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Volume 93-B, Issue SUPP_I January 2011

L. Jeavons S.M. Dixon R.P. Reddy E.D. Fern M.R. Norton

We report a 10% failure rate for aseptic loosening and overall revision rate of 15% at 5 years mean follow up in 190 patients using the Cormet 2000 Dual coat ace-tabular component.

Between April 2001 and March 2004, this cup was used in our region by 4 surgeons. It was peripherally expanded and comprised a cobalt chrome shell, plasma sprayed with a further layer of cobalt chrome which was then coated with hydroxyapatite. This backing has since been abandoned in favour of a titanium plasma coat beneath the hydroxyapatite because of a higher than expected incidence of early loosening.

There were 190 cups implanted in 174 patients, 142 with resurfacing heads. The average age was 54 and 99 were male.

Revision for aseptic loosening was required in 20 cups (10%) at a mean interval of 23 months including five within 2 months, Of the early revisions three developed a deep infection. Undiagnosed groin pain in four further patients appeared at revision to arise from an inflamed bursa secondary to impingement of psoas tendon on the rim of the cup. There was one primary infection, one infection following revision of a trochanteric osteotomy and two neck fractures. Persistent unexplained groin pain was seen in three patients who have declined further surgery

Failure of this backing to integrate with bone led to an unacceptably high early loosening rate. Positioning of the larger resurfacing cups is critical to avoid painful irritation of psoas. Early revision carries a high risk of infection.


S. Annamalai A.D. Toms

We have analysed the early functional results in patients who have had the NRG total knee replacement at the Princess Elizabeth Orthopaedic Centre, Exeter. This is a new modern design designed for high function. We analysed a total of 54 knees (47 patients) operated between September 2005 and October 2007. The follow up ranged from 9 to 25 months averaging 16 months. Thirty eight percent of the patients were male and 62% female. The age of the patients ranged from 42 to 90 (average 72).

The Oxford knee score and satisfaction score were documented at 6 weeks, 6 months, I year and 2 years. The range of movement was also noted. Ninety eight patients had the highest satisfaction score of 3 at the one year follow up. The average Oxford knee score pre-operatively was 45 and the average was 30 at 6 weeks and 6 months and 20 at 1 and 2 year follow up. Seventy four percent of the patients had post operative knee flexion of more than 100 degrees. The average post operative value added flexion was 14 degrees.

We conclude the early results of the NRG knee replacement are very encouraging with very good patient satisfaction scores and post operative flexion of the knee.


K. Kailash B. Guhan A. Lee

This is a study of 24 patients (28 Knees) who underwent acute repair for quadriceps and patellar tendon ruptures using Leeds Keio ligament. Four patients had bilateral quadriceps tendon rupture.

The mean age of patients was 57.4 years (range from 20 to 85 years) with mean follow-up of 20 months (range from 2 months to 3 years). Four patients (6 knees) were lost in follow-up. Knee injury and Osteoarthritis and Outcome Score (KOOS) and Tegner Lysholm Knee Score were used to evaluate the outcome. Sixteen patients had scores of 80 and above in both scoring systems. The mean flexion was 125° and extension lag of 6.6°. The knees were not immobilised after surgery and patients were encouraged to fully weight bear.

One patient had patella fracture secondary to fall although technical error played a part in this. Two patients had bilateral ruptures secondary to fall and one patient had ectopic bone formation. There was no wound infection.

This technique permits immediate mobilisation and full weight bearing of the limb. The early results are promising but long term results are yet to be evaluated.


S.M. Dixon R.P. Reddy E.D. Fern M.R. Norton

Between January 2003 and December 2004, 14 patients underwent bilateral resurfacing arthroplasty via a Ganz trochanteric osteotomy. This bilateral group was mobilised fully weight-bearing with crutches. During the same period 139 Ganz trochanteric osteotomies were performed for unilateral hip resurfacing. These patients were mobilised with crutches, weight-bearing up to 10 kg on the operated leg.

Nine osteotomies (32%) in the bilateral group subsequently developed a symptomatic non union requiring revision of fixation. This compares with 10 patients (7%) in the unilateral group. Applying the Fisher’s exact test, the difference reached significance (p=0.0004). In 2 patients a second revision was required to achieve union. In 1 patient, revision of trochanteric fixation precipitated a deep infection.

Protected weight-bearing following a Ganz trochanteric osteotomy is important to the success of the procedure. Simultaneous bilateral hip arthroplasty through a Ganz approach should be avoided. If it is undertaken, we recommend that patients should be non weight-bearing for 6 weeks following surgery. Non union following a Ganz trochanteric osteotomy for arthroplasty carries a significant morbidity.


A.J. Barnett M. Prentice V. Mandalia C.J. Wakeley J.D.J. Eldridge

A number of measurements of patella height exist all of which use a position on the tibia as a reference. The Patellotrochlear Index has recently been proposed as a more accurate reflection of the functional height of the patella and described in normal knees.

We aimed to compare patellar height measurements in patients with patellofemoral dysplasia.

In a retrospective analysis of the MRI scans of 33 knees in 29 patients with patellofemoral dysplasia we assessed the inter- and intraobserver reliability of four patellar height measurements: the Patellotrochlear Index (PTI), Insall-Salvati (IS), Blackburne-Peel (BP) and Caton-Deschamps (CD) ratios. We also assessed the correlation between the different measurements in predicting patella alta. Three blinded observers on two separate occasions performed the measurements.

There were 21 females and 8 males with a mean age of 21.4 years (13–33). Statistical analysis revealed good inter-observer reliability for all measurements (0.78 for PTI, 0.78 for IS, 0.73 for BP and 0.77 for CD). Intra-observer reliability was also good (0.80, 0.83, 0.75, 0.78 respectively). When comparing the different measurements for patella alta there was a weak correlation between the PTI and the others. There was a strong correlation between the CD and BP ratios (0.96) and a moderate correlation between IS and CD and IS and BP ratios (0.594 and 0.539 respectively).

All measurements are reproducible. The PTI however suggests patella alta exists in different patients to that suggested by the established measures. We propose the PTI as a more clinically relevant measure.


K Thomason P Van Der Walt

Orthopaedic surgery accounts for about 10% of red cell transfusions used in hospital. In view of the recognized risks and decreasing availability of donor blood, every effort should be made to minimize inappropriate transfusions.

Methods: Data was collected on the number of patients prescribed blood transfusion after primary total hip and knee replacement at the North Devon District Hospital. It involved 211 patients in 2004, 599 patients in 2005 and 812 patients in ‘06/’07. The effect of withdrawing the use of drains and instigating local infiltration of the wound with diluted adrenaline on transfusion rates was monitored and the results compared against the national average.

Results: The transfusion rates for hip arthroplasty came down from 15.2% in 2004 to 8.8% in 2007 and for knee arthroplasty from 12.2% in 1004 to 5.3% in 2007.

Conclusion: Our current transfusion rates are well below the national average, without the use of cell savers. We wish to discuss the factors which might affect transfusion rates and share our experience after introducing a simple, inexpensive, safe and effective post-operative blood transfusion policy. The respective contributions of drains and infiltration will be emphasized.


E.D. Fern P. Easwaran M.R. Norton

Since 2003 we have adopted an aggressive approach to the management of slipped upper femoral epiphysis (SUFE) deformity, an important cause of femoro-acetabular impingement and associated with the development of early adult hip arthritis.

Sixteen patients aged 16.7 years (range 11–20), 13 male, have undergone surgery to manage their SUFE deformity. Nine underwent primary surgery using a Ganz approach (7) or in-situ pinning with femoral neck resection via a Smith-Peterson approach (2). Seven had previously undergone in-situ pinning 26 months earlier (range 4–44 months) of whom two had acetabular chondral flap tears with eburnated bone and six had significant labral degenerative changes associated with calcification or tears. Only one of the nine patients who underwent primary aggressive management of their SUFE, had a labral tear. Four patients underwent mobilisation of the femoral head on its vascular pedicle, followed by anatomical realignment.

At an average follow-up of 22.3 months (range 1–41 months) 15 remained well with excellent function. Leg lengths remained equal in 12, with average shortening of 2 cm in the remaining four. Segmental AVN occurred in the first patient after damage to the vascular pedicle during drilling of the neck; the technique has been modified to prevent this.

Despite having performed over 400 surgical hip dislocations, the authors continue to find the management of this condition challenging; nevertheless, having seen the consequences of femoro-acetabular impingement in these young patients, we believe that aggressive management to correct anatomical alignment is essential for the future well being of the hip.


A. Sheeraz A.J. Timperley P. Matten

The demand for primary hip replacements has grown steadily over the past 20 years and continues to do so. The challenge is to deliver a high quality and cost-effective service by developing short-stay pathways to optimise patient care and outcome.

A four-day hip protocol was established, with attention to detail on analgesia, thrombo-prophylaxis, mobilisation and patient motivation. A multi-disciplinary team was trained to deliver the pathway on a designated ward for primary hip replacements with the aim to discharge patients on the third post-operative day (four day stay in total). Before the initiation of this audit our average stay for primary hips was nine days. The national average stay is 10.6 days, with the top 10 trusts averaging 6.7 days.

In the initial three-month trial, 66 hip replacements (39 females and 27 males) done by the hip team at Princess Elizabeth Orthopaedic Centre in Exeter were audited against the four-day hip protocol. Average age was 72.4 years (range 44 – 92 years). Two patients were discharged on the second post-operative day and another 15 patients on the third post-operative day. As a result, we managed to get 25.8% of the patients home within four days. Overall, the average length of stay was only 6.3 days.

In conclusion, while we only achieved our target in 25.8% of patients, the project improved our overall length of stay remarkably. It is clearly evident that a targeted pathway focused to patient care in all aspects using a multi-disciplinary approach can improve the overall service delivery.


R P Baker M Kilshaw M Pabbruwe A Blom G C Bannister

Resurfacing hip arthroplasty is a successful option for the treatment of the young and active patient with hip arthritis. However, it is complicated by femoral neck fracture and avascular necrosis, which result from devascularisation during surgery. Devascularisation maybe caused by thermal necrosis. Thermal necrosis of bone has been shown to occur in temperatures of 47°C and above. We investigated the temperatures generated during femoral head preparation to see if the temperatures reached were great enough to induce osteonecrosis.

Method: Eight patients with osteoarthritis underwent standard resurfacing hip arthroplasty through the posterior approach. From the first over-drilling of the femoral heads until the prosthesis was cemented in place the temperatures generated at the bone surface were recorded using an infra-red thermal imaging camera. Images were captured every 4 seconds as the operation was performed with no interference to the surgeon

Results: The maximum temperatures generated occurred during sleeve reaming at 88.4°C. Seven patients had a temperature recorded greater than 47°C. Removing the femoral caput with an oscillating saw had the highest mean temperature 62.2°C, followed by sleeve reaming (mean 48.7°C). Female patients had the lowest temperature rises and patients receiving the larger femoral prosthesis the greatest temperatures at the bone surface.

Conclusions: Heat generated during femoral head preparation exceeded 47°C in all but one case. Osteonecrosis secondary to thermal insult is likely to occur during femoral head preparation. Strategies need to be devised to decrease the temperatures generated during femoral head preparation.


C P Challand D Mahadevan A Clarke J Keenan

Effective utilisation of blood products is fundamental. The introduction of Maximum Surgical Blood Ordering Schedules (MSBOS) for operations provides guidance for effective cross-matching. A retrospective analysis of blood ordering practices was undertaken to establish an evidence-based MSBOS for revision THR and TKR. The impact of the use of intraoperative cell-salvage devices was also assessed.

Methods: The patient database was searched for cases of revision THR and TKR undertaken over 58 months. These records were then cross-referenced with the transfusion database. The cross-match to transfusion ratios (CTR) and transfusion indexes (TI) were calculated using this data.

The gold standard for the CTR is 2:1 or less. The TI establishes the likelihood of blood being transfused for a certain procedure. If the TI is less than 0.5, then cross-matching blood is considered unnecessary.

Results: For revisions of non-infected THR (n=269), the CTR=2.24 and TI=1.67. In infected cases (n=69), CTR=2.16 and TI=1.68.

In revisions of non-infected TKR (n=95), the CTR=4.33 and TI=0.48. In infected cases (n=54) the CTR=2.16 and TI=1.35.

There was considerable change in the practice of ordering cross-matched blood following the introduction of intraoperative cell-salvage devices (Revision THR: CTR=1.93, TI=0.84; Revision TKR: CTR=1.20, TI=0.16)

Discussion: The analysis confirmed that more blood was requested than was actually required. Overall the results suggest that cross-matching is still necessary for both the non-infected and infected revision THR but the number of units requested could be reduced to 2 units. In revision TKR, transfusions were more likely in infected cases and, a ‘group & save’ may be sufficient for non-infected cases.

The introduction of this MSBOS in conjunction with intraoperative cell-salvage, could promote blood conservation and financial savings.


P Latimer K Sloan R Beaver

Our ongoing aim is to assess the clinical outcome of joint replacement surgery; we wish to contrast the functional outcome of primary and revision patients, and examine what factors may influence this.

Method: Patient data was collected prospectively between Jan 1998 and April 2006. The assessment scores include, the Harris Hip Score, Knee Society Score, SF 36 Health Survey and WOMAC. We compare the pain and function parts of the Knee Society Score for Primary and Revision TKR and the Harris Hip Score for Primary and Revision THR.

Results: The Harris Hip Score improves significantly up to one-year post surgery, with the largest increase occurring at three months. Post surgery improvement then plateaus between one and two years and between two and five years. Revision hip replacement patients display a significant improvement in the Harris Hip Score at three months post surgery, but improvement plateaus after this up to two years. These results are presented graphically.

The Knee Society Score in primary total knee replacement patients improves significantly over time up to one-year post surgery for all components of the score, with the largest increase occurring at three months. Post surgery improvement then plateaus between 1 and 2 years. At 5 years post op both the total score and the function score significantly decrease while there is no change in the knee score component. All components of the Knee Society Score measured in revision knee replacement patients significantly improve at three months post surgery, after which time no further significant improvement is noted.

Discussion: Primary THR patients consistently had higher hip scores than revision patients at all time frames, indicating a better outcome for these patients. When stratified for reason for revision we postulate that a number of well functioning patients are significantly worse following revision surgery. This effect is not seen in the revision TKR group. The decrease in Knee Society Score to five years probably reflects the age of the patients at the time of surgery, which is older than hip replacement patients.


N. D. Furness J. Blackburn G. Mathew V. Conboy

Proximal femoral fractures affect around 60 000 patients annually in the UK. A delay in excess of 48 hours from admission to theatre has been shown to have an adverse effect on mortality, morbidity and length of inpatient stay in this patient group (Hollingworth 1993). We set out to identify the causes and effects of any delay to theatre and make suggestions in order to improve the quality and efficiency of our service.

We tracked 224 consecutive patients all admitted with a proximal femoral fracture over an eight month period. We recorded a number of details including whether or not a delay occurred and why, on a session-by-session basis.

Of the 214 patients included, 75.7% were considered fit enough for surgery at admission; 83.2% of these suffered some sort of delay to theatre. Only 5.6% of patients (8 in total) were considered fit enough for surgery at admission, suffered a delay to theatre and subsequently became unfit causing a further delay.

We were reassured to find that our patients are not suffering a longer than average delay to theatre and that those patients who were waiting longer were not becoming ill as a result. We also found that patients admitted on certain days of the week seemed to wait longer, indicating that certain sub-specialty elective lists were taking up theatre time and exacerbating the delay. We have suggested changes to the theatre rota in order to maximise efficiency and aim to repeat this audit to evaluate the effect of these changes.


A.J. Barnett B.J. Burston N. Atwal G. Gillespie A.M. Omari B. Squires

Dislocation is a major concern following total hip replacement (THR) for fractured neck of femur. The aim of this prospective study was to investigate the use of large diameter femoral head uncemented THR to treat fractured neck of femur, and to demonstrate if the improved stability seen in previous clinical situations with these designs, can be used to benefit this difficult subgroup of patients that are particularly prone to dislocation.

Forty-six consecutive independent, active and mentally alert patients with displaced intracapsular fractured neck of femur underwent large diameter head uncemented THR. The mean age of patients was 72.1 years. The outcome measures used were the dislocation rate, reoperation and revision rate, Oxford hip score (OHS), Euroqol (EQ-5D) and residential status.

Clinical and radiological data were available on all 46 patients. At a mean follow-up of 12.5 months there were no dislocations. The reoperation, revision and infection rate were all 0%. Two patients died (4.3%) from unrelated causes. Mean pre- and postoperative OHS were 12.1 and 17.9 respectively. The mean pre- and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. The mean postoperative walking distance was 2.5 miles and there were no changes in residential status.

This is the first published series utilising a 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur in mobile, independent patients. We have demonstrated that it affords patients excellent stability with no recorded dislocations.


R.J. Poulter S.W. Parsons

Open Tibiotalocalcaneal fusion has been shown to be an effective treatment for arthritis and complex foot deformities, but with a high complication rate. We are reporting the results of the first 14 feet undergoing arthroscopic tibiotalocalcaneal arthrodesis.

Methods: Retrospective review identified 13 patients who had 14 combined ankle and subtalar arthrodeses performed arthroscopically, with no bone grafting. The procedure was performed for the treatment of combined ankle and subtalar arthritis or hindfoot deformity. The majority had fixation using 6.5 mm ASNIS screws (Stryker (Kalamazoo, Michigan, USA)) introduced percutaneously, although in one case a hindfoot nail was used. Outcome was assessed by a combination of chart review, clinical examination and questionnaire. Follow up averaged 16 (6 to 33) months.

Results: At follow up average patient satisfaction was 9.7/10. Average time to fusion was 12 (10–20) weeks. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 67 (41–83). 9 patients had no complications. Postoperative complications were pulmonary embolus, non-union, late stress fracture and infection.

Conclusion: Arthroscopic hindfoot arthrodesis is an effective technique, and allows treatment in patients whose soft tissues would not tolerate an open procedure, where often the only alternative is amputation. Patient satisfaction is high, with a short inpatient stay, but the procedure itself is demanding.


S Gupta R. Cove S. Loxdale J. Keenan J. Metcalfe

Introduction – Patients who have sustained a fracture of the hip should have their surgical treatment with 48 hours of admission to hospital. A delay results in increased morbidity and mortality.

This elderly cohort of patients often have confounding co-morbidities. A pre-operative echocardiographic assessment to guide the anaesthetic is frequently requested upon clinical grounds. A delay in acquiring the echocardiogram was observed thus delaying surgery. This instigated a change in policy within the department whereby all patients over 70 years old who sustained a hip fracture underwent echocardiographic assessment with 24 hours of admission.

Method: An audit was performed assessing delays in acquiring the echocardiograms and measuring the time taken to perform the operation.

Results: Period 1 – Selective Echo: Mean time to echo 5 days, mean time to theatre 7 days. Period 2 – Unselective Echo: Mean time to echo 1 day, mean time to theatre 2 days.

Conclusion: As a result of the unselective policy to perform echo cardiograms on all patients admitted with a fractured neck hip, the delay to perform surgery has been reduced significantly.


R P. Baker M. J. Kilshaw R. Gardner S. Charosky I. J. Harding

The incidence of degenerative scoliosis in the lumbar spine is not known. In the ageing population deformity may coexist or cause stenosis. MRI gives limited information on this important parameter in the treatment of stenosis. The aim of this study was to highlight the incidence of coronal abnormalities of the lumbar spine dependent on age in a large population of patients.

We reviewed all abdominal radiographs performed in our hospital over ten months. 2276 radiographs were analysed for degenerative lumbar scoliosis and lateral vertebral slips in patients who are ≥ 20 years old. Evidence of osteoarthritis of the spine was also documented. Radiographs were included if the inferior border of T12 to the superior border of S1 was visualised and no previous spinal surgery was evident (metal work).

2233 (98%) radiographs were analysed. 48% of patients were female. The incidence of degenerative lumbar scoliosis, lateral listhesis and osteoarthritis increased with age. Degenerative scoliosis was present in 1.6% of 30–39 year olds increasing every decade to 29.7% of patients 90 years or older. In all age groups curves were more frequent and had greater average Cobb angles in female patients except in the 30–39 year olds - where males equalled females.

Degenerative lumbar scoliosis starts to appear in the third decade of life increasing in frequency every decade thereafter, affecting almost a third of patients in the ninth decade. It is more common in female patients and has a greater magnitude. Deformity may be even greater on standing views and is important to recognise in all patients that are undergoing lumbar spinal decompressive surgery. A failure to do so may lead to inferior results or the need for further surgery.


L. Obolensky V. Ladwa J. Davis

Patient satisfaction is a driving force behind setting up and developing day case procedures. Ten months ago a service for day surgery SCARF procedures was set up in Torbay day surgery unit.

We analysed patient pre and post operative pain scores and patient satisfaction scores in respect to pain, appearance and overall satisfaction.

A questionnaire was sent to all sixty patients who had undergone a SCARF osteotomy in day surgery. Outcomes assessed were: reason for SCARF osteotomy; adequate preoperative information; pain scores pre and post operatively; satisfaction scores and admission rates.

53 patients responded (88% response rate). 79% of patients had their operation for pain, 19% for appearance and footwear, and 2% for function of their foot. 100% of patients were given adequate information by the surgeon preoperatively and 27% also used other sources for information. 62% of patients scored 6 or more on a linear pain score preoperatively. 85% of patients have a current pain score of 0 or 1. 87% were highly satisfied (scoring 9 or 10 on linear scale) with the outcome regarding their pain, 83% highly satisfied with appearance and 72% highly satisfied with function despite the questionnaire being completed less than one year post surgery. 83% of patients were highly satisfied with the overall procedure and 91% said they would have a SCARF as a day case procedure again. 9 patients were admitted, 3 due to living alone, 3 for wound problems and 3 for post anaesthetic problems including pain, nausea and vomiting.

From these figures we concluded that SCARF osteotomy in day surgery is a successful, feasible and worthwhile undertaking in our unit.

We used the questionnaires and results to further analyse our service and we have made modifications to improve it. We have now put in place a dedicated anaesthetist with an interest in foot and ankle blocks, as well as a comprehensive post operative analgesic regime and a stringent day surgery protocol.

We now run a prospective questionnaire from clinic, including AAOFAS scores, to continue analysis of our service. With these changes in place we would like to see our satisfaction scores rising towards 100%.


G.S. Carlile H. Sprot N.C.L. Giles

The management of closed ankle fractures requiring open reduction and internal fixation is dependent upon soft tissue swelling to determine the timing of the surgery. At Exeter in 2001 one third of all trauma cases were operated on “out of hours”, in 2007 less than ten percent were principally because of the lack of anaesthetic staff. The senior author has developed a technique of percutaneous ankle fixation that may be undertaken at an early stage despite the presence of swelling.

A retrospective study of four years focusing on time to surgery, time to discharge and complications was compared with a cohort selected at random that had undergone open fixation from the same period. Patients undergoing percutaneous fixation were extracted using the Plato database and all patients were included. Admission documentation, operation notes and subsequent clinic letters were used to ascertain the outcomes. Pre and post-operative imaging was evaluated.

Over a four year period two consultants and four specialist registrars performed the technique on a total of 22 patients. The mean time to surgery was 2.04 days for the percutaneous cohort (range 0–5 days) compared with 4.04 for the open cohort (range 1–10). Time to discharge was 4.6 days to 5.8 in favour of percutaneous. No complications were experienced in the percutaneous cohort compared with 6 patients in the open.

Preliminary results demonstrate a reduced waiting time for surgery and a quicker discharge. Percutaneous fixation is an option when swelling precludes open fixation.


P.A. McCann S.T. Mitchell M. Jackson

A series of 49 pilon fractures in a tertiary referral centre treated definitively with open reduction and internal fixation have been assessed examining the complications associated with such injuries. A retrospective analysis of casenotes, radiographs and computerised tomographs over a seven year period from 1999–2006 was performed.

Infection was the most common post operative problem. There were 7 cases of superficial infection. There was a single case of deep infection requiring intravenous antibiotics and removal of metalwork. Other notable complications were those of secondary osteoarthritis (three cases) and malunion (one case).

The key finding of this paper is the 2% incidence of deep infection following the direct operative approach to these fractures. The traditional operative approach to such injuries (initially advocated by Ruedi and All-gower) consisted of extensive soft tissue dissection to gain access to the distal tibia. Our preferred method is to gain access to via the “direct approach” which involves direct access to the fracture site with minimal disturbance of the soft tissue envelope. We therefore believe open reduction and internal fixation of pilon fractures via the direct approach to be an excellent technique in the treatment of such injuries.


J. Barnes F. Monsell C. Aylott R. Kirubandanan M. Jackson R. Atkins J. Livingstone

A Ring Fixator (Taylor Spatial Frame (TSF); Smith & Nephew, Memphis, TN), was used in the treatment of 5 patients (ages 11 to 16 years) with proximal tibial growth arrest following trauma. The mean corrections were 14.20 (max 280, min 00) in the saggital plane and 140 (max 380, min 20) in the coronal plane. Leg length discrepancy was also corrected (max 1 cm). The average time in frame was 17.8 weeks, with an average correction time of 29.8 days. Knee Society Clinical Rating System (KSCRS) scores post operatively ranged from 95 to 100. All patients returned to full activity, and would accept the same treatment if offered again.

The circular fixator is an effective, minimally invasive method of treatment for post-traumatic proximal tibial deformity. Patients remain active during treatment encouraging a rapid return to school/work activities.


M. J. H. McCarthy R. Long R. Weston S. Gheduzzi J. Keenan A. Miles

Objectives: To compare the biomechanical properties of lag screw insertion in a laboratory model. Two blades, the Synthes Dynamic Helical Hip Screw (DHHS) and Proximal Femoral Nail Antirotation (PFNA), and two screws, the Synthes Dynamic Hip Screw (DHS) and Stryker Gamma 3 lag screw, were compared.

Setting: Orthopaedic biomechanics laboratory.

Design: Insertion testing was carried out in high and low density polyurethane foam mounted and attached to a Zwick Roell Amsler Hydrowin.

Outcome Measures: The axial load and torque during insertion of the implants was measured.

Results: The force required to insert the DHHS and PFNA blades was greater than the DHS and Gamma 3 screws into both low and high density foam. The force required to insert the DHHS and PFNA blades into high density foam was greater than low density foam. The torque required to insert the DHHS and PFNA blades into high density foam was less than that to insert the DHS and Gamma 3 screws. The torque required to insert the DHS and Gamma 3 screws into low density foam was less than the DHHS and PFNA blades. The torque during insertion of the DHHS and PFNA blades seemed to be independent of foam density.

Conclusions: The insertional properties of blades are significantly different to screws and this may have clinical importance.


S.A.C. Morris A. Omari

Immobilisation is known to be a risk factor for thromboembolic events and the management of ankle fractures often involves immobilisation of the fracture in a below knee cast. Recent literature has found a 5% rate of subclinical deep vein thrombosis (DVT) and suggested thromboembolic prophylaxis is not required.

This study involved all adult patients with isolated ankle fractures presenting to a district general hospital orthopaedic department over a 6 month period. This included patients undergoing internal fixation as well as non-operative management. A 3 to 7 month follow-up was performed to assess the incidence of clinical DVT or pulmonary embolism (PE) proven using Doppler imaging, venogram, and computed tomography pulmonary angiography. 119 patients met the entry criteria and, of these, 3 patients developed DVT and 2 patients presented with pulmonary embolus. 15 patients in the study were taking aspirin (75–300 mg daily) during their cast immobilisation and 1 patient was taking warfarin. None of these patients developed a thromboembolic complication. 4.8% of patients not taking aspirin or warfarin experienced a thromboembolic complication.

This study demonstrates a relatively high incidence of symptomatic thromboembolism following ankle fractures in the absence of prophylaxis. Previous studies have found aspirin to be an effective method of prophylaxis following hip fractures and total hip arthroplasty. We recommend that thromboembolism prophylaxis is necessary following ankle fractures and suggest that aspirin may be an economical option. Larger studies are needed to evaluate the role of aspirin in this setting.


L. Jeys M. David R. Grimer S. Carter S. Abudu R Tillman

Chondrosarcoma is treated with respect by oncology surgeons, given that it is relatively resistant to chemotherapy and radiotherapy. The aim was to study the outcomes of surgery for chondrosarcoma and determine the role of initial surgical margins and local recurrence on outcome.

Electronic patient records were retrieved on all patients seen with chondrosarcoma of bone with a minimum of two years follow up. A total of 532 patients were seen with Chondrosarcoma between 1970 and 2006. Patients were excluded if they had initial treatment in another unit (20 patients), a subdiagnosis of dedifferentiated chondrosarcoma (due to very poor prognosis, 43 patients), metastases at presentation (30 patients), if they presented with disseminated metastases prior to local recurrence (12 patients) or were not offered surgery, leaving 402 patients in the study group.

The mean age was 48 years old (range 6–89 years) with the most commonly sites of presentation being in the pelvis in 132 patients (29%), proximal femur in 81 patients (18%), distal femur in 40 patients (9%) and proximal humerus in 40 patients (9%). Grade at presentation was grade 1 in 44%, grade 2 in 44% and grade 3 in 12%. Surgical margins were radical in 3%, wide in 44%, marginal in 29%, planned incisional in 13% and unplanned incisional in 11%. Local recurrence occurred in 87 patients (22%). Local recurrence rates were significantly different for surgical margins on Fisher exact testing (p=0.003), which held true even when stratified by presenting grade of tumour. Surgery for local control was successful in 62% of cases.

Complex relationships exist between surgical margins, local recurrence and survival. Long term survival is possible in 1/3 patients who have local recurrence in intermediate and high grade chondrosarcomas and therefore ever effort should be made to regain local control following local recurrence.


R. Grimer S. Carter R. Tillman A. Abudu L. Jeys

We have compared the cost:benefit ratio of the new type of non invasive extendable prostheses with the old type which required lengthening under general anaesthetic with an invasive procedure.

Over the past four years we have inserted 27 non invasive endoprostheses (cost £14,000). Two have failed to lengthen due to problems with the inbuilt motor. So far there have been no infections, no loosenings and no patient has required revision. The lengthenings are painless and take half an hour. In the past 25 years we inserted 175 extendable endoprostheses (cost £7,000). All lengthenings were performed under a general anaesthetic. The risk of infection was initially 20% at ten years but had decreased to 8%. Pain and stiffness arose in about 10% requiring physiotherapy or occasionally manipulation under anaesthetic.

Assuming the following costs (current NHS cost) are accurate and appropriate, then the non invasive extendable prosthesis becomes cost effective when Cost EPR < Cost old EPR + (Additional risk physio(P) x cost) + (additional cost x number of lengthenings (L)) + (additional cost of revision for infection x risk of infection (R)). 14000 < 7000 + (300 x P) + (1500 x L) + (20000 x R). Assuming a 10% need for physiotherapy, four lengthenings and a 10% risk of infection gives: 14000 < 7000 + (30) +(6000) + (2000) = 15030.

Given the high complication rate of the old type of extendable procedure and assuming there are few if any with the non invasive type, then the non-invasive endoprostheses becomes cost effective if more than three lengthenings are required. They are certainly more popular with parents and children alike!


P. Pechon S.R. Cannon T.W. Briggs R. Pollock J.A. Skinner A. Datir A. Saifuddin

Objectives:

To determine the diagnostic performance of image-guided percutaneous core needle biopsy (CNB) in patients presenting with pathologic fractures of the appendicular skeleton.

To determine factors associated with non-diagnostic biopsy and identify cases which should be considered for primary open biopsy.

A retrospective audit identified 129 consecutive patients presenting with pathological fractures to a specialist orthopaedic oncology unit over a 9 year period. All patients underwent percutaneous CNB using CT (n=98), fluoroscopy (n=15) or US (n=16) guidance. In all cases MRI or CT was available prior to biopsy to assess the presence and degree of extra-osseous tumour mass. The resulting sample was classified as diagnostic (Group 1) or non-diagnostic (Group 2) on histopathological study. Diagnostic performance was evaluated on the basis of the diagnostic yield and accuracy; these were related to the site of the lesion and presence/absence of extra-osseous mass.

Of 129 biopsies, 99 (77%) were classified as Group 1 and 30 (23%) as Group 2. The commonest sites of pathological fracture without associated soft tissue component and resulting in a non-diagnostic biopsy were the proximal femur and proximal humerus. The average cross-sectional diameter of lesions in Group 1 was 5.7 x 5.9cm. Of the 30 lesions comprising Group 2, no soft tissue component was identified on pre-biopsy cross-sectional imaging in 27 lesions (90%) whereas the remaining 3 (10%) showed a smaller extra-osseous soft tissue component compared to the lesions in Group 1.

Image-guided percutaneous CNB is a reliable method for obtaining a tissue diagnosis in patients presenting with a pathologic fracture of the appendicular skeleton with high accuracy rate. However, those lesions which are purely intra-osseous or have only very small extra-osseous components are likely to be associated with a non-diagnostic biopsy, and should be considered for a primary open procedure.


B. Youssef L. Jeys B. George A. Abudu S. Carter R. Tillman R. Grimer

The purpose of our study was to examine the survival and functional outcome of endoprosthetic replacements for non-oncology limb salvage purposes. Although initially designed for bone tumours, such is the versatility of these implants they can be used to salvage failed joint replacements, peri-prosthetic fractures, failed internal fixation and non-union.

Thirty eight procedures were identified from September 1995 to June 2007 from a prospectively kept database, including 17 distal femoral replacements, 12 proximal femoral replacements, 4 proximal humeral replacements, 2 distal humeral replacements, 2 hemi-pelvic replacements and 1 total femoral replacement. The quality of patients’ mobility was used to assess functional outcome and the survival of the prosthesis was calculated using a Kaplan-Meier survival curve.

The Kaplan-Meier implant survival was 91.3% at 5 years, 68.5% at 10 years and 45.7% at 20 years. The limb salvage survival for all reconstructions was 75% at 10 years.

The best survival was as follows pelvic (n=0/2) and total femoral prostheses where there was no failure in either group (n=0/1). Distal femoral replacements survival was 91% at 5 years, a single humeral prosthesis failed at 11 years post surgery, and proximal femoral replacements had a survival at 87.5% at 5 years. Three implants failed, two as a result of infection and required staged revisions and 1 failed as a result of aseptic loosening. Two patients dislocated their proximal femoral replacements, both were treated successfully by closed reduction.

Endoprosthetic replacement appears to be effective and the medium term survival is encouraging. The aim of a pain free functional limb is achievable with this technique. The complication rates are acceptable considering the salvage nature of these patients. We recommend referral of complex cases to a tertiary centre with expertise in this type of surgery.


M. Cartwright-Terry A. Miah R. Savage

The Patient Evaluation Measure (PEM) was designed at the Derby consensus meeting in 1995. It was validated for Carpal Tunnel Syndrome (CTS) in 2005 (Hobby et al) and was preferable to the DASH score for CTS assessment. We aimed to audit CTS treated by surgical decompression in our unit using the PEM, and to compare our results with the published literature.

Thirty consecutive patients undergoing carpal tunnel decompression were questioned about one hand. Patients completed a preoperative PEM and a postoperative PEM at 3 months.

Mean PEM scores improved from 41.3 to 23.9 (P< 0.001). Individual questions showed statistically significant improvements in mean scores: Feeling in the hand, Cold intolerance, Pain, Dexterity, Movement and Hand in general (all P< 0.001): Work (P< 0.005): ADL (P< 0.01): Movements, Grip and Appearance (P< 0.05). Our results are similar to previously published series, both overall, and for individual questions in the PEM.

Results for Carpal Tunnel Decompression in our unit match those of other units. We found the PEM was easy to use; and effective, both in the assessment of patients with CTS, and for outcome measurement following surgical decompression. Our study supports the idea that the PEM could be used widely as an audit tool, to assist Hand Surgeon and/or Hand Surgery Unit Appraisal.


R. Grimer S. Carter R. Tillman S. Abudu L. Jeys

Pelvic reconstruction after tumour resection is challenging. Pelvic replacements are usually custom made at considerable expense and then need very careful positioning at the time of surgery. They have a very high rate of complications with up to 30% risk of infection and 10% dislocation. In 2003 we developed a new type of pelvic replacement which would be simple to make, simple to use and which would hopefully avoid the major complications of previous pelvic replacements whist being versatile to use even when there was very little pelvis remaining. The concept is based on the old design of Ring stemmed hip replacement and has become known as the ice-cream cone prosthesis. It is inserted into the remnant of pelvis or sacrum and is surrounded by bone cement containing antibiotics. One of the main advantages is it’s flexibility, allowing insertion after resection at a variety of levels. It is also suitable for patients with metastatic disease.

We have inserted 12 of these implants in the past 4 years, resolving very difficult reconstruction problems. There was one case that became infected but was cured with washout and antibiotics. In one patient there was excessive leg lengthening resulting in a sciatic and femoral nerve palsy and the prosthesis had to be revised. All patients can walk with one stick or less.

These results are encouraging and suggest that this versatile implant may be the way forward for pelvic reconstruction because of it’s flexibility of use and low complication rate.


D. Forward T. Davis

We aim to assess the AP distance and teardrop angles in a cohort of normal wrists and to assess their possible use as prognostic indicators in fractures of the distal radius.

Two hundred standardised PA and lateral wrist radiographs from uninjured wrists and 95 patients with fractures of the distal radius were assessed and anatomic parameters measured, including the Teardrop angle and AP distance. Clinical assessment at a mean of 6 years post fracture included an assessment of grip strength and range of motion along with the DASH score.

The mean teardrop angle in 200 normal wrists was 68 degrees (95%CI:67–69 degrees) and did not differ significantly between sexes (p=0.148). The average teardrop angle at presentation in 95 fractures of the distal radius was 47 degrees (95%CI:41–50 degrees), improving significantly to 58 degrees (95%CI:56–61 degrees, p< 0.0001) post-reduction, and this improvement was maintained at 56 degrees (95%CI:54–59 degrees) at union. The final position was significantly better than at presentation (p< 0.0001).

Loss of teardrop angle between the fractured and uninjured wrist was significantly related to reduced grip strength (p=0.04) and worse DASH score (p=0.03). The mean AP distance in 200 normal wrists was 19.6mm (95%CI:19.4–19.9mm) in males and 17.6mm (95%CI:17.2–18.0mm) in females, which is significantly different (p< 0.0001). The mean AP Distance at presentation in 95 fractures of the distal radius was 21.0mm (95%CI:20.4–21.7mm), which improved significantly to 19.6 (95%CI:19.1–20.2mm, p< 0.0001), but subsequently worsened to 20.8mm (95%CI:20.2–20.4mm) at union. This is not significantly better than at presentation (p=0.397). An increase in AP distance in the fractured wrist correlated to loss of range of motion (p< 0.01).

The value of these parameters is that they offer quite detailed assessment of the articular surface of the distal radius in the absence of more detailed imaging. They appear to be of prognostic value.


A. Nisar A. Pendse A. Bhosale I. Chakrabarti

Osteoarthritis of the first trapeziometacarpal joint (TMCJ) is a disabling disease which reduces the function of the thumb and the hand. Replacement arthroplasty offers a pain free joint as well as mobility, stability and strength.

This study reviews the results of TMCJ arthroplasty using a cemented metal-on-polyethylene implant (Sr TMC, Avanta®). Between 2001–2005 seventy two (n = 72) TMCJ cemented Arthroplasties were performed by a single surgeon. Patients were followed in the clinics for up to six years (median follow up 36 months, range 24–72). Patients were reviewed clinically and radiologically by two independent assessors. For outcome, Sollerman and Quick-DASH scores were used. A Jamar dynamometer was used to assess the grip and pinch strengths. Thirty six patients (46 joints), were seen at final follow up. There were 13 male and 23 female patients. Ten patients had bilateral TMCJ replaced.

Six patients were revised to trapeziectomy and ligament reconstruction with tendon interposition. Four for aseptic loosening and two for traumatic dislocation. Survival after a median follow up of 36 months was 91%. At final follow up mean Quick DASH score was 29.2 and mean Sollerman Score was 77.1. Radiological review of the surviving joints showed lucencies around trapezial component in 8 joints, 4 of which were loose. However these patients had good hand function and grip strength and therefore declined revision surgery. We found that the radiological findings did not correlate with clinical findings. 83% patients were satisfied with the outcome of their treatment.

Early results of Sr-TMC (Avanta) joint replacement are encouraging. We recommend the use of this prosthesis for osteoarthritis of the trapeziometacarpal joint.


H. Nagata S. Hosny G. Giddins

Distal radio-ulnar joint (DRUJ) instability is increasingly recognised and can lead to disabling symptoms. Clinical assessment can detect gross instability but is much less reliable for subtle instability. The normal range of DRUJ dorso-palmar translation is not known. Previous biomechanical research has studied DRUJ kinematics using cadaveric models.

We aim to develop a simple, reliable and reproducible tool to measure DRUJ stability and thereby assess the normal range of DRUJ dorso-palmar translation in-vivo.

A test rig was designed and 20 volunteers recruited. The rig held the subject’s elbows at 90° flexion with the distal ulnar secured and the forearm in neutral rotation. Dorso-palmar shear force was applied to the distal radius and displacement measured 3 times on each wrist alternately by the same operator. Volunteers with previous wrist injuries were excluded.

Ten male and 10 female volunteers were recruited. Mean male age 39.1 years (range 22–74). Mean female age 35.8 years (range 25–57). Mean male translation 5.4mm (range 3–9, SD 1.1). Mean female translation 5.5mm (range 4–7, SD 0.9). Mean right sided translation 5.3mm (range 3–8, SD 1.0). Mean left sided translation 5.6mm (range 3–9, SD 1.0). Total mean translation 5.5mm (SD 1.0). Same-sided mean measurements for two subjects taken days apart varied by only 1mm. Intraclass correlation coefficient was 0.93.

The rig is reliable, reproducible and appears to be a valid test of DRUJ translation. The mean DRUJ translation in neutral is 5.5mm. Contralateral sides and between sexes were comparable. We anticipate that the rig will be a research tool to guide clinical practice in DRUJ instability.


R. Rathore E. Gendall E. McEwen J. Haines R. Grimer

We aim to establish the likely functional scores following different types of surgery for bone tumours. All living patients who had undergone treatment for a bone tumour were contacted and invited to complete a TESS self-report questionnaire. The TESS contains 32 items of day-to-day activities which the patient scores themselves against. The final score is a percentage, with 100% being ‘normal’. The project was approved by the local ethical committee.

723 responses were obtained from just over 1000 letters that were sent. Thirty seven sets of data were incomplete leaving a total of 686. There were 369 males and 317 females, with an average age of 49 (range 15 to 93). The mean interval from their initial operation was 12 years (range 1 to 42). 590 of the procedures were in the lower limb and 96 in the upper limb. 126 patients had an amputation and 560 limb salvage (82%).

Mean scores obtained for each procedure were: EPR mid-femur 86%; EPR distal femur 77%; EPR proximal tibia 74%; EPR proximal humerus 71%; EPR proximal femur 71%; Below knee amputation 70%; EPR total femur 63%; Disarticulation of the hip 61%; Above knee amputation 60%; Hindquarter amputation 57%; EPR pelvis 54%.

Younger patients had much better scores (80% for those under 30 vs. 69% for those over 30, p< 0.0001) than those over 30. Additionally, the scores for those that had had an amputation following a EPR procedure were no worse than those who had had an amputation originally. Significantly, EPR proximal tibia was better than AKA (78% vs. 67% p = 0.0003), as was EPR distal femur (80% vs. 67% p < 0.0001).

This data from a large series is helpful in indicating likely outcomes following surgical treatment of sarcomas, both for patients and surgeons.


W. Khan R. Jain B. Dillon L. Clarke M. Fehily M. Ravenscroft

The aim of this study was two-fold; firstly, to investigate the construct validity of the Disability of the Arm, Shoulder and Hand (DASH) score in patients following injuries to the upper and lower limbs, and to confirm that DASH score does not measure disability solely attributed to the upper limb. Secondly, to create a modified DASH questionnaire (M2 DASH) with fewer questions that can discriminate clearly between disabilities due to problems at the upper limb, and is more specific to the upper limb.

Patients were asked to fill in the DASH questionnaire in a fracture clinic following ethical approval. This included upper limb injuries (79), lower limb injuries (61) and control subjects (52). The median DASH scores for the three groups were 57, 16 and one respectively. The DASH scores varied significantly between the three groups (Kruskal-Wallis: p< 0.001); the scores for the upper limb group were higher than the lower limb group, and the scores for the lower limb group was higher than the control group (Mann-Whitney: p< 0.001). The M2 DASH questionnaire was developed using questions specific to the upper limb and included questions 1–4, 6, 13–17, 21–23 and 26–30. The median M2 DASH scores for the three groups were 50, 7 and 0 respectively. The revised questionnaire score was then calculated for the upper limb group and a correlation study showed good correlation between the two questionnaires.

Our study shows that the original DASH questionnaire is not specific for the upper limb. This has important implications in measuring response in injuries and disease that involve both upper and lower limbs. We have devised a revised questionnaire that we suggest is referred to as M2 DASH questionnaire. The M2 DASH questionnaire has the advantage of being more specific for the upper limb than the DASH questionnaire.


D. Makki G. Packer

To assess whether by improving patient’s knowledge about the wrist arthroscopy procedure would positively affect the amount of postoperative pain. We tested the effect of a fact sheet that contained detailed information about the procedure on the outcome of such a surgery.

Fifty-five patients undergoing diagnostic wrist arthroscopy were randomly allocated into 2 groups. Group 1 included 28 patients to whom an explanatory form named fact sheet was provided prior to the procedure. 27 patients in the second group did not have the fact sheet. However both groups had the usual preoperative verbal instructions during consenting and all patients had Visual analogue scale pain assessment before surgery. Pain scores were recorded over a 10 day period postoperatively, the end point being the day on which the patient returned to the preoperative pain status.

There were 34 females and 21 males with 47 right and eight left wrists but all were the dominant side. The mean age of the patients was 35 years (range of 16 to 54 years).

In the first 48 hours all patients had flare up of pain in their wrists but by day five, 75% of patients who had the fact sheet, recovered to their preoperative pain status whereas only 22% of patients in the control group had done so. Furthermore, Patients in group 1 resumed their routine daily activities on average three days earlier (day seven) when compared to the control group in whom this return was not complete up to day 10.

Supplying a fact sheet prior to wrist arthroscopy has a positive influence in terms of decreasing the preoperative pain score and reducing the time patients required off work. Given the clear benefits demonstrated by this simple manoeuvre, it is now our practice to provide such a fact sheet to all patients.


G. R. Harigovindarao

Saggital plane deformities are difficult to treat and pose major challenge to orthopaedic surgeons and we are presenting short series of patients who have undergone the deformity correction with ring fixator.

Sixteen deformities in 15 patients were corrected during 1996 to 2004. The aetiology was congenital pterigium five cases, post traumatic seven cases, one each of polio, septic knee and post osteomyelitic sequelae. Nine patients had fixed flexion deformity, four had procurvatum and one had recurvatum and one patient had combined deformity.

All cases were analysed with adequate x-rays two level fixation above and below the apex of the deformity was done with the hinges placed at the apex of the deformity. The motor was provided perpendicular to the axis of the hinge. Bony correction was performed in eight cases and rest were corrected by soft tissue distraction. After achieving correction fixator was retained for a month or two to prevent recurrence.

Out of the eight cases of fixed flexion deformity (FFD) in nine knees, full correction was achieved in seven knees. One adult with septic knee was planned for correction of deformity and fusion which was completed in 4 months time. Out of five congenital pterigium three had full correction. One case had complete recurrence which was recorrected completely in the second attempt and the 5th case had residual 20 degree deformity. Knee deformity in PPRP patient underwent SC osteotomy with good correction of the deformity which compensated the quadriceps gait. Post traumatic FFDs were corrected fully. The bony deformities of tibia namely the procurvatum and recutvatum deformities were corrected fully. Average fixator time is 7 months.


H. Singh J. Dias

To assess the effect of deformity on Grip strength characteristics in the Rheumatoid Hands using force time curves. Forty seven (6 males and 41 females) patients with mean age 62 years (29–79 yrs) with Rheumatoid arthritis had their handgrip strength measured with closed fluid dynamometer generating force-time curves.

These were analysed further in blinded fashion for:

peak force;

average force;

time to peak

and variance of the force data through the plateau region (final 60% of curve).

Data was also collected on joint mobility, pain and disability using Patient Evaluation Measure (PEM) and Functional Disability Scores (FDS).

The patients were divided into five groups according to the degree of deformity: No deformity, ulnar deviation, Boutonniere, Swan neck or combined deformities (two or more deformities). These patient groups showed significant differences in grip strength (p value < 0.01). Patients with combination of deformities showed low peak and average forces as measured on force-time curves. The hands with Swan neck deformities had the highest variability in the plateau region of the curve and had the greatest disability scores both with PEM and FDS scores (P Value < 0.005). This group was particularly disabled (P Value < 0.007) being less able to sustain the grip over time.

Swan Neck Deformity causes the most significant dysfunction and this should be carefully considered when making decisions regarding surgery.


L. Hajipour A. Gulihar S. Ahmed J. Dias A. Ullah

Treatment of a partial laceration in zone two of a flexor tendon remains controversial. The intact part of the tendon can sustain forces of normal un-resisted motion, and repaired partially treated tendons can actually be weaker than un-repaired ones. Trimming these lacerations has been shown to be beneficial in partially lacerated tendons with triggering or entrapment.

The purpose of this study is to observe the behaviour of a partially lacerated and subsequently trimmed tendon under strain, and measure their friction coefficient at different flexion angle and load. Ten long flexor tendons from long digit of turkey foot, along with the equivalent of A2 pulley were used. All experiments were carried out for intact, lacerated (50%) and trimmed tendon at 10, 30, 50 and 70 degrees of flexion and two load settings of 200 and 400g.

The friction forces were measured by the difference between the two load transducers and the friction coefficient was measured using this formula, μ = Ln[(F2/F1)]/Ø.

Friction coefficient (μ), Tension forces (F2 and F1), arc of tendon and pulley contact (Ø).

Results: Friction coefficient increased significantly by three folds (0.3) after laceration compare with intact tendon (0.12) at both loads. This was reduced significantly after trimming the tendon but the friction coefficient was still approximately twice the value of the intact tendon (0.2).

Triggering was noticed in all tendon lacerations. Triggering was reduced after trimming in 10 and 30 degrees of flexion but increased markedly at 50 and 70 degrees of flexion associated with tendon fragmentation at the trimmed area.

Trimming partially lacerated flexor tendons will reduce the gliding resistance of the tendon through the pulley but this can lead to further fragmentation and triggering at higher flexion degrees and loads.


J. Gilbody K. Ho R. Kundra R. Wellings A. Gaffey

Modern methods of deformity correction such as the Taylor Spatial Frame (TSF) allow correction of deformities to within tolerances of 1° and 0.5mm. Plain X-radiography using orthogonal views is the current standard for the assessment for the evaluation of angular limb deformities. CT has been used for the assessment of torsional and axial deformities but its use has not been described for the measurement of angular deformities. Furthermore, dedicated correction planning software (SpatialCad™) may allow more accurate deformity definition.

This study aims to evaluate the accuracy of CT and SpatialCad™ to measure angular deformities in vitro. A tibia sawbone was coated in radio-opaque paint. A TSF was mounted on it and an osteotomy made in the mid-diaphyseal region. Four deformities were created and imaged with plain radiography and CT. Four observers measured the deformities using paper and pencil, PACS and SpatialCad™ for plain radiographs and Spatial-Cad™ for the CT scout views. The variance of the mean response of observed differences between main treatment factors was measured using analysis of variance.

There was no significant difference in variability (precision) between observers or methods of measurement. However, measurements made with PACS and Spatial-Cad™ on plain radiographs, but not CT scout views, were also accurate.

There does not appear to be any evidence at present that the use of CT for measurement of angular limb deformity is justified over plain radiography. Spatial-Cad™ is designed to optimize deformity correction planning for use with TSF, but PACS appears to be adequate for use with other deformity correction systems.


M.C. Rao O. Richards C. Meyer R. Spencer-Jones

To assess the outcome of knee “arthrodesis” using cemented Endo-Model knee fusion nail in failed Total Knee Replacement (TKR) with significant bone loss due to infection. This is a retrospective case study of seven patients with infected TKR and multiple surgeries with significant bone loss.

All patients had antibiotic loaded cement with a temporary K-nail as a first stage procedure to eradicate infection. All seven patients had “arthrodesis” performed using cemented modular Endo-Model Knee Fusion nail (Waldemar Link, Hamburg) by the senior author. Cement was used to hold the stems in the diaphyses and not used around the coupling mechanism. The “arthrodesis” relied entirely on the coupling mechanism which has been shown to have good axial and torsional rigidity by mechanical testing. Outcome was assessed using pre and post Visual Analogue Score (VAS).

Mean age was 72.3 years(62–86). Mean follow up was 39.6 months (7–68). The VAS pain score improved from pre-operative mean score of 7.9 to a postoperative score of 1.5. One patient suffered fracture of femoral cement mantle at 50 months who underwent a technically easy exchange revision. One patient had recurrent infection with distal femoral fracture at 36 months and was revised to distal femoral replacement.

The Endo-Model knee arthrodesis nail restores limb lengths, has good early results in terms of pain relief and provides a stable knee “arthrodesis” in cases where there is significant bone loss and extensor mechanism insufficiency following an infected TKR.


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G. R. Harigovindarao

Extension contracture of knee is a disabling deformity in Indian population. The cause for the contracture may be congenital or acquired. The treatment for the contracted quadriceps is quadriceps release which is done either proximally or distally. The latter method is common and in adults it leaves quadriceps lag.

The method was originally described by Judet in 1932. It is modified and used in this series. It is a stepwise procedure :

Lateral release and joint adhesiolysis;

Medial release and joint adhesiolysis;

Rectus release;

Entire quadriceps slide from proximal to distal.

Thirty six patients with extension contracture of the knee have been undergone surgical release. There were 27 males and 9 females. 32 patients were adults and four were children. The aetilogy was post-traumatic in 31 out of which two were following epiphyseal injury. There were three cases of arthrogryposis, and one each of post osteomyelitic and post TKR. The age group ranged from 5 years to 45 years. Male:Female ratio was 27:9.

All patients were followed from minimum period of one year. One arthrogrypotic child developed skin necrosis which healed by secondary intention. Thirty-three patients achieved 0 to 120 degrees of ROM. Two of the arthrogrypotic patients obtained 0 to 60 and last patient had only 20. None of the patients had quadriceps lag. Judet quadricepsplasty has been demonstrated to be very effective in treating contractures of the knee.


K. A. N. Saldanha S. Nayagam

Fibular hemimelia is associated with equinovalgus deformity of the ankle and hind foot and antero-medial bowing of tibia. A wedge shaped distal epiphysis of the tibia and tight posterolateral soft tissues play an important role in the pathogenesis of ankle valgus and lateral subluxation of foot. Tethering effect of fibular anlage may contribute to the deformities in the tibia and ankle. Lengthening procedures are associated with progression of these deformities.

The purpose of this study is to determine whether Exner Osteotomy and Excision of Fibular anlage will correct the valgus deformity of the ankle and antero-medial bowing of tibia. A bending osteotomy through the distal tibial physis as described by Exner and excision of Fibular Anlage was performed in six limbs in five children (4 boys, 1 girl) with fibular hemimelia. Histology of Excised Fibular anlage was studied under light microscopy. The mean age at the time of surgery was twenty two months (range: 8 months to 5 years).

The mean follow-up was two years and two months (13 months to 4 years and 8 months). Full Correction of ankle valgus and tibial bowing was achieved in three feet where, a cortical strut graft was used in the open wedge osteotomy. In two feet synthetic bone substitute was used. In these, tibial bowing corrected but slight ankle valgus remained. In one foot where synthetic bone substitute was used and the postoperative compliance with AFO was poor, bowing of tibia improved but ankle valgus recurred. Premature fusion of growth plate did not occur in any of the cases. Histology of fibular anlage showed replacement of bone tissue by mature collagen bundles surrounded by fibroconnective tissue.

Exner Osteotomy and Excision of Fibular Anlage in Fibular Hemimelia corrects the ankle valgus and antero-medial bowing of tibia.


P. Loughenbury R. Tunstall S. Britten

Wire crossing angle affects the stability of circular fine wire frames. Anatomical atlases document safe ‘corridors’ to avoid neurovascular structures, although this may limit crossing angle. In the distal tibia the furthest posteriolateral safe corridor described is through the fibula. The present study describes a new and safe ‘retro-fibular’ corridor for wire placement in the distal tibia that provides a greater crossing angle. Two different methods of wire insertion are considered to determine which provides greater protection to neurovascular structures.

A dissection based study of 20 embalmed lower limbs divided into two groups. 1.8mm wires were inserted at increments along the tibia, from posterolateral to antero-medial, at 30–45 degrees to the sagittal plane. In the first group wires were placed against the posterior surface of the fibula and ‘stepped’ medially onto the tibia. In the second wires were inserted midway between the border of the fibula and tendoachilles. Standard dissection techniques were used to identify the path of wires and distance from neurovascular structures.

In group one distal tibial wires avoided the posterior tibial neurovascular bundle (mean distance 21.7mm) although passed close to the peroneal artery (mean distance 1.2mm). In group two both the posterior tibial and peroneal structures were avoided (mean distances 15.5mm and 7.1mm respectively). Comparison of the two groups shows a significant difference (p< 0.001).

Retrofibular wire placement is safe in the distal quarter of the tibia and facilitates an optimal crossing angle, although is not described in standard atlases. Insertion of wires mid-way between the posteromedial border of the fibula and the tendoachilles appears the most reliable technique.


A. Johnston C. Andrews M. Laverick

Limb lengthening is described by means of external fixator in limb length discrepancy. Intramedullary distraction is a relatively new procedure undertaken infrequently. We present our initial results following the use of the ISKD for lower limb lengthening.

Methods: A retrospective review, over a three year period, revealed six patients (five femurs and one tibia) underwent lengthening by ISKD. Four of the femoral cases were secondary to trauma. The other femoral case and tibial case were secondary to congenital shortening.

All cases were male with mean age of 35 years (20 – 54 years). The mean total distraction was 42mm (10 – 65mm) and a mean daily distraction of 0.96mm/day (0.78 – 1.75mm). Mean time to full weight bearing was 12.5 weeks. The planned length of distraction was achieved in all patients undergoing femoral lengthening. Four of these patients regained full movement of the knee at 6 months and the other regained an arc of 5 – 105 degrees.

The tibial lengthening only achieved 28.5% of the desired length as a result of premature consolidation and poor patient compliance. There were no cases of infection, DVT, non-union or hardware failure. Three patients experienced no complications. One patient experienced premature consolidation and required repeat corticotomy. Two patients experienced inappropriate lengthening. One experienced distraction at the previous fracture site and as a result required 5 further operations and application Ilizarov frame. The other was as a result of a runaway nail achieving 56mm distraction in 32 days (1.75mm/day).

This review, although with small numbers, highlights that the ISKD is a satisfactory treatment for femoral lengthening although we experienced difficulties with tibial lengthening. Following our experience all patients require a CT scan preoperatively to confirm union at the fracture site. ISKD has been considered an option for femoral lengthening only.


S. Chummun A. Bhatti T. Chesser U. Khan

The aims of this study were to review the management of open tibial fractures in our specialist ortho-plastic centre and to assess whether our practice concurred with the BAO/BAPS guidelines. A retrospective note review of patients with open tibial fractures was undertaken. Data was collected on time to referral to the plastic surgery unit and time to definitive soft tissue cover. Return of limb function was assessed using the Enneking score.

Forty five consecutive patients (27M vs. 18F), with an age range of 11–86 yrs (median age of 42 years), were treated using strict protocols. Seventeen cases were referred by the on-site orthopaedic unit, and 28 patients were from 7 neighbouring units. Time from injury to initial plastic surgery assessment ranged from 0 to 19 days, with a median of 4 days. Time from injury to definitive soft tissue cover ranged from 0 to 21, with a median of 5 days. 41/45 cases had definitive surgery within 5 days of initial plastics assessment. 5 patients with definitive treatment at days 4, 4, 7, 7, 12 developed superficial wound infection.

Patients referred from neighbouring units underwent on average 1 extra operation. We failed to detect any significant difference in return of function between the 2 groups indicating that referral to a specialist centre may produce equivalent functional return even if there is a delay in definitive treatment.

Open tibial fractures should be managed in a specialist centre, manned with dedicated lower limb plastic and orthopaedic reconstructive surgeons and followed up in a combined ortho-plastic clinic. However, more emphasis should be put on improved communication between referring units and the specialist centre.


A.J. Bowey A. Molloy C. Butcher A. Bass P. Herdman

Scarf osteotomy is a commonly performed method of hallux valgus correction. Release of deforming lateral soft tissue structures is an integral part of this correction. The aim of this study was to determine if there was any difference in the correction achieved by dorsal and transarticular releases as part of a scarf osteotomy.

This radiological study was performed at a single institution. One surgeon utilised the dorsal first web approach for the distal soft tissue release and one the transarticular approach. There were 23 patients in each group. The same post-operative regime was used on both sets of patients. Data was collected on hallux valgus angle (HVA), intermetatarsal angle (IMA) and AFS sesamoid scoring.

The pre-operative deformity as measured by hallux valgus angle and intermetatarsal angle where similar for both groups (p= 0.25, 0.79 respectively) with a significant difference in severity of AFS scoring in the dorsal group (p < 0.001). Patients who underwent a dorsal approach release had a mean improvement in IMA of 5.46 degrees compared to 3.86 in the transarticular group. The HVA improved by 17.92 degrees in the dorsal group compared to 8.08 in the transarticular group. Both these results were statistically significant (p= < 0.01,< 0.002 respectively). There was a statistically significant difference in number of patients returning to within normal limits of the HVA (p= < 0.05); 18 patients returned to a normal hallux valgus angle after undergoing the dorsal approach compared to 9 patients in the transarticular group.

Our study shows that when performing a distal soft tissue release in conjunction with a scarf osteotomy for correction of hallux valgus, a dorsal first web approach is significantly better at correcting the HVA as compared to a transarticular approach. We would, therefore, recommend the use of a dorsal approach when performing this surgery.


S. Maret A. Richards A. Khaleel

The Ilizarov technique can be used to achieve bony union in high energy trauma and in non-union. There is much interest in the augmentation of bone healing using growth factors, GPS II collects the patients own platelets into a highly concentrated formula. Activated platelets release growth factors that may stimulate fracture healing.

We used the GPS II system in 13 cases of either high-energy trauma (2 cases) of non-union (11 cases) treated with the Ilizarov Circular frame in our institution. The group included two tibial fractures, eight tibial, one femoral and two ulnar non-unions. The minimum follow up of a year. The average age of the patient was 45 (22–66). We observed complications and measured time to clinical and radiological union from the start of treatment with circular frame.

No complications associated with GPS. One patient had an infection remotely in the limb resulting in amputation. All fractures and non-unions went on to solid bony union. The average time to radiological union was 21 weeks (range 13–36 weeks). Frame removal in these cases was 6.5 months (range 4–10 months). No patient underwent any further surgical intervention.

This pilot study features a heterogenous group of patients in which it is difficult to assess the role of GPS II. The use of GPS II, however, was uncomplicated in our study. The use of GPS II may act as a adjuvant therapy in the treatment of high energy trauma and non-union treated with the Ilizarov technique. Furthers studies are required to investigate the efficacy of GPS II in the management of non-union.


N. Maffulli G. Walley M. Sayana U.G. Longo V. Denaro

To evaluate the effects of eccentric strengthening exercises (ESE) in athletic patients with Achilles tendinopathy. Forty five athletic patients (29 men, average age 26 years; 16 women, average age 28 years; average height: 173 ± 16.8, range 158 to 191; average weight 70.8 kg ± 15.3, range 51.4 to 100.5) with clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks.

The mean pre-management VISA-A scores of 36 (SD 23.8; 95% C.I.: 29 – 46) improved to 52 (SD 27.5; 95% C.I.: 41.3 – 59.8) at the latest follow up (p = 0.001). Twenty seven of the 45 patients responded to the eccentric exercises. Of the 18 patients who did not improve with eccentric exercises, 5 (mean age: 33 years) improved with two peritendinous aprotinin and local anaesthetic injections. 10 of the 18 patients (9 men, mean age 35 years; 1 woman aged 40 years) who did not improve with eccentric exercises and aprotinin injections proceeded to have surgery. The remaining three patients (3 women, mean age 59.6 years; 2 men, mean age 63 years) of the 18 non-responders to eccentric exercises and aprotinin injections declined surgical intervention.

ESE in athletic patients provide comparable clinical outcome compared to our previous results in non-athletic patients. ESE are a viable option for the management of AT in athletes, but, in our hands, only around 60% of our athletic patients benefited from an intensive, heavy load eccentric heel drop exercise regimen alone. If ESE fail to improve the symptoms, aprotinin and local anaesthetic injections should be considered. Surgery is indicated in recalcitrant cases after 3 to 6 months of non operative management.


A. Roche L. Hunter N. Pocock D. Brown

To test the knowledge of clinicians in Orthopaedic clinics and Emergency departments of the surface anatomical landmarks that should be examined during assessment of foot and ankle injuries. Specifically trained assessors observed 109 clinicians examining 6 anatomical landmarks on uninjured subjects. Each landmark was chosen for their relevance in assessment of foot and ankle injuries. The landmarks were the medial malleolus, lateral malleolus, fibula head, navicular, base of the 5th metatarsal and the anterior talo-fibular ligament (ATFL).

Two participants failed to identify a single landmark. Of 109 assessed, 27% correctly identified all 6 landmarks. The average correctly identified by each clinician was 4.1 with a standard deviation of 1.5 and range of 0–6. One hundred and seven clinicians correctly identified the lateral malleolus, the most consistently identified. The most poorly identified landmark was the ATFL, by 45%.

The knowledge of surface anatomy overall by junior Orthopaedic and Emergency clinicians was found to be poor and only seems to significantly improve once higher specialty training is reached. Despite the potential for subjectivity and bias the authors believe the methodology is sufficient to demonstrate a lacking in anatomical knowledge amongst clinicians. Poor anatomical knowledge leads to inaccurate examination. This can lead to incorrect diagnoses or even mal-treatment of patients. Clinicians are becoming more reliant on potentially unnecessary and expensive imaging investigations. They have neglected the basic art of physical examination based on sound knowledge of human anatomy. At present, the authors believe that the anatomical teaching in undergraduate medicine is inadequate.


V. Prasad J. Whittaker N. Makwana P. Laing P. Harrison J. Richardson G. Smith E. Robinson J-H Kuiper S. Roberts

We aimed to assess the long term results of patients who underwent Autologous Chondrocyte Implantation (ACI) for osteochondral lesions of the talus. Between 1998 and 2006, 28 patients underwent ACI for osteochondral lesions of the talus. All these patients were prospectively reviewed and assessed for long term results. Outcomes were assessed using satisfaction scores, Mazur ankle score and the AOFAS score, and Lysholm knee score for donor site morbidity.

