The trampoline is a popular source of recreational and competitive sport. However, little is documented about the dangers associated with its use particularly in the paediatric population.

We reviewed paediatric patients referred to our service from April to September 2005 inclusively, having been injured on a trampoline. This unit services a catchment area of approximately 400,000 patients.

Eighty-eight patients were assessed (mean age: 8 years 6 months). There were 33 males and 55 females. Most injuries (53/88) occurred while bouncing on the trampoline, while 34 were secondary to falls off the trampoline. The injured child was supervised in only 40% cases. In 31 cases, the injury was attributable to the presence of others on the trampoline. Thirty-six children required surgery. Fracturesof the upper extremities occurred in 70% of cases.

Injuries related to the recreational use of trampolines are an important and significant cause of paediatric injury. These results strongly suggest that there is a clear need for guidelines.

Fractures of the proximal humerus account for 4–5% of all fractures with 80% requiring no surgical treatment. However, the management of the other 20% remains controversial. Multiple surgical modalities have been examined with no consensus as to which if any is the most effective.

This study followed a series of 27 patients who had PHILOS plate fixation of their proximal humeral fractures. All patients were followed up clinically and radiologically for at least one year to a mean of 27.6+/−7.8 months.

We reviewed 27 patients with a mean age of 62.2 years (16 patients were aged at least 60 years). The patients were classified as per the AO system into type A (n=11), type B (n=12) and type C (n=3) fractures. The mean DASH score was 51.8. The mean SF-36 scores for physical and social functions were 68.7 and 88.0 respectively. The mean Constant score was 50.5%.

These results how that the PHILOS plate offers good functional outcomes across a spectrum of fracture severities and in an older population group. Its use should be considered where appropriate in the management of displaced proximal humeral fractures.

Aim: To review the prognosis of Pelvic Osteosarcoma in the files of the Scottish Bone Tumour Registry between 1955 and 2001.

Text: The cases of 40 consecutive patients with osteosarcoma of the pelvic ossea registered in the files of the Scottish Bone Tumour Registry between 1955 and 2001 were reviewed. 6 of these patients had underlying Paget’s disease and 2 had received previous radiotherapy to the pelvis. The median age at diagnosis was 60 years (mean 55.7 years). 12 patients had distant metastases at initial presentation (Enneking stage III). 24 patients had stage IIB ostesarcomas, 3 patients had stage IIA osteosarcomas and 1 patient had stage IB osteosarcoma. The median survival of stage IIB and stage III ostesarcoma was 9.5 months (1–39 months) and 5.5 months (0.5–16 months) respectively. The median age of survival for stage IIB tumours treated prior to the introduction of chemotherapy was 9 months (1–30 months) compared to those whose treatment included chemotherapy of 12 months (4–39 months). 5 of the 40 patients treatment regimens included surgical intervention- all had stage IIB tumours. The median survival for this group was 13 months (4–39 months).

Conclusion: Despite the introduction of modern multimodality treatment regimens the prognosis for pelvic osteosarcoma remains poor.

In patients with DM (Diabetes Mellitus types I & II), primary frozen shoulders tend to be refractory to all forms of treatment. We collected tissue from the joint capsule of shoulder joints from a variety of patients undergoing surgery as follows:

Diabetic Group (DFS): patients with DM who have primary frozen shoulders.

Tissue was collected from near to the rotator interval under arthroscopic control. Fibroblast lines were established by serial passage. Thereafter they were exposed to graded concentrations of insulin in vitro for 24 hours and the supernatant retained for assay. Fibroblast lines were analysed from 3 subjects in each group (n=9). Luminex multiplex analysis was performed for MMPs (Matrix Metalloproteinases). TIMP-1 (Tissue Inhibitor of MetalloProteinases) expression. Informed consent was obtained from all subjects.

