Stable, anatomical fixation of acetabular fractures gives the best chance of a good outcome. We performed a biomechanical study to compare fracture stability and construct stiffness of three methods of fixation of posterior wall acetabular fractures.

Two-dimensional motion analysis was used to measure fracture fragment displacement and the construct stiffness for each fixation method was calculated from the force / displacement data.

Following 2 cyclic loading protocols of 6000 cycles, to a maximum 1.5kN, the mean fracture displacement was 0.154mm for the rim plate model, 0.326mm for the buttress plate and 0.254mm for the spring plate model. Mean maximum displacement was significantly less for the rim plate fixation than the buttress plate (p=0.015) and spring plate fixation (p=0.02).

The rim plate was the stiffest construct 10962N/mm (SD 3351.8), followed by the spring plate model 5637N/mm (SD 832.6) and the buttress plate model 4882N/mm (SD 387.3).

Where possible a rim plate with inter-fragmentary lag screws should be used for isolated posterior wall fracture fixation as this is the most stable and stiffest construct. However, when this method is not possible, spring plate fixation is a safe and superior alternative to a posterior buttress plate method.

Nationwide, proximal femoral fractures contribute a significant workload for the NHS and are the commonest trauma admission. Timely discharge from the acute hospital setting is beneficial to both patient and orthopaedic team.

The Community Care Act 2003 formed part of Governmental strategy to reduce ‘bed blocking’. Introduced on 5 January 2004, the scheme enabled Trusts to charge Local Authorities £100 a day where there was delayed transfer of care due to lack of Social Service [SS] provision. The Act brought with it a £250 million package of funding over three years.

We looked at patients admitted to Weston Area Healthcare Trust [WAHT] sustaining fractured neck of femur. These were pre-scheme group A, admitted 08/09/2003-06/10/2003 and post scheme group B, 08/03/2004 – 05/04/2003. Patient numbers, group ‘A’ 33 patients, group ‘B’ 28 patients. Average length of stay, ‘A’ 22.3 days, ‘B’ 16.1 days. The average time spent in hospital after being declared ‘medically fit’, ‘A’ 6.6 days, ‘B’ 2.3 days. Only 13 patients were referred to SS post scheme, with combined delayed discharge of 116 days.

The impact of the scheme in reducing length of stay has not been proven. Few patients were referred to SS even after the implementation of the scheme; however, the delay in discharge for these patients would have amounted to £11600 of funding. To date, WAHT have not received any funds for patients in whom discharge was delayed.

The Act states that lack of SS input must be the ‘sole reason’ for delay in discharge. The scheme is not applicable if delay is due to family choice, lack of equipment or lack of intermediate care package and for these reasons transfer of funds from SS to Trusts has become a multidisciplinary minefield. The impact of the reimbursement scheme will only become apparent if the Act is enforced.

Introduction: Inadequate cementation of the acetabular component in hip replacement surgery leads to early aseptic loosening, the most common cause of revision. The optimum method of cementation has not been fully evaluated. This study aimed to determine the effect of the acetabular component flange on mean and peak pressure during component insertion.

Method: A 53mm deepened hemisphere was machined from aluminium. Pressure transducers were positioned at the rim, at 45 degrees, and at the base. Polyethelene acetabular components of different sizes and flange designs were mounted onto a materials testing machine and inserted at a constant rate into Palacos R cement within the aluminium hemisphere. Insertion was stopped at a pre-determined point when an even cement mantle was achieved. The same components were then tested without a flange. Each test was repeated six times. Output data from the transducers was analysed.

Results: Components with a flange create a mean pressure 6–18 times higher at the rim than those without a flange. At the base pressures are 2–4 times higher. A stiffer flange generates higher peak and mean pressures than a more malleable flange. Delaying insertion by one minute does not increase the pressures achieved unless a flange is used.

Discussion: These results strongly support the use of a flange to contain cement during insertion of the acetabular component. Unflanged components fail to achieve satisfactory mean or peak pressures, even if insertion is delayed. This is likely to result in poor cement penetration into bone and reduced longevity of interface fixation.

Rotator cuff arthropathy is characterised by pain and loss of function. Surgical management of the condition is difficult and controversial.

We have conducted a direct comparison between two shoulder replacement systems with different design rationales specifically recommended for the management of rotator cuff arthropathy.

15 patients who had previously undergone bipolar shoulder replacements (BIOMET) were matched for sex and age with patients who underwent DELTA reverse geometry shoulder replacements (DEPUY). All patients in this study were over 70 years old and had rotator cuff arthropathy with pain as their primary complaint and with a maximum active elevation of their arm of 50°. Patients were assessed clinically and radiologically, preoperatively in the 12 months after surgery.

All patients benefited from surgery with regard to pain relief, but the improvement as measured on the visual analogue scale was greater in those with the reverse geometry group (p< 0.05). Active range of movements was only marginally improved in the bipolar group. However there was a marked improvement in the reverse geometry group with 14 out of 15 patients able to actively elevate their arm about shoulder height. This was a highly statistically significant finding (p< 0.01).

This case comparison study strongly supports the reverse geometry design rationale over the bipolar design for the management of rotator cuff arthropathy in the elderly.