The 28 patients who underwent the procedure included 18 males and 10 females. Follow up ranged from 1–9 years. In all patients, there was an improvement in the Mazur and AOFAS ankle scores and the Lysholm scores showed minimal donor site morbidity. Improvement in ankle score was independent of age and gender. The better the pre-op score the less the difference in post-op ankle scores. Patients were unlikely to benefit with pre-op ankle scores over 75.

The mid to long term results of ACIs in the treatment of localised, contained cartilage defects of the talus are encouraging and prove that it is a satisfactory treatment modality for symptomatic osteochondral lesions of the talus. Complications are limited. However, in view of limited number of patients, a multi-centre randomised controlled study is required for further assessment.


A. Jowett C.L. Birks M.C. Blackney

Chronic exertional compartment syndrome of the foot is well recognised. There has been debate over the exact number and location of compartments. While the medial compartment has been consistently reported, the exact anatomy of the fasciotomy has been poorly documented in orthopaedic literature.

Over a four year period (2003–7) five patients (seven feet) with history and examination findings compatible with chronic exertional compartment syndrome affecting the medial compartment of the foot were treated in our unit. There were three female patients and two males, average age 23 (17–34).

Assessment was made using the Stryker compartment pressure monitor inserted into the compartment following exertion. The measurements were compatible with chronic exertional compartment syndrome according to the Pedowitz criteria. The patients then underwent complete surgical release of the medial compartment of the foot. This involved two small oblique incisions, over the proximal and distal ends of the muscle belly of abductor hallucis, the fascia on the superficial and deep surfaces was then released, thus releasing the distal end of the tarsal tunnel. Decompression was bilateral in one, sequential in one and unilateral in three. Three patients also had surgical treatment of chronic compartment syndrome elsewhere in their lower limbs. One patient underwent a simultaneous calcaneal osteotomy for a planovalgus foot.

Preoperative post exertional compartment pressure measurements were 67.8 (32–114) at 1 minute and 50.2 (28–97) at 5 minutes. At an average of 21 (9–57) months follow up all but one patient had significant relief of their symptoms.

We recommend that the surgical treatment of chronic exertional compartment syndrome affecting the medial compartment of the foot should involve full release of the fascia both superficial and deep to abductor hallucis. It is safe to perform this bilaterally and in association with other lower limb decompressions as required.


S. Giannini A. Leardini M. Romagnoli S. Casanelli M.T. Miscione J. O’Connor

A linkage-based mathematical model was used to design a ligament-compatible prosthesis to keep certain ligament fibres isometric during passive motion. The sagittal plane talar component radius is about 50% longer than that of the normal talus, the tibial component is spherically convex. A fully conforming meniscal bearing is interposed between them. Experiments in cadaver specimens confirmed the mathematical prediction that the bearing moves forwards on both metal components during dorsi-flexion and backwards during plantar flexion.

Between July 2003 and July 2008, the prosthesis was implanted into 250 patients at nine hospitals in Northern Italy. By November 2007, 158 in 156 patients were seen at least six months post-operatively. Mean age was 60.5 years. The diagnosis was post-traumatic osteoarthritis in 127, primary osteoarthritis in 17, rheumatoid arthritis in 10.

The mean follow-up was 32.5 months. The pre-operative AOFAS score of 36.2 rose to 75.9, 79.3, 77.9, and 79.0 respectively at 12, 24, 36, 48 months. Dorsi-flexion increased from 0.1° to 9.7°, plantarflexion from 15.1° to 24.6°. In 30 patients at one hospital, the range of postoperative motion, 14° – 53°, was significantly correlated to the range of bearing movement on the tibial component, 2mm–11mm, measured radiologically, (r2 = 0.37, p < 0.0005).

By December 2007, 2 revision operations had been performed at 24 months, one for unexplained pain not relieved by a successful arthrodesis, one in a patient with Charcot-Marie-Tooth disease. There were no device-related revisions (loosening, fracture, dislocation). The Kaplan-Meier survival rate (component-removal as end-point) at 4 years was 96% (Confidence interval 90–100%).

Early clinical results have demonstrated safety and efficacy. The survival rate at four years compares well with multi-centre 5-year rates published by the Swedish (531 cases, survival 78%), Norwegian (257, 89%) and New Zealand (202, 86%) registries.


B. Purushothaman P. Lakshmanan D. Rawlings P. Patterson M. Siddique

There is limited literature available looking into circumstances surrounding the development of stress fracture of the medial and lateral malleoli after ankle replacement. We present the preliminary results of a prospective study examining the effect of ankle replacement upon local bone mineral density and the phenomenon of stress shielding.

We aimed to assess the effect of ankle replacement loading of the medial and lateral malleoli, by analysing the Bone Mineral Density (BMD) of the medial and lateral malleoli before and after Mobility total ankle replacement.

Ten consecutive patients undergoing Mobility total ankle replacement for osteoarthritis had pre-operative bone densitometry scans of the ankle, repeated at 6 months after surgery. The bone mineral density of a 2 cm square area within the medial malleolus and lateral malleolus was measured. The pre-operative and postoperative bone densitometry scans were compared. The relation between the alignment of the tibial component and the bone mineral density of the malleoli was also analysed.

The mean preoperative BMD within the medial malleolus improved from 0.57g/cm2 to mean 6 months postoperative BMD of 0.62g/cm2. The mean preoperative BMD within the lateral malleolus decreased from 0.39g/cm2 to a mean 6 months postoperative of 0.33g/cm2. The mean alignment of the tibial component was 88.50 varus (range 850 varus to 940 valgus). However, there was no correlation between the alignment of the tibial component and the bone mineral density on the medial malleolus (r = 0.09, p = 0.865).

The absence of stress shielding around the medial malleolus indicates that ankle replacements implanted within the accepted limits for implant alignment, load the medial malleolus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in the lateral malleolus.


J. Phadnis G. Subbhiah A. Khaleel

We aim to assess the long term functional and symptomatic outcome of patients after open reduction internal fixation (ORIF) of the ankle. A retrospective telephone interview of patients (n=113) in years five, six and seven after ORIF of the ankle was conducted. The Olerud-Molander Ankle Score (scale 0–100) and SF-12 Health Survey scores were utilised to assess symptomatic and functional outcome. Fractures were classified in accordance with the Danis-Weber system. All patients were operated upon in the same unit by the same group of surgeons.

Sixty five patients were male and 48 female. The mean age was 56 (range 15–96). Patients with Weber B fractures (n=83) had a mean OMAS of 89.2. Those with Weber C fractures (n=25) had a mean OMAS of 85.4. Five patients had isolated medial malleolar fractures. At five to seven years post-operatively, 67.3% of patients were symptomatic. Of these, 75% complained of swelling; 39% of pain and 30% of stiffness whilst 19.5% of all patients felt they had not returned to their pre-operative functional level. Regardless of fracture type or follow up time, patients under 40 years old, had a significantly higher mean OMAS (90.7) as compared to those between 40 and 65 years old (85.3) (p=0.024). There was no significant difference in the mean OMAS of patients followed up at five or seven years post operatively or between those with Weber B or C fractures.

Patients suffer ongoing symptomatic and functional problems up to seven years after ORIF of the ankle and a significant number do not return to their pre-injury functional state. Patients under 40 years old had a better outcome as compared to older patients, whilst Weber type or year of follow up did not affect outcome. Surgeons should counsel patients pre-operatively regarding possible long term problems when undertaking ankle fracture fixation.


J.R. Ramaskandhan E.A. Lingard M.S. Siddique

Total Ankle Arthroplasty (TAA) using the uncemented three component mobile design has shown encouraging results. There is limited literature on the optimal postoperative management. In our centre, TAA patients are mobilised 48 hours after surgery without a short leg plaster. The aim of this prospective audit was to measure the outcomes of these patients to ascertain if this is a safe and effective protocol.

Patients who underwent primary TAA between March 2006 and March 2008 were invited to participate in the audit. Assessment included patient questionnaires which collected demographics, height and weight, Foot and Ankle Outcome Score (FAOS) and Short-Form-36 (SF-36). Clinical examination collected American Orthopaedic Foot and Ankle Score (AOFAS). Data was collected pre-operatively and at 3 and 6 months after surgery.

A total of 48 ankle replacements in 46 patients were included. Primary diagnosis was osteoarthritis (25), post-traumatic osteoarthritis (9), and rheumatoid arthritis (12). Mean age was 63 years (range 33 to 83) and the majority were males (29, 60%). The average body mass index was 28 (SD 5.3). There were significant improvements to 3-months after surgery for AOFAS (mean 29 to 76, p< 0.0001), FAOS (mean scores changes: Pain 36 to 72, Function 41 to 68, Stiffness 38 to 65, p< 0.001) and physical domains of the SF-36 (means score changes: Physical Functioning 25 to 39, Role Physical 27 to 40, Bodily Pain 29 to 48 and Vitality 42 to 50, p< 0.05). All outcome scores were maintained with a non-significant trend for better scores from 3 to 6 months.

These early results demonstrate encouraging outcomes for TAA patients who are mobilised early after surgery without a short leg plaster. Further studies of post-operative management are needed to compare outcomes after TAA between patients undergoing this protocol and patients who are immobilised in plaster.


R. Rambani A. Sood H.K. Sharma

It is generally accepted that urgent debridement and fixation of open tibial fractures minimizes the risk of infection. Traditionally surgeons follow the unwritten six hour rule. The purpose of this study was to determine the association between time to definite surgical management and rates of infection in open fractures of the tibia.

One hundred and twenty-seven patients with one hundred and twenty-eight open tibia fractures were retrospectively reviewed. Of these ninety patients with ninety-one one fractures were available for this study. All patients were followed up to clinical and radiological fracture union or until a definitive procedure for infection or non-union had been carried out.

The time from injury to surgery ranged from 2 hours 35 minutes to 12 hours with an average time of 5 hours 40 minutes. There were 24 Gustillo type I fractures (26.37%), 11 type II fractures (12.08%), 23 type IIIA fractures (25.27%) and 33 type IIIB fractures (36.26%). 5 patients (5.49%) in this study went onto develop a deep infection and there were 4(4.39%) non-unions. No infection occurred when the surgery was done within 2 hours. All the 5 infections in this study occurred in patients operated between 3 to 8 hours of the injury and were all in Gustillo Grade III fractures. The average time to treatment was not significantly different between the infected versus non infected group across all fracture types. There was no increase in infection rate in those treated after 6 hours compared to those treated within 6 hours.

The risk of developing an infection was not increased if the primary surgical management was delayed more than 6 hours after injury provided intravenous antibiotics were administered on presentation to the emergency department. The Gustillo grading of open fractures is a more accurate prognostic indicator for developing an infection.


S. Fogerty S. Nakhjavani V.S. Nikolaou P.V. Giannoudis

We aim to evaluate the effect of fasciotomies following compartment syndrome on the healing of closed tibia diaphyseal fractures. Between January 2002 and January 2005 165 patients were treated in our institution with closed tibial diaphyseal fractures. Patients were divided in to two groups; Group A (study group) consisted of patients that, after surgery, developed compartment syndrome and were submitted to fasciotomies and group B (control group) of patients who underwent reamed IM nailing and did not require such intervention.

Patients with open fractures, pathological fractures, revision surgery, severe brain injuries, prolonged ITU stay and severe co-morbidities were excluded. Fracture pattern, ISS score, smoking habits, drugs intake, mode of mobilization and additional procedures were prospectively documented. Fracture healing more than 24 weeks was defined as delayed union and over 36 weeks as non-union. All patients had been followed-up clinically and radiologically until fracture union.

One hundred twenty five out of 165 patients fulfilled the inclusion criteria for this study. 30 patients were classified in group A and 95 in group B. Eighteen patients of group A required skin graft coverage after the fasciotomies. There was no difference between the two groups in terms of the studied parameters. Four patients from group A and one from group B, went to non-union and required second procedures to achieve union. These patients were excluded from the final analysis. Delayed union occurred in 11 (36.6%) patients in group A and in 10 (10.5%) patients in group B (P< 0.05). Overall, fracture healing was prolonged in the fasciotomy group but the difference was not statistical significant, 24.27 weeks (10 – 48) versus 22.19 (12 – 40), (P= 0.157) in group A and group B respectively.

Compartment syndrome and fasciotomies is associated with delayed fracture healing. Nevertheless, this delay was not statistically significant different.


P.V. Giannoudis V.S. Nikolaou N.K. Kanakaris

We investigated whether lateral compression type I injuries of the pelvic ring are inheritably mechanically stable. Between January 2005 to January 2007 all consecutive admissions of a tertiary referral center for pelvic ring reconstruction with a LC I injury pattern were eligible for inclusion. Exclusion criteria were other patterns of pelvic ring injuries.

All patients underwent radiological assessment including AP pelvis, inlet/outlet views and CT. Patient demographics, mechanism of injury, other associated injuries, ISS, length of hospitalisation, type of operation, mode of mobilization, preoperative and postoperative visual analogue score pain VAS and follow up until fracture union were prospectively documented. Mechanical stability of the pelvic ring was assessed in the operating theatre under general anaesthesia. Instability was defined as displacement > 2 cm of the anterior or posterior elements. The minimum follow up was 12 months.

Of 210 patients admitted with pelvic fractures, 40 fulfilled the inclusion criteria (LC1 type). There were 23 female 17 male and with a mean age of 33.5 (range 18–68). The mean ISS was 10 (range 9–19). 23 patients (group 1) were found to have more than 2 cm rotational displacement during EUA and were stabilised with SI screws posteriorly and a combination of retro-pubic screws, external fixator or plating anteriorly. 17 patients (group 2) exhibited minimal displacement less than 5mm and were not stabilised. Rotational instability > 2cm was characterised by complete fracture of the sacrum posteriorly. Stabilisation of the pelvic ring in group I was associated with a significant reduction of the VAS within 72 hours from surgery, early ambulation and discharge from the hospital.

This study supports the view that not all LCI fracture patterns are mechanically stable. Examination under anaesthesia of the pelvic ring can assist the clinician in the decision making progress.


N. Kanakaris H.C. Pape P.V. Giannoudis

The safety and efficacy of bone-healing enhancement with Bone Morphogenetic Protein-7 (BMP) has been studied in the clinical setting of persistent post-traumatic and post-partum pelvic instability. Prospective collection and analysis of all cases with pelvic ring instability after trauma or childbirth, treated with reconstruction and local application of BMP-7. Patient demographics, hospitalisation, operative interventions before and after the BMP-7 grafting, and follow-up data were recorded and evaluated. The median follow-up period was 1 year (range 12 to 18 months).

Over a two-year period (March 2005 – January 2007) nine patients (8 females) with median age of 39 years (31–62) were operated for persistent pelvic instability and pain. The mean number of previous operations was 1,6 procedures. Reconstruction of the pelvic ring included 4 cases of post-partum pubic symphysis instability, 2 traumatic non-unions of pubis symphysis and 3 sacroiliatis (1-septic and 2-aseptic). Reconstruction included double plating of pubis symphysis (4-cases), external pelvic fixation (2-cases), sacroiliac screw fixation (1-case) and anterior sacroiliac plating (2-cases).

In 4 cases BMP-7 was used alone; in 5 it was used together with iliac crest autograft. All patients were mobilizing with a wheelchair for a period of 8 weeks (6–12) before progressing to full weight bearing. Clinical and radiological union occurred in 8/9 cases at a median time of 14 weeks (range 12–20). One female patient with post-partum pubic symphysis instability and a chronic psychiatric disorder is still complaining of pain despite the radiological evidence of progress of fusion. The rest reported resolution of symptoms. No local or systemic complications or adverse events associated with the use of BMP-7 were recorded.

The application of BMP-7 alone or supplementing autografting has been proven to be radiologically 100% and clinically 90% successful and safe following pelvic ring reconstruction as seen in this series of patients.


A.A. Odutola R. Baker J. Loveridge R. Fox A.J. Ward T.J. Chesser

We aimed to determine multi-modality outcomes in surgically treated patients with high energy pelvic ring injuries. A retrospective cohort study of all patients with pelvic ring fractures treated surgically within our specialist tertiary referral unit was undertaken between 1994 and 2007. Case-notes and radiographs were reviewed and patients were contacted by postal questionnaire. Outcome measures were return to work, return to pre-injury sports and social activities, and the Short Form-36 (SF-36) outcome tool. Injuries were classified using the Young and Burgess (YB) classifications.

There was a response rate of 70% (145 of 209 patients), 74% of the study subjects were male. Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3 yrs (1–12 yrs). There were 45 Antero-Posterior Compression (APC) injuries, 51 Lateral Compression (LC) injuries and 49 Vertical Shear (VS) injuries. 58% of the APC injuries had returned to work (including changed roles at work), compared with 68% of the LC injuries and 51% of the VS injuries. 27% of the APC injuries had returned to their pre-injury sports, compared with 39% of the LC and 33% of the VS injuries. 64% of the APC injuries had returned to their pre-injury social activities compared with 77% of the LC and 49% of the VS injuries.

The SF-36 average Physical Functioning Score was better for the LC group (73.2) than the APC (61.7) and VS (63.3) groups. This general trend was repeated when the General Health and Social Functioning scores were reviewed.

These results illustrate the long-term morbidity associated with pelvic ring injuries and relationship with injury subtypes. The LC injuries appear to have better outcomes with all outcome measures than APC and VS injuries. Further studies are underway to look at other factors and their relationship to outcomes.


E. Katsoulis N.K. Kanakaris V.S. Nikolaou C. Court-Brown P.V. Giannoudis

The purpose of this study was to evaluate the efficacy of autologous cancellous bone grafting (ABG) for the treatment of long bone fracture non-unions. Patients who were treated with ABG for fracture non-unions of the lower extremities were identified from our prospectively entered database. Non-union was defined as failure of the fracture to unite within a period of 9 months. Demographics, comorbidities, medications, complications and surgical outcomes were all recorded and subsequently analysed. Chi square test was used to analyse the results.

In total 82(54 male) patients met the inclusion criteria. The mean age was 43.6 years (range 18–78). Ten patients were diagnosed with femoral and 72 with tibial fracture non-unions. Fifty three (64.6%) were open fractures at presentation. In the tibial non-union group, initially, 67 fractures were stabilised with IM nailing and 5 with plating. During revision surgery, 33 patients underwent exchanged nailing and ABG whereas 34 received ABG without revision of the metal work.

All five tibial plantings required re-plating and ABG. In the femoral non-union group, five fractures were initially stabilised with IM nailing and the rest with plating. During revision surgery, six patients underwent change of fixation (exchange nailing) and ABG and four received only ABG. Overall 73/82 patients progress uneventfully to union and the success rate was 89%. A second and a third attempt of ABG was made for 6/86 patients (7.31%) and 2/82 patients (2.44%) respectively, till clinical and radiological union. All but one of the patients united their fractures. One patient underwent amputation due to underlying osteomyelitis.

The mean time to union following the ABG procedures was 8.4 months (range 3–18). Autologous bone grafting is an effective method of treating fracture non-unions. Success rates of as high as 89% can be achieved as seen in this series of patients.


D. Forward C. Doro R. O’Toole J. Floyd H. Kim A. Hsieh J. Nascone

Comminuted subtrochanteric fractures pose a clinical challenge; locking plate technology has been theorized to offer treatment advantages. A comminuted subtrochanteric femoral fracture model was created with a 2 cm gap below the lesser trochanter in fifteen matched pairs of human cadaveric femora confirmed to be non-osteoporotic. The femora were randomized to treatment with a trochanteric femoral nail (TFN), proximal femoral locking plate (PFLP), or 95° angled blade plate (ABP). Each was tested under incrementally increasing cyclic load up to 90,000 cycles to simulate progressive weight bearing during three months.

The TFN was the strongest implant: it withstood significantly more cycles, failed at a significantly higher force, and withstood a significantly greater load than either plate (p< 0.001). Varus collapse was significantly lower in the TFN construct (p< 0.0001). Mode of failure differed among implants, with damage to the femoral head through implant cut-out in five of ten blade plate specimens and two of ten nail specimens, whereas no damage to the femoral head bone was observed in any of the PFLP specimens.

The TFN was biomechanically stronger than the PFLP and this may have clinical relevance during the slow healing of subtrochanteric femoral fractures. The PFLP was biomechanically equivalent to the ABP but failure occurred without significant damage to the femoral head, suggesting that although biomechanically equivalent, the PFLP might have clinically relevant advantages in its mode of failure over the ABP.


P. Kanabar S. Mirza P. Hallam A. Cooper

Historically the management of distal radial fracture has been often inadequate. It can be difficult to internally fix complex distal radial fractures with conventional plates. The fracture often collapses with metalwork failure. Literature suggests that malunion may lead to painful wrist with loss of function. In recent years fixed angle locking plate has been advocated for treatment of complex distal radius fracture. Our aim was to assess to assess the effectiveness of the volar locking plate (DePuy) in maintaining fracture reduction in distal radial fractures.

Radiographs of 170 distal radius fractures treated by the DVR plate were analysed. Fractures were classified according to the Melone and AO classifications. The post injury, intra-operative, 6 weeks postoperative and final postoperative radiographs were reviewed to obtain measurements for radial height, radial slope and volar inclination. The measurements were correlated with fracture pattern, locking screw length, presence or absence of radial styloid screw and plate placement in relation to the wrist joint. The results were analysed statistically using Wilcoxon signed rank test.

Radiologically there was minor loss of radial height, slope and volar inclination but this was not statistically significant. There was a statistically significant correlation between complexity of fracture and loss of radiological parameters. There was no statistically significant correlation between loss of radiological parameters and screw length, plate placement or presence or absence of radial styloid screw.

The DVR volar locking plate appears to maintain a satisfactory reduction of the fracture except for some complex fractures with dorsal comminution in which case dorsoradial plates may be preferable.


S.L. Bali G. Abbas R. Thomas M. Hamzeh

Ankle injuries in cricket fast bowlers are of topical interest with a number of elite pace bowlers recently sustaining injuries. Previous biomechanical research has concentrated on the injury risk to the fast bowler’s lumbar spine with no research focused on the leading leg and specifically the ankle biomechanics of the fast bowler and its predisposition to injury.

We investigate the leading leg biomechanics in maximal and submaximal fast bowling. Ten fast-medium paced bowlers of elite level had their leading leg biomechanics assessed during their bowling action. Using a nine camera infra-red ViconTM 612 motion analysis system linked to a KistlerTM 9281CA force platform the moments of the subjects leading leg during their delivery stride was analysed. Each subject performed ten trials at a maximal ball release speed (> 97km/hr) and ten trials at a submaximal ball release speed (< 97km/hr) with the speed of the ball tracked by a SR3600 radar gun.

All three large joints of the leg were observed and joint moments examined in both directions of all three orthogonal planes giving a total of eighteen joint moments investigated. Of these results only the difference in the ankle plantar flexion was found to be significant. The average ankle plantar flexion peak moment in the maximal and submaximal ball release speed groups were found to be 2.008Nm/kg and 1.790Nm/kg respectively. This difference was statistically significant (p< 0.02)

The increased ankle plantar moment reflects the important role the ankle plays in the generation of extra ball release speed in the fast bowler. However this role does place increased stress on the ankle which may predispose it to injury. This study suggests that the ankle plays a significant role in the fast bowler’s delivery action and post injury rehabilitation needs to take this into consideration.


K.K. Singisetti S. Swarna L. Loknadh M. Ambedkar

Fractures of humeral shaft are commonly seen in orthopaedic practice accounting for approximately 3% of all fractures. Treatment of these injuries continue to evolve as advances are made in both nonoperative and operative management. We performed a prospective study in the management of fractures of diaphysis of humerus by interlocking nail fixation and dynamic compression plating (DCP) was undertaken over a period of 3 years.

Forty five patients with humerus fracture were treated with either interlocking nailing or plating. Rodriguez-Merchan et al criteria was used to compare results of both groups postoperatively. Fractures with unacceptable alignment was the most common indication for operative intervention (53%). While only 50% of the interlocking group had healed by 16 weeks, 75% of the plating group had united by this time. Overall results (Rodriguez-Merchan) show 65% excellent and good results in interlocking group and 93% similar results in the plating group. Postoperative radial nerve palsy was not seen in the interlocking group but was noted in 6.25% of the plating group. All of them recovered uneventfully with time.

Plating is generally considered gold standard and to have predictable results in treatment of humerus shaft fractures. We have noted earlier union and better overall results in the plating group. Interlocking nailing is particularly preferable in communited, segmental and pathological fractures.


N. Maffulli B. Datta A. Turner M. Neil W.R. Walsh

Repair of chronic Achilles tendon rupture is technically complex. Flexor jallucis longus (FHL) and peroneus brevis (PB) tendon transfers have been described, but the mechanical properties of these tissues have not been well reported.

The FHL, PB and tendo achilles (TA) tendons were harvested from 17 fresh frozen human cadavers free of gross pathology (mean age 69 years). Samples were tested in uniaxial tension at 100% per minute. Samples were secured using special jigs for the bony aspect or by freezing the tendons in cryogrips using liquid carbon dioxide. The peak load (N), linear stiffness (N/mm) and energy to peak load (N*mm) were determined. Mechanical data was analysed using one way analysis of variance (ANOVA) followed by a Games Howell multiple comparison post-hoc test.

Fifty one tendons were harvested and mechanical testing was successfully completed in all samples apart from one PB that slipped from the grips during testing (sample was omitted from the analysis). The mean ultimate loads differed for each group, with the TA tendons being the strongest (1724.5 N ± 514.3) followed by FHL (511.0 N ± 164.3) and PB (333.1 N ± 137.2) (P< 0.05). Similar results were found with respect to energy, with TA tendons absorbing the most energy followed by FHL and PB (P< 0.05). Stiffness for the TA tendons (175.5 N/mm ± 94.8) was greater than FHL (43.3 N/mm ± 14.1) and PB (43.6 N/mm ± 18.9), which did not differ from each other.

FHL is stronger than PB, but have similar stiffness. The mechanical properties of PB and FHL were both inferior to TA. Graft stiffness appears to be an important variable rather than ultimate load based on the clinical success of both techniques.


N. Maffulli C. McGregor S. Ghosh D. Young

Both acute and chronic hamstring injuries are disabling injuries, and occur almost entirely to elite athletes. We report our experience in the management of injuries of this location. Twenty seven patients (29 injuries) were included in the present study. They completed a questionnaire detailing their pre-injury activity, injury mechanism, rehabilitation and a subjective assessment of their recovery. At clinical examination pain and hip motion were evaluated.

Hamstring injuries predominantly affect males on the left side. Most procedures carried out were explorations with limited debridement and suture of the tendon. One third of patients felt they had returned to 100% of their pre-injury level, and 33% felt they had returned to 80–90% of their pre-injury level, the rest varied between < 20–80%. 45% gave a value of zero on the visual analogue pain scale independent of activity, those who gave a value above this had pain during active sports but not at rest.

Early repair leads to a much better recovery of muscle function, especially when dealing with complete avulsions. Lesions to the origin of the hamstring can be successfully managed if a high suspicion for the condition exerted.


H. Bosman J. Mewton B. Parsons G. Bannister

Tibial shaft fracture occurs commonly in the young active population with high demands. Tibial fracture is potentially life changing. There are no published studies with long-term follow-up to provide accurate prognostic information regarding return to leisure activities, employment and driving.

We aim to define the patient demographic and mechanism of injury and quantify the time period following tibial shaft fracture to return to sport and sporting level achieved at long-term follow-up. A retrospective multi-centre study was performed. Data collection was by questionnaire including Tegner activity scale score for sporting level and closed questioning on employment and driving.

Ninety-three patients were recruited with an average 46 month (18–64mo) follow-up period. Patients were predominantly male (77%) with a median age at injury of 37 years. Road traffic accidents were responsible for 43% of injuries; sport 31%; falls 25% and assault 1%. High energy mechanisms accounted for 49% of injuries Seventy-eight percent of patients felt that prognostic information given at the time of injury was inaccurate.

At follow-up, only 31% had regained their original level of sporting ability. Median Tegner score prior to injury score was 5 and at 18 months the mean score fell by 1.85. Patients sustaining high energy injuries were worst affected, dropping an average of 2.13 compared to low energy mechanisms with an average fall of 1.35 on the Tegner scale (p=0.503). High demand patients had a greater reduction in functional outcome, with a fall of 0.8 for patients with pre-injury activity level of 1–3 compared to the fall of 2.6 on the scale for more active patients scoring 7–9 pre-injury.

Tibial fracture can result in significant long-term morbidity. Patients sustaining high energy injuries and high demand patients have significantly worse outcome. Patients are unlikely to achieve their pre-injury level of sporting activity at 2 years.


D. Arvinte G. Radcliffe S. Bollen

The purpose of the study was to establish if there is a consensus amongst knee surgeons in U.K. related to rehabilitation protocols following microfracture/drilling procedure performed for treatment of full thickness chondral lesions of the knee. Successful rehabilitation is accepted to be essential for achievement of best results.

A questionnaire was produced including questions about use of a CPM machine, use of a brace, weight-bearing status, use of an exercise bike, time allowed for patient to resume running, time allowed for patient to return to contact sports and surgeon’s expectancy of when symptoms will plateau. A simple scenario was put at the beginning of the questionnaire: “ A 23 year-old rugby player sustained a full thickness 1.5 x 1.5 cm chondral fracture on

the medial femoral condyle and

the femoral trochlea.

The lesion is treated using microfracture or a standard debridement method – post-operatively how is the patient managed?”. Questions were asked with regard to each site. The questionnaire was sent to BASK members. One hundred and twenty surgeons replied.

Analysis of responses showed an unexpected variability regarding the rehabilitation for patients having treatment for a full thickness chondral lesion, with no common agreement (less than 50%) even about such aspects as the use of CPM, allowed range of motion, weight bearing status or return to sport.

There is a marked disparity amongst knee surgeons in UK regarding the protocol of rehabilitation after treatment for full thickness chondral lesions of the knee. The majority of patients suitable for microfracture are young and active and a successful rehabilitation program is crucial to optimize the results of surgery. There is a need for development of accepted practice guidelines, to standardise the outcome for these patients.


A. Saithna R. Carey-Smith P. Thompson M. Dhillon T. Spalding

We aim to assess the clinical and radiological outcome following cartilage repair in the knee using the TruFit plug (Smith & Nephew). Eleven active sporting patients underwent cartilage repair using TruFit plugs between February 2006 and August 2007. Postoperatively patients were touch weight bearing for 2 weeks and partial until 4 weeks.

Data was collected prospectively, patients underwent clinical review and completed Lysholm, IKDC subjective, Tegner, KOOS and SF-36 scores pre-operatively and at 6 monthly intervals. One patient has been excluded from the analysis as she emigrated and was lost to follow up. The remaining 10 patients (mean age 35 years (21–49)) had defects on the medial femoral condyle (n=6), lateral femoral condyle (n=3), and lateral trochlea (n=1). Patients received one (n=5), two (n=3) or three (n=2) plugs and four were primary procedures, and six revision procedures (1 failed OATS, 5 failed microfracture). Eight implantations were performed arthroscopically and, and two were mini-open. All patients were reviewed at 12 months, five were reviewed at 18 months and four have also been reviewed at 24 months.

Statistically significant improvements from mean pre-operative scores are seen at 12 months; Lysholm (48.3 to 71), IKDC Subjective (37.7 to 65.1), Tegner (2.4 to 4.6), SF36 physical (39.5 to 50.3) and all components of KOOS. These improvements are maintained at the latest follow up. MRI evaluation including T2 mapping demonstrates reformation of the subchondral lamina, resorption of the graft and a similar signal from neo-cartilage as that of adjacent native cartilage.

TruFit plugs offer an exciting novel solution for cartilage repair in the knee with advantages of low morbidity and rapid recovery without the need for prolonged non-weight bearing. The implant may be suitable for small lesions only and further prospective study is required to establish long-term outcome.


N. Fisher V.V. Killampali R. Kundra N. Jagodzinski K. Mathur A. Reading

The purpose of this study was to evaluate and assess the sporting and physical activities of patients who have undergone hip resurfacing. One hundred and seventeen patients who underwent hip resurfacing between 2003–2007 were reviewed.

Demographic data such as age, sex and comorbidities were recorded. University of California and Los Angeles (UCLA) activity level ratings and Oxford hip scores were collected pre-and postoperatively for each patient. The sporting and physical activities of all patients were pre-and post-operatively recorded.

The mean age of patients at surgery was 54 yrs and 56 yrs at review. The mean follow up time was 19 months. Following surgery there was a significant improvement in UCLA activity level scores from 4.4 to 6.8 (Wilcoxon Matched-pairs Signed rank test, p< 0.05). Oxford hip scores significantly improved from 43.4 to 17.7 following surgery. Eighty six patients regularly participated in sport before they became symptomatic with significant hip pain, and 75 regularly participated in sports after surgery. In total 87% of patients successfully returned to their regular sporting and physical activities following surgery. Many patients were returning to high impact sports including football, tennis, cricket and squash.

The published medium-term survivorship of the Birmingham hip has given surgeons increasing confidence to use the prosthesis on a younger generation of patients. Our study has demonstrated that hip resurfacing can allow patients to remain extremely active.


M. Freudmann S. Bollen

We aim to identify any changes in the demographics of ACL injured patients over the last decade. Over a twelve month period, the demographic data from 117 consecutive new patients with ACL injuries attending one consultant’s clinic in 1994 was prospectively recorded. This was then compared with data from a similar cohort of 103 consecutive new ACL injured patients attending the same clinic some twelve years later.

Since 1994, the proportion of women seen with ACL injury doubled from 12% to 25%. The proportion of skiing related injuries trebled from 9% to 28%. The average age at presentation rose by 6.5 years from 26.5 to 33. In 2006, the average age of the skiers was 40 and 72.4% of them were female compared to only 8% of non-skiers.

The population of patients with new ACL injuries has changed significantly over the last twelve years. The average age, proportion of women and number of skiing related injuries have all increased significantly. We speculate that the most likely cause of these changes is the skiing population, which has enlarged and, due to retention of participants, has aged over the period of this study (1). Most skiing injuries are sustained abroad and the vast majority of skiers buy holiday insurance to cover themselves against injury. Yet it is the NHS that ends up footing the bill for any reconstructive surgery and rehabilitation. We propose that if the insurance companies maintained responsibility for their clients’ injuries until a full recovery had been made, the NHS would save millions of pounds.


B. Balain O. Ennis G. Kanes S. Roberts D. Rees

The details of 320 consecutive patients undergoing knee microfracture, with a minimum follow up of 6 months, were taken from the Sports Injury Database at the Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry. All had same phsyiotherapy regime post operatively. Two rounds of postal questionnaires were administered to assess patient satisfaction along with Lysholm, Tegner, VAS for pain and a modified IKDC scores. 196 patients responded (61.25%).

The mean age of our patients was 40.64 years and the mean follow up 37.02 months (range 6–78 months). There were 35 smokers and 161 non-smokers. 64 patients had surgery in the medial compartment, 35 in lateral, 50 in patella-femoral and 47 belonged to the combined category. 93 patients had other surgeries (partial meniscectomies, ACL reconstruction etc) along with microfracture(47.45%).

Seventy two percent of patients were satisfied with their outcome and 18.95% weren’t. 51.43% of smokers were satisfied with their outcome and 76.88% of non smokers (p=0.021). Patients more than 50 years of age were less satisfied (p=0.023) than younger patients. Having concomitant knee surgery, including ACL reconstruction, made no difference to patient satisfaction or functional scores.

The location of the lesion in the knee did not affect patient satisfaction. However, all five post op score levels were statistically different among them. The Lysholm post op scores were significantly better in lateral and PFJ compartments than medial. Lateral and combined groups were significantly better than medial for Tegner post op scores. Lateral and PFJ groups were significantly better than medial for VAS and modified IKDC scores.

Smoking and age significantly affect patient satisfaction after knee microfracture. Having concomitant knee surgeries doesn’t make a difference to either satisfaction or functional outcome. Our results suggest that the medial compartment doesn’t do as well in functional scores as previously thought.


A. Lakdawala J. Ireland

The aim of this study was to investigate the function, limitations and disability of a large cohort of active golfers following total knee replacement (TKR). The study group comprised the membership of the New Knee Golf Society (NKGS) and 211 members were reviewed with a questionnaire which asked the patient’s experience & difficulties of playing golf before and after TKR.

The functional outcome was recorded using the Oxford knee score. A total of 299 knees (TKR only) in 209 patients were included in the final analysis. The mean age was 70 years. Majority of the prostheses were cemented (95%) and had patellar resurfacing (90%). The mean post-operative period was 5 years. We found 196 patients (94%) returned to playing golf after a mean of 4.6 months following the TKR; 184 (88%) continue to play at review; 93% claimed significant improvement in their capability to play golf following TKR. However, none claimed to have achieved a significant improvement in their handicap.

Seventeen knees (5.7%) underwent revision surgery. Six knees (2%) were revised for infection at mean 17.3 months and eleven (3.7%) for aseptic loosening or instability at mean 5 years. Seven left knees (lead knee) of eleven right-handed golfers required revision for aseptic loosening. Varus collapse of the tibial component in the lead knee was observed.

The main problems experienced after playing 18 holes were knee stiffness (47%) and swelling (18%). Oxford Knee Scores: 69% excellent; 27% moderate functional impairment; 4% poor outcomes.

Although the capability to play improved the handicap remained the same. We found that the left TKR in a right-handed active golfer is more likely to require revision, which may be due to the increased torque on the lead knee.


J. Foote H. Smith S. Jonas R. Greenwood A. Weale

We present a retrospective study of a consecutive cohort of 109 patients, under the age of 60, who had either a patello-femoral replacement (PFR), uni-compartmental replacement (UKR) or a total knee replacement (TKR). They were operated on by 2 senior surgeons between 2002 and 2006 at the Avon Orthopaedic Centre in Bristol. The aim of this study was to look at the effect of knee replacement on the employment status of this group of patients.

Data were collected from patient’s hospital records and a questionnaire regarding occupational status sent postoperatively to patients. Statistical analysis showed that our groups were similar which meant that further comparison between them was valid.

Eighty two percent of patients who were working prior to surgery and who had either a TKR or UKR were able to return to work postoperatively. Only 54% of those who had a PFR were able to return to work and this was statistically significant when compared with patients in the other two groups p=0.047. The median time for return to work postoperatively for the study population was 12 weeks. Those in the PFR group took significantly longer to do so (20 weeks) compared to those who had either a UKR (11 weeks) or TKR (12 weeks) p=0.01. Patient’s subjective opinion as to their ability to work following knee arthroplasty was worse in the PFR group p=0.049.

This is the first study to compare employment status following patello-femoral, uni-compartmental knee and Total Knee Replacement. TKR and UKR are effective in returning patients to active employment and that this is typically 3 months following surgery. Patients who had a PFR did not experience the same benefits in terms of numbers returning to work, time to do so and their subjective opinion as to their ability to cope with normal duties.


I. Smith R. Elton J. Ballantyne I. Brenkel

In Scotland, the number of primary total knee replacements (TKRs) performed annually has been steadily increasing. Data from the Scottish Arthroplasty Project has recently demonstrated that the number of knee replacements performed annually has now outstripped the number of hip replacements. The price of the implant is fixed but the length of hospital stay (LOHS) is variable. An understanding of what currently influences LOHS may therefore be of paramount importance in order that we can influence some of these parameters, with resulting benefit to our patients as well as contributing significantly and favourably towards the health economics of this procedure. This study investigates the influence of intra- and post-operative variables on LOHS.

All patients who underwent primary unilateral TKR in the region of Fife, Scotland, United Kingdom, during the period December 1994 to February 2007 were prospectively investigated. The following intra and postoperative details were recorded: length of operation, need for urinary catheterisation, patella resurfacing, lateral release, blood transfusion, the presence of superficial or deep infection, day 1 post-operative haemoglobin and haemoglobin drop (haemoglobin drop between admission haemoglobin and day 1 post-operative haemoglobin). The data was analysed using univariate and multiple linear regression statistical analysis.

Data on LOHS was available from a total of 2105 primary unilateral TKRs. The median LOHS was 8.0 days. The highly significant intra and post-operative factors associated with an increased LOHS were lateral release, post-operative haemoglobin, blood transfusion, urinary catheterisation, deep and superficial infection. An awareness and understanding of these factors may enable us to influence them favourably with resulting reduction in the LOHS and, therefore, the associated costs.


S. Bridgman G. Walley D. Griffiths I. dos Remedios D. Clement G. Mackenzie N. Maffulli

Orthopaedic surgeons vary in their surgical approaches to total knee arthroplasty. The aim of this investigation was to compare outcomes after two different surgical approaches. The study was a prospective single-centre longitudinal randomized controlled trial. A sub-vastus approach was compared with a medial para-patellar approach. Participating surgeons elected to randomize their patients to one of the two types of approach. Outcomes included the Knee Society (KS) Clinical Rating System, WOMAC Osteoarthritis Index, SF-36, and EuroQol (measured at 1, 6, 12 and 52 weeks post-operatively compared to baseline) complications, surgeon rated ease of exposure, and proportion of patients who had a lateral release.

Two hundred and thirty one patients were randomized to the two approaches. One hundred and sixteen patients were randomized to the sub-vastus approach. At one week compared to baseline, range of motion, KS global, KS knee, and KS pain scores were significantly better in the sub-vastus group. At six weeks, the medial para-patellar group tended to have better outcomes, but not statistically significantly. At fifty-two weeks compared to baseline, the WOMAC global and pain scores, the SF36 physical function and role-physical scores, and the EuroQol utility and pain score were significantly better in the sub-vastus group. Surgeons reported the ease of exposure in the sub-vastus group was significantly worse on average.

This trial is the largest of its kind to date, and the first, so far as we are aware, to compare clinical outcomes of different surgical approaches at one year post-operatively. The sub-vastus approach to total knee arthroplasty was more effective than a medial para-patellar approach at both one week and fifty-two weeks post-operatively in patients whose surgeons considered either approach would be suitable. However, surgeons reported worse ease of exposure in the sub-vastus group.


T. Yarashi A. Sahu J. Rutherford S. Anand D. Johnson

We aim to create a set of reference data of commonly used scoring systems in the normal population, and to compare these results with published postoperative scores for commonly performed knee operations. This was a questionnaire-based study and a total of 744 questionnaires were sent out, of which 494 replies were received. Six scoring systems were addressed: Lysholm and Oxford Knee Scores, Tegner and UCLA activity scales and Visual Analogue Scales (VAS) for both pain and function. Data was collected into groups based on age (20–29, 30–39, 40–49, 50–59, 60–69, 70–79, 80–89 years). The reference data obtained was then compared to published postoperative scores for knee arthroplasty and ACL reconstruction, to assess whether these patients did indeed return to “normal”.

The mean scores for sequential age groups (described above) were as follows: Oxford Knee Score – 13, 13, 14, 14, 17, 15, 17; Lysholm Knee Score – 96, 95, 92, 89, 89, 89, 79; Tegener Activity Scale – 6, 5, 5, 4, 4, 3, 3; UCLA Activity Scale – 8, 7, 7, 7, 6, 6, 5; VAS pain – 5, 8, 10, 9, 14, 12, 20; VAS function 96, 95, 90, 90, 86, 84, 84. Symptom based scoring systems (Oxford Knee Score, Lysholm) were independent of age whereas activity scores (Tegner, UCLA) decreased with age. There was no significant difference detected between scores in different sexes in the same age group. Compared to published scores in an age-matched population following TKR, the data obtained showed that patients do not return to normal scores following arthroplasty. Following ACL reconstructive surgery, activity scores were higher than compared to the data obtained from our population.

Data generated from this study can be used as reference data and can play an important role in interpreting post-intervention scores following knee surgery.


S. Rajaratnam C. Jack A. Tavakkolizadeh M. George R. Fletcher M. Hankins J. Shepperd

The medium term results of the JRI Furlong Total hip replacement have been very impressive to date. We report the longest prospective series to date of a hydroxyapatite coated femoral prosthesis (Joint Replacement Instrumentation limited, London, UK) at 15–21 years follow up. We describe the long term clinical and radiological femoral stem survival of 331 consecutive JRI Furlong Hydroxyapatite coated total hip replacements in 291 patients at an average follow-up of 17.5 years (15 – 21 year). Two patients (0.6%) were lost to follow-up over the 21 years of the study period. Using revision of the femoral stem for any reason as an endpoint, we report a stem survival of 97.4 % (81.0 to 99.5). Using Aseptic loosening as an endpoint, stem survival was 100%.

The average Merle, D’Aubine & Postel scores recorded for the patients was 5.63/6 for Pain, 5.42/6 for mobility and 4.50/6 for function. There were no cases of anterior thigh pain relating to the uncemented femoral stem.

These results compare favourably with the best long term survival of cemented or uncemented femoral stems used in total hip replacements.


P. Mereddy R. Pydisetty K. Howard P.R. Kay R.W. Parkinson

Infection in total knee replacement is a devastating complication. Current literature supports two-stage revision as the gold standard treatment. The alternative single stage procedure has been reported to have favourable results. We assessed the early clinical results of single stage revision for infected total knee replacement.

Between February 2005 and August 2007, 12 patients had revision total knee replacement for infection by the senior authors at two centres. In the majority of the patients, the infective organism was isolated by arthroscopic synovial biopsy prior to revision. Standard single stage procedure included the explantation, debridement and re-implantation of the prosthesis. All the patients received intravenous antibiotics for six weeks and oral antibiotics were continued for further 6 weeks. All the patients had the inflammatory markers monitored during follow-up.

Significant improvement was noted in the SF-12 PCS, WOMAC pain and stiffness scores at the latest follow-up. None of these patients required re-revision. Radiological evaluation was done using the Knee Society system. None of the knees showed evidence of progressive loosening. Radio-opaque lines were found around the stems and were present on immediate post-operative radiographs; this did not indicate loosening or infection at a mean follow-up of two years.

Early clinical and radiological results of the single stage revision for infected total knee replacement appear to be promising. One operation, one anaesthetic and quicker recovery are the advantages for the patient and with the reduced hospital stay it is cost-effective. The problems of stiffness in the knee and muscle wasting with cement spacer are avoided.


J. Boldt

Femoral stress shielding in cementless THA is a potential complication commonly observed in distally loading press-fit stems. This prospective study describes long-term femoral bone remodeling in cementless THA at a mean of 17 years (range: 15 to 20) in 208 consecutive fully HA-coated stems (Corail, DePuy Int. Ltd, Leeds, UK).

All THA were performed by one group of surgeons between 1986 and 1991. The concept of surgical technique included impaction of metaphyseal bone utilizing bland femoral broaches until primary stability was achieved without distal press-fit. Radiographic evaluation revealed a total of five (2.4%) stems with periprosthetic osteolysis, which were associated with eccentric polyethylene wear. They were either revised or awaiting revision surgery. The remaining 97.6% stems revealed biologic load transfer in the metaphysis alone (52%) or in both metaphysis and diaphysis (48%).

Stem survival of 97.6% after 15 to 20 years without stress shielding were considered to be related to: impaction of metaphyseal bone, bland broaches, HA coating, and unique prosthetic design.


M. Akula P. Mc Shane C. Shaw A. Mohsen

A recent meta-analysis for total knee replacement (TKR) undertaken with navigation demonstrated improved accuracy of implant positioning but did not have sufficient evidence on functional outcomes. This meta-analysis evaluates the functional outcomes for TKR with and without navigation.

We present a randomized prospective and comparative studies on functional outcomes of TKR with and without navigation were identified. The selected articles were tested for publication bias and heterogeneity. Studies presenting the functional outcomes in terms of knee society score, oxford knee score and HSS scores were included in the study. The data was then aggregated by random-effects modelling after which estimated weighted mean differences for individual functional scores were calculated.

Sixty two studies were identified and reviewed independently by two researchers; ten studies fulfilled the inclusion criteria, resulting in 976 cases for the meta-analysis (490 with navigation and 486 without). The mean age of both groups was similar (68 and 69). Results of a meta-analysis are best demonstrated by funnel graphs, forest plot, P values, and confidence intervals. In summary, the weighted mean of difference of KSS score is −0.288, with a p value of 0.867. Moreover, the standard means of difference of Oxford knee score was 0.133, with a P value of 0.257. The HSS scores resulted in a SMD of −0.099 and a ‘p’ value of 0.686. Finally, the range of motion weighted means of difference was 1.428, and a ‘p’ value of 0.228.

This meta-analysis demonstrated that there is no statistical advantage to the use of navigation for TKR in terms of functional outcome; the increased positional accuracy does not impart an improved outcome as has been proposed. This is probably due to the tolerances available in the implant positioning. This meta-analysis is providing the early outcomes & highlighting the necessity of long term studies.


P. Mereddy S. Hakkalamani D. Shivarathre R.W. Parkinson

The principles of revision total knee replacement are to understand the cause of failure, adequate surgical exposure, achieving appropriate soft tissue balance, restoration of limb and joint line alignment, correct implant alignment, and a good range of motion. It is a technically and economically demanding procedure and its successful performance requires thorough preoperative planning, adherence to the principles, availability of diverse implant options and adequate bone graft.

We prospectively assessed the survivorship of Co-ordinate Ultra prosthesis (DePuy, Warsaw, Ind) used for revision knee arthroplasty. Forty-nine patients had 53 revision knee replacements performed by the senior author between April 1999 and September 2001. Seven patients (7 knees) had died. At a mean follow-up of 6 years (range: 5–7 years), 46 knees in 42 patients were available for review. None were lost to follow-up. There were 31 women and 11 men, with a mean age of 74.2 years. The reason for revision was instability in 39 knees, infection in 3 knees, pain in 2 knees and stiffness in 2 knees.

Significant improvement was noted in the SF-12 PCS and WOMAC pain and stiffness scores at the latest follow-up. None of these patients required re-revision. None of the knees showed evidence of progressive loosening. Radio-opaque lines were found around the stems and were present in immediate post-operative radiographs; this did not indicate loosening or infection on further follow-up. Cumulative survival analysis (Kaplan-Meier method) was 100% at 7 years.

Clinical and radiological outcome analysis has revealed that the Co-ordinate Ultra revision knee system continues to function satisfactorily at a mean follow-up of 6 years.


J. Rutherford E. Mulgrew D. Johnson P. Turner

Complex primary total knee replacements have been poorly reported in the literature We review all complex primary total knee replacement procedures at Stepping Hill Hospital. Patients underwent knee examination, knee scores, notes review and pre- and post-operative radiograph review. There were 29 patients with 36 knees that had a complex primary total knee replacement. Most frequent indications for surgery were osteoarthritis, rheumatoid arthritis or following trauma. Mean age at surgery 70 years. The prosthesis used were : 3 Stryker Kinemax; 32 De Puy PFC and one rotating hinge. Complex Primary Oxford knee score; preoperative mean 45 (range 33 to 57); postoperative mean 26 (range 14 to 53). NJR Total Knee Replacement Oxford knee score postoperative mean 30. Mean visual analogue scores; pain in the knee, mean 19; knee function, mean 77; outcome of the operation 76; satisfaction with the surgery 87. Mean length of hospital stay 13 days.

Using the Knee Society Radiographic Scoring System, there were no signs that need to be monitored or signify failure. Seven patients were transfused postoperatively, four patients had minor wound problems, three required further surgery, two to washout the knee and exchange the polyethylene liner, one femoral plating to stabilise an osteotomy site. Long term complications : one above knee amputation for infection, one foot drop.

Revision implants can be used in complex primary knee replacements, and pose technical difficulties but address various pathologies. The surgery is associated with an increased risk of complications and transfusion. Clinical scores at least match scores for routine total knee replacements, patient satisfaction is excellent.


J-P. Vidalain

Providing a long-lasting total hip arthroplasty for patients younger than 50 years remains one of the greatest challenges for modern arthroplasty surgery. Survival has been considered to be poor in young and active patients. We evaluated the benefit of total osteointegration of the prosthetic components in term of durable biological fixation.

This study concerns a prospective series of 113 patients operated between 1986 and 1994. The femoral component (Corail, Landos-DePuy) and the acetabular shells (Atoll & Tropic, Landos-Depuy) were totaly coated with a 150μ thick layer of pure HA following a plasma-spray process. The mean age at the time of surgery was 40.3 (range 17 to 49.8). Two patients are now deceased, 11 patients (9.7%) are lost to FU. The mean FU for 100 patients still on file is 14 years. AVN represents 29 % of the cohort, primary arthritis 22% and dysplasia 17%.

Functional results are excellent (mean PMA score 17.7 at the last control), as well as the subjective appreciation from the patients (94.9 % excellent or very good). 18 THA’s required components revisions: 6 without any implant removal (head or insert exchange); 1 stem (periprosthetic fracture) and 11 cups (6 well-fixed and 5 for loosening) were removed. Owing the high incidence of wear-related revision, actuarial survivorship, using re-operation for any reason as end-point, was 82% at 18 years ± 8.5, and considering aseptic loosening only, the survival probability of the stem is 99% ± 1.5 and 97 % ± 3.5.

It is clear that HA-coatings have given lesser performance in the cups than in the stems. We advocate for HA and the eradication of wear debris using hard on hard bearings. This combination seems to be a reasonable solution in this subgroup of young patients.


S. Rajaratnam T. Waters S. Sexton W.L. Walter B. Zecat W.K. Walter

Previously ankylosed or surgically arthrodesed hip joints can be converted successfully to a total hip replacement (THR) in order to improve patient mobility and function. We present a long term prospective cohort study of cementless revisions of previously ankylosed hips.

Sixteen hips (15 patients) with a mean age of 52 years (range 16 to 75) had ankylosed hips for a mean of 36 years (range 3.5 to 65 years). They all received a cementless THR between August 1988 and January 2003 and were prospectively followed-up for a mean of 11 years (range 5.0 to 19 years). Two patients died during the study period of unrelated causes and none were lost to follow-up.

All patients showed improved mobility and function following the conversion of their ankylosed hips. The Harris Hip Score improved from a pre-operative mean value of 70 (Standard Error of Mean (SEM) 3.4) to a post-operative value of 83 (SEM 4.4) at the latest review, which was statistically significant (p < 0.05).

There was one acetabular cup revision at 5 years post implantation for aseptic loosening. At a mean of 11 years post THR, all other femoral and acetabular components remained clinically and radiographically well fixed. One patient with systemic ankylosing spondylitis and spontaneous bilateral bony hip ankylosis developed the unusual complication of Paget’s disease of the left hemipelvis and proximal femur two years after successful bilateral THR surgery. His symptoms resolved following medical therapy for Paget’s disease.

We conclude that a previously ankylosed hip can be effectively converted to a cementless total hip replacement with good long term results.


D. Hardy

A prospective study of displaced femoral neck fractures was conducted, using the Corail® stem, a non cemented HA-coated device, provided with a bipolar head. 293 consecutive patients were included. Our reasons to shift to an uncemented implant were:

the existence of intraoperative deaths during cementation;

Cardiac failures consecutive to overhydration during cementation (to prevent drop of blood pressure);

As life expectancy increases, concerns about skeletal fixation of cemented devices in osteoporotic patients, when the cortico-medullary index decreases.

Follow-up was extended up to 5 years, unless the patient died before. 7 patients were lost from FU. Function was assessed every year using various clinical scores (Parker’s mobility score, Qureshi’s mental status, Jensen’s autonomy index,). An X-Ray was obtained at each visit when possible, with a special insistence at completion of the follow up (136 out of the 144 still alive patients).

Intraoperatively, 11 isolated calcar cracks and 1 fracture of the major trochanter were seen. In three cases, it was impossible to obtain a stable implantation. In two of these, a cemented implant was used. In the third patient, instability was not seen, leading to an 8 mm subsidence, along with thigh pain and distal hypertrophy of the femur. The 278 other patients had no intra-operative complications.

Late complications were:

1) 14 patients had a secondary subsidence of their device (1–4 mm), with a subsequent good stability and unaltered fixation to the skeletal tissue;

2) No loosening;

3) One femoral fracture, due to a second fall (at M4) requiring ORIF;

4) 14 small radiolucent line of less than 1 cm in the major trochanter area, whose the meaning remains obscure, as no adverse reactions are seen thereafter;

4) no stress shielding, despite a full coating of HA.


A. Malik D. Chou P. Jayakumar J. Witt

Juvenile idiopathic arthritis (JIA) affecting the hip can cause debilitating pain and walking disability in children. Total hip replacement offers the potential of a pain free joint and a significant improvement in function. There remains the concern regarding the high rates of aseptic loosening of cemented total hip replacements in this group of patients, and there is evidence that younger patients have higher failure rates.

The aim of this study was to look at the results of uncemented total hip replacement in children with Juvenile Idiopathic Arthritis and in particular to assess any problems associated with performing this surgery in the presence of open growth plates in the acetabular and trochanteric regions.

Between 1995 and 2005, 56 uncemented total hip replacements were carried out in 37 children with JIA with a mean follow up of 7.5 years (range 3 to 12.5). 25 of the hips had ceramic on ceramic bearings. The mean age at surgery was 13.9 years (range 11–16). 19 patients underwent bilateral procedures. All patients showed a significant improvement in their HSS Hip scores (p< 0.01). Two CAD CAM femoral stems were revised for gross subsidence and three acetabular components were revised for loosening. Four polyethylene liners were exchanged due to wear. 51 of 53 (96%) femoral stems and 50 (94%) acetabular components remain well fixed at latest follow up with no signs of loosening. There were no dislocations or infections.

Uncemented fixation appears to work well in this challenging group of patients even in the presence of open growth plates. Implant choice is important to avoid problems of subsidence and loosening. Ceramic bearings available for small implant sizes give promise of improved performance compared to polyethylene over the long term.


J-P. Vidalain

Bio-active fixation has increasingly gained acceptance over the last two decades. However extent of the coating is still a subject of debate. We introduced in 1986, the concept of total osteointegration of a tapered stem with the hope that we could achieve durable biological fixation while preserving normal periprosthetic bone trophicity.

Patients from our first clinical series using this stem are now eligible for 18-year follow up. Between July 1986 and December 1990, we performed 615 THA using the Corail stem (DePuy). Corail is a straight tapered stem totally coated with a 150 μthick layer of HA following an atmospheric plasma-spray process. The mean age at surgery was 64.5 (range 16 to 95). 242 patients are now deceased (39%), 62 patients (10%) are lost to follow-up. The mean follow-up for 243 living patients on file is 17.7 years.

Eighty nine THA’s required component revisions: 72 cups, 9 stems, 8 “cups and stems”. 8 cups and 4 stems have been revised for aseptic loosening. Owing to the high incidence of wear-related revision, Kaplan-Meïer survivorship at 18-year follow-up, using component revision for any reason as an endpoint, was 80.7 ± 3.3 (95% confidence intervals). In contrast, Corail stem survivorship, using stem removal for any reason as an endpoint, was 95.0% ± 3.0 at 18-year follow-up, and considering aseptic loosening only, the survival probability of the stem is 98.9% ± 1.1 at 18 years.

Therefore, despite wear and proximal osteolysis, the fixation achieved with this totally HA-coated stem remained durable through 18-year follow-up. Regarding the periprosthetic remodelling during this period, modifications of the bone pattern have been strictly limited: slight resorption at the calcar level, absence of cortical hypertrophy, anecdotic significant stress-shielding. The radiological silence is one of the paramount facts demonstrated by this prospective study.


R. Raman V. Eswaramoorthy P. Angus H. Sharma T. Madhu C. Shaw G. Johnson

We aim to report the clinical, radiological outcome of consecutive primary hip arthroplasties using the JRI-Furlong Hydroxyapatite ceramic coated acetabular components. We reviewed 412 consecutive primary THA using fully coated acetabular shell in 392 patients, with minimum 12-year follow-up to 18 years, performed at two institutions. Twenty (22 THA) were lost prior to 12-year follow-up, leaving 372 patients (390 THA) available for study.

Fully HAC coated stems were used in all patients. Clinical outcome was measured using Harris, Charnley Oxford, EuroQol EQ-5D scores. Radiographs were systematically analysed for implant position, loosening, migration, osteolysis. Polythene wear was digitally measured.

Mean age was 74.4 yrs. Dislocation occurred in 10 patients (3 recurrent). Revision operations were performed in nine patients (1.9%). Four acetabular revisions were performed for aseptic loosening. Other re-operations were for infection (3), periprosthetic fractures (1), cup malposition (1), revision of worn liner (3). The mean Harris and Oxford scores were 87 (78–97) and 19.1 (12–33) respectively. The Charnley score was 5.6 (5–6) for pain, 5.2 (4–6) for movement and 5.3 (4–6) for mobility. Migration of acetabular component was seen in 4 hips. Acetabular radiolucencies were present in 54 hips (9.7%). The mean linear polythene wear was 0.06mm/year. Mean inclination was 48.4 deg(38–65). Mean EQ-5D description scores and health thermometer scores were 0.81 (0.71–0.89) and 86 (64–95). With an end point of definite or probable loosening, the probability of survival at 12 years was 96.1%. Overall survival at 12 years with removal or repeat revision of either component for any reason as the end point was 94.2%.

The results of this study support the continued use of a fully coated prosthesis and documents the durability of the HAC coated components. In our clinical experience, the Furlong prosthesis revealed encouraging radiographic stability over a long term period


N.M. Orpen R. Shetty J.A. Corner R.W. Marshall

Decompression of the lumber spine for spinal stenosis is the most commonly performed spinal surgical procedure in patients over 60 years old. The aims of surgery are to relieve compression of the spinal nerves and retain integrity of the structural elements of the spinal column and its function as a supportive structure. In trying to avoid excessive removal of the posterior supportive structures of the spinal column without compromising full and safe decompression of the spinal nerves, techniques are being developed to reduce bone removal but also allow access to the spinal canal.

One such micro-decompression involves a hemi-laminectomy and lateral recess decompression on the more symptomatic side followed by undercutting the spinous processes and decompressing the opposite side from within the canal aided by the use the operating microscope, a high speed burr and a copper moldable retractor to protect the dura and nerves.

We have reviewed our first 100 consecutive patients who have had a spinal micro-decompression over a period of 5 years. 58 Female and 42 male patients are included in this series. Mean age was 65 years. Patients were assessed by a combination of clinical review and self-assessment questionnaires. After a follow-up period of up to five years (mean 3.5 years) we have seen symptomatic late instability develop in four patients requiring a further surgical procedure in two of these. Symptoms typically developed two years after the original operation following an initial improvement in radicular symptoms and back pain.

This compares favourably with published results for wide decompression where re-operation rates of 18% are reported. We have analysed the cases of delayed instability in more detail to evaluate whether the late deterioration could have been predicted.

Micro-decompression is shown to be safe with few complications and has advantages over wide decompression without compromising safety.


C. Lawrence G. Keene

Total hip-joint arthroplasty is associated with a high rate of perioperative blood transfusion, which increases the risk of blood-borne disease, anaphylactic and haemolytic reactions. Devices are used which collect and allow the re-infusion of blood lost during surgery, with the aim of reducing allogenic blood transfusion requirements. The purpose of this study was to establish whether the use of a ‘cell-saver’ device reduces the risk of post-operative allogenic blood transfusion in total hip joint arthroplasty.

All total hip arthroplasties performed by a single surgeon over a twelve month period were divided into two cohorts of patients; one which used an intra-operative cell saver device, the other which did not. Data was collected for patient demographics, pre-operative blood tests and blood loss, with the outcome measure as post-operative transfusion requirements. The total number of patients was 233; 166 primaries, 33 resurfacing & 20 revision arthroplasties: 14 excluded for insufficient data.

Comparison of the two cohorts (intra-operative cell saver used vs. no cell-saver used), demonstrated no significant difference in the post operative blood transfusion requirements for patients undergoing primary total hip joint arthroplasty (n=166, 18.3% vs. 11.0%, p=0.08), Birmingham resurfacing arthroplasty (n=33, 5% vs. 7.7%, p=0.49), and revision arthroplasty (n=20, 28.6% vs. 50%, p=0.26). There were no significant differences demonstrated between the patient demographics of the two cohorts for any of the groups. In the cell-saver cohort, the average volume of blood re-transfused was 117mls per patient (range 0 – 400mls).

Intra-operative use of cell-saver devices does not decrease post-operative transfusion requirements in primary hip arthroplasty. A larger size study is required to assess the outcome in resurfacing and revision hip arthroplasty surgery.


M.J. Stenning C. Hargood S. Grange G. Wills

Patients admitted with spinal injuries following trauma require careful serial examinations to detect any neurological deficit that may develop. Thorough documentation of the findings is of paramount importance. Enforced working practice within the NHS means that these patients are often assessed by different members of staff with varying levels of experience, thus inconsistent documentation can be a cause for concern.

The project aim was to design a human computer interface to standardise the performance and documentation of serial neurological examinations in patients with spinal injury, allowing the user to accurately detect any neurological deterioration.

A prototype system was developed for ward based PC’s incorporating the essential requirements of the neurological examination. Usability testing was performed on the prototype by recruiting fifteen users who would be expected to routinely perform the neurological examination on spinal injury patients. Usability was defined by a number of well defined goals (impression, efficiency, learnability, memorability, safety and effectiveness) and methods used in the evaluation included direct observation during completion of tasks, a questionnaire and unstructured interview.

Both quantitative and qualitative data was collected. This data was subsequently analysed using descriptive and inferential methods. The results of the analysis showed that the users responded favourably to the prototype in respects to the all usability goals except efficiency. This lack of efficiency was expected due to the rigid nature of computer based systems compared to paper based methods of recording data but this disadvantage was more than compensated for by the increased patient safety that the system would provide.

It can be concluded from the usability testing that the prototype achieves the aims of the project but further work is required in developing the prototype into a final interface design before beta testing in a clinical environment can be considered.


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T. Taneja C. Critchley A. Bhadra A. Sivaraman C. Natali

Backpain is a common cause of patient referral to pain clinics. Around 120 000 patients with back pain are seen in UK Pain Clinics every year. Facet joint injections are a commonly used treatment modality. However there is considerable controversy regarding their efficacy. Most of the evidence supporting the use of injections is anecdotal, rather than being based on randomised studies.

We carried out a prospective study to assess the efficacy of facet joint injections in relieving chronic low back pain. Our study group comprised 41 patients (57% females, 43% males). Patients completed the Oswestry Disability Index (ODI) and marked their pain levels on a Visual Analogue Scale (1 to 10).

We found that though the pain score improved from 6.9 to 4.3, there was only a marginal improvement in the ODI from 52.5 to 50.8. Overall 85 % of patients experienced some improvement, while 15% felt their symptoms had worsened after the injections. One of the most significant findings of this study was the fact that the improvement in most patients lasted only for an average of three weeks. This is significantly less than most previous studies indicate. Interestingly, inspite of this limited improvement, almost all patients expressed the desire to be placed back on the list for repeat injections.

Our study demonstrated a beneficial short term effect of facet joint injections. In our opinion, they are a reasonable adjunct to non operative treatment of chronic backpain.