Results: Production of MMP 1,2,3 and 8 by fibroblast lines were distinct between patient groups. MMP-1 production in DFS (mean 716pg/mL) was significantly reduced compared to FS derived patient cells (mean 972pg/mL) (p=0.0138, Mann-Whitney Test). Moreover, striking differences were observed when fibroblasts from DFS patients were compared with those from NS controls (mean 5898pg/mL) (p< 0.000). Calculating MMP-1/TIMP-1 ratios revealed significantly lower ratios in DFS (2597), or FS (2860) compared with NS (24,326) (p < 0.001). There was no significant difference between ratios of MMP1/TIMP1 in DFS and FS (p=0.977). MMPs 7,9,12 and 13 were not detected in any of the samples.

This is the first time these enzymes have been measured and quantified in cells derived from shoulder tissues. Primary Frozen Shoulders produce less MMPs and have a smaller MMP/TIMP ratio than controls. Similarly the diabetic patient derived cells produce less MMP-1, at an even lower level. These deficiencies in MMP1 production may reflect an altered capacity for local tissue re-modelling. MMP modulation may allow therapeutic intervention in the diabetic and frozen shoulder group of patients.

The purpose of this study was to evaluate the effect on movement under load of different techniques of reat-tachment of the humeral tuberosities following 4-part proximal humeral fracture. Biomechanical test sawbones were used. 4-part fracture was simulated and a cemented Neer3 prosthesis inserted. Three different techniques of reattachment of the tuberosities were used – 1)tuberosities attached to the shaft, and to each other through the lateral fins in the prosthesis with one cerclage suture through the anterior hole in the prosthesis, 2)as 1 without cerclage suture, and 3)tuberosities attached to the prosthesis and to the shaft. All methods used a number 5 ethibond suture. Both tuberosities and the shaft had multiple markers attached. Two Digital cameras formed an orthogonal photogrammetric system allowing all segments to be tracked in a 3-D axis system. Humeri were incrementally loaded in abduction using an Instron machine, to a minimum 1200N, and sequential photographs taken. Photographic data was analysed to give 3-D linear and angular motions of all segments with respect to the anatomically relevant humeral axis, allowing intertuberosity and tuberosity-shaft displacement to be measured. Techniques 1 and 2 were the most stable constructs with technique 3 allowing greater separation of fragments and angular movement. True intertuberosity separation at the midpoint of the tuberosities was significantly greater using technique 3 (p< 0.05). The cerclage suture used in technique 2 added no further stability to the fixation. In conclusion, our model suggests that the most effective and simplest technique of reattachment involves suturing the tuberosities to each other as well as to the shaft of the humerus. The cerclage suture appears to add little to the fixation in abduction, although the literature would suggest it may have a role in resisting rotatory movements.

Object: To assess the benefit of prescribed Iron supplementation on the recovery of patient’s Haemoglobin level after elective joint replacement.

Design: A Prospective, Randomised Trial was undertaken. All patients undergoing elective arthroplasty (Hip, Knee, and Revision Hip) at our unit were considered. Qualifying parameters included: a normal store of Iron (Fe) prior to surgery (based on the serum Ferrittin level) and normal markers of inflammation (serum C - reactive protein [CRP] and erythrocyte sedimentation rate [ESR]). Elevated CRP and ESR are known to be factors affecting the serum Ferrittin level.

Method: 318 patients undergo joint replacement from May 2004 to Oct 2004 were considered for the study. 208 patients were excluded for the following reasons: 52 patients had low serum Ferrittin level or elevated ESR and CRP levels pre-operatively. 156 patients was normal post operative Haemoglobin (> 11 mg %). This left 110 patients with normal pre-operative inflammatory markers and Iron stores. This cohort formed the basis of the study and was randomised to either receiving prescribed Iron Supplementation (Oral Ferrous Sulphate) twice a day for 8 week or no supplementation. Randomisation was performed based on the month of surgery. Even numbered months received the intervention, odd numbered did not. Post-operatively all patients had serum Haemoglobin checked at intervals 2^nd–7^th day and 8 weeks

Results: There was no significant different in mean Haemoglobin level between treatment group i.e. 12.72 mg% (10.8–15.4) and controlled group 12.71 mg% (11–15.3) at 8 weeks follow up.

