A patient in his thirties developed synovitis with grade 4 chondrolysis and a stiff knee with a fixed flexion deformity between three and six years following PLC and PCL reconstruction using LARS (Ligament Augmentation and Reconstruction System, Corin). There was histologic evidence of foreign body reaction, the knee was painful, swollen and stiff.

We did not use any further LARS ligaments for soft tissue reconstructions of the kneein our practice. We commenced a recall programme for all 83 patients patients who underwent a soft tissue knee reconstruction using LARS. Of those contacted, 41 replied (49%) and 16 patients had symptoms (19%) and were investigated further with XRay, MRI and arthroscopy as indicated.

We discovered a total of five patients had histologically proven synovitis with foreign body reactions (6%), three of whom had life-changing symptomatic pain, swelling and stiffness with degenerate changes (3.6%). These patients had undergone various reconstructions, including a) PLC only, b) ACL and PCL, c) PCL and PLC and d) ACL, PCL and PLC. A further single case of massive bone cyst formation was noted, following PCL reconstruction using LARS (1.2%).

The management of patients with displaced intra-capsular hip fractures is usually a hip hemiarthoplasty procedure. NICE guideline 124 published in 2011 suggested that Total Hip Replacement (THR) surgery should be considered in a sub group of patients with no cognitive impairment, who walk independently and are medically fit for a major surgical procedure.

The Royal Devon and Exeter Hospital manages approximately 600 patients every year who have sustained a fracture of neck of femur, of which approximately 90 patients fit the above criteria. Prior to the guideline less than 20% of this sub-group were treated with a THR whereas after the guideline over 50% of patients were treated with THR, performed by sub-specialist Hip surgeons. This change was achieved by active leadership, incorporation of ‘Firebreak’ lists, looking for cases, flexible use of theatre time and operating lists and the nomination of an individual senior doctor who was tasked with a mission to improve practice.

This practice is financially viable; the Trust makes over £1000 per THR for fracture. Complete outcome data at 120 days show significantly fewer patients stepping down a rung in terms of both independent living and independent walking.