Total elbow arthroplasty (TEA) usage is increasing owing to expanded surgical indications, better implant designs, and improved long-term survival. Correct humeral implant positioning has been shown to diminish stem loading in vitro, and radiographic loosening in in the long-term. Replication of the native elbow centre of rotation is thought to restore normal muscle moment arms and has been suggested to improve elbow strength and function. While much of the focus has been on humeral component positioning, little is known about the effect of positioning of the ulnar stem on post-operative range of motion and clinical outcomes. The purpose of this study is to determine the effect of the sagittal alignment and positioning of the humeral and ulnar components on the functional outcomes after TEA.

Between 2003 and 2016, 173 semi-constrained TEAs (Wright-Tornier Latitude/Latitude EV, Memphis, TN, USA) were performed at our institution, and our preliminary analysis includes 46 elbows in 41 patients (39 female, 7 male). Patients were excluded if they had severe elbow deformity precluding reliable measurement, experienced a major complication related to an ipsilateral upper limb procedure, or underwent revision TEA. For each elbow, saggital alignment was compared pre- and post-operatively. A best fit circle of the trochlea and capitellum was drawn, with its centre representing the rotation axis. Ninety degree tangent lines from the intramedullary axes of the ulna and humerus, and from the olecranon tip to the centre of rotation were drawn and measured relative to the rotation axis, representing the ulna posterior offset, humerus offset, and ulna proximal offset, respectively. In addition, we measured the ulna stem angle (angle subtended by the implant and the intramedullary axis of the ulna), as well as radial neck offset (the length of a 90o tangent line from the intramedullary axis of the radial neck and the centre of rotation) in patients with retained or replaced radial heads. Our primary outcome measure was the quickDASH score recorded at the latest follow-up for each patient. Our secondary outcome measures were postoperative flexion, extension, pronation and supination measured at the same timepoints. Each variable was tested for linear correlation with the primary and secondary outcome measures using the Pearson two-tailed test.

At an average follow-up of 6.8 years (range 2–14 years), there was a strong positive correlation between anterior radial neck offset and the quickDASH (r=0.60, p=0.001). There was also a weak negative correlation between the posterior offset of the ulnar component and the qDASH (r=0.39, p=0.031), and a moderate positive correlation between the change in humeral offset and elbow supination (r=0.41, p=0.044). The ulna proximal offset and ulna stem angle were not correlated with either the primary, or secondary outcome measures.

When performing primary TEA with radial head retention, or replacement, care should be taken to ensure that the ulnar component is correctly positioned such that intramedullary axis of the radial neck lines up with the centre of elbow rotation, as this strongly correlates with better function and less pain after surgery.

The National Joint Registry (NJR) for England & Wales provides a useful reference for hospitals to assess and compare their current practice with national figures. We aimed to identify patient and surgical factors at time of primary total knee arthroplasty (TKA) responsible for the revision.

A retrospective case note review was performed of all revision TKAs performed at Musgrove Park Hospital 2005–2010. Exclusion criteria included primary TKA performed elsewhere.

38 TKAs and 13 unicompartmental knee arthroplasties (UKAs) were revised. Mean time to revision was 1.8 years and 2.1 years respectively. Reason for revision was pain or disease progression in 54% revised UKAs and infection in 53% revised TKAs. 35% infected cases were therapeutically anticoagulated, 75% ASA 3 and 50% had a BMI >30. No problems were identified with surgeon grade or level of supervision. 5 cases of revision were of a trial primary prosthesis.

There were large numbers of high risk patients (increased BMI, ASA grade or on anticoagulants), which may contribute to increased infection rates and subsequent revision. We suggest avoiding trial prostheses and recommend delaying anticoagulation reintroduction until the wound is fully healed. This information may be useful for aiding with patient selection and consent.

The PFNA is used routinely at the RUH for unstable peri-trochanteric and femoral fractures. Failure of operative treatment is associated with increased morbidity and financial burden. We analysed surgical and fracture factors, aiming to identify those associated with fixation failure.

