We sought to evaluate the impact of a dedicated weekly ortho-plastics operating list on our ability to provide definitive soft tissue cover of open lower limb fractures within 72 hours.

We reviewed all open lower limb fractures at our centre before and after the introduction of an ortho-plastics list to determine whether definitive soft tissue coverage was achieved within 72 hours.

There were 23 open lower limb fractures at our centre in 2012 before the introduction of the ortho-plastics operating list of which only 7 (30%) had definitive soft tissue coverage within 72 hours. We hypothesised that the main reason for this was not patient or injury related factors but rather the logistical difficulties of coordinating theatre time on a routine trauma list with senior orthopaedic and plastic surgeon availability. To test this hypothesis we re-audited our time to soft tissue cover six months after the introduction of the ortho-plastics list and 70% of cases achieved coverage within 72 hours.

Achieving definitive soft tissue coverage of open lower limb fractures within 72 hours of injury is a challenge. A dedicated weekly ortho-plastics operating list significantly improves our ability to deliver this service.

Introduction: Accurate templating prior to hip replacement requires that the magnification of the radiograph is known. This magnification is usually measured using a scale marker ball or disc of known diameter, but this method is inaccurate when the marker is not precisely positioned in the coronal plane of the hips.

Our aims were to design a novel scale marker which does not require such precise positioning, and to compare the accuracy of this new marker with a standard single ball marker.

Methods: The new marker consists of two separate markers: one behind the patient’s pelvis, the other at the front. It can be shown that the radiographic magnification of such markers is consistently related to the magnification of the hips.

The posterior marker consists of a 75x75cm square foam mat, incorporating multiple 25.4mm metal rods arranged in series down the centre. The anterior marker is made from five 25.4mm steel balls, linked in series at 20mm intervals. The mat is positioned just underneath the patient’s pelvis as they lie supine for their radiograph. The five balls are placed in the midline over the patient’s suprapubic region, and the x-ray is then taken. The radiographic dimensions of the ball and rod which are located between the hips are then measured. The magnification of the hips may then be calculated from these dimensions using a simple equation.

To validate the new “double” marker, it was compared with a conventional single marker ball. 74 hip arthroplasty patients undergoing routine radiographic follow up were recruited. Both the new double marker and the single marker were applied at the time of x-ray, the magnification according to each was calculated, and these were compared to the true radiographic magnification as determined from the known dimensions of the prosthesis. All markers were positioned by independent radiographers trained in their use.

Results: The correlation between true and predicted magnification was excellent using the double marker (r=0.90), but only moderate for the single marker (r=0.50). The median error of the single marker was 4.8%, but only 1.1% for the double marker (p< 0.001). The reliability of the double marker as a predictor of true magnification was very good (intraclass correlation coefficient, ICC=0.89), but was poor for the single marker (ICC=0.32). The accuracy of the double marker was unaffected by the patient’s body mass index. The inter and intraobserver variability of the new method were both excellent (ICC> 0.94).

Discussion: The double marker method is significantly more accurate and reliable than the single marker method when used in a clinical setting, as it does not rely on precise positioning of the marker by the user. We believe that this technique may become the gold standard method of calculating radiographic hip magnification in clinical practice.

Narrowing of the femoral neck after resurfacing arthroplasty of the hip has been described previously in both cemented and uncemented hip resurfacing. Traditionally hip resurfacing has been performed via a posterior approach though other surgical approaches including the Ganz and the anterolateral approach have been well described. In addition it is known that the blood supply of the femoral neck arises largely from posterior structures and it has been postulated that neck narrowing is a consequence of poor post-operative femoral neck vascularity. Our null hypothesis in this study was that the choice of surgical approach does not influence postoperative femoral neck narrowing. We retrospectively measured the diameter of the femoral neck in a series of 135 consecutive patients who underwent uncemented cormet hip resurfacing, with follow up from one to 3 years. Our sample included 50 females and 85 men with an average age of 56.4 years (standard deviation of 9.47). Seventy six patients had a Ganz approach, 5 had an anterolateral approach and 55 had a posterior approach. There were no failures due to femoral neck fracture and no revisions to total hip arthroplasty. Eleven patients required subsequent surgery all of which were due to complications following trochanteric osteotomy. Seven patients needed removal of metalwork and 4 patients had non-union of their osteotomy requiring revision. At one year the posterior approach group had an average of 5.2% neck narrowing versus 2.7% neck narrowing in the Ganz approach group (p value 0.06). At three years the average neck narrowing amongst all patients was 6.8% (standard deviation 3.1%) but the number of patients who had had a Ganz approach was too small to meaningfully apply inference statistics. Our study shows early results which show a statistically significant reduction in the rate of femoral neck narrowing in patients who have had a Ganz approach as compared to a posterior approach for unce-mented hip resurfacing arthroplasty. It also shows a high rate of complications inherent with the Ganz approach which in our patient group are entirely related to the trochanteric osteotomy.

Purpose: To report on our early experience with a synthetic meniscal substitute inserted for symptomatic post meniscectomy medial or lateral knee pain.

Methods and results: Six patients underwent underwent insertion of a collagen meniscal implant (Menaflex, Hospital Innovations, UK). These were inserted onto a trephinated rim of vascular meniscus to permit the structural incorporation of healing tissue. Specific rehabilitation included 8 weeks on crutches and restricted activity for 6 months. Patients were prospectively analysed documenting KOOS, IKDC, Lysholm and SF36 outcome scores.

All patients were male, 4 patients had deficiencies in the right knee, 2 the left knee and the mean patient age was 28.8years (range 17–45). Four CMI were inserted for lateral meniscal deficiencies, two medial. The mean length of implant sutured in place was 41mm (range 35–55). Median pre op scores were KOOS P/S/ADL/QOL 53/100, 54/100, 66/100, 25/100, 44/100, IKDC 49.43%, Tegner 3, SF-36 35.38 PCS and 27.48 MCS and Lysholm 87/100. The mean elapsed time post meniscectomy was 20 months (range 2–51). All but one of the implants used were 9.5mm in width and sizes ranged 35–45mm.

At early follow up there have been no complications and background pain has improved in all 6. MIR imaging has shown that none have separated. Post operative follow up suggest improved outcome.

Conclusion: Though this is very early data, close scuritny of new treatment options is essential. So far the clinical outcome is favourable and we believe that CMI may be beneficial in reducing post menisectomy pain. Hopefully, in the future CMI may become a means of preventing post meniscectomy osteoarthrtitis.

We have developed a novel method of calculating the radiological magnification of the hip using two separate radio-opaque markers. We recruited 74 patients undergoing radiological assessment following total hip replacement. Both the new double marker and a conventional single marker were used by the radiographer at the time of x-ray. The predicted magnification according to each marker was calculated, as was the true radiological magnification of the components. The correlation between true and predicted magnification was good using the double marker (r = 0.90, n = 74, p < 0.001), but only moderate for the single marker (r = 0.50, n = 63, p < 0.001). The median error was significantly less for the double marker than for the single (1.1% vs 4.8%, p < 0.001). The double marker method demonstrated excellent validity (intraclass correlation coefficient = 0.89), in contrast to the single marker (0.32).

The double marker method appears to be superior to the single marker method when used in the clinical environment.