Conclusion: The prescription of oral Iron in healthy postoperative joint replacement patients did not hasten the recovery of Haemoglobin level provided adequate tissue Iron stores were present. The use of Fe supplementation provides no benefit in these patients and our study confirms this. Iron supplementation therapy should be reserved for patients identified pre-operatively with either low Iron stores or elevated serum inflammatory markers.

MRSA wound infection following Total joint arthroplasty is catastrophic with disastrous consequences. Our aim was to determine the prevalence and risk factors for MRSA colonization in patients presenting for orthopaedic surgery in our unit. All patients admitted to the hospital for elective arthroplasty over a four year period were included in the study. At the time of admission, a detailed questionnaire was completed by each patient. Routine nasal, throat, axilla, perineum swabs and from any pre-existing wound sites were sent for culture.

Among 2900 patients studied, 42 patients (1.4%) were positive for MRSA on admission. The prevalence of MRSA colonization in patients who were admitted directly from Nursing homes or from own home was 36.7% and 1.3% respectively. All MRSA positive patients who were admitted directly from home had at least one documented hospital admission in the preceding year and/or antibiotic administration within three months prior to admission. The risk factors identified for MRSA colonization were in risk order : Nursing home residency(p< 0.05), previous hospital admission(p< 0.05), antibiotic administration in previous three months(p< 0.05), and female gender(p< 0.01 )Statistical analysis with Chi squared test for independence p< 0.05 considered significant.

Present MRSA screening focuses on all patients being admitted for surgery, this contrasts to North American policies of screening only patients with risk factors. We would question the validity and economical reasoning of general rather than targeted screening procedures.

Background: Interest is growing in minimally invasive techniques to treat vertebral fractures in the elderly population. Amongst the benefits mooted are relief of pain and prevention of deformity. However little background data is available concerning the long-term outcome of such patients treated by either conservative or surgical means.

Aim: To describe the natural history of a cohort of patients with osteoporotic vertebral fractures, treated conservatively with bedrest and a Taylor brace.

Patients and Methods: All patients admitted to our institution over a five-year period following a vertebral fracture were identified. A total of 223 patients were admitted over the study period. Of these, 61 were suitable for inclusion in the study. Following departmental approval all patients were contacted by phone and invited to participate in the study. Patients were examined in the clinic, plain radiographs were performed and the Oswestry pain score, a visual analogue pain score (VAS), and SF36 questionnaire were completed.

Inclusion criteria: Patients over 65years at time of injury

Minor trauma e.g. minor fall

No neurological deficit

Exclusion criteria

Patients over 65years who were involved in major trauma.

Non-Irish residents.

Results: Mean patient age at the time of injury was 72.1years. Mean duration of follow up was 8.2 years with a minimum follow up of 5 years. Seven patients were lost to follow up. Of the remaining fifty-four patients, five had died since their admission. According to family members none had any pain or neurological symptoms related to their backs. Forty patients attended the clinic for review while nine completed telephone questionnaires.

On examination two patients had a clinically evident kyphosis. The mean range of anterior flexion was 78.9° + 15°. The mean VAS pain score was 2.2 + 2.0. No significant correlation existed between the magnitude of the initial vertebral collapse and the Oswestry or SF36 scores. No significant further vertebral collapse was noted on radiographic follow up. A small cohort of patients did develop chronic back pain. These patients’ outcome could not be predicted on the basis of initial radiographs.

Discussion: Our study supports conservative management: most patients recovered normal function and suffered little long-term pain. It was not possible to predict which patients would develop chronic back pain on the basis of initial radiographs. This calls into question the indications for undertaking vertebroplasty or kyphoplasty in the treatment of such patients.

Study Design: Prospective Cohort Study.

Objective: To describe the natural history of a cohort of patients with osteoporotic vertebral fractures treated conservatively with bedrest and a Taylor brace.

Summary of Background Data: Interest is growing in minimally invasive techniques to treat vertebral fractures in the elderly population. Amongst the benefits mooted are relief of pain and prevention of deformity. However limited background data is available concerning the long-term outcome of such patients treated conservatively.

