Construction of a functional skeleton is accomplished through co-ordination of the developmental processes of chondrogenesis, osteogenesis, and synovial joint formation. Infants whose movement in utero is reduced or restricted and who subsequently suffer from joint dysplasia (including joint contractures) and thin hypo-mineralised bones, demonstrate that embryonic movement is crucial for appropriate skeletogenesis. This has been confirmed in mouse, chick, and zebrafish animal models, where reduced or eliminated movement consistently yields similar malformations and which provide the possibility of experimentation to uncover the precise disturbances and the mechanisms by which movement impacts molecular regulation. Molecular genetic studies have shown the important roles played by cell communication signalling pathways, namely Wnt, Hedgehog, and transforming growth factor-beta/bone morphogenetic protein. These pathways regulate cell behaviours such as proliferation and differentiation to control maturation of the skeletal elements, and are affected when movement is altered. Cell contacts to the extra-cellular matrix as well as the cytoskeleton offer a means of mechanotransduction which could integrate mechanical cues with genetic regulation. Indeed, expression of cytoskeletal genes has been shown to be affected by immobilisation. In addition to furthering our understanding of a fundamental aspect of cell control and differentiation during development, research in this area is applicable to the engineering of stable skeletal tissues from stem cells, which relies on an understanding of developmental mechanisms including genetic and physical criteria. A deeper understanding of how movement affects skeletogenesis therefore has broader implications for regenerative therapeutics for injury or disease, as well as for optimisation of physical therapy regimes for individuals affected by skeletal abnormalities.

Cite this article: Bone Joint Res 2015;4:105–116

Background: This study was carried out to record and compare the opinions of junior and senior orthopaedic surgeons with regards to the amount of training necessary to achieve competency in knee arthroscopy.

Methods: At a recent international orthopaedic conference a questionnaire was given to 50 orthopaedic residents and 40 consultants. Consultants were also asked if they performed regular knee arthroscopy (> 50/year). Competency for this study was deWned as the ability to perform the procedure without supervision.

Participants were asked to estimate the number of times a trainee needs to do the following procedures to achieve competency: diagnostic scope, partial medial meniscectomy, partial lateral meniscectomy, and anterior cruciate ligament (ACL) reconstruction.

Results: Participants completed the questionnaire immediately ensuring a 100% response. Of the 40 consultants, 22 performed regular knee arthroscopy. The greatest similarity was between the opinions of the consultants who performed regular knee arthroscopy and the junior surgeons, for both diagnostic and partial medial meniscectomy. There was a substantial diVerence in opinion for partial lateral meniscectomy and ACL reconstruction, with junior surgeons estimating a much greater amount of practice being needed to achieve competency. Consultants who did not perform regular knee arthroscopy consistently estimated approximately half the number of operations when compared to others.

Conclusions: The information presented in this study demonstrates the opinions of both junior and senior surgeons as to how many repetitions of four common arthroscopic procedures are necessary to achieve competency: this information may be useful in designing eVective arthroscopic training programmes.

Aim To document an outbreak of Vancomycin Resistant Enterococci in an elective Orthopaedic Unit. To describe the clinical course of the affected patients and treatment options. To describe methods employed in eradicating endemicity following the outbreak and to evaluate the lessons learnt.

Background VRE first appeared in the Microbiological literature in 1988. Very little is known about its effect in the Orthopaedic Realm. To our knowledge, this is the first report of a serious outbreak in such a unit and only the second reporting of peri-prosthetic VRE infection.

Material and methods All patients in the unit over a 1/12 unit formed the cohort for the study. Following identification of the index case, samples were taken form all in-patients. Immediately a nurse specialist in infection control oversaw sampling of all patients. Microbiological data, Clinical Data and antimicrobial therapy data was collected on all positive patients. Rapid laboratory procedure were instituted, environmental screening was preformed and a dedicated cleaning team was formed. The assistance of a Clinical Microbiologist and an Environmental Microbiologist was sought.

Results Following identification of the index case, 11 patietns had microbiological proven VRE. 1 patient had a VRE confirmed peri-prosthetic infection. This necessitated removal and appropriate anti-microbial therapy. However, this patient died. 2 pateints were found to have superficial wound infection, which resolved with oral Linezolid, while 8 patients showed colonization with the organism. No treatment was required other than clinical follow up and staged screening in these patients.