A. Hudd J. Bernard

The SF 36 questionnaire has been validated and used in multiple studies. However, it remains unclear how well patients complete the SF-36 questionnaire in a spinal outpatient clinic setting outside the context of a study. We aim to assess the quality of information gained if the SF 36 is used as an audit and outcome measure in real clinical practice.

The SF 36 has been used in our clinic as a routine for the initial assessment and outcome audit of patients for the last 4 years. A prospective, consecutive sample of 85 patients’ SF-36 forms was evaluated during a spinal out-patient clinic over one month at our teaching hospital. Completeness of data entry was assessed. All patients had access to a translator and clinic nurse to help complete the questionnaire if needed.

There were 34 males and 51 females (age range 16 to 81, average 48). Thirty seven patients were White British, 22 other and 26 undisclosed ethnicities. Thirty eight (45%) forms were complete leaving 47 (55%) which had at least one question unanswered or spoiled. Of these, two had five to ten errors, one had 10 to 15 errors, four had 15 to 20 errors, seven had 20 to 25 errors, ten had 25 to 30 errors and 17 had 30 to 35 errors. In addition six forms were entirely incomplete beyond patient identifier information. White British patients had fewer errors (average 4) compared to other (9) and unknown (9) ethnicities.

Outside the context of a research study, the SF-36 questionnaire in an urban teaching hospital spinal outpatient clinic is not a reliable tool. Redesign of the questionnaire may be required. The SF-36 questionnaire is less well completed by patients declared as non White British, even with the facility for a clinic nurse and a translator.


R. Bharadwaj N. Harshavardhana A. Sahu M. Singh A. Singla R. Hartley

Spinal pathologies requiring spinal/neurospinal unit’s input/opinion from tertiary centres for their management are initially admitted to DGHs. The referral is made by mailing radiographs with clinical details to the on-call registrar who gets back with a management plan. This arrangement is fraught with delays at various levels having an impact on patient care, financial and medico-legal implications. We discuss these issues between index DGH (Poole General Hospital) and its tertiary referral centres.

To review the existing management of spinal injury admissions at our hospital, analyse critical/adverse incidents and to identify areas for improving patient care.

A comprehensive retrospective review of all spinal admissions/referrals made to tertiary centres over 6 months was undertaken. Twenty eight of the 64 admissions warranted referrals. A structured proforma was used to document the time of admission, time of booking and performing scans, time of referral & response from tertiary centre and time of transfer from hospital notes and delays at each level were critically analysed.

Seven of the 28 referrals had either neurodeficit or spinal instability. Common issues were delay in obtaining CT/MRI scans (av 2.5 days), delay due to reporting/failing to act on results (av 1.8 days), delays due to missing/lost in transit’ scans (av 1.5 day), delay in obtaining opinion (av 4 days) and non-availability of bed for transfer (av 5.5 days). There was 1 mortality and 5 other complications while awaiting transfer. The financial costs incurred were approximately £73,000 & loss of 246 patient-days.

Training on induction day, implementation of spinal care pathway and diligent documentation/communication coupled with succinct referral were strictly enforced following this study. The website www.neurorefer.co.uk was set up by Wessex neurological centre to streamline referrals and enhance efficiency. This website has now grown into a national secure referral portal incorporating other referral centres.


S. Konan P. Kalia S. Oussedik M. Dodd M. Coathup F. Haddad G. Blunn

We investigated the hypothesis that autologous bone marrow stromal cells (BMSC) sprayed on the surface of acetabular cups would improve bone formation and bone implant contact.

Total hip replacements were implanted in 11 sheep, randomly assigned to receive either acetabular implants sprayed with autologous BMSCs suspended in fibrin (study group) or fibrin only (control group). Sheep were sacrificed after six months and the acetabulum with the implant was retrieved and prepared for undcalcified histology. Implant bone contact in both groups was compared, by microscopically noting the presence or absence of new bone or fibrous tissue along the implant at 35 consecutive points (every 1000 μm). The observers undertaking the histological analysis were blinded.

Significantly increased bone implant contact was noted in the BMSC treated group 30.71% ± 2.95 compared to the control group 5.14% ± 1.67 (p = 0.014). The mean thickness of fibrous tissue in contact with the implant was greater at the periphery 887.21mm ± 158.89 and the dome 902.45mm ± 80.67 of the implant in the control group compared to the BMSC treated group (327.49mm ± 20.38 at the periphery and 739.1 mm ±173.72 at the centre). Conversely direct bone contact with the implant surface was significantly greater around the cups with stem cells.

BMSC sprayed on surface of implants improves bone implant contact. Spraying acetabular cups using stem cells could be used in humans where acetabular bone contact is compromised such as in revision procedures.


A.M.H. Latif K. Ong S. Siskey R.E. Field

Sectioned femoral components retrieved from failed hip resurfacing arthroplasties show resorption of proximal femoral bone or formation of a fibrous membrane at the bone cement interface. Our study uses Finite Element Analysis (FEA) to examine the effects of the implant orientation on bone remodelling following hip resurfacing arthroplasty. A radiographic analysis of the proximal femur following hip resurfacing was conducted in order to draw a comparison to the FEA findings.

A 3D FEA model of the Birmingham Hip Resurfacing (BHR) was created based on the geometry and material properties of a 45 year-old female donor hip. Hip joint and muscle loads were applied. Bone remodelling stimuli was determined using changes in strain energy. A range of implant orientations were compared to study the affect on bone remodelling. A retrospective radiological analysis was undertaken on 100 hips with a minimum of 5 years follow up. Femoral neck diameter was measured at post-op, 2 and 5 years, as well as neck and stem shaft angles.

FEA showed that valgus orientation was associated with increased resorption underneath the shell. Varus orientation showed increased bone formation at the stem tip. The radiological analysis identified 2 distinct patterns of neck thinning. Slow thinners (76%) had < 5% reduction in neck diameter at 2 years and < 10% at 5 years. Rapid thinner (24%) had > 5% thinning at 2 years and > 10% at 5 years. The mean percentage reduction in neck diameter was significantly different between the two groups at the two time points (p< 0.01). The rapid group had a higher proportion of valgus aligned implants (88%) and a significant decrease in reconstructed offset (p=0.0023).

The FEA results have shown that stem alignment can affect bone resorption resurfacing. FEA results were consistent with the radiological findings. Additional retrieval studies are necessary to help understand aetiology of implant failures.


N. Pradhan S. Gajjar L. Morrissey V. Clark R. Pandey N. Purushotham

Spinal anaesthetic (SA) with intrathecal diamorphine and general anaesthetic (GA) with blocks and/or patient control analgesia (PCA) are commonly used in hip and knee replacement surgery. Drop in blood pressure, feeling light-headed and drowsiness, itching are known early complications respectively. This causes delay in patient mobilization post operatively. Our study examines the use of a local anaesthetic infuser device (LAID) (pain buster pump) for post operative pain relief after total hip or knee replacement surgery.

Forty six patients (25) THRs and (21) TKRs were included in this study. Each were given a LAID which consisted of 0.25% bupivicaine infused at 4ml/hr via an elastometric pump over 48 hours. 100mls of 0.1% bupivicaine with 0.5mg adrenaline was infiltrated locally into the wound at closure. All patients were prescribed regular analgesic as per the multimodal pain regime and an hourly pain score maintained. Rescue opioids were prescribed if pain score crossed 5. Patient satisfaction score was recorded as excellent, some or no pain relief. Eleven patients were given general anaesthetic and 25 patients were given spinal anaesthetic.

26% were able to sit out of bed within 6 hours of surgery and 65% (30 patients) were sitting out by the first post operative day. Average length of stay was 6.15 days, decreased to 4 days for patients mobilised on day zero and compared to eight days prior to this study. 21% had excellent result, 29% had some pain and 6% had poor result. 90% needed oral rescue analgesia within the first 48 hours.

LAID allowed some patients to be mobilised within 6 hours of surgery. The use of LAID helps avoids the need for PCA or diamorphine and hence its associated complications though some amount of oral rescue analgesia was necessary. Patient compliance was satisfactory. The early results are encouraging and further studies are been conducted at our hospital.


I. Pountos V.S. Nikolaou J. Morley H.C. Pape P.V. Giannoudis

The purpose of this study was to assess the effect of human autologous serum on the proliferation and differentiation of MSCs and to analyze the serum growth factor content. Serum was obtained from 8 patients suffering from lower limb long bone fractures requiring surgical intervention.

Serum samples were obtained on admission and the 1st-3rd–5th and 7th postoperative day. During the surgical procedure cancellous bone pieces from the fracture were obtained and MSCs were isolated. Cells were cultured with autologous serum from each sample. The cellular potential for proliferation and osteogenic differentiation was assessed. Fetal calf serum (FCS) was used for comparison. The presence of growth factors in the serum was investigated using commercially available colorimetric assays read on Elisa plate reader. We studied the serum content on Platelet Derived Growth Factor (PDGF), Vascular Endothelial Growth Factor (VEGF) and Insulin-like Growth Factor I (IGF-1).

The maximal upregulation of cellular proliferation and osteogenic differentiation was noted in cells cultured from serum obtained between third and seventh days. Cellular proliferation in comparison to FCS was increased by 32% with the use of serum from admission, 23% with the use of serum of the 1st day and 37% and 42% with the serum from 3rd and 7th days respectively. Serum analysis revealed an increase of 80% of PDGF between the 1st and 3rd postoperative day and 135% from 3rd–7th postoperative day. IGF-1 was increased by 35% between day 1 and 7. VEGF was increased by 120% during the first two postoperative days and a further increase of 190% occurred between days 3 and 7.

Growth factors are released in peripheral circulation and are gradually increased after fracture. MSCs under their influence proliferate faster and up-modulate their osteogenic differentiation. These findings should be considered when using functional assays for tissue regeneration techniques.


N.L. Millar R. Tatanu E. Silverstone X. Wu G.A.C. Murrell

The purpose of this study was to assess the clinical outcomes of three different rotator cuff repair techniques and to correlate these results with the integrity of the cuff as determined by ultrasonographic evaluation.

Three cohorts of patients had repair of a symptomatic rotator cuff tear using:

an open technique with Mitek RC Quickanchor double row, one mattress suture per anchor (n = 49);

arthroscopic knotted Mitek RC Fastin single row, two simple sutures per anchor (n = 53);

arthroscopic knotless with Opus Magnum single row, one inverted mattress suture per anchor (n = 57) by one surgeon.

Standardised patient and examiner determined outcomes were obtained prospectively pre-operatively and at 6 weeks, 3 months and 6 months post-operatively. Ultrasound studies were performed with a validated protocol at 6 months post surgery.

Arthroscopic knotless repair was, on average,14 minutes faster than both open cuff repair (p< 0.001) and arthroscopic knotted repair (p< 0.01).Clinical outcomes were similar with the exception that the arthroscopic groups had, on average, 20% better ASES scores than the open group at 6 months (p< 0.001). The only complication was re-tear, which correlated with tear size (r=0.5, p< 0.001) and operation time (r=0.3, p< 0.001) and occurred more frequently following open repair (39%) compared with arthroscopic knotted (25%) and arthroscopic knotless (16%) repair (p< 0.01). The retear rates of tears > 8cm2 were significantly greater (p< 0.01) when using an open (88%) or arthroscopic knotted (67%) technique compared to the arthroscopic knotless (25%) cohort.

Rotator cuff repair, whether performed via an open or arthroscopic technique resulted in improvements in pain, motion, strength and function. An intact cuff on ultrasound corresponded to better results with regard to supraspinatus strength, patient outcomes and rotator cuff functional ability. Tears > 8cm2 fixed with an arthroscopic knotless technique had better structural outcomes at 6 months.


G. Myers G. Mercer D. Campbell P. Ryan S. Graves

The five year results of 8187 primary total knee replacements undertaken for osteoarthritis in patients under the age of 55 years are presented. The casese were submitted to the Australian Orthopaedic Association National Joint Replacement Registry in the period 1st September 1999 to 31st December 2006. This represents 6.3% of the 130,377 primary knee replacements recorded by the registry for this period.

The five year cumulative revision rate for patients under the age of 55 years was 8.0% (95% CI: 7.2 to 8.9). We compared the results to outcomes of older patients aged over 70 years at the time of surgery. The younger patients have a significantly higher risk of revision in the first five years (hazard ratio of 2.9; 95% CI= 2.59 to 3.26; p< 0.0001). Gender, mode of fixation, the use of cruciate retention or substitution prostheses or patella resurfacing did not significantly affect the rate of revision in those patients aged 55 years or less. Survival of fixed bearing implants was significantly better than that of mobile bearings. The most common reason for revision in this group was loosening (32.3%).

Total knee replacement in patients under the age of 55 years is associated with a much higher risk of revision in the first five years. A decision to proceed with total knee replacement in this age group should be accompanied by a careful explanation of this significantly increased risk compared to knee replacement in older individuals.


T.J. Bonner P. Patterson M. Tye P.J. Gregg

This study evaluates the effect of lower limb post-operative mechanical axis on the long term risk of revision surgery following primary total knee arthroplasty (TKA). The study is relevant because many recent clinical trials have evaluated the optimal surgical technique for accurately aligning components in TKA, despite little evidence that alignment may effect the long-term clinical outcome.

The data used in this study was collected prospectively as part of a randomized control trial comparing the long term survival of cemented versus uncemented TKA. The trial included 501 press-fit condylar posterior cruciate ligament-retaining prostheses performed by the senior author (PJG) or under his direct supervision. The post-operative mechanical axis alignment of the lower limb was measured following TKA using standard AP weight-bearing long leg alignment radiographs. A comparison was made between a well-aligned group with a mechanical axis alignment within 3° of neutral; and a poorly-aligned group whose mechanical axis alignment deviated greater than 3° from neutral. Survival analysis used revision surgery, with exchange of any of the three originally inserted components (femoral, tibial, polyethylene insert), as the endpoint.

There was no loss to follow-up in this study. The minimum follow-up of TKAs in this study was 5.8 years. In the population of TKAs that were followed up at 10 years, 6% (17/270) required revision surgery. There was a significant difference in the rate of revision surgery between the well-aligned group 5% (11/227) and the poorly-aligned group 14% (6/43 p< 0.05)

This study shows that post-operative lower limb mechanical axis alignment is an important determinant of the need for revision surgery at 10 years. Surgeons performing TKA should pay particular attention to the placement of the tibial and femoral components, so that a mechanical axis within 3° of neutral is achieved.


S. Prasad S. Kumar K. Luscombe

Surgeon’s ability to anticipate the implant size requirements for total knee replacements is important to the success of the procedure. Previously, this has been inconsistently accomplished using plain radiographs. The purpose of this study is to assess the accuracy of digital templating software in predicting the size requirements of the femoral and tibial implants in total knee replacements.

Thirty consecutive PFC (DePuy) total knee replacements were templated preoperatively using digital templating software (TraumaCad, Orthocrat Ltd). The knees were templated by two surgeons working independently using standardised digital AP and lateral radiographs. All films were magnification-calibrated using markers of known size. Postoperatively, the predicted implant size was compared to the actual components selected at the time of surgery.

The size of the femoral prosthesis was accurately selected on the AP view in 53.5% and on the lateral in 66% of cases. The size of the tibial implant was correctly selected on the AP view in 65.5% and on the lateral in 70.5% of cases. The tibial prosthesis was always templated within one size. The femoral prosthesis was predicted within two sizes (93% on AP + 98% on lateral +/− 1 size). There was no correlation with failure of the software to recognise the metal marker and inadequate lateral x-rays.

The lateral x-ray was found to be more reliable than the AP on predicting both the femoral and tibial implants. The tibia was more accurately templated than the femur on average. There was good inter-observer and intra-observer reliability for both prostheses (0.75 – 0.85). Discrepancies in templating may have been due to inaccuracies in placement of the metal marker at the time of x-raying or due to fixed flexion deformities, which may have affected the magnification of the x-ray. Overall, templating using digital software was marginally superior to the standard acetate method.


H. Pandit C. Jenkins D. Beard H.S. Gill A. Price C. Dodd D. Murray

The results of mobile bearing Oxford unicompartmental knee replacement (UKR) in the lateral compartment have been disappointing (five-year survival: 82%). Therefore, it is recommended that mobile bearings should not be used for lateral UKR. This low survivorship is primarily due to a high dislocation rate. A detailed analysis confirmed the elevated lateral tibial joint line to be a contributory factor to bearing dislocation. A new surgical technique was therefore introduced in which care was taken neither to remove too much bone from the distal femur nor to over tighten the knee and therefore ensure that the tibial joint line was not elevated. Other modifications included use of a domed tibial component.

The aim of this study is to compare the outcome of these iterations: the original series (series I), those with improved surgical technique (series II) and the domed tibial component (series III). The primary outcome measure was bearing dislocation at one year. One year was chosen as all the dislocations in the first series occurred within a year. In the original series (n=53), implanted using a standard open approach, there were six dislocations in the first year, the average flexion 110°, and 95% had no/mild pain on activity. In the second series (n=65), there were 3 dislocations, the average flexion was 117°, and 80% had no/mild pain on activity.

In the third series with the modified technique and a convex domed tibial plateau, there was one dislocation, average flexion was 125° and 94% had no/mild pain on activity. At four years the cumulative primary dislocation rates were 10%, 5% and 0% respectively, and were significantly different (p=0.04).

The improved surgical technique and implant design has reduced dislocation rate to an acceptable level so a mobile bearing can now be recommended for lateral UKR.


H. Pandit C. Jenkins D. Beard H.S. Gill A. Price C. Dodd D. Murray

About ten years ago we introduced sophisticated instrumentation and an increased range of component sizes for the Oxford unicompartmental knee replacement (UKR) to facilitate a minimally invasive surgical (MIS) approach. The device is now routinely implanted through an incision from the medial pole of the patella to the tibial tuberosity. This has resulted in a more rapid recovery and an improved functional result. As the access to the knee is limited there is a concern that the long term results may be compromised. The aim of this study was to determine the 10 year survival.

A prospective follow up of all Phase 3 minimally invasive Oxford UKR implanted by two senior authors (DWM & CAFD) has been undertaken. So far 1015 UKRs have been implanted for anteromedial osteoarthritis. All patients received a cemented implant through a MIS approach and were followed up prospectively by an independent observer. The data was collected prospectively regarding pre-operative status, complications and clinical as well as functional outcome at predetermined intervals.

The average age of patients was 66.4 years (range: 33 – 88) with mean Oxford Knee Score 41 (SD: 7.9) at the time of last follow up, Knee Society Score (objective) of 84 (SD: 13) and Knee Society Score (functional) of 83 (SD: 21). At ten years the survival of this cohort is 96%. There were 22 revisions including 7 for progression of arthritis, 5 for infection, 5 for bearing dislocation, 4 for unexplained pain and one for rupture of ACL secondary to trauma.

We conclude that the Oxford Knee can be implanted reliably through a minimally invasive approach, giving excellent long term results.


N. Kanakaris I.N. Papadopoulos S. Bonovas C. Leukids V. Nikolaou P.V. Giannoudis

We aim to define the role of pelvic fractures (PFx) due to falls, in auditing Trauma Care. We present a retrospective case-control study, based on autopsy. Univariate analysis was used to identify factors predicting mortality and a backward stepwise logistic regression multivariate analysis determined relationships.

Of 970 patients who sustained a fatal fall, 209 (21.5%) constituted the PFx-group, and the remaining 761 the control-group. The PFx-group had a median age of 55 years (15–96), while the control 66 years (1–99). The multivariate analysis revealed that gender, age, intention, and height of fall were risk factors for PFx after a fall. An approximately 300% higher odds of suffering a psychiatric history was found in the PFx-group, (p< 0.001).

The median ISS of the PFx-group was 50(17–75), and was significant higher than the 26(1–75) of the control-group, (p< 0.0001). The “potentially-preventable” deaths (ISS< 75) constituted 78%, while the “non-preventable” 22%.

The most common AIS 3–5 injuries in the “potentially-preventable” deaths were located in the: lower extremities 133(81.6%), thorax 130(79.7%), abdominal and pelvic contents 99(60.7%), head 95(58.3%) and the spine 26(15.9%) of the patients. A subset of 126 (60.3%) “potentially-preventable” deaths of the PFx-group had at least one AIS-90 code other than the PFx denoting major hemorrhage. Deaths directly attributed to pelvic fractures were limited to 6 (2.9%).

The post-traumatic median survival-time for the PFx-group was 30 minutes, while for the control group 20 hours and 15 min. For one group increment in the range of ISS-groups, the probability of post-traumatic survival rate was reduced by 57% (p< 0.0001). Multiplicity, severity and the short posttraumatic survival time in the PFx group render PFx an index-injury for audit of polytrauma.

A reproducible method of autopsy-data analysis was outlined. Pelvic fracture is a paradigm of injury that selected an index-population among 970 fatal falls and an appropriate basis to construct a template for evaluation of trauma & polytrauma care.


G. Abbas C. Diss S.B. Mostofi

This study was aimed to develop a non-invasive technique to analyse motion of the patella during the gait cycle. Ten subjects with no history of patello-femoral pain syndrome or evidence of patella mal-tracking on clinical examination were individually assessed on 160 dynamic walking trials. Retro-reflective markers were attached to the proximal, distal, medial and lateral poles of the patella and the position of the patella relative to the centre of the knee joint was tracked and recorded during their gait cycle using a nine camera (120Hz) ViconTM infra-red motion analysis system.

We found that there was more medial-lateral motion (shift) of the patella than proximal-distal (tilt) motion during the gait cycle. It was noted that the patellar shift motion occurred in the swing phase or the early stance phase of the gait cycle of all subjects with the maximum patellar shift occurring when the knee was flexed between 30–56 degrees in the majority of subjects. Similarly the patellar tilt motion occurred in the swing phase or the early stance phase of the gait cycle with the maximum patellar tilt occurring between 20–36 degrees of knee flexion in the majority of subjects.

These results indicate that normally the maximum amount of patellar shift and tilt occurs in the swing and early stance phases of the gait cycle and that abnormal patellar motion can be detected if excessive shift or tilt occurs outside of these phases. From the findings of the current study, it is proposed that future studies are needed to quantify patellar motion during walking. The future work should be directed to assess patellar motion during swing phase and early stance phase of the gait cycle using more sophisticated techniques like dynamic magnetic resonance imaging to exactly quantify patellar motion.


G. Edwards A. Metcalfe A. Johansen D. O’Doherty

Systems for collecting information about patient care are increasingly common in orthopaedic practice. Databases can allow various comparisons to be made over time. Significant decisions regarding service delivery and clinical practice may be made based on their results.

We set out to determine the number of cases needed for comparison of Thirty-day mortality, inpatient wound infection rates and mean hospital length of stay, with a power of 80% for the demonstration of an effect at a significance level of p< 0.05. We analysed two years of prospectively collected data on 1,050 hip fracture patients admitted to a city teaching hospital. Power calculations were performed using standard equations from the literature.

Detection of a 10% difference in 30 day mortality would require 14,065 patients in each arm of any comparison, demonstration of a 50% difference would require 643 patients in each arm; For wound infections, demonstration of a 10% difference in incidence would require 23,921 patients in each arm and 1127 patients for demonstration of a 50% difference; For length of stay, a difference of 10% would require 1,479 patients and 6660 patients for a 50% difference.

Our data helps to illustrate the importance of sample size when interpreting the results of performance monitoring. Since a unit as large as our own only admits 525 patients per year, comparisons between trusts would require very prolonged data collection. Within a single unit the demonstration of poor performance by one surgeon or one team would clearly be impossible. Statistically meaningful analyses will only be possible with major multi-centre collaborations, as will be possible if hospital Trusts participate in the National Hip Fracture Database.


R. Maheshwari M. Acharya E. Hoskison R.K. Pandey

Clopidogrel, an anti-platelet agent is used in the secondary prevention of ischaemic events in high risk patients. Recent studies suggest that there are no National guidelines on when to stop clopidogrel in patients with hip fracture. It is suggested that stopping clopidogrel and waiting up to 1 week or more before surgery may have adverse effects on the patient.

This study is aimed at identifying factors predicting outcome in these patients. All patients admitted to our unit in 2006 with proximal femoral fracture were included. Patients on clopidogrel were identified for further investigation. Demographic, perioperative and postoperative data including complications and death were documented.

Thirty one of 586 patients with proximal femoral fracture were on clopidogrel on admission. Mean delay to surgery was 8.4 days (range 2–16 days SD 2.5). The mean age was 81 years (64–97) with a male to female ratio of 1:2.4. Of the 31 patients, 8 (25.8%) had died at 1 year. The standardised mortality ratio was higher in patients less than 65 years old and lower in all patients over 65 years.

Significant predictors of death on univariate analysis at one year were spinal anaesthesia (p = 0.04), postoperative blood transfusion (p = 0.03), postoperative complication (p = 0.03) and delay to surgery (p = 0.03). There was a positive correlation between delay to surgery and developing a postoperative complication (Pearson’s correlation 0.33 p = 0.04). Multivariate analysis revealed that delay to surgery was the only independent factor predicting death at one year.

No evidence exists to suggest that clopidogrel should be stopped 1 week prior to surgery for proximal femoral fracture. Waiting for 1 week or more prior to surgery is directly correlated to developing postoperative complications and subsequent death at one year.


M. Lassen W. Ageno T. Bandel L. Borris J. Lieberman F. Misselwitz N. Rosencher A. Turpie

RECORD3 was a multicentre, phase III study designed to investigate the efficacy and safety of rivaroxaban – a novel, oral, once-daily, direct Factor Xa inhibitor – compared with subcutaneous enoxaparin for thromboprophylaxis in patients undergoing total knee arthroplasty (TKA).

Patients scheduled to undergo TKA (N=2,531) were randomized to receive either rivaroxaban 10 mg once daily (initiated 6–8 hours after surgery) or enoxaparin 40 mg once daily (initiated the evening before surgery, then given 6–8 hours after surgery), and daily thereafter for 10–14 days.

The primary efficacy outcome was the composite of any deep vein thrombosis (DVT; symptomatic or asymptomatic detected by mandatory, bilateral venography), non-fatal pulmonary embolism (PE) and all-cause mortality within 13–17 days after surgery.

Rivaroxaban significantly reduced the incidence of the primary efficacy outcome compared with enoxaparin (9.6% vs 18.9%, respectively; p< 0.001; relative risk reduction [RRR] 49%). Rivaroxaban significantly reduced the incidence of major VTE (the composite of proximal DVT, non-fatal PE and VTE-related death) compared with enoxaparin (1.0% vs 2.6%, p=0.01; RRR 62%), and the incidence of symptomatic VTE (0.7% vs 2.0%, p=0.005; RRR 66%). The incidence of bleeding events was similar in both groups (major bleeding: 0.6% and 0.5% in the rivaroxaban and enoxaparin groups, respectively; any on-treatment bleeding: 4.9% and 4.8%, respectively; haemorrhagic wound complications [the composite of excessive wound haematoma and surgical-site bleeding]: 2.0% and 1.9%, respectively). There were no deaths or PEs in the rivaroxaban group during the treatment period, and two deaths and four PEs in the enoxaparin group.

Rivaroxaban was significantly more effective than enoxaparin for the prevention of VTE after TKA, with a similar rate of bleeding. The oral, direct Factor Xa inhibitor rivaroxaban, given once daily as a fixed, unmonitored dose of 10 mg, has the potential to change clinical practice for thromboprophylaxis after TKA.


M. Rahman L. Dickinson B. Harcourt A. Monro

Echocardiograms are requested in patients presenting with hip fractures and the finding of a cardiac murmur. The opinion amongst anaesthetists in our department is that general anaesthetic (GA) is safer in patients with significant aortic stenosis, mitral regurgitation, or left ventricular impairment compared to spinal anaesthetic (SA).

A retrospective review was carried out and data on fifty patients were collected, who had presented with fractured neck of femur with the finding of a heart murmur and required an echocardiogram pre-operatively.

Our results demonstrated :

Focussed history and examination was rarely performed;

Thirty five percent of echocardiograms influenced choice of anaesthetic. Of these 100% had abnormal ECG’s;

Fifty seven percent of patients with GA had no abnormality on echocardiogram, whereas 31% of patients with SA had abnormality;

The average admission to theatre time with an echocardiogram was 4.31 days, compared to 1.6 days in patients without echocardiogram.

Our audit suggests that many echocardiograms are ordered unnecessarily. Effective use of clinical skills and investigations are rarely utilised by orthopaedic doctors, in requesting an echocardiogram. There is delayed operating times, cost implications and increased workload for the cardiology department. There is no indication that the results of these echocardiograms significantly influences anaesthetic choice.

A second audit cycle was performed prospectively with the use of a proforma. An echocardiogram was not ordered if a recent echocardiogram (within last the last year) was normal or if the history, examination and ECG findings in a patient were all insignificant. This demonstrated a reduction in ordering of echocardiograms by 40%. Local guidelines have been implemented in our department.


A. Kulkarni S. Jameson P. Partington M. Reed

The first United Kingdom In-training Examination (UKITE) was held in 19 training programmes during December 2007. The aims of the project are to offer a national, online examination (providing immediate results to trainees) and to allow practice for the ‘real’ FRCS T& O examination with similarly formatted questions based on the UK T& O curriculum. All Speciality training years (StR2, StR3 and above, and all SpRs) and all deaneries will participate in the future. A total of 450 trainees sat this first examination. This is an online exam (accessed through the eLogbook/OCAP website) which is voluntary and has no bearing on RITA outcomes. To take part in the exam trainees were asked to provide 3 questions for a bank which can be used in subsequent years for both UKITE and the FRCS T& O examination.

The exam was 3 hours and questions were of multi-choice (MCQ) and extended matching question (EMQ) style covering all aspects of orthopaedics. Correct answers and explanations were available to the trainee after their answer had been submitted. Final scores ranged from 35% to 92%. Mean scores increased from 48% (StR2) to 73% in SpR year 5 (StR7 equivalent). This was followed by a drop off in performance in the final year of training. Three candidates had equal top scores at 92%. 97% stated they would sit the UKITE again and 93% felt there was educational benefit. The length and level of difficulty of the exam was felt to be satisfactory. Improvements were suggested for question quality. The UKITE is a powerful tool for self-assessment of trainees. This analysis establishes a baseline for future years.


R. Boden S. Whitehouse P. Kalale B. Ilango

In the current climate of increasing financial pressures and reducing bed numbers, a predictor of length of stay (LOS) may have a bearing on hospital finances. Independent sector treatment centres may also skew the ASA grade and co-morbidity of the patient group treated in a hospital setting. We performed a study of 100 consecutive patients undergoing Total hip or knee arthroplasty between April and September 2006.

Median age was 71 years (35 – 88) with 75% of patients having significant (cardiac, renal or respiratory) pre-existing medical conditions (24% with 3 or more conditions). Average ASA grade was 2 (15% grade 3) and average BMI was 30. A significant reduction in LOS from 8.47 to 5.87 days was seen in under 70 year olds when compared with those over 70 years (p = 0.0004), having 3 or more co-morbidities (compared with 2 or less) increased average LOS from 6.61 days to 9.3 days (p = 0.002), ASA grade of 3 increased LOS to 9.56 days from 6.27 and 6.87 for grade 1 and 2 respectively (p = 0.014) and living alone (compared with cohabiting) increased LOS from 6.55 days to 9.19 days (p = 0.0017). However no statistical significance was seen for BMI with an average of 7.19 days for < 30 and 7.37 days for patients with BMI of 30 or above (p = 0.82)

Regardless of this patient group being elderly and obese with significant co-morbidity, an acceptable outcome was seen, with 70% of patients discharged within 7 days and only 4% staying > 14 days. Although BMI did not predict outcome, number of co-morbidities, ASA, age greater than 70 years and living alone all demonstrated a significant increase in LOS. Increased resources in this at risk group within a pre-admission setting could reduce length of hospital stay.


A. Ng K. Lee B. Se To

Gentamicin is one of the most widely used antibiotics in Orthopaedic practice. It is commonly used as prophylaxis either through intravenous route, incorporated into bone cement or topical intraoperative irrigation. The former two are well studied. However, there is limited study on the therapeutic efficacy and safety of topical Gentamicin irrigation.

To assess the safety and infection rate of joint replacement surgery when topical gentamicin irrigation was used. This is a non-randomised, prospective study whereby patients undergoing joint replacement surgery were treated with gentamicin irrigation intra-operatively.

A total of 138 patients were divided into two groups in this study. Group A (98 patients) were patients with Total Joint Replacement and group B (40 patients) were patients with hemi arthroplasty of the hips and shoulders. Patients with pre-existing renal impairment were excluded. Two ampoules of Gentamicin (160mg) were irrigated into the wound before implants insertion and wound closure respectively. Intravenous Cefuroxime was also given prophylactically to all patients but none of them had intravenous gentamicin. Plasma Gentamicin level was assayed 4 hours and 24 hours post-operatively.

There were 16 patients in group A (16%; p< 0.001) and 12 patients in group B (30%; p< 0.001)) found to have plasma Gentamicin level > 2mcg/ml. All but 6 had plasma gentamicin level dropped to < 2mcg/ml at 24 hours. Although none of them developed systemic complications, the raise in plasma gentamicin was alarming. The incidence of infection was 6.1% (6 patients) in group A. These were superficial wound infection responded to antibiotics. No infection was reported in group B.

This study did not show apparent reduction in infection rate as compared to the reported literatures. Nevertheless, there was significant systemic absorption of topical gentamicin irrigation. Therefore, monitoring of post-operative plasma gentamicin levels is mandatory to avoid unforseen toxicity.


T. Colegate-Stone C. Roslee A.M. Latif R. Allom A. Tavakkolizadeh J. Sinha

We performed a prospective audit to investigate the comparability of subjective and objective assessment scores of shoulder function following surgery for rotator cuff pathology. A consecutive series of 372 patients underwent surgery for rotator cuff disorders with post-operative follow up over 24 months. 248 patients solely underwent subacromial decompression, whereas 124 had additional rotator cuff repair (93 arthroscopic; 31 open).

Assessments were made pre-operatively, and at 3, 6, 12, and 24 post-operative months using the Disabilities of the Arm, Shoulder, and Hand (DASH) score; Oxford Shoulder Questionnaire (OSQ); and the Constant score, which was used as a reference. Standardisation calculations were performed to convert all scores into a 0 to 100 scale, with 100 representing a normal shoulder. The student’s t-test was used to compare the mean score for each subjective tool (DASH and OSQ) with the objective score (Constant) at each time point. Correlation coefficients (Pearson’s) were used to analyse the changes with time (post-operative course). Each statistical test was used for all surgeries collectively and for the individual surgery types.

The relationship between the DASH and the Constant score was robust in all types of surgery. The relationship between the Oxford and Constant was generally robust, except in the open rotator cuff group. There was no statistical difference between the mean DASH and Constant scores for all interventions at each time point. A significant difference was seen between the mean Oxford and Constant scores for at least one time point in all but the open rotator cuff repair group.

We demonstrate the DASH and Oxford scoring systems would be useful substitutes for the Constant score, obviating the need for the trained investigator and specialist equipment required to perform the Constant score, alongside the associated cost benefits. Further it provides evidence of service, aids appraisal and revalidation.


A.L. Khan A. Khan W.A. Wallace C.L. Marx

An online survey has been carried out to evaluate the compliance with the OCAP learning tools, and the availability of clinical experience to early years’ trainees in Trauma and Orthopaedics in 2007–8. Three surveys were planned over the year, and we present the results from the first two surveys. Over the initial eight month period, 335 trainees in Trauma and Orthopaedic posts responded. There was considerable variation in the proportion of responses from different deaneries, and it was felt this reflected differences in the use of the two logbooks available (FHI or ISCP).

Respondents were FTSTAs (50%), ST1s (11%) and ST2s (29%). The respondents reported their operative experience was poor with low numbers of index procedures – the median values being 2 DHS, 1 Hemiarthroplasty and 0 for Ankle ORIFs performed as the lead surgeon in the first 4 months, rising to 3, 1 and 1 respectively in the second. As an assistant the numbers were 3, 4 and 3. FTSTAs had done more procedures as lead surgeon. It is not clear whether this reflects motivation, or whether they are trainees who were unable to secure training posts due to seniority and were already more experienced. Many posts were entirely ward based.

Improvements in meetings with Assigned Educational Supervisors were noted, as was the use of the learning agreements, and with registration rates with the ISCP. There was considerable variation between posts, hospitals and deaneries, and a tool was developed to summarise this data to be post-, trainee-, and duration-specific. Summaries of each post were distributed to Training Program Directors, Heads of School, and the SAC. Although some improvement has occurred, further rounds of the survey are necessary to ensure that this continues. The next round will commence in September 2008 to complete twelve months of data.


R.A. Sankey J. Turner J. Healy J. Lee C. Gibbons

MRI was used to diagnose occult hip pathology in patients with a clinically suspected femoral neck fracture where no abnormality was detected on plain x-ray. All patients admitted into our unit with post traumatic hip pain, an inability to weight bear, and no abnormality found on a series of plain radiographs, underwent an MRI scan of the pelvis and affected hip to look for an occult femoral neck fracture.

The study included 102 consecutive patients who were prospectively studied over a 10 year period between 1997 and 2007. Four patients were excluded due to contraindications or an inability to tolerate having an MRI scan. Of the remaining 98 patients 81 had abnormalities detected (83%). 42 of these patients had evidence of a proximal femoral fracture. 23 patients underwent an operative procedure.

Eight incomplete intertrochanteric fractures were treated non-operatively with good results. One patient had a primary diagnosis of malignancy made on the basis of the MRI scan. One patient had a known primary malignancy but this was the first diagnosis of bony metastatic disease. Seventy five patients were scanned within 48 hours of admission (average 2.4 days).

The use of MRI in our unit was felt to be appropriate in patients with a high suspicion of proximal femoral fracture. Our results show that there is a significant incidence of fractures that are not apparent on plain x-rays. MRI led to early diagnosis and initiation of definitive management, potentially reducing cost and complications of immobility. It was most useful in showing the extent of the fracture, and picked up on other occult pathologies of the hip and pelvis. We recommend stabilisation of femoral neck fractures and non operative management of all incomplete intertrochanteric fractures if able to non weight bear. There must be a high index of suspicion of undiagnosed malignancy


I. Malek K. Loughney S. Ghosh J.R. Williams R. Francis

We aimed to audit the results of one stop fragility fracture risk assessment service at fracture clinic for non-hip fractures in 50–75 years old patients at Newcastle General Hospital. Currently, fewer than 30% of patients with fragility fractures benefit from secondary prevention in the form of comprehensive risk assessment and bone protection because of multifactorial reasons. We have a fragility fracture risk assessment service staffed by an Osteoporosis Specialist Nurse equipped with a DEXA scanner located at the fracture clinic itself.

We carried out a retrospective audit of 349 patients of 50–75 years with suspected non-hip fractures referred from A& E Department from October 2006 to September 2007. Patients over 75 years were excluded because as per NICE guidelines, they should receive bone protection without need of a DEXA scan.

Out of these 349 patients with suspected fractures, 171 had fragility fractures. Median age was 64 years. 69 patients had humerus fracture, 65 had forearm fracture and 23 patients had ankle fracture and 14 had metatarsal fractures. Fracture risk assessment was carried out in 120 (70%) patients. Thirty Seven (31%) patients had osteoporosis and bone protection was recommended to GP. 38 (32%) had osteopenia and lifestyle advice was provided. 45 (37%) had normal axial bone densitometry. 90% patients had DEXA scan at the same time of fracture clinic appointment. Patients with male gender, undisplaced fracture and fewer fracture clinic appointments were more likely to miss fracture risk assessment.

Our experience suggests that locating fragility fracture risk assessment service co-ordinated by an Osteoporosis Specialist Nurse at fracture clinic is an efficient way of providing secondary prevention for patients with fragility fractures. This can improve team communication, eliminate delay and improve patient compliance because of ‘One Stop Shop’ service at the time of fracture clinic appointment.


C.L. Loizou M.J. Parker

There is continuing debate regarding the merits of internal fixation versus arthroplasty for intracapsular hip fractures. For displaced fractures there is a higher risk of fracture healing complications but many of the studies reporting on this are now from some years ago using surgical methods that are now outdated. The aim of our study was to determine the incidence of avascular necrosis (AVN) related to age, gender, displacement and operation delay for a large series of patients with intra-capsular fractures treated with internal fixation using contemporary methods.

We prospectively studied 1023 patients, 988 fractures were internally fixed with three cannulated screws and 35 with a sliding hip screw. The average length of radiographic follow-up for those patients who survived to one year was 337 days (range 25 to 3521 days). The average age of the patients was 75.4 years (range 16–100); 243 (23.8%) were male. The overall incidence of AVN was 6.6%. AVN was less common (p=0.0004) for undisplaced fractures than for displaced fractures (21 of 528 [4.0%] vs 47 of 495 [9.5%]) and in men than women (p=0.03) who had a displaced fracture (7 of 143 [4.9%] vs 40 of 352 [11.4%]). The incidence of AVN for those aged less than 60 years and who sustained a displaced fracture was 20.6%, compared to 12.5% for those aged 60–80 years and 2.5% for those aged more than 80 years (p< 0.0001). We found no association between the incidence of AVN and operation delay.

Our study showed an increased risk of AVN with younger age and in females with a displaced fracture. This is in contrast to the decreased incidence of non-union seen with younger age. Knowledge of the predicted incidence of fracture healing complications should help surgeons make a more balanced decision between internal fixation and arthroplasty for this condition.


V.S. Nikolaou N.K. Kanakaris N. Efstathopoulos G. Kontakis P.V. Giannoudis

In order to assess the effect of osteoporosis on healing time we retrospectively reviewed the files of 165 patients with femoral shaft fractures that were treated in our service by locked, intramedullary nailing. Patients were divided in two age groups; Group A (study group) consisted of patients over 65 years old with radiological evidence of osteoporosis and group B (control group) of patients between 18 and 40 years old with no signs of osteoporosis.

Sixty-six out of 165 patients fulfilled the inclusion criteria for this study. Patients with open fractures, pathological fractures, revision surgery, severe brain injuries, prolonged ITU stay and severe co morbidities were excluded. Twenty-nine patients were classified in group A and 37 in group B. All patients had been assigned the Injury Severity Score (ISS) and had been followed-up clinically and radiographically until fracture union.

In all patients the Singh Index Score for osteoporosis was assigned. In all group A patients Singh score 4 or less was assigned, suggesting the presence of installed osteoporosis, whereas group B patients were assigned with Sighn score 5 or 6. Fracture healing was significantly different between the groups.

Fractures of Group A healed in 19.38±5.9 weeks (12–30) and in group B 16.19±5.07 weeks (10–28) (P=0.02) Fracture healing of nailed femoral diaphyseal fractures significantly delays in older osteoporotic patients. Further studies are mandatory to clarify the exact impact of osteoporosis in the whole healing process and the possible future therapeutic strategies.


M. Parker

400 patients with a trochanteric hip fracture were randomised to fixation with either a 220mm long Targon PF (proximal femoral) nail or a Sliding Hip Screw. All surgery was undertaken or supervised by one surgeon. All patients were followed up for a minimum of one year by a blinded observer.

The mean age was 82 years (range 27 to 104 years), 20% were male. Mean length of surgery was slightly increased for the nail (44 versus 49 minutes, p=0.002). Fluoroscopic screening time was increased in the nail group (0.3 versus 0.6 minutes, p< 0.0001). Intra-operative complications were more common with the nailing. There was no difference in blood transfusion requirement between groups. Postoperatively there was no difference in the occurrence of medical complications or mortality.

Deep wound infection requiring removal of the implant occurred in one case in the SHS group. In addition there were two cases of cut-out, three of plate detachment from the femur and one non-union in the SHS group, requiring secondary surgery. There were only once compilations in the nailed a case of cut-out which required secondary surgery. At follow-up there was no difference in pain scores between groups but there was a tendency to improved mobility in the nailed group (p=0.004).

These results suggest that with improved designs and surgical technique, the newer versions of short nails for proximal femoral fractures may not suffer from the complications of the earlier short intramedullary nails. Intramedullary fixation can result in a lower re-operation rate (3.5% versus 0.5%) and improved mobility in comparison to the sliding hip screw.


B.J. O’Daly J.C. Walsh J.F. Quinlan R. Stapleton G.A. Falk W.R. Quinlan S.K. O’Rourke

Hip fractures are a significant cause of mortality and morbidity in the elderly. Malnutrition is a major element of this but no consensus exists as to the detection or management of this condition. Reported incidence in elderly hip fracture patients varies widely between 9.0% and 88.6%.

The aim of this study was to evaluate the nutritional status of 415 patients with operatively managed hip fractures and determine the prognostic relevance of admission serum albumin and total lymphocyte count (TLC) assays. Protein-energy malnutrition (PEM) was defined as serum albumin < 3.5g/dl and a TLC < 1,500 cells/mm3. Delay to operation, duration of in-patient stay, re-admission (< 3 months) and in-patient, 3- and 12-month mortality were assessed as outcome variables.

Survival data was available for 377 patients at 12 months. Of 377 patients, 53% (n=200) had both a serum albumin and TLC levels taken at admission, while 47% (n=177) had not. The incidence of PEM was 51%. Inhospital mortality for PEM patients was 9.8%, compared with 0% for patients with normal values of both laboratory parameters. Older patients were more likely to have lower albumin (p=0.017) and TLC (p=0.023). Nursing home patients were also more likely to have lower albumin (p=0.033). Multivariate analysis revealed a significant difference in 12-month mortality, with patients who had both a low albumin and a low TLC 4.6 times (95% CI: 1.0–21.3) more likely to die within 12 months postoperatively than patients who had normal values of both laboratory parameters. This was significant after adjusting for age, gender and domicile (p=0.049).

Serum albumin and TLC in combination are accurate predictors of 12-month mortality in hip fracture patients. These results highlight the relevance of assessing the nutritional status of patients with hip fractures at the time of admission and emphasises the relationship between nutrition and outcome.


D.C. Perry P.N. Unnikrishnan H.L. George R. Bassi C. Bruce

Primary pyomyositis is increasing in incidence in the western world. Although a commonly encountered condition in the tropics it was not described in the USA until 1971 and the UK until 1998. The reason for the increasing incidence is not understood.

Typically pyomyositis affects the muscles around the hip and may present in a variety of ways to orthopaedic or general surgeons – occasionally leading to unnecessary operative intervention. We sought to identify the experience gained, of this condition, within a UK paediatric tertiary referral unit.

A retrospective review of cases of pyomyositis, from our institution, since 1998 was undertaken to identify demographics, presentation, diagnosis and management. Thirteen cases of pyomyositis were identified. Obturator internus was most commonly affected (n = 7). Trauma was implicated in three cases and group A staphylococcus was cultured in nine cases. Male:Female ratio ~ 3: 2. Initial working diagnosis at presentation was septic joint in eight cases, appendicitis in three cases and soft tissue abscess in two cases. Ten cases settled with antibiotics alone. One diagnostic retroperitoneal exploration was performed which may have been avoided with greater preoperative awareness of this condition. On reflection, all cases were identified by CT or MRI.

To our knowledge, this is the first UK series of pyomyositis, reflecting its increasing incidence in the western world. Its presentation is similar to other common paediatric surgical emergencies, yet its management is very different – often not requiring surgery. A greater awareness of this emerging condition is therefore essential to both general and orthopaedic surgeons in order to prevent misdiagnosis and unnecessary surgical intervention.


A. Barnett B. Burston N. Atwal G. Gillespie A. Omari B. Squires

Dislocation is a major concern following THR for fractured neck of femur. The aim of this prospective study was to investigate the use of large diameter femoral head uncemented THR to treat fractured neck of femur, and to demonstrate if the improved stability seen in previous clinical situations with these designs, can be used to benefit this difficult subgroup of patients that are particularly prone to dislocation.

Forty-six consecutive independent, active and mentally alert patients with displaced intracapsular fractured neck of femur underwent large diameter head uncemented THR. The mean age of patients was 72.1 years. The outcome measures used were the dislocation rate, reoperation and revision rate, Oxford hip score (OHS), EuroQol (EQ-5D) and residential status.

Clinical and radiological data were available on all 46 patients. At a mean follow-up of 12.5 months there were no dislocations. There were no reoperations, revisions or infections. Two patients died (4.3%) from unrelated causes. Mean pre- and postoperative OHS were 12.1 and 17.9 respectively. The mean pre- and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. The mean postoperative walking distance was 2.5 miles and there were no changes in residential status.

This is the first published series utilising a 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur in mobile, independent patients. We have demonstrated that it affords patients excellent stability with no recorded dislocations.


A.D. Patel B. Jani

As part of the workup long length femur radiograph may be carried out pre-operatively in patients presenting with a proximal femur fracture in order to rule out distant metastasis in patients with a history of malignancy but also in some patients in whom a suspicion of possible distal abnormality is aroused by the configuration of the proximal fracture

Using our unit’s database we identified all patients (n=689) presenting with a proximal femoral fracture between Sept 2006 and August 2007 at the Norfolk and Norwich University hospital in Norwich.

Of 689 patients, 92 patients (13.2%) had long length femur radiograph performed before surgery. Indications included history of cancer (39), subtrochantric fractures (14), spontaneous fracture without any fall(2), paget s disease(1), early onset osteoporosis(1) while no clear indication was available in 35 patients. Five patients (5.5%) were found to have some abnormality. Three of the 39 patients with a history of previous cancer were found to have a distal femur metastasis. Two of the 35 patients where a clear indication was not apparent had abnormal findings: one patient had a distal femur infarction and another was found to have a distal femoral malunion. In both cases long leg films did not influence choice of implant. Of the 39 patients with a previous history of cancer, 24 had short implants (hemi-arthroplasty, intramedullary device, DHS), 14 had long implants and one patient died before the operation.

Long length femoral radiographs appear to be indicated in patients with a documented history of a cancer as it helps to decide whether to use a long or short implant. However in patients without a history of malignancy, long leg films were of no value in decision making even if the configuration of the fracture was suspicious.


P. Gikas W. Aston A. Saiffudin R. Pollock J. Skinner T. Briggs S. Cannon A. Flanagan

Non-bacterial osteitis (NBO), a term referring to sterile bone lesions with non-specific histopathological features of inflammation, may be either uni- or multifocal, acute (6 months) or chronic, and recurrent. Only when the condition is chronic, recurrent and multifocal is it appropriate to use the term chronic recurrent multifocal osteomyelitis (CRMO).

We present our clinical experience as the largest reported series of children with NBO to date. Of 41 children (2–16 years) diagnosed with NBO in our institution over the last 6 years, 21 (51%) had recurrent disease and 18 of 41 (44%) had multifocal disease. The most common bones affected were the clavicle, femur and tibia (in order of decreasing prevalence) accounting for 44 (63%) of a total of 70 lesions. Only one individual had SAPHO syndrome and no other patients had evidence of bowel or skin disease. In the absence of evidence for an infective aetiology, we recommend non-steroidal anti-inflammatory agents as first line therapy, and bisphosphonates only in cases of resistant disease.

On the basis of our findings we propose a patient questionnaire and protocol for investigating and managing patients who present to orthopaedic surgeons with NBO. We predict that this will benefit patients with this disorder by providing valuable information about the pathogenesis, clinical outcome and response to treatment. In the future, clarification of the pathogenesis of this disease will undoubtedly help rationalise the therapeutic approach improving both quality of life and outcome for these patients.


M. Khan S. Mathew S. Salam S. Lambert J. Price K. Willett

This study aims to determine, by outcome analysis, the appropriateness of current criteria employed to select patients for total hip arthroplasty (THA) as the primary treatment for displaced intracapsular hip fracture (DICHF) and to inform prospective randomised controlled trials investigating the efficacy of THA as a primary treatment.

Contemporary THA eligibility criteria were derived from recent publications relating to pre-fracture residence, mobility and independence. Outcome data were analysed for 96 patients (19% of 506 consecutive patients with DICHF between 2003–2005) who fulfilled those criteria. The variables analysed included age, gender, co-existing injuries, co-morbidities, social circumstances, mobility, independence, delay to surgery, readmission, and death. Patients were followed for three years. The primary outcome was the combined achievement of home or warden-assisted accommodation at three months, no re-admission within 6 weeks and survival to 1 year. Secondary outcome was survival to three years.

At 3-months 86 patients (90%) had returned home, three (3.1%) required nursing or residential home placement, four (4.2%) were still resident in a community hospital, and three (3.1%) had died. Eight patients (8.3%) were re-admitted within 6-weeks. Mortality was 8.3% at 1-year and 25% at 3-years. Patients not achieving return to home were older (84.8 years vs. 79.7 years, p=0.19), were more likely to use a walking aid (OR 2.35) or required home support (OR 1.74) prior to fracture. The number of co-morbidities was not an association. Backward selection identified age as a significant variable in patients successfully discharged home (OR 1.12, CI 1.01 – 1.21).

If maintaining a high level of activity and independence is the expectation for hip fracture patients considered for THA then current selection criteria appear appropriate in identifying those 15% capable of returning home, remaining independent and surviving to one year.


Q. Choudry R. Paton

An 11 year prospective longitudinal study assessed the relationship between major neonatal foot deformities and developmental dysplasia of the hip (DDH). From 41,474 infants born between 01/01/1996 and 31/12/2006 with 614 foot deformities were referred as ‘risk factors’ in a screening/surveillance programme for DDH. All hips were clinically examined and sonographically imaged in a specialist Paediatric Orthopaedic clinic.

The 614 cases were subdivided into: 436 postural equinovarus deformities (TEV), 60 fixed congenital talipes equinovarus (CTEV), 93 congenital talipes calcaneovalgus (CTCV) & 25 metatarsus adductus. The overall risk of sonographic dysplasia/instability was as follows: TEV 1:27, CTEV 1:8.6, CTCV 1:5.2, Metatarsus adductus 1:25

The Relative Risk (RR) of sonographic dysplasia/instability in TEV vs CTEV was 0.31 (95% CI 0.12–0.80; p=0.0057; OR=0.29). The Relative Risk of dysplasia/instability in CTCV vs. Postural TEV is 5.27 (95% CI 2.57–10.8; p< 0.0001; OR=6.30).

The risk of Type IV hip instability or irreducible dislocation in CTCV was 1:15.4 (6.5%), 1:25 (4%) in metatarsus adductus and 1:436 (0.2%) in TEV. There were no cases of hip instability (Type IV) or irreducible dislocation in the CTEV cases.

The routine screening for DDH in cases of postural TEV and fixed CTEV is no longer advocated. Postural TEV is poorly defined as a deformity in the literature leading to the over diagnosis of a possibly spurious condition. Sonographic imaging and surveillance of the hips in cases of CTCV and metatarsus adductus should continue.


K. Ho D. Morgan A. Gaffey J. Clegg

Universal neonatal screening of developmental dysplasia of the hip (DDH) remains controversial and a few centres have adapted this practice in the United Kingdom. Our institute has established a DDH screening programme over the last 19 years. The following shows our result after a recent change in our screening programme protocol. All infants born in Coventry are screened for DDH by a clinical examination and ultrasound scan (USS). 5,084 babies were born over a 12-months period. Normal examination and USS were detected in over 90% of the cases. Abnormality detected through either clinical examination or USS was referred to a special orthopaedic/USS clinic.

However, in the majority of the cases, subsequent assessments were normal and only 23 babies required treatment. In these cases, the majority had not shown any signs of clinical abnormality. However, serial USS had shown persistent abnormality of at least Graf grade II or higher. The average time from birth to a treatment with a Pavlik Harness was 35 days and the average duration of a treatment was 48 days. Apart from one case, all the babies were treated successfully. The unsuccessful cases had a Graf grade IV at the presentation and had shown no sign of improvement on sequential USS. No complications were noted.

While the sensitivity of detecting DDH through clinical examination remains poor, USS has become an essential tool in our screening programme. Many initial abnormalities are secondary to hip immaturity and they tend to resolve. Those with clinical instability and persistent USS Graf grade II or higher should be treated with early Pavlik Harness. Early detection has led to better results than late diagnosis, and in addition to this, the overall number of operations required could be reduced. Yet, the need for a major surgical intervention has been all but eliminated.


A. Karantana M. Suri C. Howell A. Pace S. Dhar

This is a case series of 25 patients with Multiple Epiphyseal Dysplasia (MED), a genetically determined disorder characterised by abnormal ossification of multiple epiphyses. The Nottingham Skeletal Dysplasia Clinic has run since 1966. In 1994 it combined with the Clinical Genetics Service providing care to patients from throughout the region. We collected data on MED patients with follow up of 1 to 41 years (average 12 years) and described their presenting symptoms, genetic, clinical and radiographic features. We followed the natural history and vast array of treatments.

From the genetic point of view, 90% of patients counselled had typical AD-MED and 10% syndromic MED. Seven families opted to have testing. There were MATN3 mutations in 10% of the cohort, with marked intra-familial variability of phenotype. The average age at presentation was thirteen, with 80% of patients presenting before their sixteenth birthday. A third was seen because of a known family history of MED. Newly diagnosed index patients tended to present later. The most commonly affected joint at presentation was the hip and the most common knee deformity genu valgum. Symptoms progressed with time and joints not clinically affected at presentation became symptomatic later. Sixty percent of patients had further joint involvement within 10 years of diagnosis. Treatment ranged from orthotics to arthroplasty. Half of patients required surgical intervention at least once. Six patients underwent hip arthroplasty at an average age of 37.

MED is a rare diagnosis but has significant impact on the quality of life of those diagnosed, who require the support of a multidisciplinary team from an early age. This is not only to help manage symptoms and preserve function, but also to counsel on the progressive nature and the genetic aspects of the disorder.


M. Lwin M. Nayeemuddin J. O’Hara

Treatment of severe Perthes disease remains a major challenge. Various surgical options exist for containment. We describe the Birmingham interlocking triple pelvic osteotomy (BITPO) and report the results at skeletal maturity.

We reviewed 22 hips in 21 consecutive patients with severe Perthes who had the BITPO. There were 16 males and 5 females. The mean age at presentation was 7 years 7 months. Seventeen hips were Herring group C and five were Herring group B. Six patients had four head-at-risk signs (HARS), 9 had three HARS, 4 had two HARS and 3 had a single HARS. The mean age at operation was 8 years 2 Months.

Clinical, radiological and functional evaluations were under taken on these patients who have since reached skeletal maturity. The minimum follow up was 6 years. Average age at review was 18 years 8 months (range 16–25). Two patients have since had hip resurfacing, and two patients a double femoral osteotomy and one patient a surgical dislocation of the hip and valgus osteotomy.

The average Harris Hip Score pre-operatively was 52, which improved to a mean score of 82. Eleven hips were classified as Stulberg I/II (50%), 9 hips Stulberg III/IV (41%) and 2 hips Stulberg V (9%). The average increase in Centre-Edge angle was 31 degrees and there was an average improvement of 24.6% in the head coverage. At follow up the average abduction was 31 degrees (improvement of 8.5 degrees), internal rotation 22 degrees (10.5 degree improvement) and flexion 106 degrees (11 degree improvement).

We conclude that the Birmingham interlocking triple pelvic osteotomy provides excellent coverage of the femoral head in severe Perthes disease, recaptures and remoulds the deformed head and avoids retroversion of socket. Good results in severe Perthes disease are maintained beyond skeletal maturity.


R. Banerjee S. Parsons D. Melling N. Kiely

DDH incidence falls from 5–20 per 1000 at birth to 1–2 per 1000 by 3 weeks. Some patients present late and frequently require surgical intervention. If the hip cannot be contained without tension, these children undergo open reduction +/− a femoral shortening, varus and derotation osteotomy. Salter’s osteotomy, may be performed either at index surgery or later in the presence of persisting acetabular dysplasia. Our aim was to see if we could predict which cases of persistent DDH would require both femoral and pelvic surgery to contain the affected hip, using a single plain AP radiograph of the pelvis in the outpatient setting.

We performed a retrospective study of all children older than 18 months with persistent DDH of one or both hips, over the last 5 years, who had undergone femoral and/or pelvic surgery to contain the hip. Plain AP pelvic radiographs were standardised according to the method described by Tonnis. From these radiographs the acetabular indices and child’s age in months, were recorded. Syndromic and children with non-standard x-rays were excluded.

Thirty nine hips (34 female, 5 male), age range of 18–102 months, formed our study group. 53% of hips having femoral surgery later required pelvic surgery for persisting acetabular dysplasia. Examining the data in these cases, the difference between the acetabular index of the normal and affected hip was always greater than 20 degrees and the child’s age in months.

Using this method we conclude that it is possible to predict which cases of persistent DDH will require pelvic surgery to fully contain the affected hip and that this can be done with one AP pelvic radiograph in the outpatient clinic. The benefit is avoidance of unnecessary pelvic osteotomies, and being able to determine the cases which should have a pelvic osteotomy at index procedure.


K. Ho J. Gilbody G. Thomas C. Modi I. Dunnvan der Ploeg

The management of spasticity of children with cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, orthotists, occupational therapists, physiotherapists and orthopaedic surgeons. Botulinum toxin A therapy in the lower limb has been shown to relieve spasticity and to improve the function in the short term. However, the use of Botulinum toxin A in the upper limb remains controversial, moreover only selected few orthopaedic surgeons have experience in managing it. The aim is to assess the functional improvement following an upper limb Botulinum toxin A injections to the upper limb and then to evaluate the patient’s and parents’ satisfaction after the procedure.

During 2007 a total of 36 spastic cerebral palsy patients underwent 47 episodes of Botulinum toxin A injections to the upper limb. There were 22 male and 14 female with an age range between 2 to 17 years (average age was 2 years). Following the surgery, all patients received a course of an intense exercise regime with the physiotherapist and occupational therapist. All patients were prospectively followed-up by the clinic with no loss to follow-up. We also assessed the functional movement of the patients as well as the patient’s and parents’ subjective evaluation of the procedure.

Overall, the range of movement of the upper limb has improved following the Botulinum toxin A injection. Most patients/parents were satisfied with the procedure and would consider further injection in the future. Botulinum toxin A injection to the upper limb is generally well received with good short term results. Many would consider further injections to sustain improve function.


C. Robb M. Nayeemuddin A. Datta C. Bache

Salter’s innominate osteotomy predisposes the hip to acetabular retroversion as it hinges upon the symphysis pubis. Retroversion is a recognised cause of osteoarthritis, hip pain and clinical signs of impingement, but there is uncertainty as to whether this over cover persists with growth and development.

We reviewed the long-term follow up of twenty patients that had undergone a Salter’s osteotomy between 1985 to 1993 at The Royal Orthopaedic Hospital Birmingham or New Cross Hospital Wolverhampton. Sixteen skeletally mature patients were available for review that had previously had the pelvic osteotomy performed at a mean five years of age with a contralateral normal hip. Salter’s osteotomy had been performed for developmental dysplasia of the hip in 13 patients and for Perthes’ disease in three patients. Follow up was performed at an average age of 20 years. Outcome was assessed using the Harris Hip Score and a clinical examination for signs of impingement and by a measurement of acetabular version, on well centered pelvic radiograph.

Acetabular version was evaluated by the relationship between anterior and posterior walls of both the normal and Salter acetabulum, using radiographic templates as described by Hefti. Mean acetabular version averaged 16.9 degrees (95% CI 7.6 to 26.1) of anteversion on the Salter side and 17.6 degrees (95% CI 10.4 to 24.8) anteversion on the contralateral normal hip. There was no statistical difference between the version on operated and normal hips, paired t test (p = 0.83). Harris Hip Score averaged 85, indicating a good outcome at long-term follow up. Two patients (12%) demonstrated retroversion, however neither of these had signs of impingement on clinical examination.

After a Salter innominate osteotomy in childhood, we believe there is remodelling of acetabular version by skeletal maturity.


N. Walsh M. Walsh J. Walton N. Millar

Lateral hip pain is a common problem in middle-aged females. After investigation, a group of patients remain who are given the diagnosis of ‘trochanteric bursitis’. Treatment to date has included physiotherapy, non-steroidal anti inflammatory medication and judicious use of a combined corticosteroid and local anaesthetic preparation injected into the bursa with or without imaging control. Some surgical procedures have been described. The aims of this study are to document and describe our experience with 88 patients and to raise awareness of the condition as a common cause of lateral hip pain which is amenable to surgical repair.

This study has the approval of the Western Sydney area health service. Between 2000 and 2008, 161 patients were referred to the senior author for management of lateral hip pain. 121 patients underwent surgery to repair a gluteal tendon detachment. 32 patients were excluded from the study due to concurrent or previous surgery to the area. A surgical audit was performed on the remaining 88 patients.

Assessment was performed using the Merle d’Aubigne and Postel scoring system. The average duration of symptoms was 6 – 144 months. At 6 months, 88% patients had minimal or no pain. There were also significant improvements in range of motion and ability to walk. The most significant complication was deep vein thrombosis (6%).

Based on our experience, any patient who does not respond to treatment for trochanteric bursitis should be investigated for a gluteal tendon tear. Those with a positive MRI scan of the trochanteric region can be offered surgery for gluteal tendon repair.


R. Kampa A. Hacker E. Griffiths J. Rosson

We assessed polyethylene wear and osteolysis in 15 patients (30 hips) undergoing staged bilateral total hip arthroplasty, who had a cemented hip arthroplasty on one side and a hybrid arthroplasty on the other. All factors apart from mode of acetabular component fixation were matched. Wear was measured radiographically using Livermore’s technique.

The mean clinical and radiological follow-up was 11.2 years for the cemented arthroplasties and 10.7 years for the hybrid arthroplasties. Mean annual linear wear rate for the cemented cups was 0.09mm/year, and 0.14mm/year for the uncemented cups. This difference was statistically significant (p=0.03), confirming previous reports that polyethylene wear in uncemented cups is greater than in cemented cups. Polyethylene wear in the uncemented cup exceeded wear in the cemented cup by more than > 0.1mm/year in 5 patients, 4 of whom had a BMI of greater than 30.

No periacetabular osteolysis was noted. Femoral osteolysis was present in 5 hybrid arthroplasties and 2 cemented arthroplasties. Zone 7 femoral osteolysis occurred in 3 patients on the side of the hybrid arthroplasty, multifocal femoral osteolysis not involving zone 7 was seen in 2 patients in both hips.


A. Kakkar L. Borris R. Friedman S. Haas M. Huisman W. Geerts T. Bandel E. Muehlhofer F. Misselwitz B. Eriksson

Rivaroxaban is a novel, oral, once-daily, direct Factor Xa inhibitor in advanced clinical development. RECORD1 was a multinational, randomized, double-blind, double-dummy, phase III study investigating the efficacy and safety of extended thromboprophylaxis with rivaroxaban compared with subcutaneous enoxaparin following THR.