Patients and Methods: All patients admitted to our institution over a five-year period following a vertebral fracture were identified (n=223) Of these, 61 were suitable for inclusion in the study. Following departmental approval all patients were contacted by phone and invited to participate in the study. Patients were examined in the clinic, plain radiographs were performed and the Oswestry pain score, a visual analogue pain score (VAS), and SF-36 questionnaire were completed. Patients over 65 years, involved in minor trauma without neurological deficit were included. Patients over 65 years who were involved in major trauma or non-Irish residents were excluded from the study.

Results: Mean patient age at the time of injury was 72.1 years. Mean duration of follow up was 8.2 years with a minimum follow up of 5 years. Seven patients were lost to follow up. Of the remaining fifty-four patients, five had died since their admission. According to family members none had any pain or neurological symptoms related to their spinal injuries. Forty patients attended the clinic for review while nine completed telephone questionnaires. Two patients had a clinically evident kyphosis. The mean range of anterior flexion was 78.9° ± 15°. The mean VAS pain score was 2.2 ± 2.0. No significant correlation existed between the magnitude of the initial vertebral collapse and the Oswestry or SF-36 scores. Physical Function and Bodily Pain subsets of SF-36 were no different to an age matched Irish population. No significant further vertebral collapse was noted on radiographic follow up. A small cohort of patients did develop chronic back pain. These patients’ outcome could not be predicted on the basis of initial radiographs.

Conclusion: This study supports conservative management: most patients recovered normal function and suffered little long-term pain. It was not possible to predict which patients would develop chronic back pain on the basis of initial radiographs. This calls into question the indications for undertaking vertebroplasty or kyphoplasty in the treatment of such patients.

Introduction and Aims: Numerous internal as well as external fixation techniques have been reported for achieving tibiotalocalcaneal fusion in rheumatoid arthritis with varying results. The purpose of this study was to assess the union rate and functional outcome following tibiotalocalcaneal fusion using the locked supracondylar nail.

Method: Twenty-four patients (27 ankles) were followed up. The mean age being 57 years (44–73 years) and mean follow-up was 37.4 months (10–74 months). Severe disabling ankle pain was the indication for operation in all cases. Standard operative technique and post-operative mobilisation protocol was followed. Seventeen cases had ankle debridement. The severity of rheumatoid arthritis was assessed using the Fries scoring system. Results were analysed using Rheumatoid ankle score (RAS), modified American Orthopaedic Foot & Ankle Society Score (AOFAS). All the patients were evaluated for clinical and radiological evidence of union.

Results: The mean Fries score of 2.3 suggest that most of the patients in the study group were affected by severe rheumatoid arthritis. The mean RAS score was 77 (35–95) and mean AOFAS score was 74.6 (40–95). Using the rheumatoid ankle scoring system, five ankles (20%) were rated excellent, ten ankles (40%) were rated good, six ankles (24%) were rated fair and four (16%) were rated poor. In general, patients who had ankle debridement at the time of nailing fared well in terms of clinical, radiological union and ankle scoring.

Conclusion: Tibiotalocalcaneal arthrodesis with supracondylar nail in rheumatoid arthritis provides pain-free stable joint and satisfactory functional outcome. Better functional results are achieved with bony union and this can be achieved only with joint debridement.

Introduction and Aims: The purpose of this study was to evaluate the effect on movement under load of different techniques of reattachment of the humeral tuberosities following four-part proximal humeral fracture.

Method: Biomechanical test sawbones were used. Four-part fracture was simulated and a cemented Neer3 prosthesis inserted. Three different techniques of reattachment of the tuberosities were used: 1) tuberosities attached to the shaft, and to each other through the lateral fins in the prosthesis with one cerclage suture through the anterior hole in the prosthesis; 2) as one without cerclage suture; 3) tuberosities attached to the prosthesis and to the shaft. All methods used a number five ethibond suture. Both tuberosities and the shaft had multiple markers attached. Two digital cameras formed an orthogonal photogrammetric system, allowing all segments to be tracked in a 3-D axis system. Humeri were incrementally loaded in abduction using an Instron machine, to a minimum 1200N, and sequential photographs taken. Photographic data was analysed to give 3-D linear and angular motions of all segments with respect to the anatomically relevant humeral axis, allowing intertuberosity and tuberosity-shaft displacement to be measured.