The unit was closed for 9 weeks following the outbreak and deep cleaning resulted in eradication of endemicity.

Conclusion Tracing of the index case and typing allowed us to confirm the source of the outbreak and to take steps to prevent a recurrence. Appropriate microbiological advice is essential in an outbreak situation, management of peri-prosthetic infection and follow up of affected cases. All protocols have been re-evaluated and retraining of all staff in good clinical hygiene has been undertaken. The speed of the outbreak and its devastating effect on a Joint Replacement Facility is alarming and should serve to aid other units in establishing preventative protocols and in preplanning their treatment options and an outbreak team.

Chordoma is low grade, locally aggressive and mainly in the sacrococcygeal region. Treatment is a combination of surgery and radiotherapy. We reviewed, to determine our outcome and functional deficits, the cases treated over 15 years by the senior author.

Out of 26 chordoma’s referred 14 were in the sacrococcygeal region. We reviewed them retrospectively looking at presentation, diagnosis, surgical approach, neurological result, complications and survival.

The mean age was 55 years (range 26–80 years), 9 males and 5 females. 13 were primary and 1 was recurrent. Patients reported 18 months of symptoms prior to diagnosis. The tumour sites were S1-5, S2-2, S3-2, S4-3, S5-1 and coccyx −1. Surgery was performed via an anterior/posterior-combined approach in 10, a posterior approach in 2, anterior in 1 and posterior/perineal combined in 1. Complete excision was possible in 11 cases. Surgical resection with radiotherapy was used for inadequate surgical margins, in 3 cases. Neurologically we found that we needed an intact unilateral S3 nerve root for continence in our series. All patients had minor wound complications, 2 wounds required further surgical intervention, and there were 2 cardiac arrhythmias, 1 pulmonary embolus. There were 5 recurrences, 3 were local and 2 metastatic. The survival data for 5 and 7 years is 88% and 71% respectively. Our disease free survival at 5 and 7-years was 44% and 57% respectively.

We achieved an excellent 5 and 7-year survival in our series. The results following complete excision were best, but those treated with adjuvant radiotherapy also responded well. We saw that a solitary S3 nerve root is needed for continence. Treating by a combined anterior/ posterior approach suggests improved survival.

Introduction: Hip arthroplasty for dysplasia of the hip provides a challenge to all hip surgeons. The choice of prosthesis used depends on the severity of the deformity, and the challenge of acetabular reconstruction. We report a review of 105 of our cases operated since 1992 with a minimum two-year follow-up.

Methods: The data in this study has been collected and entered prospectively since 1992 on an arthroplasty database. A total of 105 cases were identified and reviewed. The indication for surgery was painful hip osteoarthritis secondary to dysplasia. All patients were reconstructed with some attempt at restoration of the hip centre, and without femoral osteotomy.

Results: There were 96 patients (10 bilateral), 66 females and 29 males whose mean age at surgery was 53 years (23 to 97 years). The mean follow-up period was 59 months (27 to 107 months). The hip was exposed via a posterior approach in 98% of cases. The majority (94%) of cases had no previous surgery. Depending on the degree of dysplasia either an ABG or S-ROM prosthesis was used.

There were 78 Crowe I & II, and 18 Crowe III & IV hips. The more dysplastic hips required the versatility of the SROM stems to avoid excessive lengthening or femoral osteotomy. These cases also had significantly more inferior reconstruction of the hip centre, and medialisation of the hip centre.

Complications occurred in 8/106 (8%) of cases, the mean time to occurrence being 25 months. The majority were dislocations 7 (7%). There were no sciatic nerve palsies. Revision was required for 5 cups and 1 stem. Clinical evaluation showed all patients were living at home and 85% had no activity restrictions. Mean Harris Hip Score was 92/100. None or mild thigh pain only was reported in 90% of cases. In 98% of cases patients were satisfied with their outcome. Radiographic evaluation showed stem ingrowth occurred in all cases. Minor osteolysis was apparent in 6% of cases. Spot welds were identified in 76% of cases. One case demonstrated pedestal formation.

Conclusion: Reconstructing hip joint mechanics is a challenge in the dysplastic hip. The use of different prostheses for the varying severity in dysplasia has been an effective approach to optimise hip mechanics. Our results using this approach with cementless implants has given excellent short term clinical and radiographic results.