Patients (N=4541) were randomized to receive oral rivaroxaban 10 mg (6–8 hours after surgery and once daily thereafter) or subcutaneous enoxaparin 40 mg (administered the evening before surgery, 6–8 hours after surgery, and once daily thereafter) for 35±4 days. The primary efficacy outcome was the composite of deep vein thrombosis (DVT: symptomatic or detected by mandatory, bilateral venography if asymptomatic), non-fatal pulmonary embolism (PE), and all-cause mortality up to day 36±6. Major venous thromboembolism (VTE), the composite of any DVT, non-fatal PE and VTE-related death, was a secondary outcome. Safety endpoints included major and non-major bleeding while receiving study medication.

Rivaroxaban significantly reduced the incidence of the primary efficacy outcome compared with enoxaparin (1.1% vs 3.7%, respectively; p< 0.001; relative risk reduction [RRR] 70%). Rivaroxaban also significantly reduced the incidence of major VTE compared with enoxaparin (0.2% vs 2.0%, respectively; p< 0.001; RRR 88%). There were no significant differences in the incidence of major bleeding (0.3% vs 0.1%; p=0.178) or non-major bleeding (5.8% vs 5.8%; p=1.000) between rivaroxaban and enoxaparin, respectively. There was no evidence of liver safety issues associated with rivaroxaban.

Thromboprophylaxis with once-daily, oral rivaroxaban was significantly more effective than subcutaneous enoxaparin following THR without an increased risk of bleeding. This trial demonstrates the efficacy and safety of a fixed, unmonitored, once-daily dose of oral rivaroxaban for extended thromboprophylaxis after THR.


M. Chawda P. Hucker S. Whitehouse R. Crawford H. English W.J. Donnelly

Data from recent AOANJRR shows a higher incidence of acetabular revision for dislocation of THA in uncemented compared to cemented THA (RR 1.59). We hypothesized that a difference in accuracy of component placement may be a factor. We aimed to assess any difference in accuracy between these 2 types of THA.

Patients undergoing navigated THA were prospectively recruited. Choice of uncemented or cemented THA was based on individual surgeon’s routine practice and preference and no adjustments were made for this study. All THAs (Cemented Exeter-21 and uncemented Trident/Secur fit-20) were performed through a posterior approach.

Statistical analysis: the mean and 95% confidence intervals (or median and interquartile range (IQR) for non parametric data) for each measure in both groups. ANOVA and nonparametric Mann-Whitney U test (significance level 5%). Levene’s test for homogeneity, Comparison of frequencies with chi-squared test or Fishers Exact test. Bonferroni correction where necessary.

We demonstrated a significant difference in reproducibility between components. Four of 20 (20%) uncemented cups deviated from the target inclination by 5 degrees or more compared to none of 21 in the cemented group (p=0.048). Seven of the 20 (35%) of the uncemented cups deviated from the target version by 5 degrees or more compared to none of 21 in the cemented group (p=0.003). There was a significant difference between the groups with regard to deviation from planned leg length (p< 0.001). Deviation from target leg length of greater than 5mm was found in 36.4% of the uncemented cases as compared to 8.3% of the cemented cases although due to the small numbers this was not statistically significant (p=0.16).

Statistically significant reduced accuracy of cup placement is demonstrated with uncemented compared to cemented implants. It is harder to control implant positioning in uncemented implants than cemented implants.


G. Abbas A. Waheed S.B. Mostofi

The ability to drive represents autonomy and independence of individuals. For many patients not being able to drive severely restricts their social, personal and professional activities leading to adverse effects on their well being. This study assessed the current evidence on driving advice after total hip replacement (THR) and compared it with the real time ability of patients to drive their own cars after primary THR. We present a prospective review of car driving ability of 130 patients (80 males and 50 females) who were treated with THR.

The results show that 105 patients (81%) were able to drive within 6–8 weeks after surgery. It took more than 12 weeks for 22 patients (17%) to start driving again. There was no reported deterioration in the driving ability after primary total hip replacement surgery. Conversely, 49 patients (38%) felt a subjective improvement in their driving capability after THR. Three patients (2%) were still not confident to drive even at 12 weeks post THR. In spite of the clear advice, only 69% practiced on a stationary car before driving on the road. In our study sample 67 patients (63.8%) had a right THR and 65 patients (61.9%) were manual car drivers and all were able to drive between 6–8 weeks.

This study demonstrates that patients should not resume driving motor vehicles for a minimum period of six weeks following total hip replacement surgery. This is inclusive of automatic and manually operated automobiles, and irrespective of laterality of surgical interventions. Return to driving after a six week period should be based on the individual’s capability and confidence to control the vehicle safely. Patients should be given clear advice to practice on the stationary vehicles before starting to drive on the road.


B. Davis B. Jani A.D. Patel

Printed plain radiographs have traditionally been the method of image transfer between hospitals, but the advent of digital imaging has revolutionised modern day radiology. It is now commonplace for compact discs to be used as the transport media for digital images, the theoretical advantages being ease of transport and storage, integration with PACS systems and the ability to perform image manipulation. However, in our tertiary referral centre for pelvic and acetabular trauma, we noted problems with digital image transfer using this method.

We examined the last 25 compact discs sent to our unit for functionality on 3 separate computers. Only 17/25 discs loaded on all computers, and 2 discs failed to load on any computer. 9 of the remaining 23 discs did not allow image manipulation, and 1 disc would not allow retrieval of all the contained images. 5 of the 23 discs took longer than 5 minutes to retrieve the contained images. In summary, we classed 10 of the 25 discs as acceptable. Patient transfer to our unit was not delayed, but 4 patients underwent repeat CT scans due to incomplete imaging

Digital technology has made great advances into medical imaging. Standardisation using the DICOM format for image creation has attempted to eliminate issues of compatibility, but variation in software used to produce and view images can still vary from these standards. Technical errors in the creation of discs should be eliminated at source, and it is mandatory that referring units check the functionality of discs before they are sent. In this way, the potential for delay to transfer and subsequent repeat exposure to ionising radiation can be avoided.


K. Willett A. Briggs T. Kemp K. McIntyre J. Rowley R. Pullinger O. Wu

Objectives: to determine whether initial contact with emergency services via a mobile phone (MP) in life threatening situations is associated with increased survival or reduced length of stay when compared to contact via a landline.

A retrospective cohort – data from all emergency dispatches from a UK county ambulance service was linked to the Patient Admission System at local hospitals. All emergency dispatches for immediately life-threatening events (designated as Code Red) between 01/01/1995 and 31/06/2006 were tracked to death or discharge.

Main Outcome Measures:

Mortality (at scene, at emergency department, and during hospitalisation), admissions (to the emergency department (ED), inpatients care, and the intensive care unit (ICU)) and mean lengths of stay were analysed by initial exposure (MP versus landline) using multi-variant analysis with logistic regression controlling for potential confounding variables.

354,199 ambulances were dispatched in the 11.5 years. Mobile phone use rose to 25% by study end. 66% of ambulances subsequently transferred patients to hospital. MP compared to landline reporting of emergencies resulted in significant reductions in the risk of death at scene for medical events (OR 0.74; 95% CI 0.65 to 0.85), but not for trauma (OR 1.04). ED medical deaths were higher (OR 1.33; 95% CI 1.33 to 1.72) as were in-patient (OR 1.19). There was no effect on ED or hospital trauma deaths (ORs 0.81, 0.84). The probability of being admitted to hospital and ICU was higher with MP call for trauma (ORs 1.22, 1.44). There was no difference in mortality between mobile or landline calls from either urban or rural areas.

There is little evidence to suggest a lower threshold to make an emergency call from a MP. The potential advantages of MP use of ease of access, supplying bystander/patient advice and shortening the ‘golden hour’ appear confined to non-trauma emergencies.


S. Jameson A. Lamb A. Wallace L. Sher C. Marx M. Reed

Since 2003 Trauma and Orthopaedic trainees in the UK and Ireland have routinely submitted data recording their operative experience electronically via the eLog-book. This provides evidence of operative experience of individuals and national comparisons of trainee, trainer, hospital and training programme performance. We have analysed trauma surgery data and established standards for training.

By January 2008 there were over 4 million operations logged. Operations performed and uploaded since 2003 have been included. Each trainee’s work is analysed by ‘year-in-training’. Data on levels of supervision, missed opportunities (where the trainee assisted rather than performed the operation) was analysed. The average number of trauma operations performed annually by trainees was 109, 120, 110, 122, 98 and 84 (total 643) for YIT one (=ST3) to six (=ST8) respectively. There were only 22% of missed opportunities throughout six years of training. A high level of experience is gained in hip fracture surgery (121 operations) and forearm (30), wrist (74) and ankle (47) operative stabilisation over the six years. However, the average number of tibial intra-medullary nails (13), external fixator applications (12) and childrens’ elbow supracondylar fracture procedures (4) performed is low. We are also able to identify trainees performing fewer operations than required during their training (two standard deviations or more below the mean for their YIT). We expect a trainee to have performed at least 255, 383, 473, and 531 trauma operations at the end of YIT three to six respectively.

The eLogbook is a powerful tool which can provide accurate information to support in-depth analysis of trainees, trainers, and training programmes. This analysis has established a baseline which can be used to identify trainees who are falling below the required operative experience.


A. Gulati S. Glyn-Jones D.J. Simpson J. Palan D.J. Beard H.S. Gill P. McLardy-Smith R. Gundle D.W. Murray

Roentgen Stereophotogrammetric Analysis (RSA) can predict long-term outcome of prostheses by measuring migration over time. The Exeter femoral stem is a double-tapered highly polished implant and has been shown to subside within the cement mantle in 2 year RSA studies. It has a proven track record in terms of long-term survivorship and low revision rates. Several studies have demonstrated excellent clinical outcomes following its implantation but this is the first study to assess stem migration at 10 years, using RSA.

This is a single-centre study involving 20 patients (mean age: 63 years, SD=7) undergoing primary total hip replacement for degenerative osteoarthritis using the lateral (Hardinge) approach. RSA radiographs were taken with the patient bearing full weight post-operatively, at 3, 6, 12 months and at 2, 5 and 10 years follow-up. The three-dimensional migration of the Exeter femoral stem was determined.

The mean Oxford Hip Score at 10 years was 43.4 (SD=4.6) and there were no revisions. The stems subsided and rotated internally during a 10-year period. The mean migrations of the head and tip of the femoral stem in all three anatomic directions (antero-posterior, medio-lateral & supero-distal) were 0.69 mm posterior, 0.04 mm lateral and 1.67 mm distal for the head and 0.20 mm anterior, 0.02 mm lateral and 1.23 mm distal for the tip. The total migration at 10 years was 1.81 mm for the head and 1.25 mm for the tip.

The Exeter femoral stem exhibits migration which is a complex combination of translation and rotation in three dimensions. Comparing our 10 year with our previous 2 year migration results, the Exeter stems show continued, but slow distal migration and internal rotation. The subsidence continues to compress the cement and bone-cement interface which maintains secure fixation in the long term.


G. Swamy G. Armugam S. Pickering

Ruptures of the patellar and/or quadriceps tendon are rare injuries requiring immediate repair to re-establish knee extensor continuity and to allow early motion. Ultrasound is extensively used as a diagnostic tool before surgery on acute traumatic tears of the patellar tendon and quadriceps tendons.

Our aim was to re-evaluate the value/role of sonography in diagnosing quadriceps and patellar tendon rupture and in differentiating partial from complete tears. To correlate the intra operative findings with the ultrasound report.

A retrospective review of 32 consecutive patients who had a surgical intervention for suspected acute quadriceps and patellar tendon rupture over the last 3 years. Intra-operative findings, clinical, x-ray, ultrasound and MRI reports were correlated.

Seventeen patients had a suspected patellar tendon rupture on clinical examination and 15 patients had suspected quadriceps tendon rupture. Diagnosis was confirmed by clinical examination and x-rays alone in 9 patients, with additional ultrasound in 18 patients and with MRI scan in 5 patients. There were 6 false positives out of 18 [33.3%] in the ultrasound proven group and 1 false positive out of 9 [11.1%] in the clinical examination and x-ray only group. MRI was 100% accurate [n=5].

This is a small, but important study. Ultrasound offers a low degree of sensitivity and specificity in diagnosing acute quadriceps and patellar tendon ruptures. As a result, patients are being exposed to the risks of surgery unnecessarily. We recommend MRI scan as a first line of investigation in patients where the diagnosis is clinically ambiguous. Ultrasound assessment should not be relied upon in when making the decision to operate.


R.P. Baker M.J. Kilshaw R. Gardner S. Charosky I.J. Harding

The incidence of degenerative scoliosis in the lumbar spine is not known. In the ageing population deformity may coexist or cause stenosis. MRI gives limited information on this important parameter in the treatment of stenosis. The aim of this study was to highlight the incidence of coronal abnormalities of the lumbar spine dependent on age in a large population of patients.

We reviewed all abdominal radiographs performed in our hospital over ten months. 2276 radiographs were analysed for degenerative lumbar scoliosis and lateral vertebral slips in patients who are over 20 years. Evidence of osteoarthritis of the spine was also documented. Radiographs were included if the inferior border of T12 to the superior border of S1 was visualised and no previous spinal surgery was evident (metal work).

2233 (98%) radiographs were included. 48% of patients were female. The incidence of degenerative lumbar scoliosis, lateral listhesis and osteoarthritis increased with age. Degenerative scoliosis was present in 1.6% of 30–39 year olds increasing every decade to 29.7% of patients 90 years or older. In all age groups curves were more frequent and had greater average Cobb angles in female patients.

Degenerative lumbar scoliosis starts to appear in the third decade of life increasing in frequency every decade thereafter, affecting almost a third of patients in the ninth decade. It is more common in female patients and has a greater magnitude. Deformity may be even greater on standing views and is important to recognise in all patients that are undergoing lumbar spinal decompressive surgery. A failure to do so may lead to inferior results or the need for further surgery.


A. Hudd J. Bernard S. Molloy

The aim of the study was to assess the safety of a novel anatomical landmark in the placement of thoracic pedicle screws. It is our clinical observation that the sagittal plane of the screw trajectory is perpendicular to the plane of the superior articular facet, when the entry point is in the lateral half of the articular surface of the corresponding superior facet.

Using SECTRA software on a PACS digital imaging system, morphometric analysis was performed on thoracic vertebrae imaged using computed tomography (CT). For inclusion, the scan had to have no reported bony abnormality. It was determined whether a trajectory as described at 90 degrees to the articular facet, with an entry point just caudal to the lateral half of the facet to a depth of 25mm would breach either the medial wall of the pedicle or lateral vertebral body wall anterior to the costovertebral facet.

Sixty-two CT scans (744 segments, 1488 pedicle-facet complexes) were reviewed. 1154 complexes were suitable for full analysis. Exclusions were due to the lumbarisation of the T12 facet joints (62) or inability to clearly define the facet surface due to the plane of the CT slice (272). Of 1154 entry points assessed, 1154 (100%) were safe to be entered at 90 degrees to a depth of at least 25mm.

We have demonstrated the safety and reliability of a novel anatomical landmark in normal thoracic pedicles. We believe this will improve sagittal plane alignment and reduce further the risk of medial pedicle breach.


J. Langdon A. Way J. Bernard S. Molloy

Acute osteoporotic vertebral compression fractures (VCFs) are frequently misdiagnosed as there is often no history of preceding trauma. VCFs not only cause back pain, but can also result in a loss of function, spinal deformity and increased mortality. Cement augmentation has been shown to effectively treat these fractures. It is impossible to diagnose an acute fracture on plain x-ray and therefore identify those likely to benefit from this treatment. The definitive investigation to determine the presence of an acute fracture is a MR scan, but this is a limited resource. The aim of this paper is to evaluate 2 new clinical signs which we believe aid in the diagnosis of an acute VCF: firstly closed fist percussion at the level of an acute VCF resulting in a severe, sharp fracture pain, and secondly the inability of a patient to lie supine. This was a prospective study of 78 patients with suspected acute VCFs.

48/78 had an acute fracture on MR. 42/45 patients who were positive for closed fist percussion, had an acute fracture on their MR scan. There were 6 patients who were negative for closed fist percussion who had an acute fracture (sensitivity 87.5%, specificity 90%).

39/41 patients who were positive for the supine sign had an acute fracture on their MR scan. There were 9 patients who were comfortably able to lay supine who had an acute fracture (sensitivity 81.25%, specificity 93.33%).

Either a positive closed fist percussion sign or a positive supine sign is a reliable indicator of the presence of an acute VCF. By incorporating these signs into our routine clinical assessment we are better able to predict which patients have an acute fracture, and therefore decide which patients need a MR scan.


G. Swamy J. Crosby D. Calthorpe Z. Klezl R. Bommireddy

Very few reports exist regarding use of intra-operative autologenous transfusion in adult spinal fusion surgery. Specific indications for use of cell saver in thoraco-lumbar spinal instrumentation are not clearly determined. Our objective was to identify the clinical factors associated with increased risk of intra-operative blood loss. To analyse the safety and benefits of using cell saver and to determine the cost-effectiveness.

51 consecutive thoraco-lumbar instrumented fusion over 14 months reviewed. There was no randomisation. Cell saver group consisted of 25 patients and control group consisted of 26 cases. Patients with degenerative scoliosis and tumours excluded. Clinical notes were reviewed.

Demographic data were comparable between the two groups. Iliac crest bone graft harvested in 20% of cell saver group and 40% in control group. Levels of fusion ranged from 1–7 (Mean=2.8) in the cell saver group and 1–4 (Mean=1.9) in the control group. Mean duration of surgery was 15 minutes longer in study group. Intra-operative blood loss was higher in cell saver group (mean=1245 mls vs 800 mls). Significant indicators for duration of surgery were number of levels fused (p< 0.0001), patient weight (p=0.003) and revision surgery (p=0.029). Significant indicators for predicting blood loss were number of levels fused (p< 0.001) and duration of surgery (p=0.0304). 20% in study group (8 units of red cells) and 26% in control group (17 units of red cells) required blood transfusion. Percentage drop in the post-operative haematocrit was 19.1 in study group compared to 36.3 in control group.

In conclusion, 44.38% blood salvaged (35–38% in spinal literature). Use of cell saver significantly decreased post-operative need for blood transfusion. Number of levels of fusion, duration greater than 4 hrs and a low pre-op Haemoglobin/Haematocrit were significant parameters in predicting intra-operative blood loss. If blood loss is less than 700 mls, gains from cell saver are debatable.


N. Prasad C. Dent

We analysed the outcome of the Coonrad-Morrey total elbow replacement used for fracture of the distal humerus in elderly patients with no evidence of inflammatory arthritis and compared the results for early versus delayed treatment.

We studied a total of 32 patients with 15 in the early treatment group and 17 in the delayed treatment group. The mean follow-up was 56.1 months (18 to 88). The percentage of excellent to good results based on the Mayo elbow performance score was not significantly different, 84% in the early group and 79% in the delayed group. Subjective satisfaction was 92% in both the groups. One patient in the early group developed chronic regional pain syndrome and another type 4 aseptic loosening. Two elbows in the early group also showed type 1 radiological loosening. Two patients in the delayed group had an infection, two an ulnar nerve palsy, one developed heterotopic ossification and one type 4 aseptic loosening. Two elbows in this group also showed type 1 radiological loosening. The complication rates in the early and delayed treatment group were 13% and 29% respectively. The Kaplan-Meier survivorship analysis for the early and delayed treatment groups was 93% at 88 months and 76% at 84 months, respectively. No statistically significant difference was found between the two groups.

We conclude that total elbow replacement provides a preditable and reproducible outcome in terms of pain relief and functional range of movement in elderly osteoporotic patients with difficult distal humerus fractures.


A.R. Guha A. Khurana N. Saxena S. Pugh A. Jones J. Howes P. Rhys-Davies S. Ahuja

We aimed to evaluate the effects of implementing blood conservation strategies on transfusion requirements in adult patients undergoing scoliosis correction surgery. We retrospectively studied 50 consecutive adult patients who underwent scoliosis correction surgery (anterior, posterior or combined) between 2003 and 2007. All patients had a standard transfusion protocol. Age, BMI, pre and post operative haemoglobin, levels fused, duration of surgery, hospital stay, anti-fibrinolytics used and blood transfused was noted.

50 patients with mean age 24.6 years and mean BMI 21.9 kg/m2 were studied. 14 patients had anterior surgery, 19 patients had posterior surgery and 17 had combined anterior and posterior procedures. Mean number of levels fused was 9.5 (6–15) and mean duration of surgery was 284.6 minutes (135–550 minutes). Antifibrinolytics were used in 31 patients (62%), Aprotinin in 21(42%) and Tranexamic acid in 10 (20%). Mean blood loss in patients who received anti fibrinolytics was 530mls while mean blood loss in the other patients was 672mls. (p< 0.05). Blood transfusion was not required in any of the patients undergoing anterior correction only while 7 patients (41%) undergoing anterior and posterior correction and 3 patients (15.8%) undergoing posterior correction only required blood transfusion. Mean volume of cell saved blood re-transfused was 693.8 mls and mean hospital stay was 9.2 days. Mean pre-op haemoglobin was 13.2 g/dl (10.4–17.4) and mean post-op haemoglobin was 10.7 g/dl (7.7–15). 4 patients (8%) required intra and post-operative blood transfusion while 6 patients (12%) required blood transfusion postoperatively.

In conclusion, the use of anti-fibrinolytics like Aprotinin and Tranexamic acid reduces blood loss in scoliosis surgery. In the current scenario, with Aprotinin no longer available for use, our study would recommend the use of Tranexamic acid alongwith other blood conservation measures. In our unit we do not have blood cross matched for anterior surgery alone.


G. Swamy S. Gangopadhyay J. Khan D. Calthorpe

Pyogenic haematogenous spinal infection in the elderly, described as spondylodiscitis, vertebral osteomyelitis and epidural abscess is considered a rare but life threatening condition. Our objective was to test the hypothesis that low index of suspicion leads to delayed diagnosis and referral for definitive treatment resulting in increased and perhaps avoidable medical morbidity, social drift including early mortality and to analyse pathological entities, complications and optimum treatment options.

We performed a retrospective review of medical records over 10-year period. Post-operative infections and patients under 65 years old excluded. Initial presentation, investigations and differential diagnosis, time to diagnosis, date and day of referral, mode of definitive treatment, pathologic entities, complications and outcomes were noted. Patient outcomes were measured as duration of treatment, length of hospital stay, complications, ambulatory status, complications, discharge destination and death. Outcomes were correlated with delayed diagnosis and referral.

46 elderly (age> 65) patients with a mean age of 71 years (range=65–91). 62% referral from physicians. Fever with malaise associated with chronic LBP was the commonest presenting complaint. There were 31 patients with discitis, 12 epidural abscess and 3 osteomyelitis. Lumbar spine was affected in 63% patients. Time to diagnosis ranged from 2–17 days with mean of 8 days. Mean referral time was 9 days with 39% referrals on Friday. Staphylococcus aureus (47%) was the commonest organism isolated. Duration of hospitalisation ranged from two to twelve weeks. 46% required surgical decompression with four cases of related mortality during acute hospital stay.

Time duration to spinal referral had direct correlation with increase in morbidity, social drift and mortality. The incidence of haematogenous spinal infection in the elderly has increased over the years in our series, contrary to popular belief. A high index of suspicion in elderly patients with PUO promotes early diagnosis and optimises outcome.


M. Akmal A. Meir A. Hussein M. Hamady

In severe destructive spinal infections, with neurological deficit, progressive deformity or uncontrolled sepsis, the mainstay of treatment is surgical debridement with anterior and posterior stabilisation. We retrospectively reviewed 14 patients (11 Male 3 female) with a mean age of 63 (range 38 to 85) who underwent anterior only surgery consisting of an expandable vertebral body cage and a ventrolateral locking plate (Synthes). Organisms included Tuberculosis (7), Staphylococcus (5), E-Coli (1) and Pseudomonas (1). Radiological and functional outcomes were assessed upto 18 months post surgery. Cobb angles were used to measure angular deformity.

Good early results in terms of safety, resolution of pain, control of deformity and improvement of neurological deficits was observed. Average blood loss was 633mls (range 300mls to 1500mls) with a mean deformity correction of 23 degrees. Post operative radiological assessment showed the cages to be relatively stable in the under 80 yrs groups (mean loss of correction 15 %). In elderly patients (> 80 yrs) there was significant subsidence leading to a loss of correction (mean 52%) which required stabilisation using vertebral body cement augmentation. In one case, there was implant displacement requiring revision and additional posterior stabilisation. 11 patients showed significant improvement in neurology and 3 patients remained neurologically normal ie Frankel E.

We propose assessing severe spinal infections using the spinal trilogy of neurological deficit, deformity and sepsis. Anterior stabilisation using an expandable cage and locking plate alone or with additional vertebral body cement augmentation in elderly patients provides a satisfactory solution for severe destructive spinal infections. It preserves the posterior column and reduces the need for further posterior surgery.


A. Khurana A. Guha K. Mohanty S. Ahuja

Sacroiliac joint (SIJ) is a diarthrodial joint and can often be a source of chronic low back pain complex. We present a percutaneous technique for SIJ fusion and the functional and radiological outcome following arthrodesis with HMA (Hollow modular anchorage; Aesculap Ltd, Tuttlingen) screws.

Fifteen consecutive patients operated for SIJ fusion between Sep 2004 and Aug 2007 were included in the study. The diagnosis was confirmed with MRI and diagnostic injections. Pre-operative and post-operative functional evaluation was performed using SF-36 questionnaire and Majeed’s scoring system. Postoperative radiological evaluation was performed using plain radiographs. The HMA screws packed with bone substitute were implanted percutaneous under fluoroscopic guidance.

The study group included 11 females and 4 males with a mean age of 48.7 years. Mean follow-up was 14 months. Mean SF-36 scores improved from 37 to 80 for physical function and from 53 to 86 for general health. The differences were statistically significant (Wilcoxon signed rank test; p < 0.05). Majeed’s score improved from mean 37 preoperative to mean 79 postoperative. The difference was statistically significant (student t test, p< 0.05). 13 had good to excellent results. The remaining 2 patients had improvement in SF-36 from mean 29 to 48. Persisting pain was potentially due to coexisting lumbar pathology. Intra-operative blood was minimal and there were no post-operative or radiological complications.

Percutaneous HMA screws are a satisfactory way to achieve sacroiliac stabilisation.


J. Phillips L. Rahman S. Elsayed D. Calthorpe R. Bommireddy Z. Klezl

Osteoporotic vertebral fractures predispose to significant morbidity in the elderly and are strongly associated with an overall decline in health, functional status and social drift.

In recent years various surgical morphoplastic techniques have been employed in an attempt to improve on the disappointing natural history of this manifestation of biological failure.

Current evidence supporting the use of kyphoplasty versus medical management alone in the management of these factures is limited and based on several small prospective cohort studies.

We present prospectively collected data supporting the use of kyphoplasty in a U.K. based population tested by examining Visual Analogue Pain Score (VAS), vertebral height, vertebral and kyphosis angles, Oswestry Disability Index and Hospital Anxiety and Depression Score (HADS).

50 patients in our kyphoplasty group have undergone 91 kyphoplasty procedures. With a mean follow up of 6 months, the mean post-operative VAS score was 3.8 versus a pre op score of 8.5. This reduction was maintained at 6 weeks and 6 months with mean scores of 3.3 and 2.7 respectively (p< 0.001).

Functional status ODI scoring improved from a pre-operative score of 54 to 47 post-operatively, to 40 at 6 weeks, and further, to 39 at 6 months. This result was reinforced by HADS scoring at the same time intervals recording 15.0, 11.2, 11.1 and 11.7 respectively.

Post-operative radiographs demonstrated a 24% mean increase in the vertebral angle (p< 0.01) with increases in the anterior, middle and posterior vertebral body heights of 19, 31 and 9% respectively (p< 0.001). No significant improvement of kyphosis angle was identified.

The Derby experience demonstrates that kyphoplasty can improve pain and functional status and may help correct deformity after osteoporotic vertebral compression fractures.

Our experience has encouraged further recruitment for kyphoplasty as the preferred management for those patients who fail to respond to initial non-operative management.


C. Bhatia B. Purushothaman R. Pollock M. Krishna

Failed Back Surgery Syndrome (FBSS) refers to having persistent back and/or leg pain after one or more surgical procedures aimed at correcting lumbosacral disease. Different modalities including Epidural injections, Spinal cord stimulation, Anterior/Posterior Lumbar Interbody Fusion (ALIF, PLIF) have been described in the literature with varying outcome. Our aim was to review the functional outcome of patients treated with Posterior Lumbar Interbody Fusion for FBSS since June 2000 to December 2006.

This is a retrospective study of prospectively collected data of 25 patients diagnosed with FBSS and treated with PLIF at University Hospital of North Tees. All patients were requested to fill in the Oswestry Disability Index(ODI), Numerical Rating Scale for Back Pain (NRSBP), Numerical Rating Scale for Leg Pain (NRSLP), SF36 pre and post operatively. The scores were analysed using SPSS software for statistical significance.

There were 12 men and 13 women. Mean age was 47.8 years (range 31–76 years). Mean follow up was 24.8 months (range 4 – 63 months). Four of the 25 patients had Post discectomy syndrome while the rest had post laminectomy syndrome. Most common level of surgery was L5/S1 either as a single level or in combination with other levels above. ODI decreased from a pre-op mean of 55.6(range 20–74.1) to 20.6(range 2–54) while VASBP decreased from 6.9 (range 1–9) to 2.2(range 0–6) (p< 0.05) and VASLP decreased from 6.4 (range 3–10) to 2.2 (range 0–7) (p< 0.05). SF36BP scores improved from a mean 26.7 (range 12–37.1) before the surgery to 45 (range 31–62) (p< 0.05) after surgery. 84% of the patients felt that the outcome of the surgery met their expectation and were satisfied with result.

Our results show that PLIF can be offered as a safe and effective for treatment of FBSS.


G. Barham E. Davies

We performed a retrospective follow-up study investigating the safety and efficacy of an independently constructed non-linked double rod system for anterior column reconstruction.

Our objective was to demonstrate safe and cost effective adaptation of a standard deformity system for use in anterior column reconstruction.

Anterior only surgery in patients requiring corporectomy spares the posterior soft tissue envelope. Corporectomy and neural decompression is followed by insertion of a titanium mesh cage and bone graft. Several non-adaptable implant systems (locking plates and linked-rod constructs) have been validated both in clinical and in-vitro studies and are available to the surgeon. These devices can only be used to address the anterior column and can only span a limited number of spinal segments.

Twenty-two patients have undergone anterior column reconstruction for tumour (8), trauma (11) and infection (3) in our unit are included. Mean follow up was 30.5 months. All had anterior corporectomy and decompression, insertion of a titanium mesh cage and stabilisation with an anterior non-linked dual rod construct (Synthes USS II). Follow-up records and radiographs have been analysed.

Ninety-five percent of patients fused clinically and radiologically on plain radiograph examination. There was no failure of metalwork or deterioration in neurological function following surgery. There were 5 deaths in the study group, 4 from progression of metastatic malignant tumour and one within 30 days of surgery. Three patients have had local malignant disease recurrence, two requiring posterior decompression and one requiring further anterior surgery.

This system is effective and safe. It allows fewer implants to be carried by individual hospitals and thus reduces hospital costs.


Y. Kulikov S. Brydges A. Girling R. Lilford D. Griffin

Randomised controlled clinical trials (RCTs) produce the most reliable evidence about the effects of clinical care. In surgical trials, lack of surgeons’ individual equipoise (state of genuine uncertainty about treatment arms) appears to be one of the greatest obstacles. Collective equipoise based on present or imminent controversy in the expert medical community has been proposed as a solution (Freedman, 1987), but could be applied only at the beginning of a trial to a general trial question.

We developed a system that quantifies collective uncertainty among a group of surgeons for an individual clinical case. After a successful pilot study the system was introduced as an independent project within the UK Heel Fracture Trial. The expert panel included 10 surgeons from 8 hospitals. Anonymous clinical data of potentially eligible consecutive cases including CT and X-ray images was published on a secure online forum after 6 weeks follow up clinic to avoid interference with clinical course. Surgeons registered in the panel estimated the probability that the patient would be better or worse by various degrees with operative treatment.

30 clinical cases have been analysed, including 6 bilateral fractures (otherwise excluded). 86.7% could be recommended for inclusion in the trial, compared to 43.3% recruited out of this series in the actual trial. Lack of individual uncertainty within the panel was present in every case.

The system not only has a potential to improve recruitment in surgical RCTs, but provides ethically sound grounds to offer or otherwise a patient participation in a trial. Surgeon’s individual equipoise dilemma and responsibility is shared with colleagues. Cases that otherwise will be excluded can be evaluated with broader inclusion criteria. The system is easy to use, cheap and reliable. Limitations include surgeons’ compliance and time lapse (at least 48 hours) for voting to be completed.


P.V. Giannoudis R. Dimitriou I. Gill V. Kolimarala N.K. Kanakaris R.J. Montgomery

A study to evaluate the efficacy of combined grafting (iliac crest autograft – ICAG, and human recombinant osteogenic protein 1 – rhOP1/BMP7) for long bone fracture non-unions (LBFNUs).

At both institutions prospective and retrospective data were collected. (Between Oct 2001 and Aug 2004 all LBFNUs that were grafted with a combination of BMP7 and ICAG). The records of the initial injury incident, treatment course, all operative interventions before and after the combined grafting and the follow up till final clinical & radiological union have been analysed. X2 test was used to analyse the results.

Forty-nine patients (31 males) with a mean age of 43 years (18–79) with LBFNUs were identified. The mean follow-up was 21.4 months (12–65). 7 were humeral, 13 femoral, and 29 tibial LBFNUs. Eleven were open (3 grade II, 8 grade IIIa–b). All non-unions were atrophic, and 8 had significant bone defects. The mean number of operations prior to the combined grafting was 2.5 (0–6). Clinical and Radiological union occurred within a mean time of 4.4 (3–12) months and 5.4 (4–16) months respectively. All of the fractures united. One patient, with an infected tibial non-union after an open fracture, ultimately underwent a below knee amputation. No complications or adverse effects from the use of BMP-7 were encountered.

BMP-7 was used as a bone-stimulating agent combined with conventional iliac crest bone grafting with a success rate of 98% in this series of patients with LBFNUs. This study supports the view that this combination of BMP-7 is safe and a power adjunct to be considered in the surgeon’s armamentarium for the management of such difficult cases.


I. Siddique M. Hakimi S. Javed K. Wellington R. Smith M. Khatri

Current evidence on the indications for and efficacy of non-rigid lumbar stabilisation remains unclear. The aim of this study was to review the outcome of the DYNESYS system (Zimmer, Inc.) in a consecutive series of 34 patients undergoing this procedure between 2001 and 2006.

Prospectively collected outcome measure data obtained pre-operatively and at 1 year post-operatively was analysed using the Wilcoxon Signed Rank Test. Kaplan Meier survival analysis was performed using revision surgery as the end point. Cox Regression was utilised to identify variables that were related to implant survival.

Pain rating on the visual analogue scale improved from a mean of 7 pre-op to 4 at 1 year (p=0.009), Roland Morris Disability Questionnaire scores from 13 to 9 (p=0.02), Modified Somatic Perception Questionnaire from 13 to 9 (p=0.03). When reporting subjective outcome, 54% of patients reported “better” or “much better” outcomes at last followup (12–69 months post op). Eight patients (25%) required removal of the implant and conversion to fusion, one of whom had deep infection. Kaplan Meier survival analysis revealed a survival of 78% at 5 years (95% CI, 60 – 96%). Previous spinal surgery was significantly related to the time of survival of the implant (p=0.008).

Our study has demonstrated a high revision rate for this implant and 54% patient satisfaction. We recommend that patients be counseled regarding these risks and further use of this implant should be subject to the outcome of larger studies and randomised controlled trials.


M. Khatri H. Norris R. Ross

Sub-optimal positioning of the implant is thought to be related to poor outcome after Lumbar Disc Replacement. Our aim was to analyse the impact of implant position in the outcome of Charite III Disc Replacement implants.

160 Charite III Lumbar Disc Replacements that were implanted between 1990 and 2000. The average age was 46 years with 62 Males and 98 Female subjects. An independent observer (HN) administered Pain score (VAS 1–10) for Low Back Pain (LBP) and Oswestry Disability Index (ODI). These clinical outcome parameters were compared with coronal and sagittal position of the implants from the latest available radiographs. Those with operation at L3L4 (small numbers = 20) and inadequate radiographs were excluded.

48 implants were optimally placed and 70 implants were placed sub optimally. Both the groups were in similar age groups (45.02 years, SD 7.61 and 48.31 years, SD 8.04). Clinical: No statistical or clinically significant difference was observed in LBP on VAS (4.92 V/S 4.41), ODI (42.8 V/S 38.0) and in Patient Satisfaction at an average follow up of 70 months. Average movement at optimally placed discs at L4L5 was 4.4o(95% CI 2.3 – 6.7) and at L5S1 was 5.9o(95% CI 4.2 – 7.5) and at sub optimally placed disc at L4L5 was 3.8o(95% CI 2.4 – 5.1) and at L5S1 was 3.8o(95% CI 2.3 – 5.3).

Clinical and radiological results after Charite III Disc Replacement is NOT dependent on positioning of implants. Movements at optimally placed implants are better but is of questionable clinical relevance.


J. Daniel H. Ziaee C. Pradhan D.J. McMinn

This is the first six-year report of a prospective longitudinal study of daily output of cobalt and chromium in urine and their levels in blood following hybrid metal-on-metal surface arthroplasty.

Urine and whole blood specimens were analyzed before and periodically after hip resurfacing in 26 male patients after informed consent (mean age 52.9 years, mean BMI 27.9). Two of these patients have undergone contralateral hip resurfacings for progressive pain from end-stage arthritis and had to be excluded.

All patients were found to have well-functioning resurfacings at 6-year follow-up. No patient complained of persistent pain or disability. The median 6-year Oxford hip score was 12. Urine chromium and cobalt at six years were 3.9 and 7.8 μg/24 hrs and blood levels were 1.11 and 1.17μg/l respectively. Both urine and blood levels show a statistically significant early increase reaching a peak six months to one year postoperatively followed by a steady decrease over the following five years, although the individual reductions are not statistically significant, except for blood chromium where the 4 and 6 year levels were significantly lower than the 1-year level.

Elevated systemic metal exposure following MM bearing arthroplasty continues to cause concern. Our results show that metal release in these bearings shows a reducing trend after an initial peak dispelling the fear that a steady build-up of in vivo metal occurs with progressively increasing blood levels. However, as long as the significance of these elevated levels remains unknown, the need for continued vigilance persists.


J. Morley C. Tzioupis H.C. Pape P.V. Giannoudis

Patients with a femoral shaft fracture requiring intra-medullary nailing were recruited to investigate if the femoral canal could be a potential source of inflammatory cytokines, previously implicated in the pathogenesis of life-threatening inflammatory complications.

Femoral and peripheral blood samples were obtained at the time of surgery from patients with a femoral shaft fracture requiring intramedullary nailing. The local femoral intramedullary and peripheral release of a group of ten Th1 and Th2 cytokines concentrations (IL-1b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, GM-CSF, TNF-a and IFN-g) after femoral shaft fracture and intramedullary reaming, if performed, was measured using a Human Cytokine Antibody 10-plex Bead Kit. A control group of patients(n=3) undergoing hip replacement was established to allow comparison with the normal femoral intramedullary cytokine environment.

21 patients with a femoral shaft fracture were recruited. Femoral shaft fracture caused a significant increase in the local femoral concentrations of IL-6 (median 3967pg/ml; range 128–25,689pg/ml) and IL-8 (median 238pg/ml; range 8–8,288pg/ml) compared to the femoral control group(p=0.0005 and p=0.001 respectively). No significant local femoral release of the other cytokines was demonstrated. In the patients who underwent intramedullary reaming of the femoral canal (n=6), a further significant local release of IL-6 (median post-ream 15,903pg/ml; range 1,854–44,922pg/ml) and IL-8 (median post-ream 1,443pg/ml; range 493–3,734pg/ml) was demonstrated (p=0.01 and p=0.03 respectively), thus showing that intramedullary reaming can cause a significant local inflammatory response.

Femoral shaft fracture produces a local inflammatory response releasing large amounts of the cytokines IL-6 and IL-8 into the local femoral environment but not of the other Th1 and Th2 cytokines studied. Reaming, produced significant elevation in local femoral IL-6 and IL-8 concentration, suggesting a local femoral response as a result of this procedure. Possibly, local femoral environment may act as a cell-priming or stimulating zone, for circulating inflammatory cells.


R. Rout S. McDonnell A. Hollander R. Davidson I. Clark D. Murray H. Gill P. Hulley A. Price

Our aim was to investigate the molecular features of progressive severities of cartilage damage, within the phenotype of Anteromedial Gonarthrosis (AMG).

Ten medial tibial plateau specimens were collected from patients undergoing unicompartmental knee replacements. The cartilage within the area of macroscopic damage was divided into equal thirds: T1(most damaged), to T3 (least damaged). The area of macroscopically undamaged cartilage was taken as a 4th sample, N. The specimens were prepared for histological (Safranin-O and H& E staining) and immunohistochemical analysis (Type I and II Collagen, proliferation and apoptosis). Immunoassays were undertaken for Collagens I and II and GAG content. Real time PCR compared gene expression between areas T and N.

There was a decrease in OARSI grade across the four areas, with progressively less fibrillation between areas T1, T2 and T3. Area N had an OARSI grade of 0 (normal). The GAG immunoassay showed decreased levels with increasing severity of cartilage damage (p< 0.0001). There was no significant difference in the Collagen II content or gene expression between areas. The Collagen I immunohistochemistry showed increased staining within chondrocyte pericellular areas in the undamaged region (N) and immunoassays showed that the Collagen I content of this macroscopically and histologically normal cartilage, was significantly higher than the damaged areas (p< 0.0001). Furthermore, real time PCR showed a significant increase in Collagen I expression in the macroscopically normal areas compared to the damaged areas (p=0.04).

In AMG there are distinct areas, demonstrating progressive cartilage loss. We conclude that in this phenotype the Collagen I increase, in areas of macroscopically and histologically normal cartilage, may represent very early changes of the cartilage matrix within the osteoarthritic disease process. This may be able to be used as an assay of early disease and as a therapeutic target for disease modification or treatment.


T. Spalding J. Farr B. Cole M. Brittberg S. Nehrer F. Almqvist A. Imhoff B. Mandelbaum T. Hosea J. Richmond

The Cartilage Autograft Implantation System (CAIS) is being developed as a potential alternative surgical treatment providing chondrocyte-based repair in a single procedure for articular cartilage lesion(s) of the knee. Two pilot clinical studies were conducted to assess safety and initial performance of the CAIS system.

CAIS involves preparation and delivery of mechanically morselized, autologous cartilage uniformly dispersed on a 3-dimensional, bio-absorbable scaffold, and fixated in the defect with bio-absorbable staples. The mechanical fragmentation of cartilage tissue both maintains viability of the chondrocytes and creates increased surface area, which facilitates the outgrowth of embedded chondrocytes onto the scaffold. A proprietary disposable, arthroscopic device for precisely harvesting viable, morselized cartilage tissue was used. Two pilot clinical studies conducted in the EU and US were designed to assess safety and initial performance of the CAIS. The studies treated 53 patients at 10 enrolling sites, with microfracture as a control. Subjects returned for follow-up visits up to 3 years. Subjects were clinically evaluated and interviewed for the occurrence of adverse events and asked to complete clinical outcome questionnaires, Knee Injury and Osteoarthritis Outcome Score (KOOS), regarding disability, function, pain and quality of life. In addition, MRIs were completed at baseline, 3 weeks, and 6, 12, 24, and 36 months.

The instrumentation enabled the successful preparation and fixation of morselized autologous cartilage tissue loaded implant in a single intraoperative setting. The CAIS device has demonstrated short-term safety in subjects treated to date. Preliminary data from the US pilot study at 12 months and EU pilot study at 6 months indicate that CAIS is safe and its performance based on KOOS clinical outcomes show improvement over baseline and comparability to microfracture. Additional data must be analyzed regarding long-term safety and performance.


K. Willett B. Gray A. Handa S. Lamb D. Coleman R. Handley

Impaired vascularity of the skin in elderly ankle fracture patients causes the skin and wound complications. This is part of a RCT comparing ORIF and close contact casting (CCC) for isolated unstable ankle fractures in patients > 60 years. Assessments over 6-months

trans-cutaneous O2 saturation (TcP02) of medial and lateral ankle skin

Ankle-Brachial Pressure Index (ABPI).

3-vessel arterial duplex scan

distal calf perforator artery patency.

The uninjured limb was the control.

Eighty-nine patients eligible; 59 participated (76% female). 30 randomised to ORIF; 29 to CCC. Each had one death and one withdrawal. Vascular data available on 55. Two patients had delays in wound healing (> 25% for > 6-weeks). Two further developed wound infections. No skin breakdowns in CCC group. There was a reduced TcP02 on day-3 in the injured limb. The TcP02 rose at 6-weeks compared to day-3 (medial 58mmHg; lateral 53mmHg, p=0.002) in the injured leg. At 6-months the TcP02 measurements were not different to uninjured leg. A critical TcP02 (< 20mmHg) found in 4, correlated with skin problems (p=0.003). Two of these had the only major delays in wound healing and one of the two wound infections.

94% of participants had normal ABPI’s (> 1.0). There was no difference between patients with or without an impaired ABPI (< 0.7 mm Hg) and wound problems (p=0.20).

There was no difference in patent perforators between the injured and uninjured (p=0.39).

Occult vascular insufficiency is present but at low incidence. ABPI and Duplex-US are insensitive for predicting infection or delayed healing. The ankle fracture injury does not disrupt the local perforators. TcPO2 is sensitive and specific for predicting skin problems. Impairment of skin oxygenation is transient. Current TcPO2 technology however is impractical as a clinical tool.


S. Coupaud K.J. Hunt A.N. Mclean D.B. Allan

After spinal cord injury (SCI) rapid muscle atrophy and extensive bone loss occur in the paralysed limbs resulting in increased fracture incidence (mostly at the epiphyses in the distal and proximal tibia and distal femur). We investigated whether re-introducing mechanical loading of the lower-limb bones in chronic SCI through exercise could induce bone formation, in accordance with Wolff’s Law.

We present cross-sectional data from the Scottish paraplegic population illustrating the time course of bone loss after SCI, and review case studies describing musculoskeletal changes following lower-limb exercise interventions in chronic SCI. Reference data were obtained from 47 subjects with SCI at neurological levels T2 to L2, ranging from 6 months to 40 years post-injury. We used peripheral Quantitative Computed Tomography (XCT3000, Stratec, Germany) to scan 4 sites in the tibia and 2 in the femur, and evaluated trabecular, cortical, and total bone data, and soft-tissue parameters. Here, we focus on trabecular bone mineral density (BMDtrab) at the epiphyses, which provides an indicator of bone integrity. The same scans were performed pre- and post-training in chronic paraplegics who undertook a period of lower-limb exercise training (body-weight-supported treadmill training (BWSTT) or electrically-stimulated leg cycle (FES-cycle) training); these results are reviewed.

The temporal pattern of bone loss is characterised by exponential decline in BMDtrab, reaching steady-state at 100 mg/cm3 in the distal tibia after 7 years and at 130 mg/cm3 in the distal femur after 3 years. A subject with incomplete SCI (18 years post-injury) showed an increase in BMDtrab in the distal tibia following 5-months BWSTT. In a separate study, subjects with complete SCI had varying responses to FES-cycle training.

Bone loss appears to plateau after 7 years post-SCI. The effectiveness of physical interventions aimed at reversing bone loss in chronic SCI seemingly depends on the details of the associated bone-loading patterns.


D. Cohen E. Chapman S. Sarkar M. Manning

Over 200,000 osteoporotic fractures occur in the UK annually. Patients with fragility fractures are at highest risk of further fracture, though preventative treatment has been shown to reduce subsequent fracture incidence. In 2005, the National Institute for Health & Clinical Excellence (NICE) recommended bisphosphonates as a treatment option in women over 75 years without the need for prior DEXA scanning (Technology Appraisal Guidance 87). We prospectively reviewed the medication of such patients who were admitted to our Trauma Unit to identify if the NICE guidance was being followed.

Over a three month period between May and July 2007, 54 women over 75 years old were discharged from our Trauma Unit having sustained an osteoporotic fracture. We prospectively reviewed their medication to identify if a bisphosphonate had been commenced by the General Practitioner and their discharge letters to their General Practitioners to see if it had been suggested to start one. 7 of the 54 women (13%) were already on a bisphosphonate and were therefore excluded.

Only one (2%) of the discharge letters (written by the Orthopaedic doctor to the General Practitioner) recommended commencing a bisphosphonate. 6 of the 47 patients (13%) had been started on a bisphosphonate by the General Practitioner.

Nice guidance from 2005 is clearly not being implemented in our area. A minority of patients will have contraindications or allergies to bisphosphonates (up to 1 in 4 patients as highlighted recently by the National Osteoporosis Society). Important deficiencies in local services have been identified, particularly with respect to communication between secondary and primary care. This study lead to an education initiative to ensure the Trauma department and our local General Practitioners were aware of the NICE guidance. A second prospective audit is currently being undertaken to assess the effect on our service.


A. Ng F. Adeyemo R. Samarji

Previous studies have demonstrated higher infection rates following elective procedures on the foot and ankle as compared with procedures involving other area of the body. Previous studies also have documented the difficulty of eliminating bacteria from the forefoot prior to surgery. The purpose of the present study was to ascertain that preoperative chlorhexidine bathing provide significant local flora reduction than placebo in elective foot and ankle surgery.

From October 2005 to October 2006, a prospective study was undertaken to evaluate 50 consecutive patients undergoing planned, elective surgery of the foot and ankle. 50 patients were prospectively enrolled and randomly assigned to have preoperative footbath with Chlorhexidine Gluconate (Hibitane) (Group 1) or placebo (Group 2). Culture swabs were taken from all web spaces, nail folds, toe surfaces and proposed surgical incision sites before the preoperative antiseptics bath, during the procedures and immediately completion of surgery.

50 patients were enrolled (mean age: 42.6 years; range: 19–85; F: M = 29:21). 25 patients are assigned to each groups. 100% bacterial isolation preoperatively in both groups prior to antiseptics bathing. In group1, bacteria grew on intraoperative culture in 60% cases and 0% in immediate post-operative culture. In group 2, 96% in intraoperative swab culture and 16% in postoperative swab culture. The intraoperative swab culture bacterial count is statistically significant (p= 0.002). The postoperative swab culture bacterial count is marginally significant (p=0.055) when comparing 2 groups. No complications were recorded in both groups.

These data indicate that chlorhexidine provides better reduction in skin flora than placebo. Based of these data, we recommend the use of chlorhexidine footbath as well as the surgical preparatory agent for the foot and ankle surgery.


D. Copas B. Rocos R. Fox T. Chesser

In January 2005, NICE published their guidelines on secondary prevention of osteoporotic fractures. This audit aims to assess our compliance with these in the outpatient setting.

The records of all new patients attending fracture clinic in a large teaching hospital, over a one month period, were reviewed. All patients who required screening or treatment for osteoporosis (females greater than 50 years old sustaining a fragility fracture) were reviewed at one year to assess compliance with the guidelines.

Of the 454 patients reviewed, 90 females over the age of 50 (19%) were identified. These were further subdivided into females between the age of 50 to 75 years (Group A, n=62) and those over 75 (Group B, n=28). The inclusion criteria was presence of a fragility fracture (Group A, n=30 and Group B, n=15). Group A was investigated with DEXA scans in only 26.7% (n=8). Of these, only six were managed as per NICE guidelines and compliant at one-year. Seven patients in Group B were subsequently treated with medical therapies, but only three were managed as per NICE guidelines and compliant. Therefore of the 45 patients included in the audit, only nine were managed appropriately at one-year (20%). One patient suffered a further fracture – who had been fully compliant with treatment.

NICE guidelines have been introduced to help the nation’s health using evidence based criteria. There has been no specific extra funding to enable the setting up of additional pathways and investigations for the targeted population. Even in a busy department where systems were implemented to follow the guidelines, the overall compliance with the pathway is less than a quarter. When new guidance is produced for healthcare, there should be advice, support and funding for their implementation.


B. Derbyshire P. Kay M. Porter

‘Force-closed’, tapered, polished, collar-less stems, (e.g. C-stem, Exeter), are designed to subside in response to expansion of the cement/bone complex over time. Above a certain threshold, distal migration may predict medium-to-long-term failure of ‘shape-closed’ stems. However, no such threshold exists for ‘force-closed’ stems, and these may continue to migrate after 3 years. We believe that the tendency towards stabilisation 2–3 years postoperatively, could be the best predictor of good long-term performance.

Twenty OA patients (12F, mean age 66.6 years) were recruited for primary hip replacement with beaded C-stem femoral components. Tantalum marker beads were injected into the proximal femur, and stems were inserted using CMW1 cement and the latest generation cementing technique via a posterior approach: 17, and a lateral, trochanteric approach: 3. RSA X-ray examinations were performed at 1 week, 6 weeks, and at 3, 6, 12, 24 and 36 months postoperatively. The UmRSA system was used to measure and analyse the radiographs. At 36M the mean stem centroid subsidence was 1.05 mm and had levelled off to a low rate. The mean internal rotation of 2.5° at 36M had not significantly changed during the final year (p = 0.08).

At 36M the mean posterior migration of the stem centroid was 0.54 mm (rate of 0.11 mm/y) and posterior migration of the femoral head was 1.66 mm (rate of 0.25 mm/y).

At 36M the mean subsidence rate was very low and the mean posterior migration was about one third of that reported for another RSA study of the C-stem. Although the mean internal rotation was greater than that reported for the Exeter stem, there was no significant change during the final year. These low rates of migration at 3 years are consistent with the good results found in clinical studies of this femoral component.


W. Khan A. Adesida S. Tew G. A. T. Hardingham

Bone marrow derived mesenchymal stem cells are a potential source of cells for the repair of articular cartilage defects. Hypoxia has been shown to improve chondrogenesis in adult stem cells. In this study we characterised bone marrow derived stem cells and investigated the effects of hypoxia on gene expression changes and chondrogenesis.

Adherent colony forming cells were isolated and cultured from the stromal component of bone marrow. The cells at passage 2 were characterised for stem cell surface epitopes, and then cultured as cell aggregates in chondrogenic medium under normoxic (20% oxygen) or hypoxic (5% oxygen) conditions for 14 days. Gene expression analysis, glycosoaminoglycan and DNA assays, and immunohistochemical staining were determined to assess chondrogenesis.

Bone marrow derived adherent colony forming cells stained strongly for markers of adult mesenchymal stem cells including CD44, CD90 and CD105, and they were negative for the haematopoietic cell marker CD34 and for the neural and myogenic cell marker CD56. Interestingly, a high number of cells were also positive for the pericyte marker 3G5. Cell aggregates showed a chondrogenic response and in lowered oxygen there was increased matrix accumulation of proteoglycan, but less cell proliferation, which resulted in 3.2-fold more glycosoaminoglycan per DNA after 14 days of culture. In hypoxia there was increased expression of key transcription factor SOX6, and the expression of collagens II and XI, and aggrecan was also increased.

Pericytes are a candidate stem cell in many tissue and our results show that bone marrow derived mesenchymal stem cells express the pericyte marker 3G5. The response to chondrogenic culture in these cells was enhanced by lowered oxygen tension, which up-regulated SOX6 and increased the synthesis and assembly of matrix during chondrogenesis. This has important implications for tissue engineering applications of bone marrow derived stem cells.


R. Verma R. Gardner E. Tayton R. Brown

Painful foot and ankle joints are often pointed out as an impeding factor for lack of mobility and weight reduction. There is an assumption that weight loss will occur after their surgery due to increased mobility. The current study aimed to evaluate the effect of surgery on post-operative body mass index (BMI) in patients who underwent mid-foot or hind-foot arthrodesis. Our secondary aim was to look at the effect of sex, pre-operative obesity and good pain relief (AOFAS> 80) on post-operative BMI.

All patients who underwent mid-foot and hind-foot arthrodesis between April 2005 and November 2006 were identified from the operating theatre records. Each patient’s BMI recorded pre-operatively was compared with that recorded at a minimum of 6 months postoperatively using the paired Student’s t-test.

There were 35 eligible patients. 3 patients were excluded because of multiple trauma and 1 patient died during the period of study. We had 31 patients with 33 procedures with a mean age of 61 years (range 41–80). There were 18 females and 13 males. It was found that there was a mean increase of BMI by 0.25 (95%CI of −.95 to.44; p-value=0.47). It was noted that BMI of patients in obese group (BMI> 30) increased post-operatively by 0.07 (95%CI of −1.52 to 1.66; p-value=0.92).

This study highlights the fact that there is no significant effect on BMI in obese patients after successful fusion surgery. The post-operative BMI is neither significantly affected by sex nor quality of pain relief.


E. Fawzy T. Harrison F. Dinah J. Alvey S.H. Palmer

The main surgical options for hallux rigidus include dorsal cheilectomy, arthroplasty and fusion. Compared to other surgical procedures dorsal cheilectomy involves relatively less bone loss, maintains joint motion and still leaves the potential for a further salvage procedure such as arthrodesis. The Manchester – Oxford Foot and Ankle Questionnaire (MOXFQ) has been endorsed by the British Foot and Ankle Society and recommended as a tool to measure surgical outcome.

The aim of this study was to prospectively follow-up patients following dorsal cheilectomy for hallux rigidus using the patient-reported outcome measure, the MOXFQ. Patients were deemed suitable for dorsal cheilectomy if they had symptoms of dorsal impingement (painful restriction of terminal dorsiflexion of the hallux), with absence of pain in the mid-range of passive movement (indicative of end stage arthritis), and dorsal osteophytes on radiographs.

Twenty five patients with a mean age of 62 years (range: 39 – 80 years) and comprising 17 females underwent dorsal cheilectomy for hallux rigidus. At a mean follow-up of 17 months (range 9–27 months), the mean MOXFQ score improved from 33/64 (95% CI: 27 – 38) pre-operatively to 9/64 (95% CI: 6 – 13) post-operatively. Eighty-four percent of patients had a clinically significant improvement in their walking domain, 68% in the social domain, and 59% in the pain domain of the MOXFQ. Four patients were deemed failures: three patients underwent subsequent arthrodesis for persisting pain, and one patient had no improvement in any domain of the MOXFQ.

In conclusion, this study has provided further evidence of the success of dorsal cheilectomy as a reliable treatment option for hallux rigidus. It has also demonstrated the sensitivity of the patient focused reporting instrument the MOXFQ in assessing surgical outcomes in foot surgery.


N. Maffulli A. Saxena A. Nguyen A. Li

The Achilles tendon is commonly operated on, but has associated wound complications, ranging from 7–14% in previously reported series larger than 100 cases. We report a retrospective review of one surgeon’s practice conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon. The study evaluated the incidence of infection, and other wound complications such as suture reactions, scar revision, hematoma, incisional neuromas and granuloma formation.

A total of 219 surgical cases were available for review (140 males, 70 females; average age at the time of surgery: 46.5 ± 12.6 years, range 16–75). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, with an overall complication rate of 22 of 219 surgeries (10.1%). There were no hematomas. Seven patients had additional surgery following their wound complications; some had simple granuloma excision, while one necessitated a flap. Patients with risk factors such as diabetes, smoking and Rheumatoid arthritis necessitating steroids were more likely to have a wound complication, (Fisher’s Exact Test, P=.03).

Complications with Achilles tendon surgery may be unavoidable. Suture granulomas may appear in a delayed fashion. Absorbable and non-absorbable suture can be implicated.


R. Kearney K. Dunn C. Modi M.L. Costa

A key factor delaying rehabilitation after a tendo Achillis (TA) rupture is gait abnormality. We quantified changes in planter pressures after a rupture of the TA in four groups of patients:

15 controls subjects, mean 40 years, with no history of lower limb abnormality

14 patients, mean 48 years, treated in a non-weight-bearing plaster cast

12 patients, mean age 45 years, treated with immediate weight-bearing in a ‘rigid’ orthosis.

14 patients, mean age 51 years, treated with immediate weight-bearing in a ‘flexible’ orthosis.

Mean and maximum peak planter pressures within the forefoot and heel were measured using in-shoe pressure pads two weeks after removal of the cast/orthosis; five gait cycles were recorded. The terminal stance and pre-swing phases were also measured as a proportion of the total stance phase of the gait cycle. One-way ANOVA was used to compare the difference in means between the groups.

The normal control group had less than 2% difference between the limbs on all of the measured parameters. The patients in the plaster cast and ‘rigid’ orthotic groups had significant deficits (p = 0.04 and < 0.001 compared to control) in mean peak forefoot pressures, implying weakness in the triceps surae. However, the patients in the flexible orthosis group had only an 11% deficit (p = 0.25 compared to control). All of the patients treated for a TA rupture had increased heel pressures but only the ‘rigid’ orthotic group had cadence abnormalities (p = < 0.001). This may be the result of abnormal motor patterns secondary to mobilising in the rigid orthosis.

This study highlights the gait abnormalities associated with triceps surae weakness following rupture of the TA. Accelerated rehabilitation using weight-bearing orthotics may alleviate some of these problems, but new designs for flexible orthotics may be required for maximum benefit.


M. Bhavikatti M.A. Bawarish

The role of joint preserving surgery for Rheumatoid Forefoot is being explored. This involves a Scarf osteotomy of the first Metatarsal along with shortening osteotomy of the lesser metatarsals.

This prospective study includes 49 patients (17 Bilateral; Total 66 procedures) with Rheumatoid Forefoot deformities who underwent Scarf Osteotomy of the First Metatarsal and Weil osteotomy of the lesser metatarsals. The minimum follow up was 33 months and the maximum follow up was 58 months with a mean of 43.95 months. All patients were evaluated clinically and radiologically. AOFAS score for forefoot was collected prospectively.

The majority (90%) were females with mean age of 56.1 years. There was a significant improvement in the HVA, IMA and SP. The AOFAS score improved significantly from a mean of 39.8 to 88.7(p=< 0.001). Subjective improvement was also noted with In our study patients rated their outcome as excellent in 51 feet (77.27%), good in twelve feet (18.18%) and as fair in three feet (4.54%). Before surgery no patient was pain free but 44 feet (66.66%) caused severe,19 feet (28.78%) caused moderate and 3 feet (4.54%) caused mild pain. After surgery 55 feet (83.33%) were pain free, 7 feet ((10.6%) caused moderate, 4 feet (6.06%) caused mild pain. Residual deformity in terms of recurrence of lesser toes varus deformity was reported in 5 feet (7.5%). Stiffness of toes was reported in 5 feet and 11 (16.7%) had some residual pain.

Forefoot joint preserving reconstructive procedure for rheumatoid forefoot is a reliable procedure and should be considered as a safe method for treating rheumatoid forefoot deformities. However in severe hallux valgus with radiological destruction of the first MTPJ we recommend a primary fusion. Therefore joint preserving surgery should be regarded as a complement to various surgical treatments of rheumatoid forefoot.


L. Hajipour P.E. Allen

Non-union is a potential complication following hindfoot arthrodesis and occurs at a rate of 5–10% as reported in the literature. Following the procedure, patients are usually kept non-weight bearing (NWB) for 6–8 weeks followed by protected full weight bearing (FWB) for further 6 weeks. Based on radiological and clinical evidence of bony union at 12 weeks patients are allowed to mobilise FWB without protection. The aim of this study is to evaluate the effect of early post operative weight bearing on the union rate, following hindfoot arthrodesis.

In this retrospective study data was collected on patients who had hindfoot arthrodesis from 2003 to 2008 by a single surgeon. Two post operative mobilisation protocols were used and the union rates were compared. Protocol 1: 6 weeks Non weight bearing (NWB), 3 weeks partial weight bearing (PWB), 3 weeks full weight bearing (FWB) in plaster. Protocol 2: 2 weeks NWB, 4 weeks PWB, 6 weeks FWB in plaster.

One hundred and twenty-nine hindfoot joint arthrodesis were performed in 73 patients. Non-union rate was 1% (1 in 95 joints) in early weight bearing group and 20% (7 in 34 joints) in late weight bearing group. Union rate following the revision surgery with bone graft was 100% in both groups.

Early weight bearing following hindfoot arthodesis is safe, provides a more comfortable mobilisation for the patient and has no adverse effect on the union rate.


B. Almazedi C. Smith D. Morgan G. Thomas G. Pereira

Antero-posterior (AP) pelvis and lateral x-rays are routinely prescribed for the positional diagnosis of proximal femoral fractures, however; the usefulness of the lateral x-ray has not been previously presented in the literature. In addition, the clinical advantage of internally rotated AP views has also not been tested. This study aims to define the value of the lateral x-ray, and the internally rotated AP view, in the assessment and treatment planning of proximal femoral fractures.

X-rays from 359 consecutive patients with proximal femoral fractures were divided into: ‘un-positioned’ AP (greater trochanter overlying the lateral femoral neck), clear neck AP (internally rotated to show the lateral femoral neck), and lateral views. Three blinded reviewers independently assessed the x-rays in sequence and noted the positional diagnosis and displacement. This was then compared with the intra-operative diagnosis used as gold standard.

The addition of a lateral x-ray to an AP view significantly increased the rate of the correct diagnosis made by the reviewers when compared to an AP view alone, in intracapsular fractures only (p < 0.013), but not for extracapsular fractures (p = 0.27).

The use of clear neck AP views did not increase the rate of correctly diagnosing the type of fracture when compared to unpositioned AP views. This applies for both intracapsular (p = 0.57), and extracapsular fractures (p < 0.823).

Although orthopaedic rote dictates that every fracture should be visualised in two views, this study has shown with that for the majority of hip fractures one view is adequate and safe. The lateral x-ray is only required for intracapsular fractures that appear undisplaced on the AP view and should not be performed routinely. Specially positioned AP views are not required and should be avoided due to the unnecessary pain caused and the needless cost.


M. Parker

The Targon Femoral Neck Hip Screw has been designed to improve the fixation of intracapsular hip fractures. The new implant consists of a small plate with six locking screw ports. The two distal holes are used to fix the plate to the lateral cortex of the femur. Three of four 6.5mm cancellous screws are passes through the proximal holes and across the fracture site. The proximal screws are dynamic to allow for collapse of the fracture across the femoral neck. A jig is used to aid insertion of the device with minimal surgical exposure of the femur.

For the first 91 patients treated with this implant, the mean age of the patients was 75 years (range 46–103). The mean length of surgery was 45 minutes. The median length of hospital stay till discharge home was 8 days). For the 43 undisplaced fractures there has been one case of non-union and one case of avascular necrosis. For the 48 displaced fractures (Garden III and IV) there have been five cases of fracture non-union and one case of plate detachment from the femur treated by repeat fixation. In addition there was one deep wound sepsis treated by removal of the implant and girdlestone arthroplasty.

Observation of those fractures that have healed shows there has been between 4 to 18mm of collapse at the fracture site which occurs along the line of the femoral neck. There has been no tilting of the fracture into varus as occurs with a parallel screw method.