Results: Techniques one and two were the most stable constructs with technique three, allowing greater separation of fragments and angular movement. True inter-tuberosity separation at the midpoint of the tuberosities was significantly greater using technique three (p< 0.05). The cerclage suture used in technique two added no further stability to the fixation.

Conclusion: Our model suggests that the most effective and simplest technique of reattachment involves suturing the tuberosities to each other, as well as to the shaft of the humerus. The cerclage suture appears to add little to the fixation in abduction, although the literature would suggest it may have a role in resisting rotatory movements.

Existing classifications of fractures of the head of the humerus are inadequate in terms of interobserver reliability and the predictability of the clinical outcome. From a combined study of 73 fracture specimens in museums and 84 CT-three-dimensional reconstructions in patients, we have devised a classification which appears to be more useful clinically. Common patterns of fracture and a plausible mechanism of injury were observed.

In 3-D most proximal humeral fractures can be organised into five basic types. These correspond in some degree to the Codman/Neer classification, but differ significantly in regard to the more complex patterns of fracture. We observed a logical progression from simple to complex fractures. An interobserver reliability study was carried out which indicated the improved usefulness of this new 3-D concept in providing a common language among clinicians for classifying these injuries. When surgery is indicated, the 3-D concept is also invaluable in guiding the restitution of anatomy through either open or percutaneous means.

Introduction: Our institution is a stand-alone elective orthopaedic unit. The majority of prospective arthroplasty patients undergo in-patient pre-operative assessment.

Aim: We assessed the efficacy of a consultant physician delivered pre-operative assessment clinic for patients undergoing elective hip arthroplasty in terms of financial costs, duration of stay, cancellation rate and postoperative complications.

Patients and Methods: A study was undertaken over a six-month period comparing two age and sex matched patient cohorts. Group 1 consisted of 40 patients who were admitted directly for hip arthroplasty, while Group 2 patients were admitted for in-patient assessment prior to being readmitted for surgery. Data collected included patient age, presence of comorbidities. ASA score and the presence of post-operative complications.

Results: Group 1 comprised 40 patients with a mean age of 62.7 years (51–70), while Group 2 included 50 patients whose mean age was 63.78 years (51 – 70). A majority of patients in both groups were male. A significantly lower number of comorbid conditions and a lower ASA score were noted in group 1 patients, when compared with group 2. In addition, a shorter duration of hospital stay was noted in Group 1 patients with an associated decrease in costs.

Only one patient (2.5%) from Group 1 was cancelled pre-operatively; this for treatment of a chronic comorbidity. Five patients (10%) in Group 2 were cancelled on admission for surgery. Four of these patients were cancelled for acute illness that had developed following in-patient assessment, with one being discharged for treatment of a chronic illness.

Discussion: In-patient assessment prior to joint replacement placed a considerable burden on patients and healthcare resources. Patients referred to the assessment clinic were sicker, had a longer duration of hospital stay and had a higher incidence of cancellations than their peers in Group 1. It is important to note that the majority of all cancellations were due to the presence of acute medical problems not present at the time of assessment. Thus we feel that the current practice of in-patient assessment is financially inefficient and does not produce a notable decrease on pre-operative cancellations. In our opinion it is better replaced with an anaesthetic assessment on an out patient basis.

Sciatic Nerve Palsy (SNP) is a recognised complication in Primary Total Hip Replacement after a transtrochanteric or a posterior approach (5). It is considered to be caused by direct trauma to the nerve during surgery. In our unit this complication was rare with an incidence of < 0.2% over the past ten years. However we know describe six cases of sciatic nerve palsy occurring in 355 consecutive primary THRs (incidence 1.60%) performed in our unit from June 2000 to June 2001. Each of these sciatic nerve palsies we believe was due to postoperative haematoma in the region of the sciatic nerve.

