neoplasia. A pre biopsy referral rate of 71% compares favourably with published international rates. These tumours are rare and benign masses are 150 times more common however we must remain vigilant and consultation with a Tumour service should precede any invasive procedure whenever there is an element of doubt.

Aim: It is widely accepted that surgical skills improve with experience. Part of this experience comes from operating on patients while honing new skills. Total hip arthroplasty is one such procedure. This paper examines outcomes in relation to the primary surgeon

Methodology: All patients who had an Exeter femoral component implanted and 2 years follow-up in the hospital joint register had their X-Ray, outcome scores and complications reviewed. Complications are routinely recorded as part of the joint register and hospital computer discharge system. Radiological outcome measures were taken as recommended by Johnston et al. Procedures were recorded as either performed by consultant surgeon or registrar supervised by consultant surgeon.

Results: Post operative WOMAC scores at six months and 2 years were similar in both groups (Consultant 19.6, registrar 22.32 at 6 months) SF-36 figures were similar at six months (Consultant performed 78.56, consultant supervised 75.39). There was a difference in SF-36 at 2 years (72.77 vs 63.11) but this was not statistically significant. Average abduction angle was lower in consultant supervised than consultant performed procedure. (36.75 vs 47 deg) Barrack cement grading was similar in both groups. Consultant inserted stems were more likely to be in neutral position compared to consultant supervised stems (84% vs 56%)

Conclusion: In both goups the quality of life indexes do show a difference in outcome which relates to the primary surgeon. However decreased abduction angle may lead to decreased range of motion post operatively and should be addressed intraoperatively.

Introduction: Reconstruction of ruptured anterior cruciate ligament is a commonly performed orthopaedic procedure. There are many ways of reconstructing this ligament. One method of doing so is to harvest a tendon graft from the hamstring muscles and use it as part of the reconstruction. The tendon is usually harvested by passing a tendon stripper along the length of the tendon from an anterior knee incision. The semitendinosus and the gracilis are the hamstring muscles whose tendons are used for this. A recent case study reported injury to the sciatic nerve during the harvest of semitendinosus graft. Although morbidity arising from iatrogenic injury to nerves at the anterior aspect of the knee has been well documented, little has been written about the relationship of the sciatic nerve to the semitendinosus and gracilis in the posterior thigh. This study proposes to look at this anatomical relationship.

Method: 20 legs on ten cadavers underwent the same dissection to expose the semitendinosus tendon, gracilis tendon and the sciatic nerve while maintaining their anatomical relationships. In all cases the gracilis lay further away from the sciatic nerve than the semiten-dinosus tendon. As the semitendinosus tendon was in between the semitendinosus and the sciatic nerve in all instances it was decided not to measure the distance between gracilis and the sciatic nerve. The distance between the closest point of the sciatic nerve to the tendon of semitendinosus was measured at the joint line and at intervals of 20 mm from the joint line.

Results: In 45 % of the subjects the sciatic nerve and the semitendinosus tendon gradually moved further apart as the measurements were taken more proximally in the leg. In 10 % they consistently moved apart from 6 cm from the joint line onwards. In another 10% they moved consistently apart from the 8cm from the joint line measurement and in 15 % they moved apart consistently from 12 cm from the joint line. In the remaining 20 % the sciatic nerve and the semitendinosus tendon did not consistently move apart from each other until after 14 cm from the joint line. In one subject (a female of small stature) it was noted that the semitendinosus muscle lay almost directly upon the sciatic nerve. In 6 subjects the minimum distance between the sciatic nerve and the semitendinosus tendon was less than 18mm. In one subject the distance between the sciatic nerve and the semitendinosus tendon was found to be 10 mm at the closest point and remained in close proximity for a further 4 cm.

Conclusion: In 55 % of our patients the sciatic nerve did not consistently move further away from the semi-tendinosus tendon as it was measured more proximally. In some subjects the minimum distance between the nerve and the tendon was less than 2 cm. Both these facts would put the sciatic nerve at risk during tendon harvesting if the tendon stripper were to move outside of the tendon during the procedure.

Aims: To confirm that the augmented (MGH) Becker extensor tendon repair is a strong four-strand technique that allows earlier mobilisation of repaired tendons after only 3/52 of postoperative static splinting and to assess functional outcome using revised disabilities of arm, shoulder and hand (DASH) score.

Methods: In this prospective study we used the augmented Becker (MGH) suturing technique with Ethilon. Postoperatively patients were immobilised 3 weeks in volar splint and then fully mobilised with physiotherapy. 3/12 postoperatively all patients had final assessment in hand clinic for: pulp to palm distance, power grip, pinch grip, pain, Dragan criteria of progress, total active motions (TAM) of the fingers and revised DASH score.

Results: Eighteen patients had extensor tendon lacerations repaired with augmented Becker (MGH) technique. Results were compared with the uninjured hand and statistically evaluated. At the final assessment the average pulp to palm distance was 0cm. All patients had good pinch and power grip (> 80% of uninjured hand for dominant hand and > 60% for non-dominant hand) and were free of pain with excellent progress using Dragan criteria. Average TAM was 268° without statistically significant difference between this and the uninjured side. Average scaled DASH score was 7.6 and within normal values. We had no wound complications or ruptures of repaired tendons.

Conclusion: Augmented (MGH) Becker technique is a strong four-strand extensor tendon repair technique that allows early mobilization of patients after only 3/52 of static splinting postoperatively. Injured fingers can then be safely mobilized with expected full return of movements at 3/12 postoperatively.