The results to date show an incidence of fracture non-union that is about a third that which is to be expected with a parallel screw method. This new implant may be a significant advance in the treatment of this difficult and common fracture.


A.J.L. Jowett C.L. Birks M.C. Blackney

Medial malleolar stress fractures are uncommon even in the sporting population. They tend to occur almost exclusively in athletes involved in sports involving running and jumping. We believe that stress fractures of the medial malleolus may be the end stage of chronic anteromedial ankle impingement in elite running and jumping athletes. Anterior impingement spurs are thought to be caused by repetitive microtrauma at the limit of dorsiflexion causing subperiosteal haemorrhage and subsequent ossification. More specifically the lower surface of the anterior tibia and the anterior part of the medial malleolus undergo similar trauma during severe supination injuries. Repetitive trauma to the cartilage from the kicking action in soccer is also thought to play a part, the cartilage responding by the formation of scar tissue and subsequent calcification.

We present five cases of elite athletes (three AFLplayers, one sprinter and one A Grade cricketer) who presented to our establishment with vertical stress fractures of the medial malleolus over a three year period (2004–7). In each case preoperative imaging revealed an anteromedial bony spur on the tibia. All patients had the fractures internally fixed and at the same sitting had arthroscopic debridement of the impingement spur.

Average time to union was 10.2 weeks (6–16). At most recent review (average 18 months (8–37)) all fractures had united and all patients had resumed sporting activity. No patient had suffered a further fracture of the medial malleolus.

We believe this region of impingement causes premature abutment of the talus on the tibia in the supination-adduction motion that in severe trauma leads to the vertical fracture through the medial malleolus according to the Lauge-Hansen classification. We therefore feel it should be addressed at the time of fracture fixation to reduce the re-fracture rate.


M.R. Acharya S. Almedeghio W.M. Harper

It is has been suggested that as a result of the skewed age distribution, the incidence of hip fracture will increase disproportionately among Asians. The epidemiology of hip fracture among the Asian and White populations in Leicestershire the five year survival between the two groups was investigated.

All patients in Leicestershire with hip fracture between 2001–2 were studied. Demographic data, type of fracture, and treatment was recorded. Ethnic origin was noted as White, Asian, or other. Survival at 5 years was documented as number of days survived. The results were analysed statistically.

On thousand one hundred and thirty-four patients were admitted to our unit with hip fracture, 617 intracapsular fractures and 517 extracapsular fractures. Leicestershire Census data in 2002 showed that 85.7% of the population was white, 11.9% Asian and the remaining 2.4% of other ethnic group. The percentage of Asians > 65 years was 8.8% compared to 18.9% of whites. The number of Asian patients < 65 years with a hip fracture was significantly greater than the number of whites < 65 years (p =0.002, Fishers exact test). Five year survival of Asian patients < 65 years with hip fracture was significantly lower than white counterparts in the same age group (p = 0.002)

Over the last decade there has been a 30% increase in the Asian population in Leicestershire (9.3% to 11.9%). The proportion of Asians over 65 years doubled over the last decade from 4.3% to 8.8%. The proportion of Whites over 65 years increased from 16.3% to 18.9%. The 5 year survival of Asians with hip fracture under 65 years old is significantly reduced when compared to Whites. This suggests that Asians under the age of 65 years that sustain hip fracture may have other risk factors that may contribute to their earlier demise.


G. Abbas M. Taylor C. Diss S.B. Mostofi

Clinical management of ankle injuries often involves use of braces to provide pain relief and stability. Individuals with braced ankles may be at more risk of injury while turning. The aim of this study was to evaluate the biomechanical effects of one of the commonly prescribed pneumatic ankle braces on gait parameters while turning.

Three-dimensional gait data was collected using a 7 camera, VICON 612 (Oxford Metric, UK) motion analysis system (120 HZ) synchronised with a single Kistler force plate embedded in the floor and set at a sampling frequency of 600HZ. Sixteen retro-reflective markers were attached to anatomical landmarks on both lower limbs and pelvis using wig tape. In the case of the braced ankle, markers were attached on the brace over the respective body landmarks.

Out of ten trials, five were performed with and the other five without brace. Comparative results were produced between braced and un-braced ankle during turning at 90 degrees with the right foot landing on the force plate and turning right. Results show that use of brace is effective in reducing gross moments about the ankle joint even at the time of turning but it does not totally eliminate motion.

Both conditions showed different rotation moments at knee but hip rotation moments were not affected by the brace. Knee rotation moment without brace was mainly in internal rotation (0.301Nm/kg) towards the terminal stance phase and it reduced to 0.128Nm/kg by bracing the ankle.

A new type of turning strategy was identified where the subject pre-planned the turn in late swing phase before landing on the ground probably to avoid a fall. It is important that patients with ankle injuries receive supervised gait training to improve their turning confidence during their rehabilitation therapy.


T.M. Barton R. Gleeson C. Topliss W.J. Harries T. Chesser

Controversy exists whether to treat unstable pertrochanteric hip fractures with either intramedullary or extramedullary devices. A prospective randomised control trial was performed to compare the outcome of unstable pertrochanteric hip fractures stabilised with either a sliding hip screw (SHS) or Long Gamma Nail (LGN). The hypothesis was that there is no difference in outcome between the two modes of treatment.

Over a four year period, 210 patients presenting with an unstable pertrochanteric hip fracture (AO/OTA 31 A2.1/A2.2/A2.3) were recruited into the study. Eligible patients were randomised on admission to either LGN or SHS. Follow-up was arranged for three, six, and twelve months. Primary outcome measures were implant failure and implant ‘cut-out’. Secondary measures included mortality, length of hospital stay, and EuroQol outcome score.

Five patients required revision surgery for implant cutout, of which three were LGNs and two were SHSs (no significant difference). There was a significant correlation between tip apex distance and the need for revision surgery. There were no incidences of implant failure or deep infection. Mortality rates between the two groups were similar when corrected for mini mental score. There was no difference between the two groups with respect to tip apex distance, hospital length of stay, blood transfusion requirement, and EuroQol outcome score.

The sliding hip screw remains the gold standard in the treatment of unstable pertrochanteric fractures of the proximal femur.


S. Kalra A. Williams R. Whitaker M. Hossain A. Sinha G. Curtis M. Giles S. Bastawrous

Mortality after hip fractures in the elderly is one of the most important patient outcome measures. Sub-clinical thyroid dysfunction is common in the elderly population. This is a prospective study of 131 elderly patients with a mean (SD) age of 82.0 (8.9) years (range: 61–94) admitted consecutively to our trauma unit. The aim of the study was to determine the prevalence of sub-clinical thyroid dysfunction in an elderly cohort of patients with hip fracture and to determine if this affects the one year mortality.

There were three times more women (n=100) than men (n=31) in this cohort. All patients underwent surgical treatment for the hip fracture. The prevalence of sub-clinical hypothyroidism (TSH > 5.5 mU/L) was15% (n=20) and of sub-clinical hyperthyroidism (TSH < 0.35 mU/L) was 3% (n=4). Overall 18% (n=24) of patients had a subclinical thyroid dysfunction. The twelve month mortality was 27% (n=36).

Age, gender, heart rate at admission, pre-existing Coronary Heart Disease, ASA grade and presence of overt or subclinical thyroid dysfunction were analysed for association with twelve month mortality using a forward stepwise logistic regression analysis. Only ASA grade was found to significantly affect mortality at twelve months (c2 = 3.98, df = 1, p =.046). The presence of sub-clinical hypo or hyper – thyroidism was not associated with a higher mortality (p = 0.278).

We conclude that sub-clinical thyroid dysfunction does not affect the one year mortality in elderly patients treated surgically for hip fracture.


A. Lakdawala Y.M. Ho M. Blakemore

This study looks at the long-term outcome and morbidity following non-operative management of both-columns fractures (BCF) with secondary congruence.

A retrospective review was carried out of all both-columns acetabular fractures managed non-operatively from 1984 to 2004. Patients were clinically assessed using a modified Merle d’Aubigne (Matta’s modification) score and quality of life assessed using the SF-36 health survey. The results of the SF-36 scores for this group of patients were compared with the UK normative values and the student t-test was applied to compare the respective means. All these patients were managed according to the senior consultant’s protocol. Original acetabular radiographs were examined to confirm the classification had been correct. Late radiographs were inspected for the presence of union, avascular necrosis, non-union, secondary osteoarthritis (OA) and heterotopic ossification.

In the last 20 years, 57 patients have been managed non-operatively. 10 had died from unrelated causes and 16 were lost to, or declined follow-up. This left 31 patients available for assessment with at least 12 months following injury. The age at the time of injury ranged from 14 – 89 years. The majority of injuries were sustained in road traffic accidents.

The mean hip score was 15.5. 72% of the clinical scores were in excellent or good categories at the time of review. The SF-36 scores were not statistically significantly different from the normal population (P< 0.05). All fractures had clinically and radiologically united at follow-up. Surprisingly, there were no cases of heterotopic ossification or avascular necrosis. 4 patients developed secondary OA of the hip.

Most of the BCF demonstrate ‘secondary congruence’ after the injury assessed on Judet and pelvic radiographs. Good clinical outcomes with minimal complications can be achieved with conservative management of such fractures with secondary congruence, particularly in the older patients.


M.R. Acharya W.M. Harper

The literature is filled with reports of various studies identifying perioperative factors that adversely affect survival. The aim of this study was to identify perioperative factors associated with an increased risk of death at 5 years.

All patients admitted to our unit in 2002 with a proximal femoral fracture were included. Demographic details, physiological parameters and biochemical parameters on admission were documented. Survival data at five years was available for all patients and was used to perform survival analyses. 633 patients with a proximal femoral fracture were admitted to our unit between January 2002 to December 2002. Data for all patients was available for analysis. There were 118 men and 515 women, M:F =1:1.4. Average age of the patients was 81.2±9.4 years (range 45–105 years).

Univariate analysis showed that patient age, mental test score, number of days delayed to surgery, number of comorbidities, ASA grade, if the patient lived in an institution, had a previous stroke, suffered from congestive cardiac failure or valvular heart disease, heart rate, serum haemoglobin, serum urea and whether the patient developed a post operative complication were all significant factors that affected survival. Multivariate analysis showed that mental test score (Exp B=0.939 95%CI=0.901–0.978 p= 0.002), age (Exp B = 1.031 95%CI= 1.004–1.058 p= 0.025) and ASA grade (Exp B = 1.458 95%CI= 1.039–2.046 p= 0.029) were all independent variables that affected five year survival.

Various independent factors affect five year survival in patients with proximal femoral fracture. It is important that these factors are identified firstly, so that patients and relatives can be given information about survival and secondly, so that high risk patient groups can be allocated adequate resources in order that their peri and postoperative care is optimised. This may improve outcome in these subgroups of patients.


R. Cove S. Gupta S. Loxdale J. Keenan J. Metcalfe

An audit of fractured neck of femur patients indicated that the delay in acquiring an echocardiogram was delaying surgery (time to echo 5.4 days ± 3.4SD (n=72), time to surgery 7.5 days ± 5.5SD (n=72)). This instigated a change in policy with the introduction of routine ‘targeted’ echocardiography performed by a cardiac technician at the patient’s bedside.

A re-audit has demonstrated an improvement in service (time to echo 1.0 days ± 0.7SD (n=96), time to surgery 2.9 days ± 1.9SD (n=118)). A targeted echocardiogram consists of an evaluation of left ventricular function expressed as normal, mild, moderate and severe (left ventricular ejection fraction > 50%, 40–50%, 30–40% and < 30%), the aortic valve (normal, non severe aortic stenosis, severe aortic stenosis, aortic regurgitation and aortic gradient). A targeted echo gives less information than a departmental echo where more parameters are measured, however the information provided is enough to guide the anaesthetists choice of anaesthesia and intraoperative anaesthetic management. Senior Echo technicians perform the investigation at the patients bedside on the trauma ward in the mornings of the working week using a portable machine. Each echocardiogram takes 2 to 5 minutes to perform. If obvious significant other pathology is seen, the patient is referred for a full departmental echocardiogram.

A total of 28.4 patient bed days per month were saved following this change in practice, assuming days waiting for echo preoperatively equate to extra days spent in hospital. The total cost saving per month was £4435, based on the cost of routine targeted echocardiography (£10), departmental echocardiography (£60) and bed cost (£155 per night).

Expedient surgery within this group of patients should not be compromised by delays in obtaining timely echocardiography. The cost of routine ‘targeted’ echocardiography is low and this change in practice can be justified in both clinical and economic terms.


N. Briffa R. Pearce M. Bircher

The incidence of acetabular fractures within the UK is about 3 in 100,000 of the population per year. Since Letournel and Judet first proposed that operative reduction and rigid internal fixation of displaced fractures will likely lead to better outcome, operative management of such fractures has become standard management in major trauma centres. Long term outcome results following acetabular surgery have been reported sparingly.

Two hundred and fifty-seven displaced acetabular fractures underwent an open reduction and internal fixation at St. George’s Pelvic Unit between 1992 and 1997. All surgery was performed by a single surgeon. 161 patients were followed up prospectively for a minimum of 10 years. Those lost to follow up were excluded. Anthropometric data, fracture pattern, time to surgery, associated injuries, approach, complication and outcome recorded on a database. Modified Merle D’ Auberge score was utilized as outcome measures.

The mean age was 36 years (15 to 85). Road traffic accident was the commonest mechanism of injury. We observed simple fractures in 34 % and associated fractures in 66%. 52% suffered polytrauma. Average time to surgery was 11 days and anatomic reduction was achieved in 73.9%. Results were excellent 46.8 %, good 25.5 %, fair 7.5 %, and poor 19.2 %. Poor prognostic factors were increasing age, delayed surgery, poor reduction, and posterior column, transverse posterior wall and T-shaped fracture patterns.

Acetabular surgery poses a major challenge to the trauma surgeon. Complications in the immediate, mid and long term are not rare. Our results compare to other series with shorter follow-up. We believe that the gold standard treatment for displaced acetabular fractures must be open reduction internal fixation performed by a dedicated pelvic surgeon at the earliest time possible. Moreover whether we are merely postponing the inevitable post-traumatic arthritis is still unknown.


M.R. Dayton

Orthopaedic treatment of upper and lower extremities has traditionally been attended by specialists in specific areas of expertise; arthroscopy, biologic reconstruction, total joint replacement. In many specialty centers of the US and worldwide, procedures performed by specialists do not consistently coincide with subspecialty training. This is particularly true for hip surgery, where a majority of total hip arthroplasty (THA) procedures are performed by Orthopaedists that undertake less that 50 fifty such procedures annually.

With advances in knowledge and technique, surgical hip treatments have significantly progressed in recent decades. By all estimates, there is a need for specialized surgical treatment in this area, as the demand for hip replacement and revision is likely to far outpace that of population growth in the coming decades. Discreet categories of replacement versus preservation have become less clear, thus paving the way for an emerging specialty of exclusive hip surgery. The scope of such surgery encompasses an age span from the adolescent at skeletal maturity to elderly. Advances in hip arthroscopy have improved outcomes for young patients. Progressive data and knowledge have fueled biologic non-arthroplasty solutions in the hip such as osteotomy and surgical hip dislocation for femoral acetabular impingement. Development of limited replacement options such as resurfacing have also broadened the spectrum of treatments and added to the level of complexity in hip surgery. Total hip arthroplasty and revision numbers continue to climb annually. Combining preservation procedures with options for replacement and resurfacing, the hip specialty creates a continuum of medical care that may redefine the joint care paradigm.


R. Gilbert A. Carrothers J. Gregory M. Oakley

The St Leger total knee replacement is a bicondylar prosthesis developed as a cheaper alternative to other similar implants of its time. Between October 1993 and June 1999, 144 St Leger total knee replacements were implanted in 114 patients. The aim of this study was to clinically and radiologically assess these patients after a mean follow up of 10.22 years.

Between February and July 2007 ninety-one patients recalled for clinical evaluation (using functional and objective Knee Society Scores) and radiological assessment (using the Knee Society Scoring System). 11 patients had died and 12 were lost to follow up or were medically unfit to attend evaluation. Of the ninety-one patients recalled, 18 had had their prostheses revised (19 knees). 63% of prostheses had survived 10 years or more.

Of the patients with St Leger knees in situ (99 knees) the American Knee Scores showed 78% poor, 10% fair, 6% good and 6% excellent results. Radiological assessment identified 12 arthroplasties that had failed (5 femoral components, 5 tibial components and 4 patellae,) 58 that needed close follow up (18 femoral components, 31 tibial components and 38 patellae) and 29 that were well fixed. A best-case Kaplan-Meier cumulative survivorship was 87% at 10 years. (Worst-case was 71% at 10 years)

These 10 year results showed that the St Leger total knee prosthesis did not perform as well as other bicondylar prostheses of the same generation and had a higher revision rate. Despite favourable published mid-term results, the long-term results for the St Leger total knee replacement have shown it to be unreliable and not worth the initial financial saving.


S. White S. Jones A. John

From 2004–2006, in an attempt to reduce the waiting time for patients listed for total knee and total hip arthroplasty at Cardiff and Vale NHS Trust, 156 total hip replacements (THRs) were performed by Swedish Orthopaedic surgeons at an NHS treatment centre in England.

All patients were contacted and invited to a review appointment with a Consultant specialising in hip and revision hip replacement. Oxford Hip Scores and clinical and radiographic evaluation were performed. Patients who declined an appointment were sent a postal questionnaire. Radiographs were analysed for component position, radiolucent lines, medial floor breach, leg length discrepancy.

One hundred and thirteen hips were reviewed at a mean 23 month follow-up. The mean Oxford score was 26. Mean age at surgery was 69. Cemented THR was performed in 104 hips; hybrid in 7; cementless in 2. The Exeter stem and Cenator cemented cup were used in the majority of cases. 16% had acetabular inclination greater than 55 degrees. Radiolucent lines around the cup were seen in 76/113 hips. Femoral stem position was greater than 4 degrees varus in 47/113. Medial floor breach seen in 13/113. 10/113 had leg length discrepancy > 1cm. There were 3 dislocations, 1 femoral fracture, 1 pulmonary embolus, 3 deep infections, 2 superficial infections.

Revision surgery has been performed in 18/113 – the majority for a painful loose acetabular component. A further 5/113 have been recommended for surgery. The further surgery rate was 12% at 2 year follow-up.

The revision rate far exceeds the 0.5% 5-year failure rate reported in the Swedish Registry for the components used. This initiative has left a legacy of unhappy patients, and increased the workload required in our unit to correct the problems. The lack of long-term ownership of patients may be an important factor.


S. Williams C.L. Brockett C. Hardaker G.H. Isaac J. Fisher

Ceramic-on-metal (ceramic head and metal liner, COM) hip replacements have shown reduced wear in comparison to metal-on-metal (MOM) bearings. This has been attributed to reduced corrosive and adhesive wear, and differential hardness. The study assessed the performance of ceramic and metal bearings in different configurations under adverse conditions, ceramic heads on metal liners (COM) were compared to metal heads on ceramic inserts (MOC), with head on cup rim loading under micro-separation hip joint simulation.

Components used were made of zirconia-platelet toughened alumina (Biolox Delta) and CoCrMo alloy. Hip simulator testing applied a twin-peak loading cycle and walking motions with the prosthesis in the anatomical position. Testing was conducted in calf-serum for 2-million cycles. A standard simulator cycle was adapted, the head sub-luxed in the swing-phase forcing the head onto the cup rim at heel strike.

The overall mean wear rate for the MOC bearings (0.71±0.30mm3/Mc) was significantly higher than the wear rate for the COM bearings (0.09±0.025mm3/Mc). The contact of the head against the rim of the cup caused deep stripe wear on the metallic heads of the MOC bearings. This region on the head is exposed to high stress conditions and susceptible to damage in edge contact, the effect of this is increased when the cup is a harder material than the head. The wear of a metal-on-metal (MOM) couple under similar conditions was almost two-fold greater than the MOC couple (1.58mm3/Mc, Williams et al., 2006) providing further evidence of the reduced wear with COM in comparison to MOM.

The COM concept allows thin metal shells to be used with larger ceramic heads and protects against ceramic liner chipping. COM bearings are undergoing clinical trials, early data suggests reduced metal ion release in patients compared to metal-on-metal.


A. Prasthofer L. Unitt A. Sambatakakis

Indications for Total Knee Arthroplasty (TKA) include pain and disability. Correction of instability is essential to post operative outcome as instability is often a component of pre-operative functional disability, particularly in patients with valgus deformity. Soft tissue balancing is essential to the success of TKA. Anecdotally, patients with valgus deformity seemed to complain more of instability than pain. The aim of this study was to identify the role and significance of instability and determine whether patients with instability benefit more from TKA as it is useful to determine which patient characteristics will predict success in TKA.

Five hundred and two patients aged 45–90 years underwent 522 Kinemax TKAs, performed by seven surgeons in five centres between October 1999 and December 2002. Soft tissue releases were recorded and objective soft tissue balance recorded using a ‘balancer’ device. Independent observers assessed patients using 3 outcome measures including the American Knee Society Score (AKSS) for a minimum of 12 months. Pre-operative alignment was divided into 6 groups according to the degree of varus or valgus deformity (mild, moderate, severe varus or valgus). Specific components of the AKSS including pain scores, knee scores and medio-lateral stability scores were specifically analyzed.

There is a significant difference in the improvement of the knee scores between the severely valgus knees and all varus knees (ANOVA p=0.000). Significant differences were found between pre-operative pain scores, knee scores and medio-lateral stability between severely varus and severely valgus knees (ANOVA p=0.029, p=0.000 & p=0.000 respectively).

Knees with severe valgus deformities have significantly worse pre operative scores and show greater improvement with equivocal post-operative outcome, when compared to those with severe varus deformity. We believe that this significant improvement is due to the fact that both key issues in the severely deformed valgus knee, namely pain and instability, have been addressed.


R. Mohammed A. Unnithan D. Kaustubh M. Bansal T. Jimulia M. Green D. Learmonth

The results of a multi-surgeon, multi-implant series of patellofemoral joint arthroplasty performed over a ten year period are presented. All patellofemoral joint arthroplasty performed from the years 1996 to 2006 were retrospectively reviewed using case notes, radiographs and clinic appointments until their latest follow-up period.

101 arthroplasties in 91 patients were followed up for average period of 48 months (range 6–96 months). The average age was 57 years with female patients thrice as common as male patients. There were 5 (5%) complications with 1 deep infection and 4 stiff knees. 35 subsequent procedures were performed in 28 patients including arthroscopic debridement in 18, arthroscopic lateral retinacular release in 8, tibial tuberosity transfer in 3, manipulation for stiffness in 2, and revision to total knee arthroplasty in 4 patients (3 for progression of tib-iofemoral osteoarthritis and 1 for infection).

The necessity of further surgeries in one third of the study group suggests that close follow-up of these patients is needed to address any concerns that can be easily resolved.


P.V. Giannoudis V. Veysi C. Paliobeis N. Kanakaris I. Barlow

Our aim was to investigate the incidence and outcome of chest injuries after blunt trauma in patients admitted in a level I trauma centre over a 6-year period. This is a review of prospectively collected data (1996–2002); part of the (TARN-UK) data. Patients divided in 6 subgroups based on the chest AIS. Univariate analysis identified factors predicting mortality and a backward stepwise logistic regression multivariate analysis determined relationships with outcome.

There were 1,164 patients with chest injuries. The mean overall severity of chest injuries was 3.15+/−1.01. The commonest mechanism of injury was RTAs (57.01%). Rib fractures were the most common injuries (395 patients, 34%) associated with lung contusions in 12.9%. Admission GCS was highest in chest-AIS subgroup 2 and was significantly higher in groups 1 and 3. Complications, invasive operations, and investigations were more common with increasing chest-AIS. The ICU-admissions and the mean length-of-stay were similar for chest-AIS1 and 2, but significantly higher for the rest. Half of the AIS1 patients had associated head injuries; the lowest percentage was in subgroup 2 (18.8%). There was a variable correlation of abdominal injury severity with severity of chest injury. There was a significant difference in mortality rates between group 2 and group 1 and -3. The average time to death in those with chest-AIS1 was significantly lower than the average time in those with AIS4 and 5.

Patients in the higher AIS groups had both a higher overall ISS and mortality rate. Minimal chest injury severity (AIS1) showed higher ISS and significantly higher mortality compared with chest-AIS2,3. This has been attributed to the fact that the chest is spare as most of the impact during the course of the accident is been absorbed by the head (head injury). This theory also explains the shorter time period of death seen in patients belonging to the chest AIS1 group.


K. Rourke L. McGonagle B. Bolton-Maggs

The Rotaglide+ knee arthroplasty was introduced in 2000 as a successor to the Nuffield and Rotaglide knees. Both prosthesis were used in our unit and data was collected prospectively on sex, diagnosis, range of motion, pain score and American knee association score (AKSS). All operations were done under the care of one Surgical team (BBM) using the same instrumentation and the same pathway. Between 1987 and 2000 444 primary Nuffield were performed. 278 primary Rotaglide+ knees between 2000 and 2006.

65% of Nuffields implanted were in female candidates and 55% in the Rotaglide+. 75% of Nuffields were performed for Osteoarthritis, 69% in the Rotaglide+, this reflects the authors growing interest in inflammatory arthritis. Pre-operative functional range of motion and pain scores were similar. Both series showed a significant and sustained improvement in pain score, and walking time. Similar improvement was seen in range of motion. Comparison of the two series showed the Nuffield knee scored better on AKSS at year’s one and two and on pain score at year one but other than this outcomes were similar for both series. Revision rate in the Nuffield series is 9% at 25 years and in the Rotaglide+ series 4% at 8 years. This compares favourably with other published knee series’.

Despite being introduced as an improved design the Rotaglide+ fails to demonstrate any improvement in function and pain compared to its predecessor the Nuffield knee. Knee surgeons need to maintain a healthy cynicism of manufacturers ‘improved’ implants.


P. Kanabar A.D Patel

Our aim was to analyse radiological outcome of proximal humerus fractures treated with Philos plate and to assess its usefulness in treatment of malunion and non-union.

Seventy-seven patients were treated with Philos plate (24 men and 53 women). Mean age was 61 years (15–88). There were 66 acute fractures, 6 nonunion, 4 mal-union and one periprosthetic fracture. Acute fractures included 29 two part, 30 three part and five 4 part fractures. Seven had associated dislocation. There were two head splitting fractures. Deltopectoral approach was used in all. No acute fractures were bonegrafted however all nonunions had bonegraft.

Postoperative radiographs were available for review for 59. Average union time was 12 weeks (8–24). Satisfactory union occurred in 51 (86.4%). Twenty-three (39 %) fractures had inadequate reduction. Malplacement of plate was observed in 25 (42%) leading to significant malunion in 11.8%. Satisfactory union was occurred in all of last 30 patients. Nonunion occurred in 2 with infection in one. Other complications included screw penetration into glenohumeral joint, avascular necrosis, screw backing out and tuberosity detachment. Philos plate fixation was used for treatment of 6 nonunions, 4 malunions and one periprosthetic fracture with satisfactory outcome in all.

Relatively high rate of complications was observed in early cases in this series. This could be attributed to the steep learning curve with this technique. Emphasis should be put on careful and adequate reduction of fracture and optimal placement of plate (about 8 mm from the tip of tuberosity) to avoid impingement and to achieve correct screw placement in the humeral head.

In conclusion, Philos plate has been of benefit in management of complex fractures as well as management of non-union of proximal humerus. Quality of reduction and optimal placement of plate appear to be the two most important parameters for a successful outcome.


W. Eardley M. Stewart

Shoulder Instability impacts on the ability of military personnel to fulfil their operational role and maintain sporting competence. Magnetic Resonance Imaging (MRI) and Arthrogram (MRA) are increasingly available as diagnostic adjuncts. We analysed MR reports from personnel undergoing stabilisation, correlating clinical diagnosis with operative findings and reviewed the literature in order to recommend improvements. We report a retrospective, consecutive case note analysis of 106 personnel undergoing open anterior capsulolabral reconstruction (ACLR) by a single surgeon.

Seventy patients had MR (48 MRA, 22 MRI). Commonly reported pathology included Hill Sachs Lesions (41%), Soft tissue (59%) and bony Bankart lesions (16%), capsular laxity (20 %), supraspinatus lesion (20%), ACJ disease (13%) and SLAP tear (12%). The sensitivity of MR for identification of labral lesions was 82% with a specificity of 86%. For bony glenoid lesions, sensitivity was 63% and specificity 94%. Disparity between report and operative findings occurred mainly in standard MRI. Patients with lesions unrelated to instability achieved a pain free functioning shoulder following stabilisation. 100% of patients referred for ACLR with clinical evidence of instability without MR had positive pre-operative and operative correlation with instability. In 5 cases, the original equivocal MRI was repeated by MRA due to clinical suspicion of instability. In all cases the repeat MRA correlated with pre-operative and operative findings of instability. In 5 cases with equivocal clinical findings, MRA provided confirmation of instability. Delay in referral due to scanning and follow up ranged from 0 – 15 weeks.

The diagnosis of those instigating referral is accurate. Reporting of MR is open to variation and has cost implications. MRA performed by a radiologist with a musculoskeletal specialist interest is recommended on an individual basis only and routine use of non-arthrographic studies should be discontinued. This will improve the efficiency of the fast track pathway.


M. Raglan J. Chandrasenan F. Maclean J. Kurian D. Clark

The literature shows that interscalene anaesthesia (ISA) offers many advantages over general anaesthesia(GA) for arthroscopic surgery. There are benefits intra-operatively, a decrease in post-operative complications and a decrease in hospital stay. However patient satisfaction and acceptance of interscalene anaesthesia has not been fully assessed. We wanted to prospectively assess patient choice and satisfaction with interscalene anaesthesia compared to general anesthesia.

Fifty patients undergoing subacromial arthroscopic decompression and suitable for either anaesthetic technique, were prospectively identified between August and December 2006. The anaesthetic team discussed the pros and cons of general anaesthesia versus interscalene anaesthesia and the patient choose the type of anaesthesia. The same anaesthetic team and senior author managed and operated on all the patients in the study. Post-operatively patients filled out a questionnaire, which assessed patient choice, experience and satisfaction with type of anaesthesia undertaken.

Forty-sic patients successfully completed the questionnaire (27 female, 19 male, average age 59). Seventy-six percent of patients felt that they really understood the pros and cons of each anaesthetic type. Seventy-eight percent of patients felt that they really had the choice in determining their anaesthesia. Twenty-six choose ISA and twenty choose GA. Post-operative complications were less in the ISA group versus the GA group; pain(5.23ISA, 5.75GA), nausea(11%ISA, 35%GA), vomiting(0 ISA, 1GA), and drowsiness(19% ISA, 70%GA). Hospital stay was shorter in ISA patients compared to GA patients. All patients claimed to be satisfied with their choice and none would in retrospect change it.

Patients who choose interscalene anaesthesia had less post-operative pain, nausea, vomiting, drowsiness and shorter hospital stays then those patients who choose general anaesthesia for their shoulder surgery. This is consistent with the literature. All patients claimed to be fully satisfied with their hospital experience irrespective of the type of anaesthesia undertaken and none would have chosen differently.


M.N. Choudhry N. Malik T. Khan

The position of the gastrocnemius tendon relative to the calcaneus and fibular head distance may be different in children with cerebral palsy (CP) when compared to normal children. However, no such data is available. Usually, palpation of the muscle bellies or previous experience of the operating surgeon is employed to place the surgical incision. Inaccurate localisation may cause incorrect incision and a risk of iatrogenic damage to the vital structures (i.e. sural nerve). The aim of our study is to compare gastrocnemius muscle length in-vivo between paretic and unaffected children and suggest a formula to localise muscle-tendon junction.

Ten children with di/hemiplegia (seven females and three males; mean age 8y 7mo, range 2–14y) were recruited. None of them had received any conventional medical treatment. An equal number of age/sex matched, typically developing children (mean age 9y 1mo, range 4–14y) were recruited. Participants lay prone on an examination plinth with their feet hanging from its edge. Sagittal-plane ultrasound scanning of the gastrocnemius muscle at rest was performed to measure the length of gastrocnemius bellies. We also measured the heights, lower leg lengths, thigh lengths and leg lengths.

At similar age, the lower leg lengths in CP patients were shorter than normal children. Similarly, gastrocnemius medial (GM) muscles were shorter in CP children when compared to similar aged normal children. In CP children, the GM muscle and lower leg ratio ranges between 35 to 50% with an average ratio of 45%. When compared to leg length, the ratio is 22%.

Using these figures we created a formula that may be used clinically to identify the tendon for open or endoscopic lengthening and also to make simple and accurate localisation of GM-tendon junction for surgical access. This minimizes the risk of iatrogenic neurovascular injuries and decreases the length of the surgical incision.


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U. Rethnam R. Yesupalan R. Nair

There is a high incidence of ipsilateral knee injuries with the Floating knee, which makes these fractures even more challenging to manage. We present the impact knee injuries have on the final outcome of the floating knee. We propose a protocol for assessment & management of knee injuries with the Floating knee.

This prospective study included 29 patients with floating knee injuries. Knee injuries encountered were divided into bony, ligamentous and soft tissue. Bony injuries were assessed with radiographs and managed surgically along with the floating knee injury. Patients were assessed clinically for knee ligament injuries after fixation of the fractures intra-operatively and managed surgically. Soft tissue injuries around the knee were managed conservatively. Final outcome was assessed using the Karlstrom criteria.

Ten of the 29 patients had knee injuries: 3 patella fractures, 2 anterior cruciate ligament injuries, 1 posterior cruciate ligament injury, 1 medial meniscus injury and 3 extensive soft tissue injuries. The complications were knee stiffness and superficial infection. The end results according to the Karlstrom criteria were Good – 6, Acceptable – 1 and Poor – 3.

The associated knee injury in the floating knee is an important prognostic indicator. Soft tissue injury seems to have a very poor prognosis. We propose clinical evaluation of the knee after fixation of the fractures, surgical management of ligament & bony injuries and a proper rehabilitation programme to improve outcomes.


S. Fogerty E. Tsiridis V.S. Nikolaou N.K. Kanakaris P.V. Giannoudis

Our aim was to assess the outcome of the treatment of Segmental fracture of the humerus in adult patients.

From January 1994 to December 2003, 24 (17 females) consecutive adult patients with segmental humeral fractures were treated in our unit. Segmental fracture was defined as a two-level humeral fracture with at least one intermediate segment (AO type 12C). The mean age of the patients was 56.5 years(range 29–95) and the mean ISS was 14.1(range 9–29). The causes of injury included 8 vehicular accidents, 15 falls from heights, and 1 skiing injury. Thirteen patients had associated injuries. Three fractures were open (1 grade II, and 2 grade IIIA). At final follow up all patients were assessed in terms of radiological result and functional capacity (range of motion).

The mean follow up was 36 months (range 24–60). There were 5 radial nerve palsies. Seven cases involved 4 fracture segments. The mean length of segment was 7 cm (range 5–16). All fractures but 5(20.8%) progressed to union (1 infected non-union, 1 hypertrophic after ex-fix, 1 atrophic after stabilization with rush pins, one was associated with failure of fixation proximally and required hemiarthroplasty). The mean number of procedures to achieve union in total was 1.6(range 1–3). There was one implant failure and one persistent non-union. At final follow up, the mean abduction was 1100 (900–1400) and the mean forward flexion was 1200 (1000–1500). Internal external rotation was 700 (50–90) and 250 (20–45).

The risk of non-union is as high as 20.8 % and additional procedures often required to achieve union of the fragments. The method of stabilization depends on several factors including fracture configuration, the available bone stock and the surgeons’ expertise. Despite the severity of this injury a satisfactory outcome can be expected.


M.S. Ballal C. Bruce S. Nayagam

Gradual correction of periarticular deformities has necessitated the application of external fixators to accomplish the task. By contrast, such deformities when treated by acute correction are most often stabilised using internal fixation. Hemi-epiphyseal arrest, by stapling or transphyseal screw is a disadvantage by being an irreversible process which has to be delayed until later childhood. This study describes the preliminary results of using an alternative internal device which corrects angular deformity by acting as a tension band on one side of the growth plate.

Twenty nine consecutive patients with significant coronal plane deformities in the lower limb were treated using the guided growth technique. This was accomplished through the extra-periosteal application of a 2-hole plate and screws (the 8-plate, Orthofix SRL, Verona). The plate was left in-situ and the patient monitored at regular intervals until the desired correction of the mechanical axis was accomplished. Plate removal was undertaken if the child was not skeletally mature at completion of treatment.

Eighteen males and 11 females completed treatment and had their plates removed. The age of patients ranged from 5 to 14 years (average 11.5 years). There were 23 patients with genu valgum deformity with an average deformity of 9.8 degrees, and 6 patients with genu varum deformity with an average deformity of 29.9 degrees. The follow up period averaged 12.5 months from plate removal. The average duration of correction was 15.8 months. The overall rate of correction was 0.87 degrees per month. Two complications were recorded: plate migration in one patient and deep infection in another patient. We had one case of rebound deformity.

The guided growth technique using the 8-plate is a simple and safe procedure for the treatment of lower limb angular deformity which produces temporary physeal arrest.


S.N. Maripuri S. Joshy D. Goricha K. Mohanty

The knowledge of actual extent of the fracture in cases of isolated greater trochanteric fractures has paramount importance in decision-making. MRI has been the most common investigation to detect the intertrochanteric extension. However, to date there is no plain radiographic or MRI criteria to decide which fractures need surgery and which could be managed non-operatively. The aim of our study-was to assess whether the angle and the extent of the greater trochanteric fracture measured on plain radiographs could be used to predict the intertrochanteric extension.

We reviewed plain radiographs of 23 patients with isolated greater trochanteric fractures who also had MRI scans. We considered two parameters

extent of fracture in percentage along the intertrochanteric line and

angle of the fracture line. We compared these plain radiographic findings with those of MRI scans and established plain radiographic criteria to predict intertrochanteric extension.

Out of 23 patients, MRI scans revealed intertrochanteric extension in eight and they underwent surgical stabilisation. All these eight fractures had a fracture angle of 45° or less and the percentage of fracture extent of > 40%. All the 15 fractures with a fracture angle of > 45° did not show intertrochanteric extension on MRI scan. The mean angle of the fracture in those with MRI proven intertrochanteric extension was 33.5° (range 20°–45°) and in those with no intertrochanteric extension was 55.7° (Range 25°–125°). The mean percentage of length of fracture across the intertrochanteric line was 61.1% (47%–73%) and 39.6% (27%–62%) respectively.

We conclude that those isolated greater trochanteric fractures, with a fracture angle of more than 45° are unlikely to have an intertrochanteric extension. Those fractures with an extent of more than 40% and fracture angle less than 45° are likely to show inter trochanteric extension.


A. Imbuldeniya A. Liddle D. Hunt

Anterior Cruciate Ligament (ACL) injuries are increasing in prevalence amongst younger patients. Concerns exist as to the possibility of growth impairment due to transphyseal reconstruction techniques. However, due to the poor results of conservative treatment, reconstructive procedures have been employed to improve the outcome of these injuries. A growing body of evidence supports the safety of transphyseal reconstruction in older children. This study evaluates the safety and results of these techniques in younger patients.

Between 1999 and 2006, 17 patients of Tanner stage 1 or 2 underwent unilateral transphyseal ACL ligament reconstruction, using ipsilateral, four-strand hamstring grafts. Patients were aged between 9.5–14.0 years (mean, 12.1 years), and were followed up for a minimum of two years and a mean of 44 months (range 25–100 months). Graft survival, functional outcome and complications were recorded.

There was one graft failure after re-injury (6%). Of the remaining patients, all reported a good or excellent result and a normal IKDC score. Mean postoperative Lysholm score was 97.5 ± 2.6, mean Tegner activity scale was 8.1 ± 0.8 pre-injury, 4.2 ± 1.0 post-injury, and 7.9 ± 1.4 post-operatively. One patient had mild valgus deformity which caused no functional disturbance; otherwise examination was normal in all patients. There were no leg length discrepancies and KT1000 arthrometer measurements showed no significant difference between normal and operated legs.

Based on the results of this series, transphyseal reconstruction appears to be a safe option for the treatment of anterior cruciate ligament injuries in the young child.


C.W. McBryde E. Shears P.B. Pynsent R.B.C. Treacy

We report the survival at ten years of 173 consecutive Birmingham Hip Resurfacing’s implanted between August 1997 and August 1998 at a single institution. Failure was defined as revision of either the acetabular or femoral component for any reason during the study period.

The survival at the end of ten years was 96.5% (95%c. i. 89.1 – 99.5%) The mean age of the patients at implantation was 50 years (range 15 – 75). There were 124 (72%) male cases and 49 (28%) female cases. 123 (71%) cases had the diagnosis of osteoarthritis, 9 osteonecrosis, 5 rheumatoid and 3 DDH. The posterior approach was used in 154 (89%) cases and anterolateral in 19 (11%). Cases were performed by 5 different surgeons.

There were 5 revisions, 9 unrelated deaths and 18 were lost to follow-up beyond 5 years. Two revisions occurred for infection (6 months and 2 years). A revision at 3.5 years for acetabular loosening and two further at 6.4 and 7.9 years due to avascular necrosis of the femoral head and collapse were performed. No other revisions are impending. The median pre-operative oxford hip score was 61% (IQR 48–73) and the median 10 year score was 7% (IQR 0–31) for 110 completed forms.

Further analysis of the total resurfacing database at this institution of 2775 cases was performed. Cox-proportional hazard analysis identified that component size and pre-operative diagnosis were significantly associated with failure. Although females may initially appear to have a greater risk of revision this is related to differences in the size and pre-operative diagnosis between the genders. This study confirms that hip resurfacing using a metal-on-metal bearing of known provenance can provide a solution in the medium term for the younger more active adult who requires surgical intervention for hip disease.


S. Jameson D. Langton T. Joyce J. Webb A. Nargol

Metal ion concentrations following metal on metal hip resurfacing arthroplasty remain a concern. Variables associated with increased metal ion concentrations need to be established. This study provides metal ion data from a consecutive cohort of the first 76 patients implanted with a fourth generation hip resurfacing prosthesis.

All patients agreed to post-operative blood metal ion sampling at a minimum of one year. Post-operative radiographic measurements of cup inclination and anteversion were obtained using the EBRA software. Mean whole blood chromium (Cr) and cobalt (Co) concentrations in patients receiving the smallest femoral implants (Ł51mm) were greater than in the patients implanted with the largest prostheses (ł53mm) by a factor of 3 and 9 respectively. Ion concentrations in the small femoral group were significantly related to acetabular inclination (R=0.439, P< 0.001 for Cr, R=0.372, P=0.004 for Co) and anteversion (R=0.330, P=0.010 for Cr, R=0.338, P=0.008 for Co). This relationship was not significant in the large implant group. Mean Cr and Co concentrations in patients with accurately orientated cups (inclination < 45°, anteversion < 20°) were 3.7μg/l and 1.8 μg/l respectively, compared to 9.1μg/l and 17.5μg/l in malaligned cups.

A reduced surface contact area caused by cup malalignment may increase contact stresses, resulting in a high wear rate if fluid film lubrication is inadequate. Improved fluid film lubrication has previously been found in larger heads in vitro. Accurate acetabular component positioning is essential in order to reduce metal ion concentrations following hip resurfacing.


A. Qureshi A. Roberts

The purpose of this study was to assess the Interobserver Reliability of the Sauvegrain Skeletal Age Assessment.

Elbow radiographs requested to exclude injury were anonymised. Sixteen examinations were assessed by ten independent orthopaedic specialist registrars or consultants. The Sauvegrain method as modified by Dimeglio was used to score the radiographs. The observations made were then assessed for interobserver reliability by means of a multiple observer Kappa score and the total scores by intra-class correlation coefficient.

Kappa scores for the components of the score were 0.403 for the lateral condyle; 0.492 for the trochlea; 0.354 for the proximal radius and 0.508 for the olecranon. Adding item scores to produce a modified Sauvegrain score had an intraclass reliability of 0.858 (95% CI 0.758 to 0.935).

Methods of identifying skeletal maturation and predicting future growth generally depend on the use of an atlas of hand radiographs. Difficulties with poor interobserver reliability associated with these methods has led to a move towards assessments that do not depend upon bone age estimations. Unfortunately plans based on ratios of growth or average patterns produce errors when unusual types of growth disturbance are present. We conclude that use of a scoring system for maturation assessed by elbow radiographs offers a significant advantage when substituted into the straight line method of growth prediction. The Sauvegrain method as modified by Dimeglio1 has demonstrated an excellent level of inter observer reliability. We have used Sauvegrain scores to improve the accuracy of timing when using the Mosely straight line method.


M. Rae S. Jameson N. Wilson

Tarsal fractures are rare in children. Clinical and radiographic evaluation of these injuries can be difficult. We present a retrospective study documenting all tarsal fractures presenting to an inner-city children’s hospital in the UK over a fifteen year period.

Of 70 case notes retrieved from the hospital database, 7 patients were excluded due to inadequate data. This resulted in 69 tarsal injuries in 63 patients being included. Mean age at presentation was 9.3 years (2.5 – 13.9). 80% were male. 72% were calcaneal fractures, 12% cuboid, 9% navicular, 4% talus and 2% medial cuneiform. The main method of diagnosis was plain x-rays. Cause of injury was predominantly fall from height, crush or road traffic accident. 25% had another associated lower extremity injury. Three patients had bilateral tarsal injuries. Only 3% had upper limb injuries and there were no injuries with spinal involvement. Calcaneal fractures were treated with a short leg cast for a mean time of 4.1 weeks (2–6). Mean time to recovery was 5.7 weeks (2–20). Mean time to discharge from clinic was 7 weeks (2–40). There were two patients with open fractures requiring surgical debridement. One patient with a talar fracture had percutaneous fixation. Only one patient re-presented with pain following discharge. X-rays showed healing avascular necrosis of the proximal talus.

Tarsal fractures are rare, usually benign and most require simple immobilisation for only a short period of time. Surgical intervention is only occasionally required in complex injuries. Complications and long term problems are rare, even following open injuries.


D. Langton S. Jameson T. Joyce J. Webb A. Nargol

This report documents the clinical and histological findings, the operative management and the explant analyses of patients with early aseptic failure of large metal-on-metal (MonM) bearing joints.

Three hundred and fifty patients have been implanted with the ASR bearing surface (resurfacing or a modular THR) by a single surgeon at an independent centre since 2004. Six patients (all female) have been revised secondary to aseptic failure. All complained of severe groin pain exacerbated by straight leg raise and routine investigations were unable to establish a cause. Large amounts of sterile, highly viscous green fluid were aspirated from the hip joints in each case. Gross swelling of the pseudocapsule and a similar green fluid surrounding the implants were found at revision surgery. Histological examination of periprosthetic tissue samples showed changes consistent with ALVAL/metallosis, and analysis of the fluid revealed dense numbers of inflammatory cells. Symptoms in patients revised to ceramic-on-ceramic bearings improved post operatively. This was not the case with those reimplanted with MoM joints. Data from a subset of 76 patients (all unilateral resurfacings) showed that malaligned cups (anteverted > 20° +/− inclination angle > 45°) were associated with significantly higher whole blood metal ion levels than cups positioned within this range. All the patients with early aseptic failure had malaligned cups. Independent explant analysis revealed significant increases in the surface roughness values of the articular surfaces.

Our results suggest that some patients develop a significant inflammatory reaction to metal implants. This may be due to high levels of metal debris around the implant as a result of accelerated wear. Poor component alignment was found in all our patients with early aseptic failure.


A.M.H. Latif T.G. Kavanagh R.E. Field

Adverse bone remodeling in the proximal femur may be detrimental to the long term survival of resurfacing prosthesis. Bone resorption beneath the femoral shell and thinning of the femoral neck have been observed. We present a radiological analysis of the incidence, rate, site of neck thinning and changes observed within the femoral neck, in 100 cases, with a minimum of five years follow-up.

Femoral neck diameter was measured at zero, two and five years post-operatively, at the head neck junction and five mm distally. Pre and post-operative head to neck ratios, natural and reconstructed offset, femoral neck-shaft and stem-shaft angles and cup inclination angle were measured.

Two distinct patterns of neck thinning were observed. In 76 cases (slow thinning group), we observed a reduction of < 5% of original neck diameter at two years and < 10 % at five years (mean 1.5%, sd+/− 1.5). In 24 cases (rapid thinning group), a reduction of > 5% of original neck diameter at two years and > 10% at five years (mean 10.4%, sd+/− 4.8) was observed. The difference in the percentage reduction in neck diameter was significantly different between the two groups at both time points (p< 0.01). Larger head-neck ratios were observed in the rapid thinning group, both pre and post operatively (p< 0.01).

The viability of bone underneath the femoral head may be compromised as a consequence of a non-physiological bone loading mechanism. FEA has predicted stress shielding underneath the femoral head and loading of the mini stem. Compromised blood supply of the retained epiphyseal remnant may play a part in femoral head resorption.

Femoral neck thinning is a phenomenon of unproven aetiology which affects almost 25% of our resurfacing cases.


R. Raman T. Madhu R. Hamilton C. Shaw G. Johnson

The aim of this study was to compare the clinical outcome, radiological outcome, activity level and functional outcome of hip resurfacing against metal on metal (MOM) hip arthroplasty.

Matched pairs of patients were selected from consecutive patients who had either MOM arthroplasty (n=236) or hip resurfacing (n=264). We matched 346 patients (173 pairs) in terms of age, sex, diagnosis, and a minimum follow up of 60 months. The functional outcome was assessed using Harris, Charnley-MDP, SF-36, UCLA and Tegner scores. Mean follow up was 67 months (61–80).

Mean age was 54.5 years. Femoral neck fractures were seen in 4 patients in the resurfacing group. The mean acetabular inclination was 42.8 deg and 44.3 deg in the resurfacing and MOM groups. Mean stem subsidence was 1.2mm. Bony ingrowth was seen in ninety six stems and all stems were stable by Engh s criterion. Radiolucent halo was observed around the stem of two resurfacing heads. The mean Harris hip score was 87.9 and 88.2 in the MOM and resurfacing groups respectively (p=0.76). The SF 36 score was 77.8 and 80.1 (p=0.4). The UCLA and Tegner scores were 6.1 and 3.6 for the resurfacing group and 5.9 and 3.9 for the MOM group. Nine patients in the resurfacing group had a postoperative painful limp which settled by 3 months. There was no radiological evidence of implant failure at last follow up. Survival at 5 years was 100% for the MOM group and 94.1% for the resurfacing group.

Functional outcome and activity levels increased in both groups with no difference between the groups. Post operative complications were fewer in MOM group and return to activity was quicker. It appears that resurfacing arthroplasty offers no medium term advantages over MOM arthroplasty. However longer follow up is required to establish the longevity and durability of this implant.


M. El-Meligy C. Armstrong D.H.T. Miller

On hundred and ninety unselected patients, mean age 62(SD12.8) were operated upon by one surgeon, using same approach.

HSS improved from 33 to 75 post-operatively, the low figures reflecting a high percentage of Charnley C patients (71%). There was a 5% mortality rate from unrelated causes. Early complications included a 2.97% femoral fracture rate within 4–8 weeks of surgery (analysis showed no relation between implant position, BMI, age or Charnley classification, but there was correlation between high level of satisfaction and early weight bearing). There was one infection and one dislocation. Late complications included 3 periprosthetic fractures, 3 dislocations and 2 aseptic cup failures. However, 30% of patients developed groin pain, increasing stiffness and clunking at 1–2 years following surgery. These patients were investigated with an ultrasound scan. 28 patients (14%) had an effusion and were aspirated. Chrome and cobalt levels in synovial fluid, blood and urine were very high. 13 patients have been revised. 1 showed infection, 10 showed metal allergy and 2 a mixed picture of allergy and foreign body reaction.

In our MOM database (762 hips including the current study) a total of 35 patients were revised for similar problems. Two distinct histological finding were observed. Metal allergy occurred independently of cup angle. The implants were well fixed; there was tissue necrosis and histological evidence of ALVAL. There was no infection or metalosis.

FB reaction occurred more frequently when the cup was open. The Implants were loose; there was naked eye evidence of metalosis and metallic particles seen on light microscopy. We concluded that Birmingham/Freeman Hybrid had high complication rate without significant functional superiority, and other MoM devises shared similar complication. Both Metal allergy and FB reaction can occur in MOM THR. Ultra sound is a good screening tool in symptomatic patients.


S. Anand G. Bailie Y. Kalairajah A. Spriggins

Paradoxical cerebral embolism is seen in 50–60% of patients following hip and knee arthroplasty surgery. It is responsible for post-operative symptoms like confusion and cerebral ischemic episodes. Embolism is less common with the use of uncemented implants. No study has looked into incidence of cerebral emboli in hip resurfacing.

We undertook a prospective randomised study to look at the incidence of cranial emboli in hip resurfacing. Patients were randomized to receive either uncemented or cemented femoral component. An arm of the study included evaluation of the effects of femoral venting by randomising patients to ‘venting’ or ‘no venting’ of proximal femur intra-operatively. The operations were performed by a single surgeon using a uniform surgical technique. Transcranial Doppler device was used to quantify the occurrence and distribution of cerebral microemboli. Emboli counts were recorded continuously and were correlated any major procedural event.

Eight patients (5 vented, 3 unvented) underwent cemented resurfacing and 7 patients (4 vented, 3 unvented) had cementless resurfacing. There was no difference between the two groups for age, gender, weight, or ASA status. Peri-operatively both groups were similar for vital observations (heart rate, temperature, blood pressure), haemoglobin change, mini – mental score at day 1 and 2, and oxygen saturation at day 1 and 3.

The mean number of significant emboli in the cemented group was 8.1 and in the cementless group was 1.7 (significant, p=0.009). Venting did not influence rate of emboli however, venting was independently associated with significantly higher drainage (mean 604mls compared to 335mls without venting, p=0.018). There was no significant difference in post-operative haemoglobin or number of units transfused.

Cranial emboli occur commonly after hip resurfacing. Their incidence is significantly reduced by the use of uncemented femoral component, however venting of proximal femur doesnot appear to make any difference.


J. Young R. Valamshetla T. Lawrence

In revision hip surgery, a solidly cemented femoral component may obstruct access to the acetabulum, may be poorly orientated, or may have inadequate offset and head diameter. These problems can be addressed by revising the femoral component. The object of this study was to determine the outcome of cementing a polished, tapered, modular implant into the retained cement mantle. Benefits of cement within cement revision of a femoral stem include simplicity, reduced theatre time, and potentially reduced complication rates.

A consecutive series of 36 patients (11 men, 25 women) age range 35 to 90 years (mean age 70) underwent c stem cement in cement revision hip arthroplasty between June 2000 and April 2006. Indications for revision arthroplasty included 20 patients with aseptic acetabular loosening and 13 patients with recurrent instability. Follow up (12–84 months, mean 48 months) was annual and the outcome for every implant was known. Outcome measures included the shortened WOMAC score, Orthowave patient satisfaction survey, radiographic analysis, and assessment of the records for perioperative complications.

No patients were lost to follow up, 2 patients died with their hip in situ. The mean post operative WOMAC score at latest follow up was 10.89 (median 11, range 0 to 29). There has been no clinical or radiological signs of prosthesis loosening or failure on follow up. Complications included: one sacral plexus palsy which had a partial recovery, and one intra-operative periprosthetic fracture identified and treated at the time of the revision procedure. One patient underwent a further cup revision for recurrent dislocation.

Cement within cement revision hip arthroplasty using a highly polished tapered stem in the short to medium term provides satisfactory functional outcomes and is associated with low complication rates and good survivorship. Longer term results are awaited.


J. Daniel H. Ziaee C. Pradhan D.J. McMinn

It has been suggested that metal ion level elevations in certain bilateral MM bearing arthroplasties were overwhelming the renal threshold for metal excretion leading to systemic build-up of metal ions above the expected levels. In order to investigate this we studied renal concentrating efficacy through concurrent specimens of urine and whole blood over a range of metal levels.

Concurrent specimens from 305 unselected patients were obtained. They include preoperative patients (76) and those with unilateral and bilateral hip arthroplasties (229) through to ten years after operation. 39 pre-operative specimens and 4 follow-up specimens had blood levels at or below the detection limit for cobalt or chromium and were excluded. The ratio of urine to whole blood concentration was 0.78 in the pre-operative patients. In patients with MM arthroplasties the different ratios in patients increased (from 3.1 to 9.2) with increasing urine concentrations.

The ratio of urine cobalt concentration to blood cobalt concentration is a measure of renal concentrating efficacy. Amongst pre-operative controls, this ratio is 0.78, indicating that there is renal conservation of cobalt. In terms of cobalt, these patients’ urine was dilute in comparison to whole blood. In patients with MM bearings, the ratio went up to 4.8 indicating that the kidneys were now actively excreting against a concentration gradient in an attempt to maintain internal milieu. If renal threshold was being breached at higher levels, then the ratio should progressively fall at higher concentrations. The trend in this experiment shows quite the contrary effect and the ratio reached 9.2 in those with urine cobalt > 15 μg/l, demonstrating that renal clearance efficiency holds up even against this steep gradient and that the threshold is not breached within clinically relevant levels.


K. Brogan J. Charity A. Sheeraz M. Hubble J. Howell

There is evidence that recommends the retention of a well-fixed cement mantle at the time of revision hip arthroplasty. The cement-cement interface has been proven to have greater shear strength than a new bone-cement interface after removing a well-fixed cement mantle. This study reviewed a series of acetabular revision procedures with a minimum 2-year follow-up where the original cement mantle was left intact. From 1988 to 2004, 60 consecutive cement-in-cement revisions of the acetabular component were performed at our institution. Outcome was based on functional assessment using the Oxford, Charnley, and Harris scoring systems as well as radiographic analysis using the DeLee and Charnley criteria.

In total 60 procedures were performed in 60 patients (40 female and 20 male), whose mean age at surgery was 75 years (range 40 to 99 years). 80% were performed for recurrent dislocation, 13.3% during femoral component revision, 5% for acetabular component wear, and 1.7% for pain. No case was lost to follow-up.

There was one re-revision for aseptic cup loosening at 7 years, with 1 further case of radiological loosening identified at the latest review. There were 6 further cases of dislocation 4 of which were treated with further in-cement revisions. All other cases showed well-fixed components on radiographic analysis and no evidence of failure at the most recent follow up.

The cement-in-cement technique already has a good body of evidence based on revision of the femoral component and this study shows that the technique can be applied to acetabular revisions as well with good functional and radiological results in the short to medium term.


A. Ghandour C.B. Bayne H.U. Cameron

We evaluated the use of bilobed acetabular components in the treatment of acetabular deficiency during revision and complex primary total hip replacements. 79 patients (83 hips) were operated upon between august 1990 and December 2005 64 patients were reviewed clinically and radiologically.7 patients had died from unrelated causes. 3 patients were followed up clinically and radiologically for one year and were doing well at their last appointments. 5 were lost in follow up. The mean follow up of patients was 5.5 year (range, 2–15 years). One patient was revised for aseptic loosening.

The average post operative Harris hip score was 94.9 (range 74–100) at the last follow up appointments of 68 patients. Two patients developed deep wound infection and one patient dislocated three months post operatively, treated with a constrained liner. At the latest follow up the cumulative survival rate for aseptic loosening with revision being the end point is 97% at 15 years.

These results support the use of bilobed of-the-shelf cups in the reconstruction of acetabular defects with intact anterior and posterior columns.


N. Maffulli I. Stark G. Ayub G. Walley J. Orendi P. Roberts

Antibiotic-associated Clostridium difficile diarrhoea may complicate surgery for proximal femoral fracture. We undertook a 4 year case control study to evaluate the effects of a change in antibiotic prophylaxis in our department.

In the period January 2003 to January 2005, patients received three doses of cefuroxime (1.5 g). The new regimen is a single dose of cefuroxime (1.5 g) with gentamicin (240 mg) at induction. Prior to the change in prophylaxis, 912 patients underwent surgery for neck of femur fracture. Following the change, 899 patients underwent surgery over the period March 2005 to March 2007. 38 patients developed C. difficile infection (4.2%) in the initial group, compared with 14 patients (1.6%) in the group following the change in prophylaxis (P=0.009). Patients with C difficile infection also had a statistically significant increase in antibiotic exposure, inpatient stay, morbidity and inpatient mortality.

The main challenges regarding antibiotic selection are failure of prophylaxis, often because of infection with MRSA, and C. difficile-associated diarrhoea as a consequence of antibiotic prophylaxis. Infection with C. difficile is reduced with the new regimen. We advocate the use of the new regimen as an effective alternative to multiple dose cephalosporins for the prevention of C. difficile infection in this group of high risk patients.


R. Kakwani D. Chakrabarti K. Katam K. Wahab

In 1990 an estimated 1.3 million hip fractures occurred worldwide. Clostridium difficile diarrhoea has emerged as a healthcare associated infection of great clinical and economic significance especially in the frail and vulnerable group of fracture neck of femur patients. The major risk factor is peri-operative antibiotic exposure especially cephalosporins. A retrospective audit was performed to study the effect of C. Difficile in operated fracture neck of femur patients.

All the patients who were diagnosed with C. Difficile infection after an operated fracture neck of femur at the District general hospital from April 2004 till March 2007 were included in the present study. All patients received the routine peri-operative antibiotic prophylaxis of three doses of intravenous cefuroxime. Data collected included age, sex, duration between operation and the onset of diarrhoea, length of stay and associated mortality.

A total of 1023 patients underwent surgery for fracture neck of femur during the three years of study period. The average age of the patients was 81 years. 80% of the patients were females. A total of 62 patients suffered from C. Difficile diarrhoea (6%) after the arthroplasty procedure, and within this cohort, 29 patients died during the same admission to the hospital (47%). The average length of stay for a patient with fracture neck of femur was increased from 23.4 to 60 days in those affected with C. Difficile.

The patients with fracture neck of femur are generally elderly with poor body reserves. C.difficile infection in such patients not only adds to the morbidity, but also causes significant increase in the mortality rate. Propagation of simple infection control measures such as hand-washing and isolation and change of peri-operative antibiotic protocol led to a statistically significant reduction in the incidence of C.Difficile infections after fracture neck of femur surgery.


A. Bhangu M. Pell S. Bhangu A. Michael R. Dias S. Mangaleshkar

We aim to describe mortality in orthopaedic patients with Clostridium difficile associated diarrhoea (CDAD), to identify prognostic factors for 30 day mortality, and to modify a CDAD risk score to fit to orthopaedic patients.

This was a two centre, retrospective, observational study including consecutive patients with a first episode of CDAD between 2005–2007. 79 patients were identified, comprising 11 elective patients (14%) and 68 emergency patients (86%). 73 patients (92%) underwent surgery and all but two patients received broad spectrum antibiotics prior to CDAD. The overall 30 day mortality was 29% (n=26). The predominant diagnosis was a fractured femoral neck (66%, n=52).

The most significant multivariable model in predicting 30 day mortality comprised increasing white cell count (WCC, OR 1.20 [for 10% variable increase]; 95% CI 1.06–1.36 p=0.003) and decreasing albumin (OR 0.86 [for single unit decrease]; 0.86–0.95, p=0.003), with adjustment for age ł80 years (OR 6.39, 1.15–35.52, p=0.04). CRP was found to be not significant. Based on this, modification of the previously described Clostridium difficile prognostic index leads to a point awarded for WCC ł20, albumin Ł20, age ł80, urea ł15 or clinically severe disease (peritonitis, sepsis, ł10 episodes of diarrhoea per day). This produces low (0–1 points), medium (2–3 points) and high (4–5 points) risk of death groups, with mortalities of 15%, 47% and 75% respectively for all orthopaedic patients, and 14%, 41% and 67% respectively in only the validation cohort.

CDAD in orthopaedic patients mainly affects emergency patients, in particular those with fractured femoral neck. Inpatient mortality is high, and a high white count and low albumin are significant predictors of mortality. Modification of an easily remembered scoring system based on this can help identify orthopaedic patients likely to die from an episode of CDAD, allowing early aggressive therapy and early objective referral to gastrointestinal teams.


R. Rambani E. Tsiridis J. Timperley G. Gie R. Venkatesh

The aim of this study was to evaluate the cost of implants used in a large series of peri-prosthetic femoral fractures and assess its financial impact in the era of Payment by Results

We evaluated the clinical demographic and economical data associated with 202 patients with peri-prosthetic fractures of the proximal femur in two orthopaedic centers of excellence. All fractures were classified preoperatively according to the Vancouver classification. The patients were followed up until radiographic confirmation of fracture union and post-operative outcome was recorded with reference to the patients’ mobility and any complications.

The mean age of the patients operated was 81.2 years (range 33–100 years). 55% of the patients in our series were graded type B3 and 25% type B2. 80% of all fractures underwent revision. 71 percent of the fractures united within 8.4 months. 112 patients had impaction femoral grafting. Our implant cost alone for revision varied from 1900 pounds to as high as 3500 pounds without taking in to account the cost of cement and allograft (femoral heads and struts).

Hospital resource utilization for peri-prosthetic fractures is quite high compared to the reimbursement received. This is due to hospital stay and rehabilitation needs, theatre utilization, implant cost and higher readmission rates. There are neither reference costs available nor any special tariffs for these complex fractures. The reimbursement for internal fixation of these fractures could range from £2336 to £4230 and for emergency revision hip replacement is £5928. More than 50% of the reimbursement money would just be necessary to meet the implant costs. For uncemented revisions this equation is even worse. Current HRG codes for the treatment of peri-prosthetic fractures are unrealistic and new treatment algorithms and special tariffs have to be introduced to help manage these fractures.


L. Cusick D. Beverland

In response to the recent publication in April 2007 of NICE guidelines on venous thromboembolism, we report our practice and experience of VTE in adult hip and knee arthroplasty.

It is generally agreed that the 2 major complications of VTE are sudden death as a result of pulmonary embolism and post thrombotic syndrome. NICE guidelines make 2 assumptions:

That chemical and mechanical prophylaxis can reduce these complications

That Orthopaedic surgery, in particular elective Primary Joint Replacements are particularly high risk procedures with respect to these 2 complications.

We have studied a large cohort of patients who had Aspirin only as chemical prophylaxis to determine the incidence of clinical thromboembolism before and after discharge and the mortality from PE at 90 days. We performed a prospective analysis of consecutive patients undergoing primary total knee and hip replacement from November 2002 to November 2007. In total 2050 patients had total knee replacement and 2203 patients had total hip replacement. All patients were treated at one specialist centre under the care of one surgeon. Data was complete and accurate for all patients at 90 days post-operatively.

Standard practice was the use of 150mg Aspirin from Day 1 post-operatively for a total of six weeks combined with spinal anaesthesia and early mobilisation.

The overall rate for Fatal Pulmonary embolism 0.07% (3/4253), overall death rate 0.3%(13/4253), for treated non-fatal PE 0.66% (28/4253) and for treated above knee DVT was 0.33%(14/4253).