Retrospective analysis of 76 consecutive patients treated with a PFNA between 2009–2012 was performed. Patient demographics were assessed, along with fracture classification, adequacy of reduction, tip apex distance (TAD) and grade of surgeon. Failure was defined as metal work failure, non-union or need for repeat procedure.

The mean age was 78.9 years (25.9–97.4). 21 were male and 49 female. There were 17 failures (24.3%) (7 required further surgery). 10 failures were per-trochanteric, 2 sub-trochanteric and 5 mid-shaft fractures. Complications included 4 broken and 6 backed-out distal locking screws, 2 blade cut-outs, 1 nail fracture and 4 non-unions. All per-trochanteric were adequately reduced with a TAD <25 mm. 11/17 had consultant supervision.

A high rate of backed-out distal locking screws was identified. We found no concerns with adequacy of reduction, TAD or consultant supervision.

Patello-femoral arthritis can result in a considerable thinning of the patella. The restoration of an adequate patella thickness is key to the successful outcome of knee arthroplasty.

The objectives were (1) to establish a reproducible patella width:thickness index including chondral surface and (2) to investigate whether there is a difference between bone alone and bone/chondral construct thickness as shown by MRI.

Forty three MRI scans of young adults, mean age 27 (range 17–38), 34 male and 9 female, were studied. Exclusion criteria included degenerative joint disease, patello-femoral pathology or age under 16/over 40 (102 patients). The bony and chondral thickness of the patella and its width were measured. Inter/intra observer variability was calculated and correlation analysis performed.

We found a strong correlation between patella plus cartilage thickness and width (Pearson 0.75, P < 0.001). The mean width:thickness ratio was 1.8 (SD 0.10, 95% CI 1.77–1.83). Without cartilage the ratio was 2.16 (SD 0.15, 95% CI 2.11–2.21), correlation was moderate (Pearson 0.68, P < 0.001). The average patella cartilage thickness was 4.1mm (SD 1.1, 95% CI 3.8–4.5).

The narrow confidence intervals for the ratio of patella width:thickness suggest that patella width can be used as a guide to accurate restoration of patella thickness during total knee or patella-femoral replacement. We would recommend a ratio of 1.8:1.

Aim

The present study aimed to assess the accuracy of preoperative departmental ultrasound scans in identifying rotator cuff tears at our institution.

The indication for rotator cuff repair in elderly patients is controversial.

The purpose of the study was to identify factors that affect the incidence of deep wound infection after hip fracture surgery.

Data from a hip fracture database of 7057 consecutively treated patients at a single centre was used to determine the relationship between deep wound sepsis and a number of factors. Fisher's exact test and the unpaired T test were used. All patients were initially followed up in a specialist clinic. In addition a phone call assessment was made at one year from injury to check that no later wound healing complications had occurred.

There were 50 cases of deep infection (rate of 0.7%). There was no significant difference in the rate of deep sepsis with regards to the age, sex, pre-operative residential status, mobility or mental test score of the patient. Specialist hip surgeons and Consultants have a lower infection rate compared with surgeons below Consultant grade, p=0.01. The mean length of anaesthesia was longer in the sepsis group (76minutes) compared to the no sepsis group (65minutes), this was significant, p=0.01. The patient's ASA grade and fracture type were not significant factors. The rate of infection in intracapsular fractures treated by hemiarthroplasty was significantly greater than those that had internal fixation, p=0.001. The rate of infection in extracapsular fractures fixed with an extra-medullary device was significantly greater than those fixed with an intra-medullary device, p=0.021. The presence of an infected ulcer on the same leg as the fracture was not associated with a higher rate of deep infection. In conclusion we have found that the experience (seniority) of the surgeon, the length of anaesthesia and the type of fixation used are all significant factors in the development of deep sepsis. These are all potentially modifiable risk factors and should be considered in the treatment of hip fracture patients.