To our knowledge there are only five reported cases in the literature of sciatic nerve palsy secondary to postoperative haematoma (1). (Each of the six patients who developed SNP was receiving prophylactic anticoagulation).

Cases recognized early and drained promptly showed earlier and more complete recovery. Those in whom diagnosis was delayed and were therefore managed expectantly showed no or poor recovery. More than usual pain the buttock, significant swelling in the buttock region and sciatic nerve tenderness associated with signs of sciatic nerve irritation may suggest the presence of haematoma in the region of the sciatic nerve. It is therefore of prime importance to be vigilant for the signs and symptoms of sciatic nerve palsy in the early post operative period because if recognized and treated early the potential injury to the sciatic nerve may be reversible.

Background: The total cost of a joint arthroplasty is a matter of increasing interest to health economists. Patients who are admitted for elective procedures and subsequently cancelled incur significant additional costs and prevent admission of other patients.

Aim: We undertook a study to examine the incidence, causes and costs associated with pre-operative cancellation in an elective orthopaedic unit.

Patients and Methods: We reviewed all orthopaedic admissions over a twenty-month period, from March 2000 to June 2002. A total of 1,220 patients were admitted for arthroplasty. 62 patients (5.1%) were cancelled pre-operatively following admission. Detailed analysis of these cases was then undertaken, with details and costings of ancillary investigations obtained from relevant laboratory and radiology departments.

Results of Cancelled Patient Cohort: Mean patient age was 71.5 years (versus 75.3 yrs for non-cancellations) with a slight female preponderance. Almost three quarters of cancellations (72.5%, 45 patients) were avoidable, subsequently having their procedure at a later date. The remaining seventeen patients had chronic comorbidities and were judged permanently unfit for surgery following further work up. Of the 45 deferred patients, 16 patients were postponed to allow optimization of comorbid conditions. 19 patients had their surgery delayed for acute illnesses that had developed in the fortnight prior to admission. Infection was the commonest cause of cancellation in this group (n=18), with one patient cancelled due to a pre-operative DVT. The residual 10 patients were cancelled due to improvement of symptoms (4) unavailability of blood (3), anaesthetic equipment failure (2), and patient wishes (1). A comparison was performed using Student’s t test between patients temporarily deferred or permanently cancelled on the basis of age, comorbid conditions, ASA score and duration from in-patient assessment to admission. Only ASA scores demonstrated a significant difference between the two groups (Deferred 2.39, Cancelled 2.92; p< 0.01). The mean cost per admission was €10,187.26 with “Hotel” costs forming up to 75% of the total. While patients who were operated on inevitably incurred significantly higher costs (p< 0.01) it is noteworthy that the mean cost of admission per cancelled patient was €4,531, amounting to €77,010 over the study period. In addition, patient whose surgery was deferred incurred significant extra costs when compared with uncomplicated cases (mean excess €1,867). Therefore the additional costs of these 63 patients amounts to a total of €161,025.

Conclusion: Patients cancelled following admission incurred considerable costs. In order to minimize costs and maximize efficiency, we would recommend that the small cohort of patients with a high ASA score have a focused anaesthetic review pre-operatively. A program of education directed at patients and general practitioners would help eliminate minor illnesses, which necessitate cancellation, prior to admission.

Aim: To assess the blood loss in patients undergoing total knee arthroplasty and to determine the effects of surgical technique, duration of surgery and use of tourniquet. To look at the value of patient factors including gender, age, weight, pre-operative haemoglobin as predictive factors for future transfusion. We assessed the complications of wound healing, regaining the range of motion and thromboembolic effects.

Patients and Methods: A prospective review of 150 patients undergoing knee arthroplasty, with a minimum follow-up of 2 years (2–8 years). We divided the patients into three groups (n=50). Group A had no tourniquet applied and haemostasis secured before skin closure, Group B had tourniquet released after cementation to secure haemostasis before skin closure and Group C had tourniquet applied until after the skin closure.