Our data suggests that fatal pulmonary embolism is not common and does not account for most deaths following total hip and knee arthroplasty. We suggest there is no evidence that chemical/mechanical prophylaxis reduces the risk of sudden death from PE following elective primary joint replacement and with modern surgical practice elective hip and knee replacement should no longer be considered high risk procedures.


S. Al-Nammari N. Bejjanki A. Berridge V. Gulati P. Bobak

This paper could not be resubmitted: The paper was initially presented at the BHS and they have already published it in the JBJS Supplement.


T. Ibrahim B. Bloch C.N. Esler K. Abrams W.M. Harper

The aim of this study was to evaluate temporal trends in the prevalence of primary total hip and knee replacements (THR and TKR) throughout the Trent region from 1991 through 2004.

The Trent Regional Arthroplasty Study (TRAS) records details of primary THR and TKR prospectively. TRAS data in conjunction with age-gender population data from the National Office of Statistics was used to quantify the rates of primary THR and TKR as a function of age (45–55, 56–65, 66–75, 76–85 and greater than 85 years), gender and diagnosis (osteoarthritis, rheumatoid arthritis and trauma). Poisson regression analysis was used to evaluate the procedural rate over time in primary THR and TKR as a function of age, gender and diagnosis.

A total of 26,281 THR and 23,606 TKR were recorded during this period. The overall prevalence for primary THR did not change significantly over time (IRR = 1.0, 95% CI: 0.99 to 1.0, p = 0.875), whereas, the overall prevalence for primary TKR increased significantly by 2.5% during the fourteen year period (IRR = 1.025, 95% CI: 1.021 to 1.028, p < 0.001). Analysis showed that females had an increased incidence rate ratio (IRR) for both primary THR (IRR = 1.29, 95% CI: 1.26 to 1.33, p < 0.001) and TKR (IRR = 1.17, 95% CI: 1.14 to 1.20, p < 0.001). Patients aged 74–85 years had the largest IRR for both primary THR (IRR = 6.7, 95% CI: 6.4 to 7.0, p < 0.001) and TKR (IRR = 15.3, 95% CI: 14.4 to 16.3, p < 0.001).

The prevalence of primary TKR increased significantly over time whereas THR increased steadily in the Trent region between 1991 and 2004. These trends have important ramifications to the number of joint replacements expected to be performed in the future.


B. Caesar R. Morgan-Jones R. Warren R. Wade P. Roberts J. Richardson

Thirty-five patients were followed prospectively from their referral to the Problem Fracture Service with chronic osteomyelitis of diaphyseal bone between November 1994 and June 1999.

The patients were treated using a closed double-lumen suction irrigation system following reaming and arthroscopic debridement of the intramedullary canal; this is a modified system based on the work of Charles Lautenbach. Results of these procedures were regularly followed up in clinic, and between June and July 2007 the whole cohort was reviewed via postal questionnaire, telephone and case note review.

At a mean follow up of 101 months, 26 were living with no evidence of recurrence, 4 had died of unrelated causes with no evidence of recurrent infection. Four patients had persisting problems with sinus discharge requiring intermittent antibiotic therapy and 1 patient had his limb amputated for recurrent metaplastic change.

These results gave this cohort an 86% clearance of infection, with recurrence in 12%, which is comparable to the Papineau and Belfast techniques with significantly less surgical insult to the patient.


G. Dall N. Ohly J. Ballantyne I. Brenkel

Whilst clinical pathways have reduced the length of inpatient stay (LOS) and costs associated with total hip replacement (THR), it would be useful to be able to predict which factors affect the LOS following THR. In this way units could improve patient flow, and thus increase efficiency, by optimising case loads and staffing levels in all related departments. We hypothesised that there were pre-operative factors that will predict the length of inpatient stay following a unilateral primary THR.

Prospective data from 2302 patients who underwent primary unilateral THR for osteoarthritis during a nine-year period from January 01 1998 were included. The relationship between each prospectively recorded factor and LOS was analyzed separately using t-tests or Pearson correlation. Multiple linear regression was used to analyze the effect of each significant factor adjusted for others.

Length of stay varied from 3 to 58 days, with a mean of 8.1 and a median of 7.0. The pre-operative factors that were not significantly associated with the LOS were BMI, Scottish Index of Multiple Deprivation, disabling knee, back or contra-lateral hip pain. A number of pre-operative factors were found to be highly significant predictors of LOS when subjected to univariate analysis, but not significant after multivariate analysis. These were smoking, heart disease, diabetes, pre-operative aspirin, pre-operative haemoglobin and overall Short Form (SF-36) score. Pre-operative factors that were significantly associated with LOS after adjusting for the effect of others were age, sex, pre-operative NSAIDs, consultant surgeon, combined function/activity dimension to Harris hip score, general health perception (GHP) dimension of SF-36, the day of the week and the year of surgery.

Younger age, male sex, higher combined Harris hip function and activity score, higher GHP dimension of SF-36 score and NSAID use are all significantly associated with reduced length of inpatient stay following primary THR for osteoarthritis.


D. Harle S. Ilyas K. Tucker S. Donell C. Darrah

Our objective was to investigate how patients, general practitioners (GPs) and orthopaedic trainees, feel about the proposed governmental changes to reduce orthopaedic outpatient clinics by having GPs and specialist nurses follow-up post operative orthopaedics patients in the community. This was a cross-sectional questionnaire study of Teaching hospital and general practitioners in the Norfolk primary care trust.

Of 73 orthopaedic post-operative patients who attended outpatients over a one week period in July 2007, all responded. Of 250 General Practitioners, 239 responded. Of 38 orthopaedic trainees at the level of SHO (post MRCS) and SpR’s (Eastern deanery rotation and Pott rotation) 30 responded. Main outcome measures: opinions of GPs, Surgical trainees and Patients regarding proposed changes to outpatient orthopaedic clinics.

Of the patients 56 of 73 (77%) felt the surgeon was best suited to manage them post-operatively. Of these 47 felt that it was very important that the surgical team saw them post-operatively. Also 53 felt that their GP did not have sufficient knowledge and experience to adequately deal with their current orthopaedic problem. General Practitioners: Only 12 of 239 (5%) felt very confident assessing post-operative patients. Inadequate resources available to diagnose and treat post-operative complications was noted by 74% as the reason for not performing follow-up in primary care, and only 18% felt they should follow up post-operative patients. Trainees: All felt that following up their own post-operative patients was important to their training.

Most patients, GPs, and orthopaedic trainees had serious doubts about proposed governmental changes to reduce orthopaedic outpatient clinics by having GPs and specialist nurses follow-up post operative orthopaedics patients in the community.


S. Konan J. Bull F. Haddad

Our aim was to ascertain the opinion of Orthopaedic Consultants, General Practitioners, and Patients on the proposed primary care based follow up of joint replacements.

An email questionnaire was sent Orthopaedic Consultants registered with the BOA. Responders had to answer simple questions regarding follow up practices after hip and knee arthroplasty and safe alternatives to the existing system. General practitioners in London were sent a different questionnaire to assess their familiarity with follow up of arthroplasty patients and their competence in identifying complications. Finally, arthroplasty patients were directly questioned on their preference for follow up.

Eigthy-one Orthopaedic Consultants who undertake lower limb arthroplasty responded, 89.06% advocated follow up and review of radiographs by the surgeon. The Arthroplasty Practitioner, the Radiologist and the Physiotherapist were deemed suitable for follow up of patients by 50%, 14.06% and 4.69 % respectively. All responders unanimously disagreed with initial follow up by General Practitioners (0%). However, after a 12 month review, 30.15% thought primary arthroplasty patients could be discharged to the care of their General Practitioner and 11.11% were happy to discharge revision arthroplasty patients. Of the 52 General Practitioners who returned our questionnaire, only 37% were confident of interpreting symptoms related to prosthetic loosening or infection and 98% did not feel competent identifying radiological changes after arthroplasty. 94% of the General Practitioners did not think that they would be happy to follow up arthroplasty patients even if they were offered further training. The reasons for this were lack of specialty skills, work-load concerns, funding issues and surgeons’ duty of care towards the patient. All of the 104 patients who were questioned preferred to be followed up by the arthroplasty team.

In conclusion, Orthopaedic Surgeons, General Practitioners and patients prefer a hospital based dedicated Orthopaedic team for the post operative follow-up of arthroplasty patients.


B.C. Hanusch L. Goodchild P. Finn A. Rangan

Large and massive rotator cuff tears can cause persistent pain and significant disability. These tears are often chronic with substantial degeneration of the involved tendons. Surgical treatment is challenging and the functional outcome after repair less predictable then for smaller tears. The aim of this study was to determine the functional outcome and rate of re-rupture after mini-open repair of symptomatic large and massive rotator cuff tears using a modified two-row technique.

Twenty-four patients, who were operated on under the care of a single surgeon between 2003 and 2006, were included in this study. Patients were assessed prospectively before and at a mean of 27 months after surgery using Constant Score and Oxford Shoulder Score. This assessment was carried out by an independent physiotherapist specialising in shoulder rehabilitation. At follow-up an ultrasound was carried out by a musculoskeletal radiographer to determine the integrity of the rotator cuff repair. Patient satisfaction was assessed using a simple questionnaire.

The mean Constant Score improved significantly from 36 preoperatively to 68 postoperatively (p< 0.0001), the mean Oxford Shoulder Score from 39 to 20 (p< 0.0001). Four patients (16.7%) had a re-rupture diagnosed by ultrasound. 87.5% of patients were satisfied with the outcome of their surgery. Tear size and repair integrity did not significantly influence functional outcome. 87.5% of patients were satisfied or very satisfied with the outcome of their surgery.

This study shows that the two-row repair of large and massive rotator cuff tears using a mini-open approach is an effective method of repair with a comparatively low re-rupture rate. It significantly improves the functional outcome and leads to a very high patient satisfaction. We conclude that these results justify repair of large to massive rotator cuff tears when possible, irrespective of chronicity of symptoms.


N. Maffulli F. Franceschi U.G. Longo L. Ruzzini G. Rizzello V. Denaro

Arthroscopic management has been recommended for some SLAP lesions, but no studies have focused on patients over 50 with rotator cuff tear and Type II SLAP lesion. Our hypothesis was that there was no difference in clinical outcome between repairing of the Type II SLAP lesion and tenotomy of the long head of the biceps tendon after having repaired the rotator cuff tear. This was a randomized controlled clinical trial.

We recruited 63 patients. In 31 patients, we repaired the rotator cuff and the Type II SLAP lesion (Group 1). In the other 32 patients, we repaired the rotator cuff and tenomized the long head of the biceps (Group 2). 7 patients (2 in the group 1 and 5 in the group 2) were lost to final follow up.

At the 5.2 year follow-up, statistically significant differences were seen with respect to the UCLA score and ROM values. In Group 1 (SLAP repair and rotator cuff repair), the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.4 (range 6 to 14) to an average of 27.9 (24–35) postoperatively (P< 0.001). In Group 2 (biceps tenotomy and rotator cuff repair) the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.1 (range 5 to 14) to an average of 32.1 (range 30 to 35) post-operatively (P< 0.001) There was statistically significant difference in total post-operative UCLA scores and ROM when comparing the two groups post-operatively (P< 0.05).

There are no advantages in repairing a Type II SLAP lesion when associated with a rotator cuff tear in patients over 50. Rotator cuff repair alone is sufficient to produce a good post-operative outcome, allowing to avoid post-operative stiffness of the shoulder.


K.K. Singisetti D. Bhaskar M. Newby A. Hinsche

Ultrasonography for rotator cuff disease is a cheap and non-invasive investigation. Our study investigates the tendon specific pathologies leading to misinterpretation of ultrasound findings and their implication for the surgical management.

On hundred and five consecutive patients who had an ultrasound scan by a single musculoskeletal radiologist and then underwent shoulder arthroscopy by a single shoulder surgeon for rotator cuff pathologies were included.

Surpraspinatus Tendon (SST): There was a sensitivity of 90%. The relatively low positive predictive value (76%) and specificity (42.5%) were influenced by a high number of false positives. This was a mixed group of 23 cases, in which ultrasonography had described either a full-thickness (FTT) or partial-thickness (PTT) tear when arthroscopy did not show any evidence for a cuff tear. Seven of these cases were described as FTT with dimensions less than 1 cm and in ten cases the radiologist described a “possible sub-centimetre tear”. Subscapularis Tendon (SSC): There was a specificity of 100%. The poor negative predictive value (78%) and sensitivity (26%) were caused by a high number of false negatives. Further analysis of the 20 “false negative” patients showed four FTT and sixteen PTT. All partial thickness tears involved the superior fibres of the subscapularis tendon.

Our results confirm that USG is a reliable investigation in larger full thickness tears, particularly of the superior rotator cuff (SST). The reliability is significantly reduced in sub-centimetre tears and partial thickness tears, particularly of the subscapularis tendon. Associated tendon pathologies like intra-tendinous calcifications and intra-substance tears make an accurate diagnosis even more difficult and add to the tendency to ‘over-diagnose’ tears of the rotator cuff with use of ultrasonography.

The shoulder surgeon should be aware of the potential misinterpretation of ultrasonography findings and be prepared to adjust the surgical procedure accordingly.


V. Wylde R. Amirfeyz N. Blewitt

The aim of this study was to determine patient-reported outcomes after arthroscopic rotator cuff repair with a new knot-free technique.

A questionnaire was completed by 50 patients who underwent an arthroscopic rotator cuff repair with a knot-free technique. Validated questionnaires included the Oxford Shoulder Score (12–60, good to poor) and SF-36 (0–100, poor to good). Patients also completed a 100mm VAS (0–100, good to poor) to rate the following domains: daytime pain, night-time pain, movement, strength, well-being, ability to do ADLs, participation in sports, ability to do leisure activities and whether they felt their shoulder was back to the way it was before the problem started.

The mean length of follow-up was 15 months (range 7–25 months). The mean age of patients was 62 years (range 36–78) and 70% were male. The mean OSS was 22 (SD 10). Mean scores for the 8 domains of the SF-36 were: 74 for physical functioning, 71 for role physical, 66 for bodily pain, 67 for general health, 57 for vitality, 82 for social functioning, 85 for role emotional and 81 for mental health. The mean VAS for the 9 outcome domains were as follows: 16 for night-time pain and daytime pain, 19 for movement, 21 for ability to do ADLs, 22 for well-being, 23 for whether the shoulder was back to the way it was, 28 for ability to do leisure activities, 29 for strength and 33 for ability to participate in sports.

In conclusion, patients reported excellent post-operative OSS with the knot-free technique. The SF-36 revealed that patients had high social and emotional functioning and good physical outcomes were reported on the VAS for pain, ADLs and movement. However, going back to an expected level of sport is not always achievable.


D. Tennent A. Richards

Disruption of the coraco-clavicular ligaments may be associated with either dislocation of the AC joint or fracture of the distal clavicle. If sufficient displacement occurs, functional disability results. Traditional techniques have required a bra-strap incision and often require late removal of the metalwork. The Tightrope syndesmosis repair system was adapted to be used arthroscopically to reduce and hold the clavicle enabling healing of the ligaments and any associated fracture using a minimally invasive technique but ensuring accurate reduction and secure stabilisation.

Between December 2004 and November 2006, 21 patients with acute injuries to the corac-clavicular ligaments in our institution were treated using this system. As the system was in evolution the majority were treated arthroscopically and a few using an “open” technique. All had either the acromio-clavicular joint reduced or a distal clavicle fracture reduced and stabilised using the Tightrope Syndesmosis Repair system. The system had been modified from that commercially available for use in the ankle with the consent of the manufacturer (Arthrex, Naples, Fla).

All patients were evaluated at a minimum of 6 months (range 6–32 months) post operatively using the DASH, ASES and Constant scores The mean ASES score was 95, the mean Constant score was 94, and the mean DASH score was 2.5. There were no complications and two patient required removal of the clavicle endobutton.

The authors conclude that this new technique is a safe, simple, cosmetically acceptable and reproducible method of reducing and stabilising the distal clavicle allowing for healing of either the coraco-clavicular ligaments or the distal clavicle


N. Shaikh E.O. Pearse T.D. Tennent

Our aim was to compare displayed pressure with actual intra-articular pressure using three fluid delivery systems. The pumps used were the Arthrex, FMS and Dyonics.

We investigated thirty patients undergoing shoulder arthroscopy. Patients with a previous disruption to the joint capsule were excluded.

A standard set-up was used with the patient in a lateral position and arm in traction. The arthroscope was introduced from the posterior portal. The rotator interval was identified and the needle introduced from this point. The needle was attached to a arterial pressure transducer. The pressure transducer was coupled to the anaesthetic machine. Pressures of 30, 50 and 80 mmHg were dialled on the fluid management systems. Once the pressures stabilised on the pumps the intra-articular pressure was measured independently using the pressure transducer.

Median pressures for the FMS and Arthrex pumps were approximately twice set pressures. Median pressures for the Dyonics pump were closer to set pressures but the range of values was wider.

The three pumps were inaccurate and behaved differently to each other. They are not interchangeable. Each pump performed inconsistently.


R. Parmar S. Dalal B. Roy

Many procedures have been described for the operative treatment of tennis elbow (lateral epicondylitis). Arthroscopic release is a relatively recent development. The aim of this study was to review our early results of arthroscopic tennis elbow release. This was a prospective study of 28 consecutive patients with tennis elbow refractory to conservative management, who underwent arthroscopic tennis elbow release performed by one surgeon.

At surgery, arthroscopic joint assessment was performed followed by capsulectomy and debridement of the Extensor Carpi Radialis Brevis (ECRB) tendon origin using the proximal lateral and medial portals. The ECRB lesions were classified and resected with a shaver but the insertion site was not decorticated. Patients were assessed preoperatively, at 2 weeks and 3 months using the DASH score.

Of the 28 elbows 21 were noted to have a Nirschl type I lesion (intact capsule), 6 had a type II lesion (linear capsular tear) and 1 a type III (capsular rent). Degenerative articular changes were noted in 19 elbows. If arthroscopic debridement was required it was undertaken. Three elbows were noted to have eccentric radial heads. Radial plicae which were impinging on the radial head were noted in three patients. 1 patient was lost to follow up.

There was a significant improvement in DASH scores (p< 0.002) at 2 weeks post operatively. This improvement was sustained at 3 months. This is a worst case scenario analysis using a paired t test. 1 patient had post operative stiffness and 6 failed to improve of which 2 were revisions.

The early results would suggest arthroscopic tennis elbow release is an effective treatment for tennis elbow, which in addition also allows assessment of the elbow joint and the potential to address associated intra-articular pathology. This minimally invasive technique has been demonstrated to be safe and affords early post operative rehabilitation.


G. Prasad R. Gouni C. Al-Sayyad R. Hartley D. Kerr J.G. Kernohan

Our aim was to determine the prevalence of shoulder symptoms in patients with type I compared to type 2 diabetes mellitus and evaluate the clinical presentation of patients diagnosed with adhesive capsulitis. This was a retrospective case-note review of 164 diabetic patients treated for shoulder symptoms from 1996 to 2007. Diabeta 3 for relevant Diabetic data. We used ANOVA, Tukey HSD, Chi-Square and Fisher’s Exact tests.

The incidence of treated shoulder patients in diabetic population: 1.04%. 86 males; 78 females. Average age 58 years (22 – 83). DM Type I 34% (46/136); Type II 66% (90/136). Mean duration of DM at presentation: 10 years (1–33). Mean HbA1c at presentation 8.3%. Retinopathy 16% (19/90); Neuropathy 12% (12/88).

The diagnoses were: Impingement 101 (62%); Adhesive Capsulitis 35 (21%); Cuff tear 17 (10%); Arthritis 11 (7%).

Mean recorded pre-treatment ROM: Impingement (flexion 117°, abduction 103°, ER 36°); Adhesive Capsulitis (flexion 90°, abduction 75°, ER 12°); Cuff tear (flexion 109°, abduction 95°, ER 45°); Arthritis (flexion 67°, abduction 93°, ER 18°).

Adhesive Capsulitis was significantly related to: HbA1c (9.9%); p< 0.001, Type I DM; p< 0.003, Duration of DM (average 17.5 yrs); p< 0.03.

An interesting statistically significant (p< 0.003) correlation was found between Type 2 DM and Impingement Syndrome.

Treatments included: Injection (53), MUA (49), Arthroscopy (99), Open Surgery (56). 82% patients satisfactorily discharged (mild/no pain and improved ROM: flexion > 150°, abduction > 150° and ER > 50°) after an average 3.4 months. Three referred to pain clinic, sixteen patients didn’t attend their follow-up appointment and seven died. Eleven relapsed (eight adhesive capsulitis).

Persistent symptoms were more common in Diabetic patients with adhesive capsulitis, which was found to be significantly related to Type I DM, its duration and control (HbA1c levels). Type II Diabetics are more likely to be affected with impingement syndrome. Close liaison with the Diabetology Department is essential for effective treatment of Diabetic Shoulder pathology.


T. Colegate-Stone C. Roslee A.M.H. Latif R. Allom A. Tavakkolizadeh J. Sinha

We performed a prospective cohort study to investigate the comparability of subjective and objective assessment scores of shoulder function following surgery for rotator cuff pathology.

A consecutive series of 372 patients underwent surgery for rotator cuff disorders with post-operative follow up over 24 months. 248 patients only had subacromial decompression, whereas 124 patients had rotator cuff repair additionally (93 arthroscopic; 31 open). Assessments were made pre-operatively, and at 3, 6, 12, and 24 months post-operatively using the Disabilities of the Arm, Shoulder, and Hand (DASH) score; Oxford Shoulder Questionnaire (OSQ); and the Constant score, which was used as a reference. Standardisation calculations were performed to convert all scores into a 0 to 100 scale, with 100 representing a normal shoulder. The student’s t test was used to compare the mean score for each subjective tool (DASH and OSQ) with the objective score (Constant) at each time point. Pearson’s Correlation coefficient was used to analyse the changes with time post-operatively. The statistical tests were used for the individual surgery types as well as all surgeries collectively. The relationship between the DASH and the Constant score was strongly correlated in all types of surgery.

The relationship between the Oxford and Constant scores was similar, except in the open rotator cuff repair group. There was no statistical difference between the mean DASH and Constant scores for all interventions at any time point. A significant difference was seen between the mean Oxford and Constant scores for at least one time point in all but the open rotator cuff repair group.

We demonstrate that the DASH and Oxford scoring systems would be useful substitutes for the Constant score, eliminating the need for a trained investigator and specialist equipment required to perform the Constant score with the associated cost benefits.


N. Maffulli F. Franceschi U.G. Longo L. Ruzzini F. Battistoni V. Denaro F. Battistoni G. Walley G. Dicuonzo

Our objective was to determine the plasma levels of substance P (SP) in patients with postoperative stiffness after arthroscopic rotator cuff repair.

Plasma samples were obtained at 15 months from surgery from 2 groups of patients who underwent arthroscopic repair of a rotator cuff tear. In Group 1, 30 subjects (14 men and 16 women, mean age: 64.6 years, range 47 to 78) with shoulder stiffness 15 months after arthroscopic rotator cuff repair were recruited. In Group 2, 30 patients (11 men and 19 women, mean age: 57.8 years, range 45 to 77) were evaluated 15 months after successful arthroscopic rotator cuff repair. Immunoassays were performed with commercially available assay kits to detect the plasma levels of SP.

The mean plasma levels of SP in patients with postoperative stiffness were significantly greater than those in the control group (81.06 ± 27.76 versus 23.49 ± 5.64, P < 0.05).

The plasma concentrations of substance P in patients with shoulder stiffness after arthroscopic rotator cuff repair are higher compared to plasma levels of SP in patients with a good postoperative outcome. The neuronal upregulation of SP shown in the plasma of patients with post operative shoulder stiffness may underlay not only the symptoms of adhesive capsulitis, but also its development.


J.S. Heal A.W. Blom G.C. Bannister

Stable fixation with macro and micro interlock prevents early migration and therefore early failure of cemented acetabular cups.

The authors describe a cementation technique in an in-vitro model that increases the interossoeous pressure by a factor of 3.5 in the ishium, 4.5 in the ilium and 5.1 in the pubis by the injection of the cement directly into the 10 mm key holes prior to insertion of the cement bolus and cup.


S.W. Veitch J.R. Howell M.J. Hubble G.A. Gie J.A. Timperley

The review of the first 325 Exeter Universal hips reported good long term survivorship despite the majority of cups being metal backed. We have reviewed the long term performance of the concentric all-polyethylene Exeter cups used with the Universal Exeter stem.

Clinical and radiographic outcomes of 263 consecutive primary hip arthroplasties in 242 patients with mean age 66 years (range, 18 to 89) were reviewed. 118 cases subsequently died none of whom underwent a revision. Eighteen hips have been revised; thirteen for aseptic cup loosening, three for recurrent dislocation and two for deep infection. Three patients (four hips) were lost to follow-up. The minimum follow-up of the remaining 123 hips was 10 years (mean 13.3 years, range 10–17). Radiographs demonstrated 4 (4%) of the remaining acetabular prostheses were loose. The Kaplan Meier survivorship at 14.5 years with endpoint revision for all causes is 91.5% (95% CI 86.6 to 96.2%). With endpoint revision for aseptic cup loosening, survivorship is 93.3% (CI 88.8 to 97.8%).

This series included a number of complex cases requiring bone blocks and/or chip autograft for acetabular deficiencies. The concentric all polythene Exeter cup and Exeter stem has excellent long term results particularly when factoring in the complexity of cases in this series.


D.H. Williams J.R. Howell M.J. Hubble A.J. Timperley G.A. Gie

Survivorship of the standard Exeter Universal cemented stem with revision of the femoral component for aseptic loosening as the endpoint has been reported as 100% at 12 years. A version for use in smaller femora, the Exeter 35.5 mm stem, was introduced in 1988. Although also a collarless polished taper, the stem is slimmer and 25 mm shorter than a standard stem.

Between August 1988 and August 2003 192 primary hip arthroplasties were performed in 165 patients using the Exeter 35.5 mm stem. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford hip scores and radiographs were analysed post-operatively and at latest follow up.

The mean age at time of operation was 53 (18 to 86) years with 73 patients under the age of 50 years. The diagnosis was osteoarthritis 91, hip dysplasia in 77, inflammatory arthritis in 18, septic arthritis of the hip in 3, secondary to Perthes disease in 2 and avascular necrosis of the hip in 1 patient. The fate of every implant is known.

At a median follow-up of 8 (5 to 19) years survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. 15 cases (7.8%) underwent further surgery – 11 for acetabular revision, 1 for stem fracture and 3 others.

Although smaller than a standard Exeter Universal polished tapered cemented stem, with a shorter, slimmer taper, the performance of the Exeter 35.5 mm stem was equally good even in this young, diverse group of patients.


J R Berstock JCJ Webb RF Spencer

Manual templating using transparencies allows preoperative visualisation of anatomy and prosthesis size, as well as ease of exchange from prosthesis type to another. Most UK hospitals have converted X-ray provision to Picture Archiving and Communication Systems (PACS), necessitating the use of digital templating.

We assessed the accuracy and speed of templating for hip replacement on 36 occasions in 12 patients listed for hip replacement, using final component choice as an indicator of accuracy. Each hip was templated using, “Orthoview,” templating programme

without initial scaling and

following scaling and then

manually scaled images on a computer screen superimposing acetate templates in the traditional fashion.

A two pence coin taped to the lateral aspect of the thigh at the level of the greater trochanter was used for scaling purposes.

Our results showed acetate templating to be most accurate, correlating identically with the prosthesis stem size in 9/12 cases, and with the acetabulum reamed size on 10/12 occasions. Acetate templating was also the most accurate method when allowing for +/− one size difference, being within +/− one size in all 12/12 cases for both stem size and acetabulum size. In comparison, both scaled and non scaled Orthoview templating correlated with the correct femoral prosthesis size in 5/12 patients. The acetabulum ream size was correctly templated in 10/12 patients using unscaled Orthoview, and 8/12 patients using scaled Orthoview. Additionally, Orthoview templating took a mean of 6 minutes, whereas manual templating can be achieved in under 30 seconds.

Manual templating of scaled PACS images using transparencies conferred considerable advantages in terms of accuracy and speed. Moreover, this method allows a hands-on assessment of the forthcoming surgical procedure immediately prior to the operation, as well as late changes in implant choice. We recommend the continuation of manual templating using modern scaled digital images.


S. Sawalha S.M. Dixon M.R. Norton E.D. Fern

Heterotopic ossification is a recognised complication of surgery on the hip joint that can adversely affect the outcome. The aim of this study was to determine the incidence of heterotopic ossification following surgical hip dislocation and debridement for femoro-acetabular impingement using Ganz trochanteric flip osteotomy approach. We also compared the incidence of heterotopic ossification between two subgroups of patients; in the first group, a shaver burr was used to reshape the femoral head and in the second group, an osteotome was used.

Methods: We reviewed postoperative radiographs of all patients who underwent surgical hip dislocation and debridement during the period between March 2003 and July 2007. We excluded patients with radiographic follow-up of less than one year. Brooker classification was used to grade heterotopic ossifications.

Results: Ninety eight patients (mean age 35 years, range 12–65 years) were included with a mean radiological follow-up of 23 months (range 12–61 months). The overall incidence of heterotopic ossification was 31%. None of the patients developed Brooker grade III or IV heterotopic ossifications. The incidence of heterotopic ossifications in the shaver burr group (n=57) and in the osteotome group (n=41) was 30% and 32%, respectively.

Conclusions: Heterotopic ossification of minor grade is a common complication of surgical hip dislocation using trochanteric flip osteotomy approach. The use of a shaver burr did not result in higher rates of heterotopic ossifications despite the formation of large amounts bone debris.


D. Davies A. Longworth R. Amirfeyz R. Fox G.C. Bannister

Introduction: The severity of symptoms, rate and completeness of recovery after closed treatment of the fractured clavicle has not been fully explored.

Materials and Methods: The severity and duration of pain, analgesic requirements, ability to perform acts of daily living, return to work, driving and sport were recorded along with appearance of the shoulder in 58 patients between one to two years after fracture was recorded. Radiographs were assessed by Robinson’s classification8 supplemented by fracture displacement.

Results: The majority of patients experienced severe pain that required codeine, paracetamol and ibuprofen. 13/58 patients (22%) ceased to experience pain by one month, 35/58 (60%) by three and 48/58 (83%) by six. There was no improvement in the remaining ten patients after six months.

21 patients described difficulty reaching and lifting (36%), 11/36 (31%) digging the garden, 13/58 (22%) were unable to reach between their shoulder blades. Over 90% had no difficulty with feeding (55/58), dressing (50/58), personal toilet (56/58), brushing hair (41/46), hanging up clothes (52/56) or ironing (37/41) but overall 23/58 patients (40%) had some functional restriction 1–2 years after injury. 18/48 patients (38%) returned to work within one month, 39 (81%) by three, and all by six. 28/30 (93%) clerical workers had returned within three months compared with 11/18 (61%) of manual (p < 0.05) 36/42 (86%) sportsmen returned. High impact sportsmen were less likely to resume than low impact or overhead. 38/46 (83%) of drivers returned by three months and all by six.

40/58 (69%) patients noted cosmetic deformity the severity of which was associated with worse functional outcome (p = 0.002). The degree of displacement of the fracture was associated with cosmetic deformity (p = 0.015) and functional outcome (p = 0.025), but the Robinson classification8 alone was not.

Conclusion: The majority of patients with a fractured clavicle perceive a cosmetic deformity and a substantial minority impaired function. There is potential to improve outcome and deformity by reduction and fixation in those with displacement of two or more cortical diameters.


B. Guhan R. Llewelyn M. Regan

Objective: To evaluate the results of cannulated screw fixation for subcapital neck of femur fractures in our unit.

Materials and Methods: 104 patients underwent the above procedure in our unit over a two year period (Jan 2006 – Dec 2007). The case notes and xrays of these patients were reviewed retrospectively. The age group varied between 31 and 100 years.

Results: There was 20% incidence of complications. There were 9 cases of AVN and 10 cases of screws backing out and I case of subtrochanteric fracture. Of the 9 cases of AVN 3 were below 73 years of age and the rest had a mean age of 90.3 years.

Conclusion: There is a high incidence of AVN in geriatric group requiring further surgery and cannulated screws fixation is not the optimal choice in geriatric group for varied reasons. Further review is to be carried out looking for the specific reasons of failure.


P. Mukherjee J. Press M. Hockings

Background: It has been shown before that when compared with the medial para-patellar approach, the mid-vastus approach for TKR results in less post-operative pain for patients and more rapid recovery of straight leg raise. As far as we are aware the post-operative length of stay of the two groups of patients has not been compared. We postulated that the reduced pain and more rapid recovery of straight leg raise would translate into an earlier, safe, discharge home for the mid-vastus patients compared with those who underwent a traditional medial para-patellar approach.

Methods: Twenty patients operated on by each of five established knee arthroplasty surgeons were evaluated prospectively with regard to their pre and post-operative range of movement, time to achieve straight leg raise post-operatively and length of post-operative hospital stay. One of the surgeons performed the mid-vastus approach, and physiotherapists recorded the measurements.

Results: The results were analysed using a standard statistical software package, and although the mean length of stay was lower for the mid-vastus patients, the difference did not reach a level of significance (p= 0.13). The time taken to achieve straight leg raise post-operatively was significantly less in the mid-vastus group (p< 0.001).

Conclusion: Although this study confirms previous findings that the mid-vastus approach reduces the time taken for patients to achieve straight leg raise, when compared with the medial para-patellar approach, on its own it does not translate into a significantly shorter length of hospital stay.

In order to reduce the length of post-operative hospital stay with an accelerated rehabilitation program for TKR, a multi-disciplinary approach is required.


Manjunathan Sivaprakasam Rishi Chana Anand Divekar W. Dunnet H. Zahn

Aim: The aim of this study is to analyse the peri-operative complications of the Bimetric femoral hip prosthesis (Biomet UK Ltd) and to evaluate the osteo-conductive and osteo-inductive performance of HA coatings in this implant.

Materials and Methods: This is an ongoing randomised control study (retrieval) over a period of 4 years at William Harvey Hospital, Ashford, Kent. Three types of HA coatings were used – plasma sprayed HAC 60μm, bonemaster dense HAC 3μm, bonemaster graded HAC 7μm. Three retrieved implants were sent for histological examination at The Royal National Orthopaedic Hospital, Stanmore.

Results: Fifty Four patients with mean age of 77 years (66–89) were evaluated. There were 12 (22%) surgical complications- 9 (7.4%) periprosthetic fractures, 2 stems subsided, 1 stem cemented. There was 5.5 % (3/54) risk of revision in 4 years (p< 0.001). The histological photomicrograph with the three different coatings examined showed Bone master 3–7μm coating had excellent bony in growth (osteo-integration).

Conclusion: In our series there was 5.5% risk of revision rate. The periprosthetic fracture and early mortality rates are within national limits. Revision surgery is the most significant aspect and this should be our primary concern. Hydroxyapatite coated stems with newer technique coating promotes good osteo-integration.


E.J. Mounsey D.H. Williams J.R. Howell M.J. Hubble A.J. Timperley G.A. Gie

The cement in cement technique for revision total hip arthroplasty (THA) has shown good results in selected cases. However results of its use in the revision of hemiarthroplasty to THA has not been previously reported.

Between May 1994 and May 2007 28 (20 Thompson’s and 8 Exeter bipolar) hip hemiarthroplasties were revised to THA in 28 patients using the cement in cement technique. All had an Exeter stem inserted at the time of revision. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford hip scores and radiographs were analysed post-operatively and at latest follow up.

The mean age at time of hemiarthroplasty revision was 80 (35 to 93) years. The reason for revision was acetabular erosion in 12 (43%), recurrent dislocation in 8 (29%), aseptic loosening in 4 (14%), periprosthetic fracture in 2 (7%) and infection in 2 (7%) patients. No patient has been lost to follow up.

3 patients died within 3 months of surgery. The mean follow up of the remainder was 50 (16 to 119) months. Survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. 3 cases (11%) have since undergone further revision, 1 for recurrent dislocation, 1 for infection, and 1 for periprosthetic fracture.

The cement in cement technique can be successfully applied to revision of hip hemiarthroplasty to THA. It has a number of advantages in this elderly population including minimizing bone loss, blood loss and operative time.


R.A. Kapur R. Amirfeyz V. Wylde A.W. Blom I.W. Nelson

Study Design: This is a retrospective study evaluating the use of BoneSave (Stryker, UK) in posterolateral inter-transverse spinal fusion.

Objectives. To evaluate the clinical outcomes and fusion success rates associated with the use of BoneSave in posterolateral spinal fusion.

Summary of Background Data: Achieving spinal fusion is the guiding principle behind surgical treatment for a range of pathologies of the spine. The use of a substantial amount of bonegraft is often required and autograft, commonly harvested from the iliac crest, represents the gold standard. Morbidities associated with graft harvest and a limited supply of graft material have led to the development of alternatives. BoneSave, a porous tricalcium phosphate-hydroxyapatite ceramic, is one such alternative which has been employed in spinal fusion over the past few years. Despite this the outcomes associated with its use lack research.

Methods: Clinical data was collected retrospectively from the case notes of all patients who underwent posterolateral inter-transverse spinal fusion at any level, involving the application of BoneSave, between June 2003 and January 2005 at Frenchay hospital, Bristol, UK. A postal questionnaire was used to collect the latest follow-up information, with an average follow-up of 46 months. Validated outcome instruments employed included the Short Form 36 and Oswestry Low Back Pain Disability Index. In addition visual analogue scales for both back and leg pain, Patient Global Impression of Change data, work status, persisting symptoms, and patient satisfaction data was collected. Radiological evaluation of fusion was carried out from the most recent spinal radiographs available for each patient.

Results: There were 45 patients in the study group. Qualitative post-operative data was available in 96% and response rate to the follow-up questionnaire was 68.4%. Radiographical evaluation was possible in 67%. Significant post-operative improvements were seen across all outcome measures in the large majority of cases. Successful fusion was achieved in 56.7% of cases.

Conclusion: The clinical outcomes associated with the use of BoneSave are comparable to those available in the literature for more conventional techniques of spinal fusion. The fusion rate was not significantly lower than achieved with other techniques.


S.A.C. Morris B. Sheridan M. Walton L. Sandford P. Ellaparadja P. Madhavan P. Thorpe

Use of epidural analgesia post-operatively in spinal surgery is becoming increasingly common. We have conducted a prospective study examining the side-effects associated with epidurals and the need for additional analgesia in 36 adult patients undergoing either lumbar spine decompression, lumbar spine fusion, or a combination of decompression and fusion. A mixture of bupivacaine and fentanyl was used for up to 72 hours post-operatively via an epidural catheter placed under direct vision at the time of surgery. All patients had urinary catheters inserted peri-operatively.

15 patients experienced one or more side-effects; 6 patients had a subjectively unpleasant sensory block, 3 patients developed a motor block, 4 patients had pruritus, 3 developed hypotension, and 2 had episodes of nausea or vomiting. All these features resolved upon reduction of the epidural rate or cessation of the epidural. All patients required additional oral analgesia at some point during their observation. There were no serious complications, such as infection, permanent neurological deficit, or cord compression.

We conclude epidural analgesia following lumbar spine surgery is a safe practice, although the high rate of side-effects necessitates close observation by fully trained staff. It appears additional oral analgesia is required to obtain satisfactory levels of analgesia.


S.A.C. Morris A. Omari

It has been suggested that recent reduction in hours worked by orthopaedic trainees in the UK may result in less exposure to operative procedures.

To examine this possible change, operative data showing the participation of specialist registrars in orthopaedic trauma cases were examined over 6-month periods in 2002 and 2007. Operations specifically examined included dynamic hip screw, hip hemiarthroplasty, manipulation under anaesthetic, ankle fracture fixation, and tension band wiring. A traditional on-call system was used throughout but the number of working hours was reduced.

Analysing individual operations, the results demonstrated a general trend for trainees to perform fewer procedures in the 2007 group, but this difference was not statistically significant. Level of consultant supervision was not significantly different except for hip hemiarthroplasty, which was higher in 2007. When considering all operations together, there was a significant decrease in the number of procedures performed by trainees in 2007, and although there was a trend for more supervision, this was not significant. Trainees were present for a significantly lower proportion of procedures in 2007 than 2002.

We conclude that it appears operative experience in orthopaedic trainees may be less than 5 years ago and this may be associated decreased attendance in theatre.


S.W. Veitch R. Stroud A.D. Toms

We describe our technique and the early results of compaction morselised bone grafting (CMBG) for displaced tibial plateau fractures using fresh frozen allograft. This technique has been performed by the senior author since July 2006 on eight patients.

Clinical and radiological follow-up was performed on seven remaining patients at an average 12 months (range 4–19) following surgery. One patient died of an unrelated cause three months following surgery. One patient underwent a manipulation under anaesthesia at three months for knee stiffness. One patient developed a painless valgus deformity and underwent corrective osteotomy at 15 months. The height of the tibial plateau on radiographs has been maintained to an excellent grade (less than 2 mm depression) in all but one patient.

CMBG using fresh frozen allograft in depressed tibial plateau fractures provides structural support sufficient to maintain the height of the tibial plateau, is associated with few complications in complex patients with large bone loss and has theoretical advantages of graft incorporation and remodelling.


J. Matthews P. Schranz

Purpose: Patellar instability is a common clinical problem affecting a young, active population. A large number of procedures have been described to treat patellar instability. We present the clinical results in a case series of 25 medial patellofemoral ligament reconstructions in 21 patients with up to 30 months follow-up (mean 7.3 months).

Methods: Reconstruction was performed using either the gracilis tendon (6 cases) or semitendinosus tendon (19 cases) autograft. At follow-up the Tegner activity scores, objective knee function, complications and reoperations were assessed.

Results: No patella re-dislocations were observed. Five patients (20%) required a manipulation under anaesthetic but subsequently regained a satisfactory range of motion. Two patients (8%) had post operative complications. One patient developed a post operative infection which required a washout and one patient developed a neuroma related to the hamstring harvest site which was excised. Both subsequently returned to work with a full range of motion. No patients sustained a patellar fracture.

Conclusions: Medial patellofemoral reconstruction with both gracilis and semitendinosus tendon graft using a longitudinal tunnel technique provided good postoperative patellar stability restoring the primary soft tissue restraint to pathological lateral patellar displacement.

Level of evidence: Level IV, therapeutic case series.


H. Davies G. Janes S. Zhaeentan A Tavakkolizadeh

Lateral sided hip pain frequently presents to the orthopaedic clinic. The most frequent cause of this pain is trochanteric bursitis. This usually improves with conservative treatment. In a few cases it doesn’t settle and warrants further investigation and treatment. Between July 2006 and February 2008, 28 patients underwent MRI scanning for such pain, 16 were found to have a tear of their abductors. All 16 underwent surgical repair using multiple soft tissue anchors inserted into the greater trochanter of the hip to reattach the abductors.

There were 15 females and 1 male. They had a mean age of 62. All patients completed a self-administered questionnaire pre-operatively and 1 year postoperatively. Data collected included: A visual analogue score for hip pain, Charnley modification of the Merle D’Aubigne and Postel hip score, Oxford hip score, Kuhfuss score of Trendelenburg and SF36 scores.

Of the 16 patients who underwent surgery 5 had a failure of surgical treatment. There were 4 re ruptures, 3 of which were revised and 1 deep infection which required debridement. In the remaining 11 patients there were statistically significant (p< 0.05) improvements in hip symptoms. The mean change in visual analogue score was 5 out of 10. The mean change of Oxford hip score was 20.5. The mean improvement in SF-36 PCS was 8.5 and MCS 13.7. 6 patients who had a Trendelenberg gait pre-surgery had normal gait 1 year following surgery.

We conclude that hip abductor mechanism tear is a frequent cause of recalcitrant trochanteric pain that should be further investigated with MRI scanning. Surgical repair is a successful operation for reduction of pain and improvement of function. However there is a relatively high failure rate.


G. S. Carlile A. Cowley B. Thorpe D. Williams R. Spence M. Regan

The time at which patients should drive following total hip replacement (THR) is dependant upon recovery and the advice they are given. The Driver Vehicle and Licensing Agency (DVLA) do not publish recommendations following THR and insurance companies usually rely on medical instruction.

Brake reaction times for patients undergoing THR were measured before and four, six and eight weeks after surgery using a vehicle-driving simulator. Patients were prospectively recruited. Ethical approval was granted.

Participants included eleven males and nine females, mean age 69 years. Side of surgery, frequency of driving and type of car (automatic or manual) were documented. Patients with postoperative complications were excluded. No adverse events occurred during the study.

Statistical analysis using Friedman’s test demonstrated a statistically significant difference (P=0.015) in reaction times across the four time periods. Wilcoxon test demonstrated a highly significant difference between initial and six week mean results (P=0.003), and between four and six week results (P=0.001). No significant difference was found between six and eight weeks.

Our data suggests reaction times improve until week six and significantly between week four to six. Patients making an uncomplicated recovery should be considered safe to drive by week six.


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M.P. Rodger P. Mukherjee G. B. Irvine

We report experience of 207 consecutive metal on metal hip resurfacings in 179 patients, implanted by one surgeon since January 2002. The mean age at operation was 56 years (35 – 78 years) and follow-up ranged from 12 to 84 months (mean 39 months). The gender mix was 2:1 M: F. The Birmingham Hip Resurfacing was implanted in the first 155 cases with a switch to Finsbury Adept Hip Resurfacing for the remaining 52 cases.

Data was obtained on all but one patient. There were four unrelated deaths (1.9%). No primary infections and no femoral neck fractures were encountered. One secondary infection at five years was salvaged by surgery and antibiotic treatment (0.5%). One male suffered a pertrochanteric fracture as a result of significant violence 15 months after operation (0.5%). Dislocation in five cases was the commonest complication encountered (2.4%). One of these cases developed recurrent dislocation and underwent early revision to a constrained total hip replacement (0.5%). This was the only failure in the series and no further revisions are pending.

Our survivorship results compare very favourably with outcomes reported from centres of excellence and far exceed the survivorship estimates published by the National Joint Registry.


J. Barnes S. Thomas J. Wedge R. Salter

Introduction: A criticism of innominate osteotomy (IO) is that it causes relative acetabular retroversion, predisposing to OA. This study was designed to address this hypothesis.

Materials and Methods: We had access to radiographs of 30 patients 45 years after they had undergone open reduction and innominate osteotomy for late presenting DDH. Using the validated method of Hefti (1995) we measured anterior and posterior acetabular coverage, contact area and version.

Results: Group 1 – 26 Post-op hips, Group 2 – 20 Contralateral hips, Group 3 – 21 Normal hips. Anterior coverage was 10.8% in group 1, 11.0% in group 2 and 12.0% in group 3. Posterior coverage was 18.8% in group 1, 18.9% in group 2 and 21.0% in group 3. Contact area was 16.1 cm2 in group 1, 13.9 cm2 in group 2, and 22.1 cm2 in group 3. Version was 7.20 in group 1, 7.10 in group 2, and 7.70 in group 3.

A significant difference was found for contact area (p< 0.001). There was no significant difference in version (p = 0.845).

Conclusion: Early OA may be related to contact area. Any abnormal (retro)version grows out. Innominate osteotomy before the age of 5 years has the potential to facilitate, or at least not prevent, normal acetabular development and version.


S. Sawalha S.M. Dixon M.R. Norton E.D. Fern

The aim of Femoro-Acetabular Impingement (FAI) surgery is to improve femoral head-neck clearance by resection of the osseous bump deformity. The purpose of this study was to investigate whether osseous bumps will re-grow and to compare two instruments used for resection osteoplasty; a shaver burr and an osteotome.

We reviewed records of patients who underwent surgical hip dislocation and debridement via Ganz flip osteotomy between March 2003 and July 2007. We excluded patients with less than one-year radiographic follow-up.

Ninety-five patients (95) underwent 98 surgical hip dislocations and were included (mean radiological follow-up 23 months, range 12–61 months). Bump re-growth occurred in 16 cases (16%). Pre and postoperative Non-Arthritic Hip Scores (NAHS) were available for 12 of the 16 patients. The mean pre- and postoperative NAHS were 62 (range 26–95) and 83 (range 41–104) respectively (p= 0.02). In the shaver burr group (n=57), there were 6 cases of bump re-growth (12%) compared to 10 cases in the osteotome group (n=41) (32%).

In this study, recurrence of osseous bumps did not affect the outcome. Using shaver burrs resulted in lower rates of bump re-growth than using osteotomes. This could be related to heat osteonecrosis at the femoral head-neck junction.


M. Butler A.G. Lee A.D. Toms

The 4th England and Wales NJR showed that 83% of total knee replacements were cemented (47,626 knees). This study aimed to compare modern techniques of cementation of the proximal tibia in an experimental model against tourniquet-less knee replacement surgery with cancellous bone suction and a cement gun.

A metal box was constructed to approximate the proximal tibia and open cell sawbone simulated the tibia with simulated blood flow and bone suction. Each sample was prepared in an identical fashion except for the cementing technique. The techniques compared were of

Tourniquet,

No tourniquet,

No tourniquet + cancellous bone suction and

No Tourniquet, suction applied + cement gun pressurisation.

Samples were subsequently sectioned, polished and the cemented area measured using a planimeter.

ANOVA testing demonstrated that the techniques were significantly different (p< 0.0001). Bonferroni Comparison demonstrated that the Exeter technique gave significantly better cement penetration for central and lateral measurements (p< 0.0001 and p< 0.0001) compared to all other methods.

The authors believe that our technique of cementation of the proximal tibia offers an easy and reproducible way of getting good quality cementing of the tibial component in total knee replacement and this is borne out by our experimental model.


D. Weller M. Westwood R. Cove

Background: It is taught that ruptures of the Achilles tendon occur at the musculotendinous junction and indeed ultrasound reports will often confirm this. This study investigates the orthopaedic surgeon’s understanding of the clinical significance and location of the musculotendinous junction.

Materials and Methods: A survey of orthopaedic surgeons at a regional orthopaedic meeting. Two transverse lines were drawn on a photograph of a lower limb identifying the musculotendinous junction, and marking the highest level at which they would consider a surgical repair. They were asked about their understanding of the term “musculotendinous junction”.

Results: Twenty two delegates of various degrees of seniority responded.

Surgeons estimate of musculotendinous junction level: 10.1 cm

Anatomical level of musculotendinous junction: 5.51 cm

Average highest level for considering surgical intervention: 8.71 cm

Conclusions: There is confusion regarding the exact location and nature of the Achilles musculotendinous junction amongst orthopaedic surgeons. Particular care is advised when interpreting ultrasound reports. An Achilles surgical zone has been identified (0–10 cm from the calcaneal insertion) within which the majority of surgeons would consider surgical intervention for rupture.


R. Walter K. Trimble

Summary: A large number of review appointments in elective clinics are to discuss results. In well-informed patients, investigations and treatment plans can be discussed by telephone, avoiding the need for a face-to-face consultation. This saves resources, assists in achieving treatment pathway targets, and is financially viable and acceptable to patients.

Background: An audit of the Plymouth foot & ankle service highlighted a long patient wait to discuss the outcome of investigations and plan treatment. Not only is this unacceptable for patients, it adversely affects the flow of the RTT pathways.

Derriford Hospital has a wide catchment area and the foot & ankle service has a military catchment area from Cornwall to Buckinghamshire.

Method: During the initial outpatient consultation, if the clinician feels that the patient is suitable, an arrangement is made to discuss the results of investigations and subsequent treatment plan by telephone. The treatment options are re-iterated in a summary letter of the consultation to the patient.

Conclusion: The preliminary 3 month results are presented and as a concept the clinic has been successful, being acceptable to all patients involved and reducing the requirement to provide additional clinics.


A. Hughes A. Kelly

We present a series of 16 patients requiring revision forefoot procedures in Musgrove Park Hospital, Taunton.

The primary procedures were carried out in a local Independent Sector Treatment Centre as part of a regional initiative to reduce waiting times to meet national targets. Several of these patients were primarily listed for surgery at our institution. The majority of the procedures performed were first ray procedures in the time period from February 2006 to February 2009.

We present a summary of the indications for these revision procedures and some of the issues surrounding the management of these patients. We also present a summary of the costs incurred by Musgrove Park Hospital as a result of this extra workload.


H. Davies B. Twaddle

Purpose of Study: To examine if and when patients return to sporting activity following surgery, and how their subjective assessment of ability to perform activities was affected by their injury and surgery. We also wished to examine if there was any difference in the timing of return to sport between different sporting activities and by graft (hamstring or bone, patella tendon, bone (BTB)) used for ACL reconstruction.

Method and Results: 252 ACL reconstructions were followed up for 2.5 years post surgery. They were evaluated pre and post surgery with Mohtadi activity scores evaluating their function for their primary and secondary sporting activities. They were also evaluated regards exactly when they got back if at all to their primary and secondary activities. 84.2% returned to activity1 at a mean of 9.3 months 87.2% returned to activity 2 at a mean of 8.5 months. 60.7% of patients who returned to activity 1 returned at the same level as prior to their injury. 69.8% of those who returned to activity 2 returned at the same level as prior to their injury. There was no significant difference in timing of return to sport between hamstring and BTB graft.

Discussion: We can conclude from this study that the mean time to return to sport following ACL reconstruction is close to what most surgeons) are telling their patients (i.e. 6 to 9 months). However there is wide variation between subjects with a number of complex factors affecting when a person returns to their activity. It is probably wrong for us to give the expectation to all patients that they will be back to their preferred activities at 6 to 9 months.


J.D. Kosy N.C.L. Giles

The Proximal Humeral Internal Locking System (PHILOS) is being used increasingly in the treatment of proximal humeral fractures. Improvements in operative technique since its first use may represent improved functional results.

We analysed 28 cases performed in the two years following October 2006. There were 22 females and 6 males. Mean age was 65 years (Range 37–79 years). There were five 2-part, nineteen 3-part, and four 4-part fractures. Functional results were measured using the Oxford Shoulder Score, American Shoulder and Elbow Surgeons’ Score (ASES) and Constant Score (Age and sex matched). These results were compared to the patient’s non-operated shoulder to determine loss in function.

Following PHILOS fixation, the Oxford Score increased by a mean of 11 points, the ASES decreased by a mean of 25 points, and the Constant Score decreased by a mean of 31. This change was significant for all three scores (p-values < 0.01). Sub-analysis comparing patients aged < 60 years with those > 60 years and 2-part fractures with 3- and 4-part fractures showed no significant difference.

We conclude that our results confirm previously published functional data and show the patient’s age, and fracture configuration, have no impact on the results of this implant.


J. Loveridge R. Gardner A. Barnett N. Davis A. Dunkley

Suturing of portals following arthroscopic shoulder surgery may be unnecessary. We carried out a randomised controlled trial to compare patients whose arthroscopic portals were closed by suturing and those that weren’t. We randomised 60 patients undergoing diagnostic shoulder arthroscopy, arthroscopic subacromial decompression and arthroscopic acromioclavicular joint excision.

At 10 to 12 days following surgery patients attended the GP surgery for a wound check and removal of sutures as required. At 3 weeks and 3 months every patient was reviewed by a designated, blinded, observer and the wounds assessed. The patients completed a questionnaire including visual analogue scores to determine their satisfaction with wound appearance and any complications such as infection.

At 3 weeks and 3 months no patients had needed antibiotics with no wound erythema or signs of infection. The number of dressings needed was comparable in both groups. The level of patient satisfaction was not statistically different in either group. (T-test 0.91, SD 15.16) The wound cosmesis score was not statistically different in either group. (T-test 0.29, SD 6.66)

We conclude that both closure techniques were equivalent but the non-suture technique is cheaper with lower morbidity. From our study there is no need to suture shoulder arthroscopy portal wounds


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S. Punwar I. Sidwell J. Williams

In February 2007 an Electronic Emergency Board was introduced into the Orthopaedic Department at Musgrove Park Hospital. The aims of this system were to replace the often disorganized handwritten trauma white-board and improve multidisciplinary communication.

The electronic board can be accessed from any computer terminal in the hospital and a large plasma screen is kept permanently on display in the orthopaedic theatre corridor. Emergency admissions are added by the on-call registrar before the morning trauma meeting and during the day the board is managed by our Trauma Coordinator.

We performed an informal survey of orthopaedic trauma departments in the South West region to ascertain current practices for organizing the trauma workload.

In summary we have introduced an electronic system for the organising and recording of all our trauma cases. We have found this system extremely beneficial to the smooth running of the orthopaedic trauma service.


L. Obolensky R. Lofthouse G. Minto D. Spicer K. Houghton

Nationwide changes in the organisation of specialist medical training present a challenge to surgical trainees in terms of exposure to an adequate case load, the acquisition of practical experience and therefore also of judgement and decision-making. When accompanied by accredited trainers exposure to practice in the developing world offers trainees the opportunity to enhance their clinical exposure as well as skills in communication, teaching, management and leadership. This paper analyses the training value for orthopaedic trainees of a novel orthopaedic project undertaken in Kenya in February 2009 utilising an entire UK orthopaedic team.

The first Kenya Orthopaedic Project (KOP) was organised by an orthopaedic trainee and took place at Nanyuki District General Hospital in February 2009. Kenya does not have the luxury of a national health service and patients must pay for any clinics or surgery. The cost of orthopaedic surgery in this environment is prohibitive and many fractures go untreated, as do other common pathologies such as severe osteoarthritis and osteomyelitis.

The UK team undertaking the project included two accredited consultant orthopaedic surgeons and an orthopaedic trainee. Clinics, surgery and teaching sessions were performed for one week with the aim of relieving the sheer volume of orthopaedic cases and to provide those impoverished patients with treatment they would not otherwise receive.

Data was taken from elogbook to analyse the average number of cases performed by an orthopaedic ST3 in one week, and a survey was sent to all Southwest trainees (n=25) for information on how many competencies and work placed based assessments were completed in one week.

Daily challenges of health care budgeting, negotiating, organisational and intercultural communication skills are not often encountered by UK orthopaedic trainees, and bring with them a realisation of the wider picture of health care economics and appreciation of the benefits of a National Health Service.

The results showed that in one week during KOP over seventy patients were seen in clinic and eighteen operations performed. Of the 18 operations performed the orthopaedic trainee assisted in 15 of these operations and performed 3 under supervision. An average week log book entry for ST3 trainees, taken from elogbook statistics, contains six elective and three trauma operations. The figures from one week Kenya Orthopaedic Project double these operative numbers. Six workplace based assessments were completed in one week on the project, significantly more than an average of 0.16 per week in UK. (p=0.0003).

In conclusion Kenya Orthopaedic Projects offer a unique experience for orthopaedic trainees and all members of the multidisciplinary team. Trainees are offered the opportunity to put into practice managerial, teaching, organisational and communication skills as well as the chance to see and treat pathologies that would not be encountered in the UK. The experience of operating in third world conditions with minimal equipment available, communicating with patients and theatre staff from a different culture whilst ensuring all possible western world safety measures are adhered to offers a wholly challenging and valuable perspective to an orthopaedic trainee.

Both operative experience and workplace based assessments statistically surpassed that of an average week of a UK trainee. We can therefore conclude that a week’s orthopaedic experience in a third world country is not only beneficial to the patients but offers excellent training opportunities in all aspects of the delivery of health care and makes a positive contribution to orthopaedic training.


K. Naik S. Smith

Aim: According to NICE guidelines, only indication for arthroscopy of the knee, in patients with OA is clear history of ‘mechanical locking’. Are we meeting NICE guidelines?

Method: This was a retrospective study. Data was collected from the patient’s notes and WebPacs. All the patients aged more than 70 years who had knee arthroscopy in a year were included. Indications for arthroscopy, preservation of knee joint space at the time of procedure, complications and further follow up, were recorded.

Results: There were 77 patients with 79 arthroscopic procedures. Indications noted were true locking, mechanical symptoms, loose bodies, degenerative meniscus, OA, knee pain, and diagnostic procedure. Only 6 patients had mechanical locking. 30 patients had joint space less than 2 mm, 33 had between 2 to 4 mm. There were 3 complications including DVT (2) and recurrent knee swelling (1). Many patients were symptomatic. Out of 77 patients, 31 were already waiting to have, or had, arthroplasty at the time of study.

Conclusion: For patients aged more than 70 years with less than 2 mm joint space, arthroscopy of the knee is rarely indicated.


J. Penn-Barwell C. Fries L. Street S. Goonewardene S. Jeffery

Topical Negative Pressure Therapy (TNPT) has gained increasing acceptance as a useful tool in wound management. Since 2002, the Royal Centre for Defence Medicine (RCDM) in South Birmingham has gained considerable experience with managing complex combat trauma with TNPT. The mainstay of managing high-energy combat wounds has changed little over the last century of conflict and remains early debridement, wound lavage, fracture stabilisation and delayed closure. Over the last 10 years the use of TNPT has proved to be a useful adjunct in promoting delayed primary and secondary closure, and is now common practise in the US and UK military medical services. There is however, little level 1 evidence to support the use of TNPT in military trauma.

All military patients admitted to Selly Oak Hospital between April 2007 and March 2008 that were treated with TNPT were identified, those whose notes were available were included.

37 cases were included. There was a strong correlation between ISS, NISS, and antibiotic use during TNPT use and the total duration of secondary care. However, we found no correlation between delay to first TNPT application, the frequency or location of TNPT dressing changes and any of our surrogate markers of outcome.

TNPT is just one of a number of techniques for managing military high-energy injuries and should not be seen as an alternative to the established principles. The high frequency of TNPT dressing changes is not supported by this research and this should be reflected in the clinical management of patients requiring prolonged TNPT.


A. Ramasamy M. Midwinter P. Mahoney J. Clasper

Current ATLS protocols dictate that spinal precautions should be in place when a casualty has sustained trauma from a significant mechanism of injury likely to damage the cervical spine. In hostile environments, the application of these precautions can place pre-hospital medical teams at considerable personal risk. It may also prevent or delay the identification of airway problems. In today’s global threat from terrorism, this hostile environment is no longer restricted to conflict zones. The aim of this study was to ascertain the incidence of cervical spine injury following penetrating ballistic neck trauma in order to evaluate the need for pre-hospital cervical immobilisation in these casualties.

We retrospectively reviewed hospital charts and autopsy reports of British military casualties of combat, from Iraq and Afghanistan presenting with a penetrating neck injury during the last 5.5 years. For each patient, the mechanism of injury, neurological state on admission, medical and surgical intervention and cause of death was recorded.

During the study period, 90 casualties sustained a penetrating neck injury. The mechanism of injury was by explosion in 66 (73%) and from gunshot wounds in 24 (27%). Cervical spine injuries (either cervical spine fracture or cervical spinal cord injury) were present in 20 of the 90 (22%) casualties, but only 6 (7%) actually survived to reach hospital. Four subsequently died from injuries within 72 hours. Only 1 (1.8%) of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation, however this patient died as result of a co-existing head injury.

Penetrating ballistic trauma to the neck is associated with a high mortality rate. Our data suggests that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment (e.g. shooting incidents or terrorist bombings), the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk. In addition cervical collars may hide potential life threatening conditions.


A. Ramasamy K. Brown W. Eardley J. Etherington J. Clasper M. Stewart R. Birch

Over 75% of combat casualties from Iraq and Afghanistan sustain injuries to the extremities, with 70% resulting from the effects of explosions. Damage to peripheral nerves may influence the surgical decision on limb viability in the short-term, as well as result in significant long-term disability. To date, there have been no reports of the incidence and severity of nerve injury in the current conflicts.

A prospective assessment of United Kingdom (UK) Service Personnel attending a specialist nerve injury clinic was performed. For each patient the mechanism, level and severity of injury to the nerve was assessed and associated injuries were recorded.

Fifty-six patients with 117 nerve injuries (median 2, range 1–5) were eligible for inclusion. This represents 12.9% of casualties sustaining an extremity injury. The most commonly injured nerves were the tibial (19%), common peroneal (16%) and ulnar nerves (16%). 25% (29) of nerve injuries were conduction block, 41% (48) axonotmesis and 34% (40) neurotmesis. The mechanism of injury did not affect the severity of injury sustained (explosion vs gunshot wound (GSW), p=0.53). An associated fracture was found in only 48% of nerve injuries and a vascular injury in 35%. The presence of an associated vascular injury resulted in more severe injuries (conduction vs axonotmesis and neurotmesis, p< 0.05). Nerves injured in association with a fracture, were more likely to develop axonotmesis (p< 0.05).

The incidence of peripheral nerve injury from combat wounds is higher than previously reported. This may be related to increasing numbers of casualties surviving with complex extremity wounds. In a polytrauma situation, it may be difficult to assess a discrete peripheral neurological lesion. As only 35% of nerves injured are likely to have anatomical disruption, the presence of an intact nerve at initial surgery should not preclude the possibility of an injury. Therefore, serial examinations combined with appropriate neurophysiologic examination in the post-injury period are necessary to aid diagnosis and to allow timely surgical intervention. In addition, conduction block nerve injuries can be expected to make a full recovery. As this accounts for 25% of all nerve injuries, we recommend that the presence of an insensate extremity should not be used as an indicator for assessing limb viability.


D. S. Edwards A. Ramasamy B. Armstrong D. Hinsley A. Brooks

UK military forces have been deployed in Afghanistan since 2006 as part of the International Stabilisation Assistance Force. The Operation is supported by a 50-bedded hospital. In 2007 the Defence Medical Services introduced a massive haemorrhage policy. In asymmetric warfare gunshot wounds (GSW), improvised explosive devices (IED) and mine injuries are prevalent and we hypothesized that they would require significant blood products.

We prospectively collected data from consecutive trauma resuscitations over 3 months (January to March 2008). Pre-hospital time points, mechanism of injury, injury distribution, injury severity score (ISS), new injury severity score (NISS), surgical procedures, blood product utilisation and outcome were recorded.

115 trauma resuscitations were performed over the study period. Median pre-hospital time was 95 minutes (range 30–325), with median 64 minutes to the arrival of the Medical Emergency Response Team helicopter. The cause of injury was landmine (20), IED (31) and GSW (40); mean number of involved body systems was 1.4, 1.8 and 1.5 respectively and injured structures 2.8, 3.5 and 2.3 respectively (IED> GSW p< 0.05). Mean ISS was 16, 16.8, 14.9 and NISS 18.7, 20.9, and 17.9 respectively. Blood transfusion was required in 3 mine, 14 IED and 17 GSW casualties (mine< IED & GSW, p< 0.05) with 10.6, 11.4, and 13.9 units of blood transfused per casualty.

Injury severity for casualties is high with multiple injuries to body systems irrespective of mechanism. Anti-personnel mine injuries were significantly less likely to require transfusion. Large quantities of blood products were still required when necessary in all mechanisms of trauma. It is therefore recommended that during the pre-hospital time the major transfusion protocol should be placed on stand-by.


S. Dharm-datta J. Etherington A. Mistlin J. Clasper

Amputation is one of the most feared injuries in service personnel, particularly a worry that it will mean the end of their military career. The aim of this study was to determine the outcome, in relation to military service in UK military amputees.

UK service personnel who sustain an amputation undergo rehabilitation and prosthetic limb fitting at the Defence Medical Rehabilitation Centre Headley Court. This includes a realistic assessment of their employment capabilities, and they are graded by a Functional Activity Assessment (FAA). FAA ranges from 1 (fully fit) to 5 (unfit all duties). In addition the Short Form-36 Health Survey (SF-36) is completed on initial admission and at follow-up. We reviewed this information to determine the outcome of military amputees.

We identified 53 casualties who had sustained amputations. 8 had sustained an upper limb amputation, 41 a lower limb amputation, and 4 had sustained both an upper and lower limb amputation. 9 patients (including 1 Reservist) have left the forces by medical discharge, with the remaining 44 continuing to serve. 32 of the 44 have returned to work, albeit at a lower level. 49 patients have FAA grades and are at least 6 months post-injury. No patients were graded as FAA 1, 8 as FAA 2 (Fit for Trade and fit for restricted General or Military Duties), 18 as FAA 3 (Unfit for Trade but fit for restricted General or Military Duties), 18 as FAA 4 (Unfit for all but Sedentary Duties) and 5 as FAA 5. All bilateral and triple amputees were FAA 4 or 5. Other injuries such as blindness, severe brain injury or mental health issues also increased the FAA. Of the 32 patients who have returned to work, 8 are FAA 2, 12 are FAA 3, 11 are FAA 4, and 1 has not been graded. SF-36 data was available in 40 patients, available as paired scores for 34. The mean time between SF-36 scoring was 6.7 months (range 0.2 – 17.4). The mean SF-36 scores for Physical Component Summary (PCS) increased from 34.40 (SD 9.3) to 42.06 (SD 11.1), with Mental Component Summary (MCS) 52.01 (SD12.9) remaining similar at 52.92 (SD 12.0). Pre- and post-rehabilitation PCS scores improved with rehabilitation (p=0.0003). MCS scores were similar in these patients to the normal population, 50 (SD 10). No differences could be found within the unilateral lower limb amputation group regarding amputation level (trans-tibial, through-knee disarticulation, trans-femoral) and SF-36 scoring. Furthermore due to the low numbers, no conclusion could be made comparing the unilateral lower limb amputation group with the bilateral lower limb group, the unilateral lower limb plus upper limb, the bilateral lower limb and upper limb (trilateral), and the isolated upper limb groups.

This study is the first to report the outcomes, with regards to return to work, of the UK military amputee population injured in Afghanistan and Iraq. There is an almost even distribution of FAA score between 2, 3, and 4 for those back at work. Level of amputation and SF-36 scores do not seem to correlate, partly due to other injuries sustained that confound the patients’ perception of their health. SF-36 PCS scores increase significantly with rehabilitation, whilst MCS remain similar to the normal population.


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A. Ramasamy A. Mountain K. Brown M. Stewart I. Gibb J. Clasper

The biomechanics of civilian fractures have been extensively studied with a view to defining the forces responsible e.g. bending, torsion, compression and crushing. Little equivalent work has been carried out on military fractures, although fractures from gunshot can be divided into direct and indirect. Given that the effects of blast can be sub-divided into primary, secondary, tertiary and quaternary, the aim of this study was to try to determine which effects of the blast are responsible for the bony injury. This may have implications for management and prognosis as well as prevention.

We reviewed emergency department records, case notes, and all radiographs of patients admitted to the British military hospital in Afghanistan over a 6 month period (Apr 08–Sept 08) to identify any fracture caused by an explosive mechanism. In addition we reviewed all relevant radiographs from the same period at the Royal Hospital Haslar, who report all radiographs taken, and keep a copy of the images. Early in the study it became clear that due to the complexity of some of the injuries it was inappropriate to consider bones separately and we used the term ‘fracture zone’ to identify separate areas of injury, which could involve from 1 – 28 bones. It also became clear that the pattern of injury differed considerably between patients in open ground, and those in houses or vehicles. These 2 groups were considered separately and compared.

We identified 86 patients with fractures. The 86 patients had 153 separate fracture zones (range 1–6). 56 casualties in the open sustained 87 fracture zones (mean 1.55 fracture zones per casualty). 30 casualties in a vehicle or other cover sustained 66 fracture zones (2.2 per casualty). Of the casualties in the open, 17 fracture zones were due the primary effects of blast, 10 a combination of primary and secondary effects, 30 due to secondary effects and 30 from the tertiary effects of blast. Of the casualties in vehicles we could not identify anyone with a fracture due to either the primary or secondary effects of blast, all 66 fracture zones appeared to be due to the tertiary effects.

In both groups there appeared to be a significant number of fractures, often with no break in the skin, caused by severe axial loading of the limb. This was possibly due to the casualty impacting against the ground, building or the inside of a vehicle, and this is a group of injuries we are now studying in greater detail.


J. Clasper K. Brown P. Hill

It has stated that the application of a pre-hospital tourniquet could prevent 7% of combat deaths, but their widespread use has been questioned due to the potential risk from prolonged ischaemia, or local pressure. The debate centres on their ability to improve survival after major haemorrhage, versus the potential risk of limb loss. A recent US military prospective study on their use demonstrated improved survival when a tourniquet was applied, and reported that no limb was lost solely from tourniquet use. However, this study focused on early limb loss, with a median follow-up of only 7 days, and so could not consider later morbidity. The aim of this study was to investigate if the pre-hospital application of a tourniquet resulted in an increase in morbidity following significant ballistic limb injury.

We reviewed members of the UK armed forces who sustained severe limb-threatening injuries in Iraq and Afghanistan, and based on the presence or absence of a pre-hospital tourniquet a cohort study was then performed. Of the 23 lower limbs that definitely had a pre-hospital tourniquet applied it was possible to match 22 limbs with 22 that did not have a pre-hospital tourniquet. The injuries were matched for anatomical location, severity of the bony injury, initial surgical management, Injury Severity Score and Mangled Extremity Severity Score as much as possible.

Of the 22 limbs with a pre-hospital tourniquet applied, 19 limbs had a least 1 complication. Of the 22 with no tourniquet applied, 15 had at least 1 complication (p=0.13). There were 10 limbs with at least 1 major complication in the pre-hospital tourniquet group but only 4 in the group with no tourniquet (p=0.045). There was no difference in the amputation rate.

The significant difference in the incidence of major complications is a concern, particularly as the difference was mainly due to a deep infection rate of 32% vs. 4.5%. Although there are a number of variables which could have influenced these small groups, such as choice of implant, method and timing of wound closure, the use of a cohort and a p < 0.05, does suggest the use of a pre-hospital tourniquet was a factor.

Although the use of pre-hospital tourniquets cannot be decried as a result of this study, there does remain the need to continually review their use, prospectively, to determine their risk/benefit ratio.


D. Griffiths O. Templeton-Ward S. Grange S. Lambert I. Bayley M. Falworth

Arthroplasty as a salvage procedure for cuff and glenoid deficiency poses major problems due to the limitations in treatment options and debilitating symptoms. We hypothesized that computer aided deigned and manufactured (CADCAM) total shoulder arthroplasty, using a precisely fitted glenoid shell, can relieve the pain and poor function associated with irreparable rotator cuff pathology and severe glenoid deficiency in the shoulder.

Of the 127 cases so far performed, a prospective cohort study 79 consecutive subjects, with a mean 28.7 month follow-up, were evaluated by a single practitioner blinded to their group status. Outcome was assessed using a validated clinical shoulder scoring system and radiographic review.

The subjects had a mean age of 58 (41–82) and their indication (where recorded) was mainly revision total shoulder replacement (62%) with some cases for primary osteoarthritis (12%) and rheumatoid arthritis (9%) and a proportion for other reasons (19%) including 1 re-revision case for dislocation.

Clinical follow-up was limited in this population (n=58, 73%) The ‘CADCAM’ group’s mean Stanmore Percentage of Normal Shoulder Assessment scores (SPONSA) were relatively unchanged post surgery (47 to 42 p=0.3). The Oxford Shoulder scores improved significantly (15 to 33, p< 0.0001). Most significantly, and by way of explanation, post surgery subjects recorded a reduction in the Visual Analogue Scale (Pain) scores (6.6 to 2.9) p< 0.0001). Patient satisfaction was generally good.

Radiographic review of the 79 cases revealed glenoid component screw breakage (4%, n=5) which is a moderate correlate of glenoid loosening (r = 0.65, r2 = 0.42) and probably more accurate than radiographic lucent lines seen in 6% (n=7). Humeral lucency was seen in 10%, (n=8). These radiographic findings correlated well with the clinical findings.

Postoperative pain and function was significantly improved in subjects undergoing the ‘CADCAM’ technique of shoulder arthroplasty offering a consistent salvage option for situations where no alternative to glenoid reconstruction is feasible.


N.J. Ward S. Ladher R. Sharp

According to the National Institute of Clinical Excellence (NICE) Guidelines, some foot and ankle patients are, by definition, at high risk of DVT/PE. Despite NICE guidance, DVT recommendations are still controversial, and are being reviewed by the BOA to be more operation and context specific.

One consultant at our institution therefore initiated a 6 week medical DVT prophylaxis regimen for all his post-operative hind–foot surgery patients who were placed in plaster. From January 2007 to February 2008 we audited 97 hind-foot patients to measure their compliance rate, complications and DVT/PE rate.

Compliance was excellent (97%) particularly with regard to Low Molecular Weight Heparin (LMWH), but only 70% had medication prescribed for the 6 weeks, and 3% developed a DVT.

Self administered LMWH is acceptable and compliance is excellent in post operative orthopaedic patients, but not necessarily effective.


T. Halsey E. Spurrier J. Jones G. Pathak

The CMI pyrocarbon implant is a unipolar arthroplasty for trapeziometacarpal joint arthritis which is implanted in to the thumb metacarpal. Previous case series have shown these implants provide significant pain relief and good patient satisfaction. We report the first cases of pyrocarbon hemiarthroplasty from Peterborough.

Seventeen cases in fifteen patients were retrospectively reviewed. The average patient age was 59.7 years (range 47–72). 7 patients were men and 8 were women. Five were discharged with good outcome at a mean of 11.5 months (range 6–19). One failed to attend follow up.

Most patients in whom the implant survived were afforded good pain relief by the procedure and had a good functional range of thumb movement. Radiologically 8 implants were subluxed by at least 50%. One implant was revised after dislocation and loosening of the prosthesis which was associated with trauma. She made excellent clinical progress after revision of the prosthesis. One of the thirteen cases dislocated and was revised to a trapeziumectomy after 11 months.

Preliminary results suggest that this implant affords good pain relief and functional improvement in managing OA at the TMC joint. Longer term follow up will be required to correlate clinical and radiological outcomes.


C. Booth R. Shah

Back pain is common, with quotes of lifetime prevalence ranging from 50% to 80% and point prevalence of 15% to 30%. There is scarce data within the British Military.

A prospective observational study evaluated the prevalence of back pain and its impact on work in a deployed population on OP TELIC 13. 1000 questionnaires were distributed over 4 days, 768 were returned. Additionally, clinical data was collected from the ward, aero-medical, and physiotherapy dept for the period September 2008- February 2009.

Overall prevalence of back pain was 33.4% (257). A greater prevalence occurred in the combat arms (41.7%, p=0.01) and those of over 12 years service (44%, p=0.004). No statistical difference was found with rank, or BMI. 74 people (9.6%) had developed new onset back pain since deploying. Within the new pain group 10/74, (13%) were experiencing either ‘some’ or ‘great’ difficulty at work. Recurrent pain occurred in 38.9% of the whole sample, with an increased prevalence in those of over 12 years service (58% p< 0.001). Back pain constituted 23% (137/583) of the physiotherapy dept case-load, 6.6%, (25/378) of ward admissions and 0.04% (5/119) of aero-medical patients.

This study shows that back pain is a major problem among deployed personnel, but can be managed with timely medical input, and is rarely the indication for aero-medical evacuation. Adequate resources are required to maintain operational effectiveness. Further studies should be undertaken to assess if back pain persists after deployment.


T. Bonner A. Mountain J. Clasper

The role of Evidence Based Medicine in modern surgical practice is to provide a framework for the integration of expertise, evidence and the biology of the individual patient. The research presented at the Combined Services Orthopaedic Society (CSOS) annual meeting is an important source of evidence which is used to support clinical decisions made about patients on military operations and in the NHS. The purpose of this study is to review the levels of evidence presented at this meeting since 2001.

We reviewed all of the abstracts presented at the annual meetings of the CSOS between 2001 and 2008, and a single meeting of both the Society of Military Orthopaedic Surgeons (SOMOS) and the British Trauma Society (BTS). Basic science studies, animal studies, cadaveric studies, surveys and guest lectures were excluded. The research abstracts were coded by the lead author (TJB), according to the Oxford Centre for Evidence-based Medicine Levels of Evidence. A second author (AM) reviewed the coding of all abstracts to provide inter-observer reliability. Statistical analysis included a chi-squared test to compare the percentages of each level of evidence between the meetings and between each year of the CSOS meeting.

We identified 140, 51 and 96 abstracts in the CSOS, SOMOS and BTS group respectively, which met the inclusion criteria. Level 1 evidence accounted for 73.8%, 64.7% and 68.8% in the CSOS, SOMOS and BTS groups respectively. Level 1 evidence was uncommon at all three meetings representing 4.1%, 5.9% and 8.3% in the CSOS, SOMOS and BTS groups respectively. The chi-squared test did not demonstrate any statistical difference in the evidence levels between the three groups (X2=11.63 (8df), p=0.17). There was no significant difference in the levels of evidence between years during the study period at the CSOS meeting.

The average level of evidence presented at the CSOS annual meeting compares favourably with other trauma meetings. The high proportion of level 4 evidence presented at these meetings reflects the challenging task of performing research in trauma surgery. This challenge is further exacerbated in the military environment where operational commitments must be the priority. However, simple methods to strengthen research may involve the inclusion of control groups, prospective patient enrolment, standard treatment protocols, well-defined outcome measures, logistical support for good follow-up and use of patient-focused assessment tools. Co-ordination and focus of military orthopaedic research effort may advance the quality of research produced.


H. Guthrie D. Edwards C. Fetherston J. McMaster

The Orthopaedic Competence Assessment Project (OCAP) is a validated system for assessment of competence in orthopaedics. OCAP materials are increasingly used in the NHS. Defence Orthopaedic trainees now deploy for 6 weeks on Operation Herrick.

The senior author used OCAP induction and assessment materials with the 3 three trainees assigned to him at the United Kingdom Medical Facility at Camp Bastion, Afghanistan. Mini-CV and ‘Military Trauma’ Knowledge and Procedure Profiles were provided and learning agreements signed at an initial meeting. Interim and final meetings took place to review progress and update Knowledge and Procedure Profiles. Procedure Based assessments (PBAs) were also attempted during the attachments.

Afghanistan was ideal for training due to a significant trauma caseload, close one-on-one supervision and no working time directives. The use of induction and assessment materials with which trainer and trainees were already familiar gave structure and focus to training on deployment and allows the benefit of the deployment to be demonstrated.


S. Dharm-Datta J. Etherington A. Mistlin P. Hill P. Rosell

Since the recognition of chronic exertional compartment syndrome (CECS) of the leg as a cause of exercise-induced leg pain was made in the 1950s, there has been no universally accepted diagnostic pressure. A 1997 review found 16 papers from 1962 to 1990, which have differing diagnostic criteria. The threshold pressure used at DMRC Headley Court is based on the work of Allen and Barnes from 1986, where in a patient with a suitable history, a dynamic pressure in the exercising muscle compartment above 50 mmHg is diagnostic.

We present the data gathered at DMRC Headley Court during the first year of the new protocol on dynamic pressure testing, from May 2007. The new exercise protocol involved exercising patients using a representative military task: the combat fitness test (CFT) using a 15 kg Bergen on a treadmill, set at 6.5 km/h with zero incline. During this period, we performed 151 intra-compartmental pressure studies in 76 patients. 120 were successful in 68 patients, with 31 technical failures. Patients complained of exercise-induced leg pain on performing the CFT and pointed to the muscles in either the anterior or deep posterior muscle compartments and these were exclusively tested with invasive studies. No patients complained of symptoms in the lateral or superficial posterior compartments and therefore neither was tested. The majority were performed in the anterior leg compartment (110 successful), with a few (9 successful) in the deep posterior compartment, and there was only one complication with a posterior tibial artery puncture.

The mean age of patient was 28.9 years (SD 6.7). In 119 compartment studies, the mean pressure was 97.8 mmHg (SD 31.7). This data is normally distributed (Shapiro Wilk test, W=0.98 p=0.125).

In summary, we present the data using the CFT as the exercise protocol in patients who give a history compatible with CECS and have symptoms of leg pain during exercise. This data has a mean of approximately 100 mmHg, which is double that of the diagnostic criteria of Allen and Barnes, who used running as the exercise protocol. The presence of a weighted bergen as well as the stride and gait pattern used during the loaded march may be contributory factors in explaining why the pressures are higher compared to other forms of exercise. Further work is ongoing with determining the intracom-partmental muscle pressure in normal subjects with no history of exertional leg pain performing the CFT.


W. Eardley D. Taylor P. Parker

Anecdotal concern exists over the ability of current UK trainees to manage complex orthopaedic trauma.

A 15 item web-based survey sent to a sample of orthopaedic trainees. Power calculations deemed 222 responses from 888 trainees necessary to achieve a 5% error rate with 90% confidence limits.

232 responses were received. For cases involving external fixation or intramedullary nailing, perceived confidence and training adequacy was high despite infrequent exposure. Perceived confidence and adequacy of training in complex trauma is significantly lower. Less than 20% of trainees have full confidence in their ability to debride and stabilize mutilating hand injuries. 35% of trainees lack confidence in their assessment of limb viability and 56% lack confidence in amputation for extremity trauma. 71% of trainees are not confident in the management of junctional trauma and 68% regard their training in this field as inadequate. With regard to advanced resuscitation using novel blood product combinations; 65% of trainees are lacking confidence and 44% perceive their training as inadequate. For simple fracture stabilisation, vacuum dressings, antibiotic pro-phylaxis and fasciotomy, trainee perceived confidence increased with time in training. This increase did not occur in more complex trauma cases.

Perceived confidence amongst orthopaedic trainees in the management of routine extremity trauma is high despite limited exposure and concerns over changes in surgical training. This is in marked contrast to that reported in complex trauma. For military trainees, the value of supervised training on military deployment to gain experience in such cases is now apparent.


R. Gilbert A. Carrothers C. Marquis G. Kanes S. Roberts D. Rees

Radiofrequency thermal shrinkage of anterior cruciate ligament (ACL) laxity or partial injury is a relatively recent treatment. Studies have shown varied results with this technique but have had small study numbers and mixtures of both primary and reconstructed ACLs. We present our series of 109 patients.

Between 1999 and 2008 our department performed radiofrequency thermal tightening on 109 patients with partial native ACL injury or ACL laxity. Fifty three patients completed both pre and post-operative evaluations at a mean follow-up of 20.5 months. Evaluation consisted of visual analogue pain scores, Tegner activity and Lysholm scoring.

From the 110 patients that underwent thermal shrinkage for ACL instability 21 (19%) went on to require full ACL reconstruction. The decision to convert to full ACL reconstruction was made at a mean of 13 months (sd=12) following thermal shrinkage surgery. Comparing those who required ACL reconstruction with those who did not, we found those requiring reconstruction to be significantly younger. Mean = 25yrs vs. 31.5yrs. (p≤ 0.002)

Fifty three patients completed both pre and post-operative evaluations at a mean follow-up of 20.5 months. Following treatment there was a significant improvement in mean Lysholm scores from 64.4 to 79.5 (p< 8.42x10-7) and pain scores 3.7 to 2.0 (p< 3.06x10-6); however there was a reduction in patients’ activity levels as assessed by Tegner score, from 6.65 to 6.0 (p< 0.019).

Comparing those who required ACL reconstruction with those who did not, we found those requiring reconstruction to be have higher pre-operative level of activity (mean Tegner score = 7.3 vs. 6.5. (p< 0.047)).

Radiofrequency thermal shrinkage of anterior cruciate ligament significantly improves knee function but may not be appropriate for younger patients or patients with high activity levels.


J. Singleton K. Gill A. Perry J. Hull

Femoro-acetabular impingement (FAI) is an increasingly diagnosed cause of hip pain in young patients. It may progress to cause labral injury and chondral damage within the hip.

Surgery can be undertaken arthroscopically but is not universally available. Open approach to the hip with surgical dislocation, labral surgery and impingement lesion reduction is an acceptable alternative. Described by Ganz in 2001 the approach must conserve the postero-lateral blood supply to the femoral head and neck, to minimize the risk of Avascular Necrosis (AVN). Ganz recommended a sliding trochanteric osteotomy to widen access, and an anterior capsulotomy avoiding dissection postero-lateral to the femoral neck. To date there has been no published support for the Hardinge-type antero-lateral approach.

We describe a series of 26 consecutive patients with FAI, all managed by open osteochondroplasty during 2008 via a modified anterolateral approach and capsule preserving exposure. Trochanteric osteotomy was not undertaken.

The series contained 14 males and 12 females with mean ages of 33 and 29 respectively. Patients were assessed both clinically and using the Non Arthritic Hip Score (NAHS). Assessments were undertaken pre-operatively and at 8 and 16 weeks post-operatively. The mean NAHS pre-op was 54. This improved to 87 at 16 weeks. 77% of our patients achieved a NAHS of 75 or greater indicating a good or excellent result. Three patients had poor outcome and progression of osteoarthritic symptoms. There were no complications from the osteochondroplasty and all patients were Trendelenberg negative by 16 weeks.

We believe hip osteochondroplasty can be safely and effectively undertaken via an anterolateral approach, without a trochanteric osteotomy.


R. Gilbert G. Cheung A. Carrothers J. Richardson

Conversion of failed femoral components of total hip resurfacing to conventional hip replacement is reportedly a straightforward procedure. There is little published to qualify this and what is available suffers from small study numbers and various combinations pre and post-operative implants.

Between 1997 and 2002, the Oswestry Outcome Centre prospectively collected data on 5000 Birmingham Hip Resurfacings (BHRs) performed by 141 surgeons, at 87 hospitals. To date 4526 have survived, 135 died and 165 are lost to follow-up. 174 have been revised, of which 60 were failures of the femoral component. We reviewed modes of failure and post-revision clinical outcomes in this sub-group.

Isolated femoral component failure accounted for 60 hips (1.2%). 28 femoral neck fractures, 14 femoral head collapses, 13 femoral component loosenings, 3 avascular necroses (AVN), 1 femoral loosening followed by fracture and 1 dislocation. Mean time to revision surgery was 2.6 years (1.8 years for neck fracture; 3.4 years femoral loosening, head collapse and AVN). All acetabular components were left in situ. At revision surgery 25 cemented, 25 uncemented and 10 unknown femoral prostheses were used with 56 BHR modular heads, 2 custom-made Exeter heads and 2 Thrust Plate heads. 47 patients completed outcome scores post-revision surgery. Median modified Harris Hip Score was 82 (IQ range=63–93) and Merle d’Aubigne score was 14 (IQ= 9.5–15) at a mean follow up of 3.9 years post-revision. The 4526 surviving resurfacings had a median hip score of 96 (IQ=87–100) p≤4.558x10-8 and median Merle score of 17 (IQ=14–18) p≤1.827x10-7. Mean 7.0 years follow up. There was no difference in outcomes between cemented and un-cemented revision components nor were there differences between fractured neck of femur and femoral loosening, head collapse or AVN.

Following revision of the femoral component to a conventional hip replacement, function is significantly worse than surviving resurfacings.


B. Dean E. Moore J. Matthews D. Stubbs D. Whitwell C. Gibbons

Although originally designed to aid the management of primary malignant bone tumours, the indications for modular endoprosthetic replacement (EPR) have expanded to include complex periprosthetic fractures and failed internal fixation. The incidence of these challenging cases is increasing with an aged population. We reviewed retrospectively our experience with the use of EPR in patients who had undergone limb salvage following complex trauma presentations.

Between 2003 and 2008 twenty one patients underwent EPR following referral to the Oxford Sarcoma Service following lower limb trauma. The average age was 71 years (44–87). The average number of previous surgical procedures was 3 (range 0–11).

The mean Harris Hip Score was 89.5 (range 64–85). The mean American Knee Society Score was 82 (range 62–100) and the mean functional score was 62 (range 30–75). Complications included two cases of deep infection; one resulted in a two stage revision procedure, while the other retained the EPR following a washout. EPR is an effective salvage procedure for failed trauma fixation and periprosthetic fractures. Immediate weight bearing and a good functional outcome can be expected in this difficult group of patients.


P. Guyver M. Norton A. Cattell G. Bartlett D. Fern

Periprosthetic Hip Fractures (PHFs) and Complex Revision Hip Arthroplasty(CRHA) consistently present challenging management decisions. Extramedullary devices alone or in combination with strut graft or long stem prosthesis revisions (cemented and uncemented) have all been described as treatment options. A long distal locked femoral stem provides an alternative allowing immediate stability for weight bearing without impaction bone grafting or external plate fixation and strut grafting. It has a lower risk of subsidence.

24 patients underwent a Cannulok Stem procedure from 2003–2008. Each was reviewed regularly following surgery with clinical examination and Hip scores (Oxford and SF12). The indications for device use, Vancouver classification if a periprostheic fracture, radiological evidence of union and complications were all recorded from medical and radiological records. The results were then compared to similar studies.

The indications for Cannulok use were periprosthetic fracture (50%), infection with bone loss (12.5%), revision for aseptic loosening (33.3%) and subtrochanteric fracture post arthrodesis and metalwork removal (4.2%).

A 75% union rate was seen in periprosthetic fractures. There were 2 deaths, 2 deep infections and 1 superficial infection. The 40 mm offset stems resulted in 6 (25%) dislocations compared to 0% dislocations with the 45 mm offset stem. In addition there was 1 femoral stem revision for subsidence (no distal locking screws used) and 1 acetabular revision. There was an average follow up of 20 months.

This study suggests that the Cannulok Plus femoral reinforcement stem is a potential alternative treatment option in PHFs and CRHA with acceptable complication rates.


C. Fetherston J. Tice P. Chapman-Sheath

The treatment of complex intra-articular fractures involving the knee has always proved challenging. The goals are to achieve satisfactory reduction, bony union and good functional outcome. Studies have investigated the outcome of various forms of treatment, including internal fixation and primary knee arthroplasty. In recent years there have been advances in technology bringing about more sophisticated implants such as pre-contoured peri-articular locking plates. Similar advances have been made in the production of constrained knee arthroplasty prostheses with the introduction of the Rotating Hinge Knee (RHK).

The initial non-rotating hinged prostheses for total knee arthroplasty did not enjoy a good reputation. The cumulative survival rate has been quoted as 65% at 6 years, significantly lower than that of conventional stabilised prostheses. Therefore the use of such implants was restricted to complex primary or revision arthroplasty, and tumour surgery. Studies have been published advocating the use of hinged prostheses for distal femoral fractures in elderly patients. The average age in the most recent study was 82, of whom 42% had died within the first post-operative year.

This study is a case series of 16 patients with fractures who were treated with hinged knee replacements, a subgroup of whom were treated with RHK. Demographic and outcome data has been retrospectively collected. We discuss the indications, experiences and outcomes in the management of these patients. This study also stimulates debate about the use of RHK to treat fractures in a younger population.


J. Turner L. Cannon

A recognised treatment for severe sub-talar arthritis is joint fusion. This can be performed using a well established open technique or achieved through an arthroscopic approach. The aim of this retrospective study was to investigate the results of arthroscopic sub-talar arthrodesis performed by a single surgeon in our institution.

13 arthroscopic sub-talar joint fusions were performed over a 2 year period in patients presenting with isolated arthritis of the joint in question. All arthrodeses were carried out using two posterolateral portals and one posteromedial portal and fixed with two single 7 mm partially threaded cancellous screws. Outcome measures included the American Foot and Ankle (AFOS) score, time to union and post-operative complications.

No patients were lost to follow-up. 12 out of 13 arthrodeses went onto clinical and radiological fusion. The AFOS score improved from36 (range 32–50) pre-operatively to 75 (range 65–80) at final follow up. Complications included 1 non-union, 1 DVT and 1 superficial wound infection. 3 patients have had metalwork removed secondary to screw irritation.

The results of subtalar arthrodesis performed using an arthroscopic technique is comparable with an open approach and provides high patient satisfaction.


RG Kakwani R White M Barthomelow P Banaszkiewicz

Aim: Isotope bone scan has become a part of the routine workup for a painful arthroplasty. A retrospective analysis was performed to analyse the significance of isotope bone scan results in the management of painful arthroplasty.

Methods and Materials: The study group included all the 58 consecutive patients who underwent an isotope bone scan for a painful arthroplasty over a one year period. The data collected included: age, sex, date and nature of primary arthroplasty, inflammatory markers, indication, date and result of the bone scan, and the final outcome.

Results: The primary arthroplasty was a TKR (29 patients) and THR (29 patients). The average duration between primary arthroplasty and the bone scan was 44.3 months (Range 5 – 195 months). The duration was less than 1 year for 6 patients. The average age of the patients was 62 years. The male: female ratio was 31:27. 4 of the arthroplasties were uncemented and 54 were cemented. The bone scan results were normal in 32 patients, unclear in 17 patients and abnormal in 9 patients. There was no statistical correlation found between the inflammatory markers and the results of the bone scan.

Discussion: The results of the bone scan made a significant contribution in the management decision of the patient in 8 of the patients and served to reassure the patient/surgeon in most of the rest 50. In 6 patients it was performed within a year of the primary arthroplasty, during which period the results are not very specific. An isotope bone scan involves a significant radiation exposure to the patient as well utilization of time and resources, hence always ask the million dollar question: “Is it going to alter my management plan”


D Chakrabarti C Wronka R G Kakwani S A Jain K Wahab

Introduction: Hot swollen knee joints are a common presentation in clinical practice. It has wide differential diagnoses, the most serious being septic arthritis. Delayed or inadequate treatment leads to joint damage. Arthroscopic lavage should be planned appropriately after proper clinical assessment and investigation. Other differential diagnoses like crystal arthritis, reactive arthritis, monoarticular inflammatory arthritis should be considered.

Patients and Methods: This retrospective audit involved 44 patients who had arthroscopic knee lavage for suspected septic arthritis from January 2005 to May 2007. Analysis included the aspects of adequate backup supportive evidence for the procedure, the time from diagnosis to operation and postoperative antibiotic regime.

Results: There were 29 males and 15 females with age group ranging from 11 to 91 yrs. Fever was present in 15 patients(34%), preoperative joint aspiration done in 22(50%), peri-operatively pus found in 11(25%). 13 patients(29.5%) had procedure done within 6hrs, causal organism identified in 25%. Follow-up ranged upto 12 months without persistence or reactivation.

Discussion: Arthroscopic lavage is a useful adjunct in treatment of septic arthritis of knees but proper patient selection with systematic approach considering other possible differential diagnoses is important for avoiding unnecessary operations.


SA Jain AC Jarvis

Purpose: To evaluate retrospectively the functional and radiographic outcome of patients who had a thumb trapeziometacarpal (TM) joint arthrodesis using a T-plate, chevron bone cuts and autologous punch graft harvested from ipsilateral distal radius.

Material and Methods: Between 2001 and 2006, 32 trapeziometacarpal (TM) joint fusions were performed in 24 patients using the above technique. The study group comprised of 16 females and 8 males with average age 52 years (range 42–62 years). Average follow-up was 14.8 months (range 14–60 months). Indications for surgery were: failure of conservative treatment; severe pain; and diminished thumb function hampering everyday life. All patients had radiological evidence of advanced TM joint arthritis (Eaton and Littler grade II to III).

In all cases, chevron bone cuts have been used. The fixation has progressed from K-wires, through single and double lag screws, tension-band wire, to an AO mini T-plate which is the present technique. With the K-wire, or simple screw methods, the failure rates were up to 50%, leading to many revision operations. Bone graft is used; in first 15 cases this was ‘Allomatrix’ but we now use local bone from the distal radius, taken with an AO tap guide used as a trephine.

Functional outcomes were assessed using Quick DASH score, and Gartland and Werley score. There was also a radiographic review. The grip and pinch strength were compared with the contralateral side. We also looked at the progression of disease at scaphotrapezial joint after the fusion of TM joint.

Results: Patient-rated outcome scores indicated very good pain relief with preservation of grip and pinch strength. There were 2 cases (7%) of non-union which required revision surgery and were probably due to poor screw placement in the trapezium. In 8 patients (25%), pain related to prominent metalwork required plate removal. In no case was there x-ray or symptomatic progression of the disease at scaphotrapezial joint. Clinically, 75% rated good, 15% fair, and 10% poor results.

Conclusion: The present form of trapeziometacarpal arthrodesis is reproducible and offers an excellent alternative to trapeziectomy especially in younger patients.

Type of study/level of evidence: Therapeutic IV.


A Hussain K S R K Prasad

Purpose: We hypothesised that independent Notch Trial is essential on same lines as other Component Trials – Femoral, Tibial and Patellar – in posterior stabilised total knee arthroplasty and evolved Notch Trial to visually ascertain adequacy of intercondylar resection and eliminate femoral intercondylar fractures.

We undertook a retrospective study to evaluate Notch Trial by the frequency of the need to remove osteophytes or file uneven surfaces in intercondylar resection by using detachable box part of trial femoral component and occurrence of distal femoral intercondylar fractures.

Methods & Results: We studied 206 patients, 113 females and 93 males, who underwent consecutive primary posterior stabilised total knee replacements applying Notch Trial between 2000 and 2008 under our team. Outcome Measurements were

frequency of osteophyte removal or filing uneven surfaces in intercondylar resection and

distal femoral intercondylar fractures intraoperatively or on postoperative radiographs.

We had to remove osteophytes and file cut surfaces in 183 (88.88%) patients after Notch Trial. We had no distal femoral intercondylar fractures.

Conclusions: Notch Trial allows the surgeon to directly visualise and ascertain adequacy and precise fit of femoral notch cut with cam part to ensure press fit femoral component in condylar posterior cruciate substituting total knee replacement. Notch Trial prior to Femoral Component Trial effectively pre-empts intraoperative distal femoral intercondylar fractures. We recommend that Notch Trial should become part of the protocol for cruciate substituting total knee replacement and implants of all companies should have the option of a detachable box component for Notch Trial.


A. Kulkarni D. Cloke P. Partington M. Reed

Introduction: Following successful introduction in 2007, all training programs except two participated in 2008. The examination was run along the principles of curriculum based, online delivery with immediate results and providing supportive information for the questions. The examination remains free of charge for the trainees and is supported by an educational grant from Depuy.

Material and methods: In 2008 a UKITE review board was appointed to create good quality questions with supportive information. We took on board the feedback from 2007 examination. Some questions from the 2008 examination were reported as ambiguous. The review board met and ambiguous questions were deleted from the examination and the scores recalculated.

Results: 648 trainees took UKITE 2008. Central organisation (86%) and local organisation (90%) were acceptable. 95% felt the examination pages were easy to use. There was difficulty in accessing the examination from NHS networks in some centers on the final day. 95% found there was educational benefit and 99% would like to sit again in 2009.

In the feedback from UKITE 2008, 85% of trainees felt it was better quality than 2007. The trainees approaching the FRCS examination are interested in using the database towards preparation.

In 2009 we aim to open the examination for SAS doctors, other surgical specialties and international trainees through elogbook.org.

Conclusion: UKITE has made progress in 2008. We aim to improve it further and open it to SAS doctors, other specialties and international trainees in 2009.


K S R K Prasad A Hussain

Purpose: Axial alignment with restoration of mechanical axis is a major determinant of outcome in Total Knee Replacement.

Two perceived weaknesses of Intramedullary Referencing of Tibia are crucial:

difficulties in understanding where centre of medullary canal projects on the plateau to plan entry hole

in bowing of tibia, technical axis differs from anatomical axis, resulting in varus placement of tibial tray.

We evolved two technical pointers for optimal Tibial Intramedullary Referencing.

We undertook a retrospective study to analyse feasibility of our technique of Tibial Intramedullary Referencing.

Methods and Results: The study included 206 consecutive Total Knee Replacements between 2000 and 2008. Two – significant tibia vara and maluited tibial fracture- were excluded. Two techniques were used to avoid poor selection of entry hole and eccentric rod placement

Entry Drill Hole is made to a depth of 2–3 cm only and intramedullary rod is passed to find its own way into canal. This avoids tilted position of rod forced by a deeper drill hole and minimises tilted or wrongly sloped position of tibial tray.

Identification of Entry Point is facilitated by clearing soft tissue at tibial attachment of ACL over intercondylar eminence and confirmed by placing distal phalanx of surgeon’s thumb over bare area of anterior tibial plateau.

Entry point is usually at the tip of thumb.

We encountered no problems by our technique in Tibial Intramedullary Referencing in 204 Total Knee Replacements.

Conclusion: The two technical pointers help to overcome perceived drawbacks of Intramedullary Tibial Referencing.


K S R K Prasad H Gakhar B K Dayanandam K Karras

Purpose: To report concomitant dorsal dislocation of first metatarsophalangeal joint and divergent Lisfranc dislocation, a uniquely “floating forefoot” and analyse clinical pathodynamics.

Methods & Results: We treated concomitant dorsal dislocation of first metatarsophalangeal joint and divergent Lisfranc fracture-dislocation in an intoxicated patient as a heavy weight fell on foot. Closed reduction of first metatarsophalangeal joint was unstable until after open reduction and fixation of first tarsometarsophalangeal joint. First to third tarsometatarsal joints were stabilised with cannulated screws and lateral two rays with Kirschner wires. Prophylactic fasciotomies were performed to preempt potentially high risk of failure of recognition of compartment syndrome in intoxicated patient. Clinical pathodynamic analysis suggests that natural tendency to withdraw the foot contributed to primary medial loading with forced hyperextension of hallux metatarsophalangeal joint and enhanced complementary hyperflexion of midfoot. The former resulted in dorsal dislocation of first metatarsophalangeal joint.

Then load shift toward secondary axis of lateral divergent loading became the operative force to produce divergent Lisfranc dislocation, which effectively resulted in a floating forefoot.

Conclusions: Floating forefoot is a unique injury after high-energy trauma, although floating metatarsal and association between Jahss Type I complex dislocation of first metatarsophalangeal joint and Lisfranc injury were described. Floating forefoot also represents Grade V in the modified classification of metarsophalangeal injuries (Kodali Siva R K Prasad et al Modification of Clanton’s classification) as progression of injury pattern transcends the local barrier and raises the spectrum of dynamic cascade of multidirectional transmission of the operative forces with the resultant unique injury.


K Katam Z. Alshameeri M. Ibrahim P. Sonsale

Clavicle fracture account for about 44% of all adult fracture around the shoulder, although non-operative care results in high union rates for most, surgery is indicated in particular if displacement and/or shortening greater than 15–20 mm, lack of cortical apposition in young, healthy, active individual to yield the best clinical results in terms of alignment, union and early mobilisation.

We did a retrospective audit to define the guidelines for admission, safer surgical approach and functional outcome using oxford score for the period Jan2002–Jan2007.

This included 35pts, with Female: male ratio 1:2.5, Right: left side of 12:23, just over 50%were manual labours. Most common indication for surgery was displacement/shortening (16pts). 28 pts were operated within 4 weeks as acute admission.

Direct incision was used in 14pts and infraclavicular incision in 21pts.

Radiological union were seen in all pts on average 13.26 weeks (8 – 24wks). 10 patients had minor complications, 28% with direct incision and 19% with infraclavicular approach 29 patients went back to original work by 2.55 month, 5 excluded as 3 were at school, 2 unemployed and 1 did not mention. All patients had an oxford score of 12–20, showing satisfactory joint function.

Metal work were removed in 6 patients, 2 (9.5%) in infraclavicular and 4 (28%) in direct incision.

Conclusion: Our study included 35 patients, union were achieved in all with good functional results. 34 patients express to recommend surgical fixation to others. Infraclavicular approach was associated with less complication and less metal work removal.


I A Ali A K Choudhary W A. Hekal M J Farhan

Purpose: To demonstrate that Rush pin is safe and effective in selected fragility ankle fractures.

Introduction: Fragility ankle fracture is increasing proportionately to their age. It produces not only clinical challenge due to multiple co morbidities but also a challenge to heal the fracture and particularly the skin. We found that early minimal intervention by stabilizing the lateral column with a rush nail is safe, beneficial and acceptable practice in selected cases.

Material & Method: Retrospective case notes & X-rays review of fragility ankle fractures between 1st of January 2005 to 31st of August 2008 selection using the criteria below

✓ Closed Ankle Fracture

✓ Elderly or fragility fracture

✓ Minimal invasive ORIF

Results:

Seven patients found.

Mean age: 78.2

M: F – 1:5

ASA CLASS: 3–4

All patients had ankle fracture with fragile or damaged skin. All operated within 10 days of injury, including those who were on warfarin or significant medical problems. All underwent closed reduction and or percutaneous medial malleolar fixation and stabilization of the lateral column with Rush Pin through a stab incision under x-ray control. A lightweight plaster was applied for 4–6 weeks. All fracture healed in a acceptable position without any skin complication. One patient who had pre operative ulcer also healed.

Discussion/Conclusion: Minimally invasive treatment has no surgical wound complication. All fracture healed in a satisfactory position. All discharged after mean follow up of 6 month. One death due to unrelated cause after 5 weeks of operation.

Rush pin fixation in fragility fracture is a useful and safe methods of treatment in selected group.


D. Abbas

With Lord Darzi’s vision of the future of the NHS, it has become clear that quality of care will be the next focus and the hospitals providing acute orthopaedics and trauma services will have to deliver best and most efficient care for the patients being admitted with fractured neck of femur. This study is aimed at recognizing the changes and organization required at a district general hospital and their initial effect on the quality of services being provided locally.

Management of patient with hip fracture involves several specialties within the hospital as well as primary care setup. An audit of A& E waiting time showed significant variation in the delay before transferring the patients to the ward which was addressed by Fast-Track system. In the ward, preoperative assessment was standardized by agreement between orthopaedics and anaesthetics department. Three daytime lists were initiated specifically for hip fracture patients, resulting in increase in the number of patients going to theatre within 48 hours of admission, from 75% to 86%. A protocol was agreed between orthopaedic surgeons and rheumatologists for starting anti-resorptive therapy for these patients in order to decrease the chances of future fragility fractures. Impact of this measure will be assessed in due course. One senior middle grade surgeon was given the charge of managing NOF lists and to coordinate the medical management of these patients. Hospital has also started taking part in National Hip Fracture Database and a HCA has been assigned the duty of uploading the data to NHFD database. A acre pathway is being developed to streamline the whole peri-operative and after discharge management of these patients.

With just about a year left before the implementation of healthcare commissioning, it is vital that trusts start working on best and most efficient care for all patients. Hospital will have to publish their quality accounts from next year and their tariffs will be linked to patient reported outcome measures. This study highlights the main issues and the potentially vital role of orthopaedic specialists in developing the required services.


M Hossain SA Akbar J G Andrew

Objective: Notwithstanding the increasing recognition of occult hip fracture the diagnosis is not suspected in some patients who present later with displaced hip fracture. We wished to investigate if the “missed occult fracture” group had any distinct demographic or clinical details and the eventual outcome of delayed diagnosis and treatment.

Methods: Over a three year period we followed all patients admitted with fracture neck of femur to identify patients where the diagnosis was initially missed and compared them with patients admitted over the same period with a correct suspicion of occult hip fracture.

Results: Out of 797 patients with hip fractures there were 24 occult hip fractures, the diagnosis was initially missed in 9 of them. In the correctly identified occult fracture patients 8/15 were independently mobile and 9/15 were living in own home compared to 0/9 independently mobile and 2/9 living in own home with missed occult fracture (both p< 0.001, Fisher exact test).7/9 patients with a missed diagnosis had mental confusion but none in the rest (p< 0.001). All patients presented within 10 days from the index visit (range 3–10). There was no obvious history of a fall in 2 patients. 4 patients had restricted straight leg raise ability on initial examination but were dismissed. 8/9 had intra-capsular fracture of which 6 had displaced at repeat presentation and required hemiarthroplasty. Maximum follow-up is 18 months (range 13–18 months) and 1 year mortality rate is 33%.

Discussion: Patients with a missed diagnosis of occult hip fracture appear physiologically less robust compared to the patients who are correctly suspected and investigated for occult fracture. The patients with missed diagnosis have higher ASA grade and their mental confusion, restricted mobility and dependence for activities of daily living are statistically significantly different compared to patients where the diagnosis is correctly suspected. Most of them have sub-capital femoral neck fractures and will most likely return with a displaced fracture within a week. We suggest a low threshold for investigation for occult hip fracture in the elderly, infirm and mentally confused.


Y Agrawal A Desai J V Mehta

Introduction: The conventional radiological assessment of hallux valgus (HV) involves measuring the intermetatarsal angle, HV angle, congruity of the metatarsophalangeal joint and the overall clinical deformity of the forefoot. However, in the current practice, these angles are seldom measured. We observed consistent displacement of the lateral sesamoid (LS) along with HV deformity. The position of the LS in relation to the head of the first metatarsal has never been studied before. We aim to study this pattern of the LS and to quantify the severity of the deformity which could help make clinical decisions.

Methods: 112 radiographs of 60 consecutive patients who underwent a weight bearing radiographs of their feet were studied. Statistical analysis was performed to identify the correlation of displacement with conventional angle measurements.

Results: A definite pattern in displacement of the lateral sesamoid was noted. This displacement also showed a statistical correlation with the conventional measurement of inter-metatarsal angle.

Discussion: Previous research which studied the displacement of medial sesamoid in these deformities was not received with great enthusiasm due to the difficulty in locating the medial sesamoid through the head of the metatarsal. In contrast, the lateral sesamoid lies laterally and any progressive deformity makes it more accessible to assessment. We report a consistent pattern in the displacement of the LS and classified as the position as normal, mild, moderate and severe. As it does not involve any measurements, we believe, this is a quick and reliable technique of assessment of HV deformity and should help to base our operative decisions.


Y Agrawal J Karwa N Shah A D Clayson

Introduction: There is paucity in guidance on when and what should be said or who should take the consent for patients undergoing lower limb arthroplasty. Never before, the specialists been contacted for current practice and their recommendations on the content and timing of obtaining the consent in these patients.

Materials and Methods: A postal questionnaire was sent to 154 Orthopaedic consultants in the 14 units in NorthWestern region of England. We acquired information on their current practice, awareness of the guidelines and their preferences and recommendations.

Results: A total of 117/154 (76%) consultants responded, of which 84 (55%) fulfilled the inclusion criteria. Currently, 36% patients are consented at preoperative assessment clinic and 40% on admission. 75% of the consultant consent themselves or are consented by their registrars. 70% were aware of local or national policies on who should consent patients and 40% on what should be explained and documented. 75% recommended that operating surgeon should obtain consent. The recommended time for the consent was at preoperative assessment by 57%.

Discussion: If the act of signing the consent form is to be more meaningful it should be signed by the surgeon who is going to perform the operation. This study demonstrates that the consultants agree on the common complications but have a varied threshold for giving the less common risks. With shortening of the waiting time, there is a growing body of surgeons suggesting that the consent should be done at the listing itself.


K Doku R Tayar J Klosok

Purpose: to alert readers to the possibility of a ruptured abdominal aortic aneurysm presenting with femoral neuropathy and back pain.

Method: Our patient presented with a short history of left leg weakness, numbness and back pain but was otherwise in a stable condition. An MR of his lumbar spine was initially performed on a 1T GE scanner and this was followed by an abdominal ultrasound scan and a spiral CT on a Siemen’s Somatom with reconstructions.

Results: The MR unexpectedly demonstrated a large abdominal aortic aneurysm and swelling of the left psoas muscle. These features were observed easily as the saturation band was placed anterior to the retroperitoneum.

Ultrasound confirmed these findings and the subsequent CT demonstrated precisely the point of rupture with contrast entering the left psoas muscle.

Conclusion: Rupture of an abdominal aortic aneurysm may present to the orthopaedic team with back pain and femoral neuropathy. This demands a high index of suspicion as timely intervention saves lives.


G.W. McLean B Hanratty J Bunn G Lee D Marsh

Introduction: Digital X-rays have become increasingly prevalent in Hospitals throughout the UK and Ireland in the past 10 years. We have devised a semi quantitative analysis of digital radiographs that measures the extent of healing across the fracture gap.

Methods: 48 CD 1 mice underwent a femoral fracture and subsequent fixation with an external fixator. A standardised radiograph was taken. A radiographic analysis was carried out. For each radiograph taken a pixel density graph was generated at five individual points across the fracture gap, along the longitudinal axis of the femur.

A stastical analysis of intra and inter-observer variability was tested using the linearly-weighted kappa statistic for each of the 240 pixel density graphs taken and for the summation total in the 48 radiographs.

Results: For the individual pixel density graphs we expected an agreement of 67.82%. An agreement of 95.42% was recorded showing a kappa statistic of 0.8576 and a standard error of 0.0531.

On analysis of the summation scores we expected an agreement of 75.54% and observed an actual agreement of 96.30%. This showed a kappa statistic of 0.8545 and a standard error of 0.0849.

Conclusion: The results are very similar in the two analyses and indicate excellent agreements. As a result we offer a radiographic, semi-quantative analysis of bone healing across a fracture gap that is highly reproducible. Thus it has the potential for application to future research in this field and possibly to clinical practice with the increased use of digital radiographs in hospital departments


J Kulangara A Ramavath M Hossain

Objective: The practice of routine admission of isolated sternal fractures for observation is still widespread in the UK in spite of evidence to the contrary. We undertook a cross-sectional telephone survey of management of isolated sternal fractures in the UK.

Methods: We contacted 85 acute admitting units over a three month period and were able to get a response from 67 units.

Results: Most of the hospitals were district general hospitals (52) and situated in England (49)(Wales 4, Scotland 11, Northern Ireland 3). The orthopaedic department was the commonest admitting department (26) (General Surgery 19, Cardiothoracic Surgery 11, Accident & Emergency 9, Acute Medicine 2). 51 units would routinely admit isolated sternal fractures for observation. Other indications for admission include pain control (33), abnormal cardiac enzymes (28), social circumstances (23), abnormal electrocardiogram (6), and low oxygen saturation (5). Chest X-ray was performed on admission in all hospitals. 57 hospitals perform routine ECG and Cardiac enzymes prior to admission and 6 hospitals routinely carry out Echo-cardiogram subsequently. Patients were admitted for overnight observation and discharged the next day in all hospitals. Patients were not followed up on discharge except 3 units, where 2 hospitals with Cardio-thoracic unit would follow-up patients on discharge, and 1 hospital regularly advised GP follow-up.

Discussion: We found that the current practice of management of isolated sternal fractures in the UK did not conform to available evidence. A review of the literature indicated that patients with isolated sternal fractures are at low risk of significant cardiac, pulmonary or mediastinal complications and do not need extensive investigations or routine admission. In this instance, evidence based practice might help us to better utilise finite resources without jeopardising patient care.


R Khokhar A Latif A Arya A Tavakkolizadeh J Compson

We describe a new technique for fixing the proximal pole scaphoid fractures both in acute and chronic setting and present our preliminary results.

We prospectively studied fixation of 25 proximal pole scaphoid fractures (1 acute displaced and 24 non unions) with this technique between 1999 and 2007. Mean age of patients was 25 years and mean time to the operation was 6 months.

The technique involves making a transverse dorsal incision over the radius along the radio-carpal junction. The retinaculum is split in line with its fibres. Access to the radio-carpal joint is achieved through the third extensor compartment. The ligament attachment to the scaphoid is preserved by using a modified Mayo approach. A window is created initially at the proximal end of the dorsal ridge. The fracture is reduced and stabilised with an appropriate length Herbert screw. The fracture site is curetted through this window and cancellous bone graft from the distal radius is packed into the fracture site. The capsule and extensor retinaculum is then closed in layers.

Radiological union was achieved in 23 cases, one case required refixation and one case was lost to follow up. Our technique is tendon sparing, capsule retaining, and ensures maintenance of articular surface congruity. So far this technique has led to excellent results.


P Konala A.G Molajo J Panchmatia R.K Strachan

It is believed by some that knee radiographs may underestimate the extent of osteoarthritis. Often severe changes are noted at arthroscopic assessment despite the observation of preserved joint spaces on plain radiographs. This has important implications regarding the indications for different types of partial joint replacement if damage is underestimated.

Aims:

To determine the correlation if any between radiographic findings and arthroscopic findings.

To determine which radiographs are consistently useful for assessment of osteoarthritis and to determine the limitations.

To identify the proportions of patients with certain patterns of damage who might be suitable in the future for different types of partial replacement.

Methods and patient selection: The pre-operative radiographs and intra-operative articular surface mappings were collected for 100 consecutive patients undergoing prospectively audited outcome of arthroscopic debridement. All the patients examined were aged 40 and above with knee pain. The intra-operative findings and any work done (debridement of meniscal tears or cartilage flap tears) were also recorded on zoned articular maps and meniscal diagrams. The pre-operative radiographs (AP standing, lateral, Rosenberg and skyline views) were examined and graded using the Kellgren and Lawrence grading system.

Results: Correlations made between arthroscopic findings and AP standing views yielded a sensitivity of 72% and specificity of 64%. The positive predictive value was 91% and negative predictive value was 32%. Rosenberg views were better at predicting the presence of osteoarthritis (sensitivity 76%, specificity 88%, positive predictive value 97%, negative predictive value 44%). Skyline views were found to particularly unreliable in assessment of patello-femoral damage. Analysis of the actual patterns of articular damage found at arthroscopy did show that it is possible to identify cohorts of patients who may in future be suitable for different types of partial replacement.

Conclusions: Radiographs and in particular skyline views are limited in terms of sensitivity and specificity in the prediction of osteoarthritis. Rosenberg views offer better prediction of osteoarthritis compared with weight bearing AP radiographs. Arthroscopy carried out in any event for clinical indications appears to offer useful additional information regarding indications for future surgery.


AS Desai B Barkatali ML Porter TN Board

Introduction: Leg length discrepancy (LLD) following total hip arthroplasty (THA) can lead to disappointed patients, increased dislocation, increased wear and suboptimal function. It is one of the commonest reasons for litigation following THA in the United States. The purpose of this study was to radiologically and functionally assess the efficacy of a simple technique for intra-operative leg length assessment during THA via a posterior approach.

Materials & Methods: This technique was undertaken in 50 consecutive THAs. The pre-and 3 month postoperative LLD was measured on standing AP pelvis radiographs. The results were compared with 50 THAs performed by the same surgeons without using the technique. Pre-and post-operative OHS and UCLA scores were recorded in both groups.

Results: In the control group the mean pre- and postoperative LLD was 9.38 mm and 7.75mm respectively. In the new technique group the mean pre-operative LLD was 11.37 and the post-operative LLD was 1.70mm. The final LLD was significantly less in the new technique group (p< 0.001). Fifteen patients in the control group and three patients in the new technique group had post–operative lengthening. Oxford Hip and UCLA score improvement in new technique group was greater than in the control group (p< 0.05).

Discussion: The technique we introduced to assess leg length intra-operatively has shown to be safe, reliable and accurate. We have nonetheless demonstrated much greater accuracy at providing equal leg lengths and improved functional outcome using this new technique.


H Salama K Wronka B. Ramesh

Background: Ankle fractures in the elderly with osteoporotic bones are often difficult to manage. The argument of whether we should treat such fractures surgically, conservatively or even plan primary arthrodesis is always there. Also, there is risk of difficult or failed fixation.

Patients and Methods: The study was a retrospective evaluation of the management and follow up of 126 patients presented with ankle fracture between 2001 and 2007. All patients were above 60 years at the time of injury and were treated whether conservatively or surgically.

Results: About 77% of our patients underwent open reduction and internal fixation (ORIF). The remaining had closed manipulation under anaesthesia (MUA) done. Some patients had multiple co-morbidities including diabetes (around 10%). The results of fixation were satisfactory. Early complications included superficial wound infection (13% of patients-all infections settled after conservative management with antibiotics and dressings), one chest infection. No difference in diabetic patients. Late complications include development of osteoarthritis (2%) and metal work loosening (2%). There were no reported ankle deformities and satisfactory union of fracture was achieved in all patients. Amongst patients who underwent MUA, more than 20% developed post traumatic osteoarthritis of ankle and 18% had chronic ankle pain. Ankle deformity was reported in 2 patients.

Conclusion: Our results show that accurate reduction and internal fixation of ankle fracture in the elderly is beneficial and of lower complication rates compared to MUA alone. The osteosynthesis failure rate was very low and patient spent less time in plaster and started physiotherapy earlier.


S Shalaby G Morgan M Hanna M Hafez A Nakhla A Abbas T Zaman E Saavedra S Tross

Shockwave treatment in our unit is provided in conjunction with our Urological colleagues. Shock Wave Therapy has been used as a last option in patients with difficult and chronic Orthopaedic conditions with an informed consent for all patients.

Material and Methods: 28 patients from Ealing Hospital and West Middlesex Hospital were referred to The Lithotripsy unit at Charing Cross Hospital for Shock wave therapy.

Patients were consented by the Orthopaedic surgeon and the treatment was administered by urologist

The cases included:

4 Humeral fractures: 1 Case in HIV +ve 19 years old

5 Femoral non-union: 1 case bilateral in Osteogenesis imperfecta

4 Tibial non-union: 1 Recurent Fracture in 65 years old man

2 Osteochondritis of the Talus

2 Osteochondritis of the knee

4 Scaphoid fractures: 1 case had been fixed and grafted.

Medial Epicondyle fracture non union

5th Metacarpal Fracture

Trochanteric Bursitis

Tennis Elbow

4 Planter fasciitis

– The Shock wave Machine used is Storz SLX – F2 Electromagnetic shock wave generator which focus the shock wave low energy high frequency in focal zone with no harm to other tissues. Frequency 4 htz = 4 shockwave/sec

– Energy level 1–3 generate pressure value in the focal area of 5–30 megapascal

– Size of focal zone 9X 50 mm or 6X 28 mm

– Total shock wave applied per session 2000 to 3000 shock

– large focus and small focus were used in fracture of large bones and small bones respectively. Most of cases required 2–3 session with 4–6 weeks interval.

– in Soft tissue Treatment Less energy was used and patients required 1 to 2 sessions.

Results: There was complete resolution of symptoms in the 4 cases of soft tissues.

– Clinical and radiological union in 3 of the 4 Humeral Fracture including HIV+ve and in 2 of 3 tibial fracture and 1 of 2 scaphoid.

– 50% pain relief in Psedo arthrosis

– Union is promoted by Cellular stimulation and pain relief is by unknown mechanism but explained by increase vascularity and neuro-modulation.

– None of the patient’s have so far required subsequent operative interventions, several had residual symptoms.

Discussion: Shock wave therapy is a new consevative treatment modality used in orthopaedic as the last option before surgery but there is a need for RCT.


S Shetty R Khokhar A Arya J Compson

Split tendons are widely used for reconstructive procedures around wrist and hand. Different materials are used to split the tendons. There is no consensus about the most suitable material for splitting a live tendon. We compared a range of commonly available suture materials to find the best material for the purpose.

11 different suture materials (Vicryl 2/0, Ethibond 0, Ethibond 2/0, Prolene 2/0, Prolene 3/0, Silk 2/0, Steel Wire 2/0, Steel Wire 3/0, Steel Wire 4/0, PDS 2/0, Fibrewire 2/0) were used to split the flexor tendons of pig’s trotters. They were assessed for

their ablity to split the tendon successfully,

average force required to split the tendon,

quality of the split tendon graft.

Each material was tested on 3 different tendons at different times. Quality of split tendons were assessed by 2 independent and blinded observers.

All suture materials except Vicryl 2/0 were successful in splitting the tendon. Silk produced a poor quality split whilst steel wire and fibre wire resulted in excellent quality grafts. The rest produced intermediate results. The force required to split the tendon was the least for PDS 2/0 followed by Fibrewire. Steel wire and silk required higher forces to split the tendon.

From our study we concluded that fibre wire is the best material to split a live tendon as it produced a high quality split with excellent handling characteristics and required minimal strength. Wire suture produced a high quality split, however they were awkward to use as they necessitated use of a holder due to the higher forces required to split the tendon.


A Arya L Ahmad R Khokhar S Shetty J Compson

Scaphoid non-union usually requires surgical treatment in form of reconstructive or salvage procedure. Imaging helps in planning the surgical procedure. Wrist arthroscopy may also be helpful in the pre-operative assessment. This study was conducted to find the usefulness of wrist arthroscopy in formulating a management plan to treat scaphoid non-union.

We prospectively studied 17 patients of scaphoid non-unions by wrist arthroscopy. Non-union was assessed; and site and extent of any articular wear if present was noted. Some patients had additional procedures such as synovial debridement, removal of loose bodies or debridement of TFC tears. It was possible to formulate the further management plan at the same time.

Our study included 14 men and 3 women with a mean age of 34.5 years (range 18 to 49). Arthroscopic findings included mild radiocarpal wear in 3 cases and severe articular wear in 1. Additionally, in two thirds of cases there was some degree of wear present over the radial styloid region. 6 cases had TFCC tears. 4 patients had synovial debridement and in 5 cases loose bodies were removed. Based on the arthroscopic findings, it was decided to proceed to a reconstructive procedure in 12 cases and a salvage procedure in remaining 5.

We concluded that in scaphoid non-unions:

Articular surface wear is often less than suggested by imaging.

Limited wear is often present at radial styloid area which could be debrided.

Associate abnormalities such as loose bodies, synovitis and TFC tears are commonly present.

State of union can not be accurately assessed due to presence of fibrocartilage at the non-union site.


R N Thompson M Murnaghan

A prospective review was undertaken examining referrals from A& E to fracture clinic with the objective to examine diagnosis and timing of fracture clinic appointment made by A& E with that suggested by an Orthopaedic Specialist Registrar (SpR).

Over a 4 week period, xrays of all fracture clinic referrals from A& E were assessed daily by an Orthopaedic SpR. Time to presentation, site of injury, A& E diagnosis, and A& E time to clinic review, were noted alongside the diagnosis and suggested time to review clinic by the Orthopaedic SpR.

A total of 233 patients were referred. Less than 5% were excluded as non-bony injury and were given an A& E review instead. Overall the majority (85%) of cases had no significant difference in time to clinic review requested by that of the A& E staff and of that requested by the orthopaedic staff. In 4.3% of cases, time to review was increased by more than 4 days whereas 11.3% of cases were seen 5 or more days earlier than that initially requested. There was a variance in diagnosis between A& E and Orthopaedic staff in 24 (10.4%) of cases. The actual time to clinic was within 5 days of that requested by the orthopaedic SpR in 84.7% of patients.

A& E appropriately refer cases to fracture clinic, and in a timely fashion. Review of all A& E referrals by Orthopaedic staff would seem not to be a cost efficient use of time.


B.S. Mann S. Gudipati K. Eleftheriou T. Bull

Purpose of study: The aim of this study was to evaluate patient-orientated outcome of spinal dynesys fixation used for low back pain and also the re-operation rate in a retrospective review of 25 cases with an average follow-up period of four years.

Materials and Methods: A total of 25 patients who had undergone semi-rigid fixation of the lumbar spine with the Dynesys system in the Chase Farm Spinal Unit between November 2001 and March 2003 were reviewed.

Results: Two patients required removal of implant and revision to solid fusion. Both were one year post Dynesys instrumentation. All other patients had their original Dynesys implant in situ at latest follow-up. Two patients were referred to a pain specialist for further management. The mean Oswestry score pre-operatively and 4.4 year post operatively were 57.2 and 37.52 respectively. The mean VAS pre op was 9.32 and post op it was 5.04.

Conclusion: Dynamic stabilisation certainly continues to remain an attractive alternative to rigid stabilisation and the few retrospective and laboratory studies that exist in the current literature reveal results which are comparable with rigid fixation.

Discussion: Though te results were promising we think a large multicentre prospective studies are required to truly enable us to evaluate the efficacy of dynamic stabilisation. This study contributes towards furthering our understanding of this complex subject.

Ethics approval: None

Interest Statement: None


K S R K Prasad G T Zafiropoulos P Bourdenas G N Antonakopulos

Purpose: We undertook a primarily cadaveric study of trabecular architecture of olecranon to link theory of biomechanics and morphological trabecular patterns of olecranon and secondly compare with real-life trabecular pattern in CT scans.

Methods & Results: Eight pairs of ulnae (fresh-frozen bones) were obtained from cadavers following road traffic accidents, aged 25 to 60 (mean 34 years). None suffered from previous pathology of elbow. Half of the ulnae were sliced longitudinally, each slice 2–3 mm thick (Group I), and the other half vertically (Group II). After they were radiographed, orientation of trabeculae was studied. CT scans of 8 patients (Group III), originally performed for investigation of fractures of radial head, were studied for comparison of real life trabecular pattern of olecranon.

In Group I, two main sets of trabeculae were observed. The first set consists of three bundles, which arise from anterior cortex and support subchondral area – the posterior third bundle curves and spreads to posterior cortex of olecranon. The second set arises from posterior cortex and terminates under subchondral area. In Group II, trabeculae subtend a 900 angle to articular surface. CT scans of 8 patients (Group III), originally performed for investigation of fractures of radial head, ascertained real-life trabecular pattern of olecranon and confirmed cadaveric observations.

Conclusion: Trabeculae of olecranon comprise a set to resist compressive loading and a further set to resist tensile stresses. Thicker trabeculae coincide with maximal loading. Prosthetic design of elbow should take into account the trabecular pattern to facilitate stress absorption.


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S. Gupta S.D. Muller

Good medical practice predicates a contemporary knowledge of the literature to guide ones practice. The British edition of the Journal of Bone and Joint Surgery [JBJS (Br)] is considered one of the leading peer reviewed journals, guiding orthopaedic practice in the UK and abroad. Whilst seeking guidance on proposed changes to departmental policy, informal discussion with some high profile units raised concerns regarding the implementation of their published clinical recommendations. We intended to contact the publishing departments, to establish their routine practice with respect to the topic on which they have written in the literature.

We reviewed all articles published in JBJS (Br) over a 24 month period. Specifically we were seeking papers making recommendations for a change in practice. The originating department was contacted by telephone and communication sought from an individual not directly involved in the publication, but whom the change in practice stated in the literature would have direct impact.

Seventy-nine papers representing the work of 87 separate hospitals from 22 different countries were identified as making recommendations in any aspect of practice. We found that published articles were being followed in 56% of cases, 42% were not.

Our study demonstrates that a large proportion of institutions making clinical recommendations are not practicing them. Should the author’s own institution not follow their guidance, then how can the wider orthopaedic community be expected to follow? As such, have we exposed a fundamental flaw in the publication of clinical research?