Patients were matched for age, gender, pathology, weight, implant type, pre operative haemoglobin and senior operator in all three groups. We assessed intra-operative and total blood loss, transfusions requirements, postoperative wound complication, regaining of the range of motion, incidence of systemic effects of tourniquet and duration of hospital stay. We also looked at the effects of NSAIDS on blood loss and compared the validity of various factors reported in the literature to be predictive of future transfusion after the surgery. Statistical analysis used were, student’s t-test, univariate and multivariate analysis and regression statistical analysis.

Results: Group A had maximum blood loss (mean 1374 mls.) followed by Group B (mean 774 mls.) The mean blood loss of Group C was 550 mls (p< 0.001, 95% confidence interval range of 527843 mls). Statistically the duration of operation was the most important factor in minimising the blood loss (p< . 0001 R₂ =0.68). The association of pre operative haemoglobin and weight as predictors of future transfusions statistically did not show a strong relationship (R2 = 0.17, R₂ = 0.13 respectively). Statistically no significant difference was found in wound complications, hospital stay, post operative pain and regaining the range of motion in three groups (R₂ 0.58). Patients on NSAIDS did not loose more bloods than patients not on NSAIDS.

Conclusions: The use of tourniquet until after the skin closure is statistically the best method for reducing blood loss in total knee arthroplasty. It does not cause significant wound problems and does not significantly affect the regaining of range of motion. Furthermore the usage of NSAIDS does not cause excessive postoperative bleeding.

Complex fracture patterns of the proximal humerus can be difficult to understand and to treat. Classification systems are inadequate and the exact mechanisms of injury are obscure. From inspection of 73 cases of proximal humeral fractures culled from a large number of museum specimens, we propose a hypothesis as to the nature and configuration of these injuries. It is suggested that the glenoid is the “anvil” upon which the humeral head is broken and that the particular fracture personality reflects the position of the head vis a vis the glenoid at the time of injury. From this perspective, proximal humeral fractures present in a comprehensible and progressive sequence. Five different fractures patterns are identified and account for the vast majority of these injuries. X-ray examination, especially CT 3-D reconstructions, in a small group of clinical cases (30 patients) substantiated the usefulness of looking at these fractures in this way. From a combination of the museum studies and patient material, we have constructed a “fracture wheel” diagram for the presentation of these injuries in a format which may be helpful in organizing a new and clinically useful classification system.

This study was carried out to investigate the outcome of rotator cuff repair surgery in 14 centres in th UK in a randomised controlled trial. It also looked at a comparison of a long-acting absorbable suture (Panacyrl) and a non-absorbabable suture (Ethibond).

All patients were treated with open repair of their rotator cuff tear with modified Mason-Allen sutures used in 83% of cases. One hundred and fifty-nine patients were included in the analysis. patients had Constant scores carried out pre-operatively, six and 12 months as well as ultrasound real time dynamic scans at eight weeks, six and 12 months.

Constant pain scores, total constant scores and re-tear rates were measured. There was a significant improvement in the Constant score after rotator cuff repair surgery. However for large tears, the re-tear rate at six months is approximately 50%. Despite this high retear rate there was still a good benefit from surgery. Is the improvement in those cases with a re-tear a consequence of the sub-acromial decompression (SAD) and what would have been the outcome with an ASD alone?

We assessed patellofemoral joint function by combining the measurement of maximal isometric extensor torque at the knee with clinical and radiological measurements in order to calculate the patellofemoral contact force. Eighteen volunteers established the normal ranges of results and the reliability of the system. Of the 39 patients with a variety of knee problems, 29 had anterior knee pain, and all had a subsequent arthroscopy. Patients with anterior knee pain and lesions in the patellar cartilage had significantly reduced isometric contact forces, but those with normal patellofemoral cartilage had normal contact forces. Our method may be useful in providing an objective assessment of anterior knee pain and a quantitative means of monitoring its treatment.

It is difficult to establish the diagnosis of an injured shoulder if only one radiographic projection is used. We have compared two lateral projections, the Neer trans-scapular and the apical oblique in 80 patients; the radiographs were presented randomly to 10 casualty officers and nine radiologists. The apical oblique view was found to permit more accurate diagnosis of fractures and of dislocation by both groups.