In conclusion, we do practice what we preach… sometimes.


A.D. Duckworth B. Watson P.J. Walmsley B.A. Petrisor E.M. Will M.M. McQueen

The purpose of this prospective study was to determine the predictive factors and hence optimal management of closed uncomplicated proximal radial fractures. We examined all patients presenting to our unit over an 18-month period with isolated closed proximal radial fractures. 237 consecutive patients were included. Demographic data, physical examination, radiographs, treatment and complications were recorded. Patients were reviewed at 2, 6, 12, 26 and 52 weeks post injury. Outcome was determined via functional assessment and Mayo Elbow Score (MES). Data were analysed using SPSS.

There were 156 (66%) radial head fractures and 81 (34%) radial neck fractures. 225 (95%) patients were treated non-operatively in a collar and cuff for one week followed by physiotherapy. 12 (5%) patients required primary surgical intervention due to either a mechanical block to forearm rotation (n=4) or a significant degree of radiographic comminution and/or displacement (n=8). Of the 201 patients who attended follow-up, 183 (91%) patients achieved excellent or good functional results measured on the MES. 155 (78%) patients achieved this by six weeks, with an average flexion arc of 125 degrees. Of the 12 patients treated operatively, the average MES at six weeks was fair (60). Regression analysis showed that increasing age, the AO-OTA fracture classification (B2.3, C2.3), radiographic displacement and operative treatment were significant predictors of a fair or poor outcome at six weeks.

The majority of isolated proximal radial fractures can be treated non-operatively with early mobilization, achieving excellent or good results within 6 weeks. Age, fracture classification, radiographic displacement and treatment choice are important factors that determine speed of recovery.


Anish K Amin James S Huntley A. Hamish Simpson Andrew C Hall

Articular cartilage is attached to subchondral bone but it is not clear whether the tissues interact and influence in situ (within the matrix) chondrocyte survival. The aim of this study was to determine whether subchondral bone influences in situ chondrocyte survival.

Articular cartilage explants harvested from the meta-carpophalangeal joints (N=6) of three-year old cows were placed into three groups:

subchondral bone excised from articular cartilage (Group A)

subchondral bone left attached to articular cartilage (Group B)

subchondral bone excised, but co-cultured with articular cartilage (Group C).

Explants were cultured in serum-free media over 7 days. Using confocal laser scanning microscopy, fluorescent probes and biochemical assays, in situ chondrocyte viability and biophysical parameters (cartilage thickness, cell density, culture medium composition) were quantified over time (2.5 hours vs. 7 days) for Groups A, B and C.

With excision of subchondral bone from articular cartilage (Group A), there was a marked increase in chondrocyte death over 7 days primarily within the superficial zone (p< 0.05). There was no significant increase in chondrocyte death within the superficial zone over the same time period for Groups B and C (p> 0.05). There was no significant difference in cartilage thickness or cell density between Groups A, B and C (p> 0.05). Corresponding increases in the protein content of the culture media for Groups B and C but not for Group A, suggested that the release of soluble factors from subchondral bone may have influenced chondrocyte survival.

Subchondral bone significantly influences chondrocyte survival in articular cartilage in vitro. These data support the concept of a functional bone-cartilage system in vivo.


S.S. Jameson A. Malviya R.A. Bottle S.M. Muller M.R. Reed

National Institute for Clinical Excellence (NICE) guidelines on venous thromboembolic (VTE) prophylaxis for patients undergoing orthopaedic surgery recommend that all inpatients be offered a low molecular weight heparin (LMWH).

Linked hospital episode statistics of 219602 patients were examined to determine the rates of complications following lower limb arthroplasty for the 12-month periods prior to and following the publication of these guidelines. This was compared with data from the National Joint Register (England and Wales) regarding LMWH usage during the same periods.

There was a significant increase in the reported use of LMWH (59.5 to 67.6%, p< 0.01) between the two periods. However, 90-day VTE events increased following both total hip (THR, 1.67% to 1.84%, p=0.06) and knee replacement (TKR, 1.99% to 2.04%, p=0.60). 30-day return to theatre rate for infection fell following TKR, but increased after THR. In addition, there were increases in rates of thrombocytopenia, which was significant following THR (p=0.03).

Recommendations from NICE are based on predicted reductions in VTE events, reducing morbidity, mortality and costs to the National Health Service. Early results in orthopaedic patients are unable to support these predictions.


N.E. Ohly J.T. Reid

A new ‘tripod’ technique using three crossed screws to stabilise radial neck fractures has been proposed and this technique was tested in vitro to evaluate whether it has at least equivalent stiffness and strength to fixation using a T-plate.

Twenty composite sawbones with an axially stable simulated radial neck fracture were fixed either using the tripod technique (three crossed 2.3mm screws) or with a 2.3mm T-plate and screws. The specimens were tested for stiffness at 10 N load in three directions (antero-posterior (AP), ulnar-radial (UR) and eccentric axial (EA)) and load to yield and ultimate failure. The modes of failure of fixation were also evaluated.

The tripod had significantly higher stiffness than the T-plate in AP loading (168 N/mm vs 95 N/mm, p=0.006) and trended to superior stiffness in UR loading (121 N/mm vs 77 N/mm, p=0.06). Both constructs were highly stiff in EA loading (513 N/mm vs 638 N/mm). The strength to yield and failure was significantly higher for the tripod in both AP loading (yield: 432 N vs 36 N, failure: 467 N vs 143 N, p< 0.001) and UR loading (yield: 444 N vs 36N, failure: 444N vs 76 N, p< 0.001). The T-plates failed by screw cut-out and subsequent plastic deformation of the plate. The tripod constructs did not fail at the load required to cause brittle fracture in the sawbone specimen, remote to the site of fixation.

The tripod technique is a biomechanically sound construct for the fixation of axially stable radial neck fractures and thus further research to evaluate the clinical results of this technique is justified.


A. Augustine D. Macdonald H.M. Murray J. Badesha A. Mohammed R.M.D. Meek S. Patil

Infection following hip arthroplasty although uncommon can have devastating outcomes. Obesity, defined as a BMI of ≥ 30, is a risk factor for infection in this population. Coagulase negative staphylococcus aureus (CNS) is the commonest causative organism isolated from infected arthroplasties. This study was performed to determine if there has been a change in the causative organisms isolated from infected hip arthroplasties and to see if there is a difference in obese patients.

Data on all deep infection following primary and revision hips was obtained from the surgical site infection register from April 1998 to Nov 2007. Case notes were reviewed retrospectively. There were 49 patients with 51 infected arthroplasties; 25 infected Primary THAs and 26 infected Revision THAs. We found a female preponderance in the infected primary and revision THAs (n=30). 63.2% of all patients had a BMI of ≥ 30, compared to only 34.7% of the non infected population (p< 0.0001). Over the period studied, CNS was the most common organism isolated (56.8%) followed by mixed organisms (37.2%) and staphylococcus aureus (25.4%). Multiple organisms were found exclusively in obese patients. In more than half of cases the causative organisms were resistant to more than two antibiotics.

This study shows that over the last 10 years, CNS continues to be the most frequently isolated organism in infected hip arthroplasties. Multiple organisms with multiple antibiotic resistances are common in obese patients. On this basis we recommend that combination antibiotic therapy should be considered in obese patients.


E. Oburu A.H. Deakin C. Wilson

The aim of this study was to evaluate the rate of surgical site infection (SSI) in all patients undergoing a primary total knee arthroplasty (TKA) and to audit the outcomes for those who were obese.

We retrospectively reviewed data for 839 primary TKAs done at a National Arthroplasty Centre over one year (April 2007 – March 2008). Body mass index (BMI) data was available for 824 (98%) of the patients. Surgical site infection (SSI) data had been collected prospectively by the Infection Control team for up to 30 days post-operatively and was available for all patients.

There were 23 patients with SSIs, 22 having superficial SSI and only one patient with a deep SSI. The overall superficial SSI rate was 2.7%. For the BMI< 25 group (9.6% of patients) SSI rate was 1.3%. For BMI 25–30 (31.6% of patients) SSI rate was 2.3%. For BMI 30–35 (31.2% of patients) SSI rate was 1.6%. For BMI 35–40 (19.0% of patients) SSI rate was 3.2%. For BMI > (8.6% of patients) SSI rate was 8.5%. Fisher’s Exact Test between all obese patients (BMI< 30) and those with BMI< 30 showed no significant difference in superficial SSI rates (p = 0.39) but did show a significant difference between superficial SSI rates in the obese class III patients (BMI> 40) and the rest of the cohort (p = 0.008).

Obese class III (BMI > 40) patients are at an increase risk of superficial SSI as compared to other patients undergoing primary TKA. However, obese class I and II patients (BMI 30–40) do not appear to have an increased likelihood of superficial SSI as compared to patients who have BMI< 30.


AJ Bennett RMD Meek A Morrison

Revision total hip replacement is often associated with significant blood loss and subsequent transfusion. Intra-operative cell salvage is one approach to minimising this allogenic transfusion.

We carried out a retrospective study of 158 consecutive revision THRs carried out by one surgeon between June 2003 and September 2006 in the Southern General Hospital, Glasgow.

In the study group (79 patients, operated upon after October 2005) Intra-operative cell salvage was routinely used for all cases. In the control group (79 patients, operated upon before October 2005) Intra-operative cell salvage was not available.

Data was collected on transfusion of salvaged blood, transfusion of allogenic blood, operation type, indication for surgery, complications and length of hospital stay.

Results showed a 53% reduction (p=0.002) in the number of units of allogenic blood transfused in the study group compared with the control group. (1.59 units per case compared with 3.41 units).

In the study group 51% of patients received allogenic blood transfusion, compared with 68% of patients in the control group, a relative reduction of 17% (p=0.02).

There was no difference between the two groups regarding haemoglobin drop and length of hospital stay. Data regarding complications yielded no significant results due to small cohort size.

We conclude that intra-operative cell salvage leads to a significant reduction in allogenic blood transfusion with subsequent implications upon cost, resource management, and patient safety and should be used for all patients undergoing revision hip arthroplasty.


K. Treon J.E. Beastall K. Kumar M.J. Hope

Stabilisation of the ankle syndesmosis remains a topic of debate regarding the best method of fixation; the most recent development is the ankle tightrope - a tensionable fibrewire suture. Despite over thirty thousand successful surgeries(1) reported, evidence supporting its use remains extremely limited. The aim of our study was to identify complications arising after insertion of this device for syndesmotic instability.

All patients undergoing tightrope stabilisation of the ankle syndesmosis in Aberdeen Royal Infirmary between January 2006 and February 2009 inclusive were incorporated in our study. Patient identifier data was collated at the time of operation by a research nurse with case records collected and analysed by the authors at the end of the study period. Nineteen cases were identified with one subsequently excluded due to death. Of the remaining patients thirteen were male and five female. Age ranged from sixteen to fifty-eight years. Five patients required tightrope fixation alone, the remainder necessitating bony fixation according to AO recommendations. Time in cast immobilisation ranged from five to eight weeks, time to full weight bearing six to ten weeks and time to discharge eight weeks to fifteen months.

In this series, 22% of tightropes were removed secondary to wound breakdown or knot prominence. Other complications included syndesmotic widening(11%), knot prominence without removal(5.5%) and synostosis(5.5%).

Incontrast to previously published literature (2,3,4,5,6) this, the second largest series to date, demonstrates a high complication rate(44%) - perhaps the tightrope is not as advantageous as initially thought.


S. L. Barker A. J. Johnstone K. Kumar

The purpose of the study was to evaluate if use of the ArthroCare Radiofrequency Ablation Wand caused excess heating and collateral damage to the surrounding tissues during Arthroscopic Subacromial Decompression. Cadaveric studies have shown worryingly high temperatures are reached when using Radiofrequency Ablation Wands in arthroscopic shoulder surgery. We are unaware of any published literature which assesses these temperature rises in the clinical setting.

10 patients were recruited to participate in the study. A standard Arthroscopic Subacromial Decompression was performed using continuous flow irrigation with intermittent use of the Radiofrequency Ablation Wand for soft tissue debridement. The temperature of the irrigation fluid in the subacromial bursa and the outflow fluid from the suction port of the wand were measured continuously during the procedure using fibre-optic thermometers. Temperatures above 45oC in the subacromial bursa were deemed to be unsafe.

The mean peak temperature recorded in the subacromial bursa was 28.6oC (23.49 – 31.94oC) with a mean rise from baseline of 6.1oC. The mean peak temperature recorded from the outflow fluid from the wand was 73.1oC (69.09 – 76.1oC) with a mean rise from baseline of 47.66oC.

Significantly high temperatures were noted in the outflow fluid from the wand but this was not evident in the subacromial bursa itself. Although high temperatures are generated at the tip of the wand this does not appear to be transmitted to the surrounding irrigation fluid in the subacromial bursa. We therefore conclude that safe temperatures are maintained within the bursa when using this device, thereby minimizing damage to the surrounding tissues, meaning collateral thermal damage is unlikely.


G.J. Macpherson M.J. Rewhorn I.J. Brenkel E. Dunstan J.A. Ballantyne

Our aim was to identify intra-operative and post-operative factors that predict those patients most at risk of dislocation.

Data was prospectively collected on a consecutive series of 2899 total hip replacements undertaken between July 1997 and December 2007. All operations were undertaken in one institution by fourteen orthopaedic consultants. In order to ensure accuracy, our regional database was cross-referenced with the Scottish Arthroplasty Project. Age; sex; BMI; surgeon; surgical approach; monthly caseload per surgeon; and the head size of the implanted prosthesis were analyzed using chi-squared tests for categorised factors and t-tests for quantitative factors.

Of the 2899 patients, 78 (2.7%) were found to have had one or more dislocation. BMI > 35kg/m2 was a significant pre-operative predictor of dislocation (P< 0.001). BMI < 35kg/m2 had a dislocation rate of 2.3% compared with a rate of 6.7% in those > 35kg/m2. Operating surgeon was the only intra-operative factor predictive of dislocation (P< 0.001). Head size was found to be insignificant.

Three surgeons with an overall dislocation rate of < 1% had a dislocation rate of 0.8% for patients with a BMI < 35kg/m2 and 2.0% for BMI > 35kg/m2. In comparison, the remainder of the surgeons had rates of 3.3% for BMI < 35kg/m2 and 9.6% for BMI > 35kg/m2.

Analysis of this consecutive series has shown that a BMI > 35kg/m2 is associated with a significant increase in rates of dislocation. The operating surgeon is also a significant factor and the highest risk is seen in surgeons with a > 1% overall dislocation rate operating on obese patients.


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S.A. Aitken L.C. Biant C.M. Court-Brown

Mountain biking is increasing in popularity worldwide. The injury patterns associated with elite level and competitive mountain biking are known. This study analysed the incidence, spectrum and risk factors for injuries sustained during recreational mountain biking.

The injury rate was 1.54 injuries per 1000 biker exposures. Males were more commonly injured than females, with those aged 30–39 years at highest risk. The commonest types of injury were wounding, skeletal fracture and musculoskeletal soft tissue injury. Joint dislocations occurred more commonly in older mountain bikers. The limbs were more commonly injured than the axial skeleton. The highest hospital admission rates were observed with head, neck and torso injuries. Protective body armour, clip-in pedals and the use of a full-suspension bicycle confer a significant protective effect.


A.G. Marsh A. Quigley E.R. Gardner

Guidelines for cervical trauma x-rays highlight the necessity for visualization of the C7-T1 junction. However, despite 15% of thoracolumbar fractures involving the T12 vertebra, less emphasis has been placed on ensuring the thoracolumbar junction or T12 vertebra is included on lumbar trauma radiographs. This may be due to an assumption that the lower thoracic spine will routinely be seen on lumbar x-rays.

We aimed to determine the proportion of lumbar trauma x-rays that allowed adequate visualisation for fracture diagnosis. We retrospectively reviewed all lumbar spine radiographs for patients presenting with blunt trauma to the Victoria Infirmary, Glasgow from January 2007 to January 2009. Our criteria for an appropriate lumbar trauma x-ray were that the whole lumbar spine should be visualized as well as the whole T12 vertebra.

From 583 lumbar radiographs reviewed, 61 (10%) did not fulfill the criteria for an acceptable lumbar trauma x-ray. 3% did not include the lumbrosacral junction and 7% did not include the T12 vertebra. One patient had a delayed diagnosis of a T12 fracture due to incomplete visualisation of the T12 vertebra on initial lumbar radiographs.

A significant proportion of lumbar spine x-rays performed for trauma patients (up to 10%) may not allow adequate visualisation for fracture diagnosis. These x-rays may give false reassurance that no fracture is present and, in turn, may lead to potentially disabling consequences. Spinal imaging for trauma patients should be interpreted closely with clinical findings. In cases where there is difficulty visualising the lumbar spine appropriately with radiographs, a CT scan should be considered.


O.B. Murray M.J. Reidy I. McLean A Hawkins

We have encountered radiological reports of ‘normal Graf α-angles’ when the femoral head was subluxed. We therefore developed a simple method to determine femoral/acetabular congruency known as the 50/50 method. We compare our method to the established Graf method.

Two identical, randomly assorted sets of 100 ultra-sonograms were evaluated. All ultrasonograms were of patients under 3 months of age within our DDH screening program. The images were assessed to be either ‘normal’ or ‘abnormal’ by 6 FY1’s using each method after reading brief instructions. (Images were classified as normal or abnormal by consensus between an orthopaedic consultant and radiologist who also examined and preformed dynamic screening on each infant).

The mean proportion of abnormal scans with agreement and normal scans with agreement was 0.52 (95% CI 0.39–0.69) and 0.92 (CI 0.87–0.96) respectively, indicating moderate agreement (kappa 0.41, CI 0.12–0.71) for inter-observer variability using the Graf method. On average the inter-observer variability using the 50/50 method for abnormal and normal scans with agreement was 0.60 (CI 0.35–0.84) and 0.92 (95% CI 0.85–0.99) respectively with moderate agreement (kappa 0.50, CI 0.20–0.80). Intra-observer variability between the Graf and 50/50 methods revealed moderate agreement (mean kappa 0.41, CI 0.17–0.66) with the average proportion of abnormal and normal scans with agreement of 0.50 (CI 0.32–0.69) and 0.91 (CI 0.83–0.98) correspondingly. The accuracy of each test was equal, ranging from 84% to 93%.

The 50/50 method is straightforward to both use and teach. Moreover, it successfully serves as “red dot” system to flag up abnormal hips at clinic. The 50/50 method is at least as good as Graf with regard to accuracy, inter-observer and intra-observer variability. We recognise that dynamic screening remains the gold standard.


R.A.E. Clayton O.B. Murray P.R.N. Patterson C.S. Kumar

Outcomes following total ankle replacement (TAR) have been less favorable than hip and knee arthroplasty. The Mobility TAR is a newly introduced mobile bearing ankle prosthesis which, unlike its predecessor the Agility, does not require fusion of the tibiofibular syndesmosis which in theory should reduce the rate of early failure. No studies have been published yet reporting follow-up longer than 1 year after surgery with this prosthesis.

From June 2006 to May 2008, 50 Mobility TARs were performed in our unit. Data have been collected prospectively on all 50 patients and all have been reviewed annually since surgery. Follow up ranges from one to three years.

The mean age was 65 (range 35–79). 20 patients (40%) were male. 10 underwent additional concurrent procedures (six calcaneal osteotomies, one 1st metatarsal osteotomy, two lateral ligament reconstructions, one subtalar arthrodesis). There was one early wound breakdown which subsequently healed without causing deep infection. There were no malleolar fractures. In two prostheses the talar component has subsided over two years resulting in painful loosening. Interestingly both these patients had postraumatic osteoarthritis with a fibular malunion. Both have been listed for revision to arthrodesis. One further patient has a loose talar component without subsidence and is awaiting exploration with a view to revision. There was one deep infection presenting at 18 months. One further patient reports continued hindfoot pain, thought to be from the subtalar joint and is being worked up for arthrodesis. The mean American Orthopaedic Foot and Ankle Society scores (scale 10–100) increased from 30 to 69 scores following surgery.

TAR using the Mobility prosthesis gives good early clinical results. Further follow-up studies are required to see if this performance is maintained in the long term.


S.C. Reston P. Basanagoudar A.D. McNair A.W.G. Kinninmonth

The recent introduction of intra-articular local anaesthetic techniques following total joint arthroplasty have demonstrated improvements in post-operative pain control, early joint mobilisation and may contribute to early discharge. Following intra-operative infiltration, the CALEDonian Technique requires ropivicaine to be administered postoperatively via an epidural catheter and filter, 20 to 40 ml over 60 seconds, on three occasions. Epidural filter catheters are used to prevent bacterial contamination during injection and have demonstrated 100% efficacy when intact. However, on internal departmental audit we have become aware of a filter membrane rupture rate approximating 10%. We therefore investigated the variables of syringe size and rate of administration in the occurrence of filter ruptures.

Using a standard primed epidural catheter set (Perifix B Braun), pressure measurements were taken pre- and post-filter. Recordings using the filter with attached catheter tubing were undertaken using 5 ml, 10 ml and 20 ml syringes (n=10) during infusion of a standard 5 ml volume. Controlled (over 1 min and following departmental protocol) and forced (over less than 15 seconds) infusions were undertaken manually and the experiment also undertaken using an automated syringe driver with 40 ml infused at a rate of 400 ml/hr. Each experiment was repeated ten times. Infusion pressures were measured and filters examined for evidence of rupture.

Using departmental protocol, controlled infusions independent of syringe size generated consistently low pressures, averaging 115 kPa, with no filter ruptures. Forced administration, independent of syringe size, generated pressures averaging 625.1 kPa. This is above the filter threshold and resulted in almost universal filter rupture. An automated device infusing at a rate of 400 ml/hr again generated low pressures and no filter ruptures.

Our study demonstrates low infusion pressures and no filter ruptures, independent of syringe size, when departmental protocol is adhered to suggesting that a human element may be in-part responsible for filter rupture. Although the technique currently used is safe, our audit has raised awareness of a potential difficulty and has lead to re-education of staff involved in this process. Consideration is being given to the possibility of automating infusions in the future and a process of re-audit of filter rupture will be undertaken.


N.D. Clement C.M. Court-Brown

The epidemiology of adult fractures is changing rapidly. The longevity of the population continues to extend with increasing incidence of fragility fractures. The aim of this study was to map the epidemiology of fractures in patients 90 years and older.

A retrospective review of all orthopaedic trauma patients over the age of 89 years attending Edinburgh Royal Infirmary in 2000 was performed. All inpatients and outpatients were included. These patients were identified using a prospectively complied database held by the senior author. Patient notes were used to confirm place of residence, mobility, co-morbidity, management, length of admission and place of discharge.

236 fractures (4% of all fractures) were identified. There were 209 (89%) female patients. All were secondary to low energy trauma. More than 50% of the patients were admitted from home and mobilised independently or with a stick. 124 (53%) patients had nil or one co-morbidity, the commonest being dementia and hypertension. Of the 133 neck of femur (NOF) fractures 11 (8%) died as inpatients, and of the 66 patients residing independently in their own home only 5 (8%) returned with the other 61 needing step-up care. The average length of stay in hospital for NOF fractures was 13 days.

The majority of patients are female and reside at home, being independently mobile and have limited co-morbidity. The length of stay is relatively long and few patients’ return directly home following a NOF fracture. This, with the ever-growing super-elderly population, will have substantial financial implications in the future.


J.G. Cowie S.J. Butler I.J. Brenkel

Despite increasing scientific investigation, the best method for preventing post-operative deep vein thrombosis remains unclear in patients undergoing a total hip replacement. In the wake of the recent controversial National Institute for Health and Clinical Excellence Clinical Guidelines on the prevention of thrombo-embolism, we felt it was timely to survey current Scottish Surgeons thrombo-prophylactic practice when performing total hip replacements.

E-mail questionnaires were sent to all Scottish Orthopaedic consultants. They were asked about routine pharmacological and mechanical prophylaxis in patients undergoing total hip replacement. Comparison was made with a previous survey done in 2003.

The response rate was 75%. The survey showed an increased use of pharmacological prophylaxis from 93% to 100%. This was due to the increased use of aspirin, from 51% to 64%. The use of Low molecular weight heparin had remained the same at 51%. No surgeons routinely use Warfarin, low dose heparin or Fondaparinux. Use of graded compression stockings has increased from 59% to 70%.

There is increasing evidence that patients undergoing total hip replacement should receive extended prophylaxis for up to 35 days. This could explain why aspirin is commonly used. Most guidelines, however, do not recommend this drug. With the recent launch of two new oral agents we may see a huge change in prophylaxis in Scotland, as 94% of surgeons said they would use extended prophylaxis if a safe oral agent was found.


Rajinder S. Gaheer Martin Rysavy Vojtech Havlas

Fractures of proximal humerus account for nearly 5% of all fractures. Majority of these fractures are minimally displaced and can be treated non-operatively with good functional results. However, treatment of unstable, displaced and comminuted fractures remains a challenge and optimal treatment continues to be controversial.

This study was undertaken to evaluate the results of proximal humeral internal locking system (PHILOS) plating done for treatment of displaced three- and four-part fractures of the proximal humerus.

Between November 2003 and February 2008, a total of 36 patients with displaced three- and four-part fractures of the proximal humerus had an open reduction and internal fixation using a PHILOS plate.

Data was collected retrospectively and clinical and radiological outcomes were assessed.

The mean follow up was 18 months. 35 (97.2%) united clinically and radiologically, with a mean neck/shaft angle of 127.1 degrees. One patient (2.8%) had revision procedure for implant failure, with a longer PHILOS plate and bone graft. The mean time to union was 9 weeks (7 to 20). The mean Constant score at final review was 72.1 (36 to 96). A total of 16 patients (44.4%) had excellent outcome, 16 (44.4%) had satisfactory outcome, but in four (11.2%) the outcome was poor.

The PHILOS plate provides good fracture stability early-on allowing early mobilisation without compromising fracture union. It requires minimal soft tissue dissection, does not need contouring and angular screw fixation gives good stability. We stress the importance of minimal soft tissue dissection to preserve the vascularity of the head, indirect methods of reduction and early mobilization.


Rajinder S. Gaheer Stuart Bell Jon Dillon Rupert D. Ferdinand

Arthrodesis of small joints of the feet has been used for a variety of conditions. Described initially for treatment of congenital or paralytic foot deformities, arthrodesis has now been widely accepted as treatment for a range of foot disorders from inflammatory and post traumatic arthritis to acquired flat foot. A variety of fixation devices have been used to achieve compression at the Arthrodesis site.

The aim of our study is to evaluate the use of Memory compression staples in small joint fusions of the feet. The staples are made of a nickel-titanium alloy which exhibits a phenomenon called “Marmen” effect. When kept at ice-cold temperature (0–5°C), the alloy becomes plastically deformed, but, regains its original shape at body temperature. The emphasis of this study is to validate the safety of the implant for fusion of small joints of feet, as well as to determine whether the higher cost of the implant is justified by a demonstrable trend in time to fusion and period of immobilization required.

Between June 2003 and June 2008, a total of 148 feet (276 joints) had Arthrodesis using memory compression staples.

Data was collected retrospectively and clinical and radiological outcomes were assessed.

The average period of immobilization in cast was 6.8 weeks (range, 6–12). The average time to fusion was 8 weeks (range, 6–16).

The use of memory staples provides an accurate, reproducible and predictable method of achieving arthrodesis in small joints of the feet. The time to fusion is less, thereby reducing the recovery time after surgery.


Kenneth C K Cheng Jean-Pierre St Mart Hannah Robertson Alistair Leanord Ian McLeod

Eradication of bacteria in forefoot surgery in necessary to prevent post-operative infections. Currently a lack of consensus exists on the optimum solution and preparation methods needed to achieve this. We compared the effect of povidine-iodine and chlorhexidine gluconate on lowering bacterial load and if any additional benefits are gained by pre-treatment with the use of a bristled brush.

Fifty consecutive patients undergoing forefoot surgery were recruited into the study and randomised to receive one of two surgical skin preparations (Povidine-iodine 1% with isopropyl alcohol 23% or Chlorhexi-dine gluconate 0.5% with isopropyl alcohol 70%). In addition to the skin preparation of the foot with the randomised solution the other foot was also scrubbed with a sterile surgical bristled brush for a standardised period (3 minutes) and then painted again. Swabs were taken from three sites and analysed via qualitative and quantitative analysis.

All four methods significantly decreased (p < 0.001), in all three sites, the number of colony forming units. Using two-way analysis of variance no significant interaction was observed between site of swab and method of preparation (p =0.970). This confirms that no preparation method was more superior in reducing the number of CFUs at any site than the others.

We suggest that either povidone –iodine with no more that 23% isopropyl alcohol or chlorhexidine gluconate with 70% isopropyl alcohol be used for surgical preparation in forefoot surgery. No additional benefit in reduction in bacterial load is gained by scrubbing the foot prior to painting with bristles.


M.H. Schmied M. Kelly J.A. Ballantyne I.J. Brenkel

Hip and knee arthroplasty account for over 95 000 hospital days annually in Scotland. The gross cost of over £81 million can be reduced by £10 million by decreasing length of stay by just one day per patient.

We performed a retrospective analysis of the data from the Scottish Arthroplasty Project (SAP). We specifically looked at length of stay in patients undergoing total hip and knee replacements between 1996 and 2007. We analysed the data on over

91000 total hip and knee replacements. In addition we looked at the influence of age, volume and day of admission on the 2007 data

Over the 11 year period there were significant variations in improved length of stay across the health boards. For the 2007 data, we found that patients treated in boards with high patient volume had shorter hospital stays. Admission policy and age of the patients affected the length of stay it did not account for the large differences between health boards.

The data from the Scottish Arthroplasty Project shows that higher surgical volume correlates with reduced length of stay in arthroplasty patients. The reasons for this are likely to be multifactorial but generalisable and need to be examined more closely with another study.


K. Deep N. Willcox B. Smith

It is generally accepted that Hip-Knee-Ankle (long-leg) radiographs are a good measurement tool for biomechanical axis of the knee and they have been used as the outcome measure for many studies. Most of the surgeons recommend having pre operative and post operative long leg radiographs for total knee replacement surgery, although practice is not as common. We studied the biomechanical axis on long-leg films and compared it with computer navigation. The aims were

To find out repeatability of measurements of biomechanical axis with inter observer readings on long leg radiographs

To compare X-ray biomechanical axis measurements with Navigation values obtained during total knee replacement surgery.

Our institution routinely uses long-leg radiographs for total knee replacement (TKR) surgery both pre- and postoperatively. A series of 209 patients who had navigated TKR between Jan 2007 and 2008 were selected. Stryker and Orthopilot systems for navigation were used. The intra-operative biomechanical axis measurements from the computer navigation files both pre-and post- implant were recorded. The long leg films were measured with a defined protocol from the digital images on PACS system. Centre of the head of femur was taken as the upper point.

For the knee centre the midpoint of a line joining the distal femoral notch centre and upper tibia was used. For the ankle centre midpoint of the upper talar margin was used. An angle between the three points represented the radiological biomechanical axis. To investigate inter-observer error, two observers measured the pre- and postoperative biomechanical axis on long leg radiographs independently on 57 patients. For the inter-observer measurements on 57 patients, the intraclass correlation coefficient was 0.99 for pre-operative radiographs and 0.98 for post-operative radiographs. Maximum difference between the two observers was 2° in four cases. All other cases showed the same readings or 1° difference. There was a strong correlation, which was statistically significant, between the pre-operative radiographic and navigated measurements with Pearson correlation coefficient of 0.810 (p< 0.001). The maximum difference between the radiographic and navigated measurement was 24 degrees. The relationship between the post-operative measurements was weaker but statistically significant with Pearson correlation coefficient of 0.323 (p< 0.001). The maximum difference between the two methods of measurement was larger 15.5.

It can be concluded from this study that biomechanical axis on a long leg radiograph is a repeatable measure with good inter-observer correlation. Although it is statistically significantly correlated with navigated readings, the absolute values may be different with each method. This raises the question of the reliability of long leg radiographs for the prediction of true biomechanical axis. Most of the larger value differences had a fixed flexion deformities (9 – 45 degrees). This can affect the readings on the long leg radiographs and make the deformity look either smaller or bigger. Also, our knee kinematic study has proven that the deformity does not remain the same in flexion and in the extended knee. This could also account for the difference in the readings. Other possible reasons for differences in the pre operative readings: the weight bearing status and the surgical opening of the joint, before taking the pre operative biomechanical axis measurements. Differences in the post operative readings could be attributed to: weight bearing status, time length between navigation and radiographic measurements (6–12 wks), scarring of the soft tissues in the meantime and flexed posture of knee in the early post operative period.


T. J. Joyce D. J. Langton A. V. F. Nargol

Introduction: One of the latest groups of replacement hip joints are known as hip resurfacings and they consist of a relatively large diameter femoral head articulating within a thin acetabular cup. Many of these devices show good short to medium term clinical results. However there are concerns over such implants including fracture of the femur and possible wear debris related reactions. Much valuable data can be learnt from explanted prostheses which have ‘failed’ and then been removed from patients. As hip resurfacing prostheses have only recently been introduced, there are relatively few such retrieval studies.

Methods and materials: Nineteen femoral and acetabular components from metal-on-metal hip resurfacing prostheses were obtained at revision operations. There were eight patients who had femoral fractures and the remainder experienced worsening groin pain and a characteristic sterile effusion. There were eleven head components and four pairs of matching heads and cups. Each of these was examined using a Zeiss TSK Rond-com60A roundness measuring machine and a Mitutoyo LEGEX co-ordinate measuring machine (CMM). Out of roundness measurements were taken on three planes for each acetabular and femoral component. The CMM was used to obtain 12 traces at 30° intervals for each acetabular and femoral component, allowing areas of localised wear to be identified and the maximum wear depth to be quantified.

Results: The maximum out of roundness values for the nineteen components ranged from 1.8 to 91.8 microns. A similar range of values was obtained from the CMM results. From the paired components, out of roundness was greater in the head than in the cup. All eight femoral heads which were retrieved after fracture of the femur showed out of roundness of less than 5 microns.

Discussion: Both out of roundness measurements and those from the CMM provided information about the wear of the implants. For a new component, a typical out of roundness value would be no greater than 5 microns. Therefore, from the out of roundness values it was seen that the eight ‘fracture’ components showed minimal distortion or wear after removal. In contrast the remaining components, which had a minimum out of roundness of 15 microns, showed much greater wear, thus suggesting that the groin pain was associated with relatively large volumes of wear debris. CMM scans helped to identify localised areas of wear and maximum wear depths. Values in the range of < 2 microns to 164 microns have been reported previously and show good agreement with the findings of this study. Retrieved components which had been implanted at high angles of inclination and anteversion tended to show the greatest wear, implying that correct positioning in vivo is crucial to the longevity of hip resurfacing prostheses.


H. Ziaee J. Daniel C. Pradhan P. Pynsent DJW. McMinn

Introduction: Metal-metal (MM) surface replacement arthroplasty of the hip is showing promise as an effective and enduring solution in the management of hip arthritis in the young, and is being increasingly used. The main concern is the release of metal ions into the systemic circulation and their long-term effects. There is concern that metal ions cross the placenta in pregnant women with MM bearing arthroplasties with the potential for mutagenic effects in the offspring. The hypothesis is that metal ions pass freely through the placenta and that there is no difference in the maternal and cord metal ion levels.

Methods: This is a controlled cross-sectional study of women of child-bearing age with MM bearing surface replacement arthroplasties. (n= 25, mean age: 32 years, mean duration after resurfacing 60.3 months, 3 bilateral). The control group consisted of 24 subjects who do not have a metallic implant, were not taking any supplements containing cobalt or chromium salts and were registered to undergo an elective LSCS at the regional hospital. Mean age of the control group was 31.3 years. No patient in either group was known to have renal failure. Whole blood specimens were obtained from the mothers just before delivery and before infusion of any fluids, and cord blood specimens were obtained immediately after delivery. High resolution inductively couples mass spectrometry (HRICPMS) was used for metal ion analysis.

Results: Cobalt and chromium were detectable in all specimens in both the study patients and controls. In the study group, mean cord metal ion levels were significantly lower than the maternal cobalt (p < 0.05) and chromium (p < 0.0001) levels thus rejecting the null hypothesis. In the control group, the mean difference between maternal and cord metal ion levels was only 5 to 7% and was statistically not significant (p > 0.5).

The mean difference in cord chromium between the study and control groups is not statistically significant (p > 0.05), although cord cobalt in the study group is significantly higher (p < 0.01) than that in controls. Whilst there is a four-fold elevation of maternal cobalt in the study patients and an almost 7-fold increase in maternal chromium levels as compared to the control group, the elevation in the cord cobalt and chromium in the study group are smaller.

Discussion and Conclusion: The differences between maternal and cord metal ions in the control patients indicate that normally the placenta allows an almost free passage of metal ions. This is understandable when we realize that these elements are also required by the developing foetus for its cellular and metabolic functions. The relative levels of metal ions in the maternal and cord blood in the study group patients reveal that the placenta does exert a modulatory effect on metal transfer. The mean cord levels of cobalt and chromium in these patients are only 57% and 24% of the maternal blood levels respectively. There is a continuing need for efforts to reduce metal ion release from artificial joints and also to monitor metal ion levels in patients with MM devices.


YM. Kwon P. Thomas B. Summer P. McLardy-Smith S. Ostlere R. Gundle D. Whitwell CLM. Gibbons NA. Athanasou HS. Gill DW. Murray

Introduction: Symptomatic abnormal soft-tissue masses relating to the hip joint, such as those described as pseudotumours, are being increasingly reported following metal-on-metal hip resurfacing arthroplasty (MoMHRA). These were found to be locally destructive, requiring revision surgery in a high proportion (75%) of patients. Lymphocyte infiltrations seen in pseudotumours were similar to aseptic lymphocyte vascular associated lesion (ALVAL), which is thought to represent a T-lymphocyte-mediated delayed type hypersensitivity. Therefore, a delayed hypersensitivity reaction to nickel (Ni), chromium (Cr) or cobalt (Co) has been suggested to play a role in pseudotumour aetiology. In patients with bilateral MoMHRA who presented with symptoms on one side, subsequent scans have demonstrated pseudotumours both on the symptomatic and asymptomatic side. Thus, there are concerns that there may be an appreciable number of asymptomatic pseudotumours that surgeons are unaware of and these may eventually become symptomatic.

Aim: The aims of this study were:

to determine the prevalence of asymptomatic pseudotumours after MoMHRA; and

to measure Co and Cr ion levels as well as lymphocyte proliferation responses to Ni, Co and Cr (the principal elements in the CoCr alloy used in MoMHRA) in MoMHRA patients with and without asymptomatic pseudotumours.

Methods: A total of 201 MoMHRA implanted hips in 158 patients (97 male, 61 female) with a mean age of 56 years (range 33–73 years) were evaluated. The mean follow-up was 61 months (range 13–88 months). Resurfacing devices implanted included 128 Birmingham Hip Resurfacing, 66 Conserve Plus and seven ReCap. The control groups included additional 20 patients, 10 male and 10 female (a mean age 68 years, range 57–80 years) with metal-on-polyethylene total hip arthroplasty and a further 22 age-matched patients (a mean age 55 years) without any metal implants. Ultrasound was used as the initial imaging modality and MRI was used to assess the extent of the identified masses. Patients with a soft-tissue mass had ultrasound-guided aspiration or core biopsy performed. Venous blood samples were collected in all patients for serum cobalt and chromium ion levels analysis using Inductively-Coupled Plasma Mass Spectrometer and lymphocyte transformation tests (LTT). The Oxford Hip Score (OHS) was used to measure the functional outcomes of patients. Acetabular component abduction angle was measured from standardised anteroposterior pelvis radiographs.

Results: Prevalence – Pseudotumours were found in 7 patients (6 female and 1 male). The overall prevalence of asymptomatic pseudotumours was 4%, with a relatively very high (30%) prevalence in females with bilateral implants. Histological examinations showed extensive necrosis of connective tissue, in which there were scattered aggregates of metal particles and a diffuse lymphocyte infiltrate.

Metal Ion Levels – The presence of pseudotumour was associated with significantly higher median serum cobalt levels (9.2mg/L vs. 1.9mg/L, p< 0.001), chromium levels (12.0mg/L vs. 2.1mg/L, p< 0.001), hip aspirate cobalt levels (1182 mg/L vs. 86.2mg/L, p=0.003), and aspirate chromium levels (883mg/L vs. 114.8mg/ L, p=0.006), as well as with inferior functional scores (OHS 41 vs. 47 p< 0.001). There was no significant difference in acetabular cup inclination angle (p=0.51). Lymphocyte Reactivity: A higher incidence and level of enhanced lymphocyte reactivity to Ni (p=0.001), but not to Co or Cr (the principal elements in the CoCr alloy used in metal-on-metal hip resurfacing implants), was found in patients with MoMHRA compared to the patients without MoM implants. However, lymphocyte reactivity to Co, Cr and Ni did not significantly differ in patients with pseudotumours compared to those patients without pseudotumours.

Conclusion: The prevalence of asymptomatic pseudotumours in females was high, especially in females with bilateral MoMHRA implants (30%). The patients with ‘asymptomatic’ pseudotumours were in fact mildly symptomatic. Lymphocyte reactivity to Co, Cr and Ni did not differ in patients with pseudotumour compared to those patients without pseudotumours, suggesting that systemic hypersensitivity type IV reactions, mediated by lymphocyte reactivity to these metals, is not the dominant mechanism in pathogenesis of the soft tissue pseudotumours. Furthermore, pseudotumours were not detected in those patients who had normal levels of cobalt and chromium ions. This suggests that pseudotumours do not occur if MoM articulations are well functioning. Therefore, pseudotumours are likely to be a biological consequence of the large amount of metal debris generated in vivo due to excessive wear.


TB Beckingsale JE Page A Jennings T Fawcett

Introduction: Staphylococcus aureus is a major cause of chronic infections and causes particular problems in relation to implanted prostheses. Biofilm formation on abiotic surfaces affords bacteria innate protection from opsonophagocytosis and antibiotic agents and complicates the eradication of infection from bone and implanted prostheses. Increased concentrations of sodium, the major extracellular cation, have previously been implicated in increased biofilm formation in Staphylococcus aureus. In this study we demonstrate that increased concentrations of potassium, the major intracellular cation, also causes a significant increase in biofilm formation. Furthermore we also show that halide stress also leads to a primary increase in penicillin resistance in Staphylococcus aureus.

Methods: Staphylococcus aureus ATCC 9144 was cultured in broth supplemented with variable amounts of potassium chloride and sodium chloride. Biofilm formation was investigated in 96-well microtiter plates using a standard technique. Antibiotic resistance was investigated using graduated E-test strips.

Results: There was a positive correlation between bio-film formation and increased concentrations of sodium and potassium. Biofilm formation was noted to be even greater under potassium stress than under sodium stress. Sodium stress also lead to a five-fold increase in penicillin resistance in naïve Staphylococcus aureus cells.

Discussion: Cellular injury or insult can lead to cell necrosis and lysis. The intracellular concentration of potassium is 30 times higher than that of the surrounding extracellular fluid. Hence, cell necrosis leads to markedly increased local concentrations of potassium. These experiments show that an increase in potassium concentration leads to an increase in biofilm formation. This suggests that biofilm formation and hence infection of implanted pros-theses may be more likely in areas of major tissue trauma such as large resections and revisions. Furthermore, cellular stress leads to increased antibiotic resistance in naïve cells which may nullify prophylaxis and complicate bacterial eradication in vivo.


A. Karim AMJ. Bull O. Kessler NP. Thomas AA. Amis

Aims: To determine the effects of tibial component rotation and posterior slope on kinematics following Scor-pio navigated TKR in cadaver specimens.

Methods: Knee kinematics were monitored using a validated Infra Red Navigation System. Ten normal comparable cadaver specimens were mounted in a custom rig allowing assessment of kinematics under various loading conditions. The specimens then underwent Navigated TKR. The surgery was performed as per normal operating surgical protocols by an expert knee surgeon. However an augmented tibial component was implanted allowing the researchers to precisely modify its rotation and posterior slope. A pneumatic cylinder attached to the quadriceps tendon was then used to repetitively flex and extend the knee with a variety of applied loads.

Results: Kinematics were different after TKR. Increasing posterior slope resulted in increasing posterior position of the femur, particularly at maximum flexion. Posterior slope also resulted in a deviation of the neutral path of motion and alteration of the normal envelope of laxity. Tibial component malrotations over 5 degrees resulted in deviations of the neutral path of motion without affecting the envelope of laxity. A combined malrotations over 10 degrees with posterior slopes over 6 degrees resulted in prosthetic subluxation under certain loading conditions.

Discussion: Knee kinematics are different after TKR. Increasing internal and external malrotation as well as the addition of posterior slope resulted in deviations of TKR kinematics through alteration of the neutral path of movement and or the envelope of laxity. Combined misalignments of slope and rotation resulted in the greatest deviations from normal kinematics and in some cases, prosthetic subluxation. Incompatibilities of alignment may result in increased ligament tension and component articulation dysfunction that may contribute to premature wear and loosening. Surgeons should be aware of this when considering the addition of posterior slope or assessing tibial component positioning in TKR.


M. Chimutengwende-Gordon C. Pendegrass G. Blunn

Background: Osseointegrated amputation prostheses avoid soft tissue complications associated with traditional socket prostheses. Forces are transmitted directly to the skeleton resulting in improved function. However, approximately 50% of transcutaneous implants become infected due to the lack of a successful skin-implant seal. Intraosseous Transcutaneous Amputation Prostheses (ITAP) are designed to integrate with the skin preventing epithelial downgrowth and infection.

Fibronectin adsorption enhances fibroblast adhesion in vitro; however, in vivo, fibronectin becomes desorbed from the implant surface. Covalent attachment of fibronectin by silanisation has been shown to be durable in vitro. The silanisation process for fibronectin includes a stage of passivation with sulphuric acid which alters surface characteristics.

Aims: The aim of this study was to determine if in vitro fibroblast adhesion to silanised fibronectin (SiFn) titanium alloy could be improved by omitting or reducing the length of time of passivation. The study also assessed the effects of SiFn on dermal attachment in vivo comparing the results with adsorbed fibronectin substrates and with uncoated controls.

Methods: Scanning electron microscopy, Ra profilometry and contact angle measurement (n=6) were used for topographical characterization of surfaces. Anti-vinculin antibodies were used to immunolocalize fibroblast adhesion sites after 24 hours. The morphology of fibroblasts on each surface was evaluated using scanning electron microscopy. Subcutaneous plates were implanted onto the tibiae of an ovine model (n=3) in order to evaluate the performance of the modified SiFn surface in vivo. Hydroxyapatite (HA) and adsorption of fibronectin to HA (HAFn) were also tested because HA coatings are currently applied to the dermal section of ITAP in clinical trials. After four weeks, a histological assessment of the percentage of soft-tissue attachment and cell alignment relative to the implant was performed.

Results: Passivation produced rougher, more hydrophobic surfaces with numerous microcracks and was associated with poorer fibroblast adhesion and spreading than un-passivated controls in vitro.

SiFn with passivation resulted in poorer cell adhesion than SiFn without passivation. Reducing the time period for passivation did not reduce the detrimental effects of passivation In vivo, HAFn and SiFn resulted in higher median values for soft-tissue attachment than simple adsorption of fibronectin; however, the differences were not statistically significant. Cell alignment was significantly different for HAFn and SiFn compared with controls (p< 0.05), with cells on the fibro-nectin treated surfaces orientated more perpendicular to the implant surface.

Conclusion: Omission of passivation improves fibro-blast adhesion to SiFn surfaces in vitro. Coating with fibronectin either by silanisation onto titanium alloy or by adsorption onto HA surfaces affected the orientation of cells in vivo, implying that tissue attachment was enhanced. A time course may be of value to determine if fibronectin coatings are lost over time in vivo.


M. Al-Hajjar L. M. Jennings I. J. Leslie J. Fisher

Ceramic-on-ceramic total hip replacements (THRs) have shown low wear volumes in standard gait hip simulator studies1. However clinical reports have indicated a variation in wear rates and formation of stripe wear on the ceramic femoral heads2. The aim of this study was to investigate the influence of different clinical conditions such as cup inclination angle and microseparation (head offset deficiency) on the wear of ceramic-on-ceramic THRs. The six station Leeds II hip joint simulator was used to investigate the wear of size 28mm ceramic-on-ceramic bearing couples. The alumina matrix composite ceramic material (AMC, Biolox Delta, CeramTec AG, Germany) was used in this study. The lubricant used was 25% bovine serum. The study was carried out for a total of five million cycles; the first two million cycles under standard gait conditions and a further three million cycles under microseparation conditions. During microseparation, a lateral movement of 0.5mm was applied to the cup relative to the head during the swing phase of the gait cycle3. Three of the cups were mounted to provide a clinical angle of 55°, which is referred to as the ‘standard’ condition; and the other three cups were mounted to provide a clinical angle of 65°, which is referred to as the ‘steep angle’ condition. These combinations provided four different testing conditions: standard, steep cup angle, microseparation, and combination of steep cup angle and microseparation conditions. Volumetric wear was determined gravimetrically and statistical analysis was performed using One Way ANOVA (significance at p< 0.05). Increasing the cup inclination angle from 55° to 65° had no significant effect on the wear rate in Biolox Delta ceramic-on-ceramic THRs under both standard (p> 0.42) and microseparation (p> 0.55) conditions. Under standard gait conditions, the mean wear rate for both cup inclination angles was very low at 0.05 mm3/million cycles. The introduction of microseparation to the standard gait cycle significantly increased the mean wear rates (p< 0.01) to 0.13 mm3/ million cycles for the ‘standard’ cup inclination angle of 55° and 0.11 mm3/million cycles for the ‘steep’ cup inclination angle of 65°. A stripe of wear on the head also formed, with corresponding superior rim wear on the cup. For comparison, the steady state wear rate of HIPed third generation alumina ceramic (Biolox Forte) under microseparation conditions was 1.3 mm3/million cycles [4]. In conclusion, increasing the cup inclination angle by 10° had no influence on the wear rate of Biolox Delta ceramic-on-ceramic bearings. The introduction of microseparation conditions significantly increased the wear rate and resulted in stripe-like wear on the femoral head, which has previously been observed on retrieved ceramic prosthesis. However, these wear rates were still low, and were ten times lower than those previously reported for Biolox Forte.


Qiling He Chao Wan Gang Li

Introduction: MSCs were demonstrated to exist within peripheral blood (PB) of several mammalian species including human, guinea pig, mice, rat, and rabbit. We have found increased numbers of circulating MSCs in human peripheral blood after fracture and in patients with cancers. We have also compared the difference between circulating MSCs and bone marrow MSCs and evaluated their potential clinical applications in tissue engineering and cell therapy.

Methods and findings: Using culture conditions similar to those defined for bone marrow derived mesenchymal stromal cells (BMMSCs), we have isolated and expanded multi-colony and single colony derived PBMSCs strains from the GFP transgenic rats. Aspects of molecular, cellular and developmental properties of this poorly characterized peripheral blood subpopulation were examined. PBMSCs share some common phenotypic characteristics with BMMSCs, but are distinguishable in gene expression profile by cDNA microarray analysis, with 84 up-regulated and 83 down-regulated genes (> 2 fold, E-B/B-E> 100, P< 0.05). Most of these genes are related to cell proliferation, differentiation, cyto-skeleton, and calcium/iron homeostasis. Differentially expressed genes with fold change ≥10 were further confirmed with quantitative real time RT-PCR, and these genes are: retinol-binding protein 1 (CRBP1), cadherin 2, bone morphogenetic protein 6 (BMP6), SRY-box containing gene 11 (Sox11), the aquaporin 1 (AQP1), and so on, and they can be potential targets for further investigations. We have demonstrated that single colony derived PBMSCs strains possess extensive proliferation and multipotent differentiation potentials into osteoblasts, adipocytes, chondrocytes, endothelial cells and neuronal cells. In terms of potential clinical implications of PBMSCs, we have demonstrated that allogenic PB-MSCs enhance bone regeneration in rabbit ulna critical-sized bone defect model. We also demonstrated that BM-MSCs can be recruited towards to the sites of bone fracture and participate fracture healing. We are now working on using MSCs as a gene delivery vehicle for management of would healing or cancer therapy, and ways of enhancing the homing and recruitment MSCs towards to specific sites after their systemic delivery.

Conclusion: Taken the above data together, PB-MSCs may be a new cell source for cell therapy, tissue engineering and gene therapy strategies.


EEF Scott SG Williams A Muir AHRW Simpson

Background: Muscle tears and injuries are a huge problem throughout the world. Ways of reducing these injuries are welcome, with warm-up and stretching of muscles prior to use established methodologies. Forces associated with muscles can be thought of as active (stimulated muscle: actin-myosin) and passive (relaxed muscle: elastic proteins and connective tissue). In muscle tears, the connective tissue component is damaged, but there is very little information in the literature on this component of the muscle.

Objective: To examine passive (elastic) components in muscle during impact loading at differing temperatures. In particular to test the hypothesis that the connective tissue component fails at different loads according to the temperature.

Methods: Gastrocnemius and Soleus were isolated from 36 male rat limbs, clamped and exposed to increasing impact loads, by dropping a known weight from increasing heights. Muscle was given one minute to recover before an increased force was applied. Temperature was varied from 17 C to 42 C (to encompass the physiological range) in 5 C increments. The height of drop causing non-recoverable deformation, and the maximum deceleration of the weight (measured using an accelerometer attached to a picoscope) at a constant height was recorded for each temperature.

Results: The energy to failure, i.e. the point at which non-recoverable deformation occurred was found to increase above 32 C (p < 0.01) and the maximum deceleration at impact found to have a downward trend with increasing temperatures. At 17 C, the energy to failure was 317.7 ± 20 mJ, At 22 C, the energy to failure was 301.8 ± 29 mJ, At 27 C, the energy to failure was 317.7 ± 40 mJ, At 32 C, the energy to failure was 333.5 ± 21.2 mJ, At 37 C, the energy to failure was 460.2 ± 15.8 mJ, At 42 C, the energy to failure was 619.5 ± 21.2 mJ,

Conclusions: Muscle was shown to act in an increasingly elastic nature with temperature. At higher temperatures a larger energy is required to deform the muscle permanently, and the muscle decelerates more slowly, both in keeping with elastic properties. The same energy at a lower temperature causes significant deformation within the muscle. This has numerous clinical implications, as the temperature at which this change occurs is encountered during surgery and also by sportsmen on outdoor pitches. More research is required to look at the passive components within muscles in humans.


C Ho J Hua GW Blunn

Bone marrow cells are well known for improving healing. Recent studies report that stromal cell-derived factor-1 (SDF-1) and its receptor CXC chemokine receptor 4 (CXCR4) play roles in stem cell homing and are related to short-term and long-term engraftment. SDF-1 secreted from an injured organ can pass the endothelium barrier in a CXCR4-dependent manner into the bone marrow and recruit hematopoietic progenitors to the circulation. There is evidence to show that SDF-1 also has chemoat-tractive effects and is able to recruit mesenchymal stem cells and osteoprogenitors. Our previous study also showed that SDF-1 has an enhanced effect on osteoblas-tic differentiation of human mesenchymal stem cells. The purpose of this study is to investigate the effects of genetically modified bone marrow cells that overexpress SDF-1 on bone fracture healing in rat model. The hypothesis is that genetically modified rat bone marrow cells (rBMCs) that over expresses SDF-1 will enhance the fracture healing process compared to non-treated groups or to groups treated with only rBMCs. rBMCs were harvested from femora of young male Wistar rats. rBMCs were expanded ex vivo, and cells of passage 3 were used in the experiment. SDF-1 over-expressing rBMCs (rBMC-SDF-1) were engineered by infection of adenovirus carrying human SDF-1 gene at the multiplicity of infection (MOI) 500. Eighteen adult female Wistar rats were divided into three groups with 6 rats in each group:

rBMC-SDF-1,

rBMC and

control.

A 3mm gap in the middle of femur was created during surgery and stabilized by an external fixator. In two groups three hundred thousand rBMCs or rBMCs-SDF-1 were seeded into a collagen sponge and transplanted into the gap. For the control group, sponges without cells were used. Rats were sacrificed 3 weeks after operation and the femora were harvested. Bone mineral content within the gap was measured immediately after operation and compared with the bone mineral content within the same gap at the third week by dual energy X-ray absorptiometry (DEXA) scanning. The area of new bone formation was measured using histomorphometery on H& E stained sections and quantified by imaging analysis system. In the present study, the rBMC-SDF-1 group showed the most dominant influence in both new bone formation and bone mineral increase. rBMC-SDF-1 not only increases new bone formation but also has higher bone mineral content after 3 weeks compare with the rBMC only. This bone healing progress may due to the enhanced local SDF-1/CXCR4 interaction that recruited more host’s stem cells into the fracture site. The control group showed an increased new bone formation in the histological analysis but a reduced bone mineral content after 3 weeks whereas in comparison the rBMC group showed a similar new bone area to the control group but a significantly higher bone mineral content. This may indicate a faster bone repairing ability with the BMCs. Both rBMC and rBMC-SDF-1 groups have a higher bone mineral content and a more compact new bone structure that may indicate an accelerate effect of rBMC in the bone mineralization. In this study, we show that SDF-1 induces improved bone formation in early fracture healing.


A.M.H. Jones B.J.R.F. Bolland A.M. New R.O.C. Oreffo D.G. Dunlop

Introduction: Revision hip surgery is predicted to rise significantly over the coming decades. There is therefore likely to be an increasing need to overcome the large bone loss and cavitatory defects encountered in failed primary hip replacements. Impaction bone grafting (IBG) is a recognised technique for replacing lost bone stock. Achieving optimal graft impaction is a difficult surgical skill with a significant learning curve, balancing the need to achieve sufficient compaction to provide primary stability versus the need to keep impaction forces to a minimum to prevent iatrogenic fracture. In this study we have developed a revision acetabular model to test the hypothesis that the use of vibration and drainage with a new custom made perforated tamp could reduce the peak stresses imparted to the acetabulum during the impaction process and also improve the reliability and reproducibility of the impaction technique

Methods: Composite Sawbone hemi Pelvis models were used, with identical contained cavitatory defects created (Paprosky Type 2a). A strain gauge was attached to the medial wall of each hemi pelvis. A custom set of IBG tamps were made, and coupled a pneumatic hammer used to generate the vibrations. A standard impaction technique was used for the control group and the new vibration impaction for the experimental group. The cavity was progressively filled with morsellised allograft in 6 set steps for both groups with strain gauge readings taken during all impaction to monitor peak stresses. A standard Exeter Contemporary cup was then cemented into the graft bed for both groups. The models were mechanically loaded according to the protocol developed by Westphal et al at the angle of the joint reaction force during heel strike for a total of 50 000 cycles. 3D assessment of any micro motion post mechanical testing and degree of graft compaction was done with high resolution micro CT.

Results: Vibration impaction lead to a significant reduction in the peak stresses during the impaction process throughout the 6 steps (e.g. Step 1: 34.6 vs 110.8 MPa p=0.03). There was also far less variability in the peak stresses in the vibration group compared to standard impaction both in sequential impactions by the same surgeon and between different surgeons. One medial wall fracture occurred in the control group only. There was no difference in the degree of graft compaction or in the subsidence of the implant post cyclical loading.

Conclusion: Impaction bone grafting can be a difficult surgical skill with a significant learning curve. We believe that this new technique of applying vibration coupled with drainage to the IBG process in the acetabulum can reduce the risk of intraoperative fracture whilst achieving good graft compaction and implant stability. This technique therefore has the potential to widen the ‘safety margins’ of IBG and reduce the learning curve allowing more widespread adoption of the technique for replacing lost bone stock.


A.M.H. Jones T.S. Foong B.J.R.F. Bolland A.M. New D.G. Dunlop R.O.C. Oreffo

Introduction: Impaction bone grafting (IBG) using fresh frozen morsellised allograft is considered by many as the method of choice for replacing lost bone stock encountered during revision hip surgery. Bone marrow contains multipotent skeletal stem cells which have the potential to differentiate down a number of different cell lineages including osteoblasts, chondrocytes and adipocytes. In IBG it is desirable for as many as possible to go on to form bone rather than fibrous tissue to form a solid osseous construct. Whilst it is possible to push cells down the osteogenic lineage in vitro, some of these methods (e.g. the addition of Dexamethasone) are not translatable to clinical practice due to undesirable side effects. In this study we test the hypothesis that by coating the allograft with type 1 Collagen prior to seeding with human bone marrow stromal cells (hBMSC), the cellular adhesion and proliferation down an osteogenic lineage can be increased, leading to improved mechanical and biological properties of the IBG composite.

Methods: A control group of plain allograft and three experimental groups where used to determine the effects that collagen and hBMSC have on IBG (both individually and in combination). The samples where impacted in standardised fashion previously validated to replicate Femoral IBG, and cultured in vitro for 2 weeks. The samples then underwent mechanical shear testing giving a family of stress strain curves for each group, from which a Mohr coulomb failure curve can be plotted. Using the Mohr Coulomb failure equation τ = σ tanΦ + c, the shear strength (τ), Internal friction angle (tanΦ) and inter particulate cohesion (c) can then be calculated. Biochemical analysis was also performed for DNA content and Osteogenic activity.

Results: Mechanical shear testing demonstrated a significant improvement (p=0.002) in the grafts ability to resist shear with the coating of Collagen and seeding with hBMSC (245 vs 299 kPa) as well as improved cohesion between the bone graft particles (46 vs 144 kPa). Regression analysis of the shear strength showed a linear increase with compressive stress (R2 > 0.98) for all groups, indicating that the grafts satisfied the Mohr Coulomb failure law. In the two groups seeded with cells, the collagen coated group also showed increased osteogenic cell activity compared to the plain allograft.

Conclusion: This study has shown a role in the improvement of the mechanical and biological properties of IBG coated with type 1 Collagen and seeded with hBMSC. Collagen coating of IBG is a facile process and translation of the technique into the theatre setting feasible. The improvement in shear strength and cohesion could lead to earlier weight bearing for the patients and allow quicker recovery. The therapeutic implications of such composites auger well for orthopaedic applications. We are currently strengthening the above findings with an in vivo study.


K Hashimoto H I Roach

Destruction of articular cartilage in osteoarthritis (OA) is mediated by proteases and cytokines, which are silenced by epigenetic mechanisms in normal chondrocytes, but aberrantly expressed in OA. This is associated with DNA de-methylation of specific CpGs in the promoter regions (Arthritis Rheum, 2005; 52:3110–24). A widely used in vitro model to study the transcriptional regulation in OA is treating monolayer cultures of normal articular chondrocytes with inflammatory cytokines (IL-1b, TNFa or oncostatin M (OSM)) and investigating gene expression after 8–24 hours. The cytokines up-regulate catabolic, but down-regulate chondrocytic genes. However, whether this up- or down regulation is maintained after cytokine withdrawal is rarely investigated. In OA, the expression of catabolic genes is maintained in absence of cytokines and is transmitted to daughter cells, suggesting that epigenetic changes have resulted in permanent up-regulation. We asked whether it is possible to reproduce the epigenetic changes in vitro. Hence we compared gene expression and DNA methylation status in short-term (24h) versus long-term (2–3 weeks) cultures and, in particular, investigated the effects of cytokine withdrawal on these parameters.

Healthy chondrocytes, harvested from human femoral heads after hemiarthroplasty, were cultured in monolayer and passaged once (P1). For short-term culture, the P1 chondrocytes were divided into control culture or cultures with one-shot of IL-1b/OSM, harvested after 24h and 72h. For long-term culture, the cells were cultured with or without IL-1b/OSM, the latter added twice a week. Half the cells were harvested at confluence (3 weeks) and the other halves were passaged again and cultured without cytokines until confluence (2–3 weeks). RNA and genomic DNA were extracted from the same sample. IL-1b, MMP-3, MMP-13 and COL2A1 expression was quantified by real-time PCR. The percentage of cells with DNA methylation at the CpG site at −299bp of IL-1b promoter (a key CpG site) was quantified by a method we reported previously (Epigenetics, 2007; 2: 86–95).

As expected, expression of IL-1b MMP-3, MMP-13 had increased 100–4500-fold 24h after IL-1b/OSM treatment, but decreased considerably after cytokine withdrawal. COL2A1 expression was virtually abolished by IL-1b/OSM and not regained after 72h. The % DNA methylation did not change during the 72h. Repeated treatment with IL-1b/OSM in long-term culture also increased expression of IL-1b and the MMPs. However, this time expression was maintained or even increased after cytokine withdrawal and passaging. Expression inversely correlated with DNA methylation, which dropped from 59% to 35%. This de-methylation was preserved after passaging and cytokine withdrawal.

Conclusion: The widely used short-term cytokine-treated monolayer cultures of articular chondrocytes do not approximate the in vivo situation, where long-term aberrant expression correlates with DNA de-methylation. However, long-term treatment can mimic the loss of DNA methylation, which results in increased gene expression that is maintained after cytokine withdrawal. This model will facilitate studies on the mechanisms of DNA de-methylation, which might ultimately lead to novel therapeutic approaches for the treatment of OA


D J. Mason K. Brakspear C. Wilson R. Williams R S. Kotwal

Purpose: Since the neurotransmitter glutamate mediates nociceptive and pathological processes in arthritis, we have investigated how glutamate receptor and transporter expression varies with anatomical site or disease severity in subchondral bone of patients with osteoarthritis.

Methods and Results: Subchondral bone was sampled from tibial cuts derived from total knee arthroplasty (n=2, TKR, Kellgren Lawrence[KL] grade 3) and from tibial drill hole sites from high tibial osteotomy (n=2, HTO, KL grades 2 and 3) for osteoarthritis. RNA was extracted, reverse transcribed and RT-PCR performed for the housekeeping gene GAPDH, the glutamate transporter EAAT-1, and glutamate receptors (NR2A and KA1). Quantitative RT-PCR assessed differences in the expression of EAAT-1, a dominant negative splice variant called EAAT-1ex9skip and osteocalcin after normalisation to GAPDH.

Good quality RNA was obtained from bone cores removed from drill holes during HTO surgery, with GAPDH, EAAT-1, NR2A and KA1 expression detected. Osteocalcin expression was high indicating RNA was derived from osteoblasts and osteocytes, but did not vary with anatomical site or disease status. End-stage RT-PCR indicated differential expression of EAAT-1 between medial and lateral bone samples in total knee arthroplasty, however these differences were not significant by quantitative RT-PCR. In one patient, EAAT-1 expression was significantly reduced in the anterior zone versus the middle or posterior zones (ANOVA, p< 0.001). EAAT-1ex9skip represented a significant proportion of the total EAAT-1 mRNA expression in bone from TKR patients, but appeared less abundant in HTO samples.

Conclusion: We have shown for the first time that glutamate transporters and receptors are highly expressed in subchondral bone of patients with osteoarthritis and that EAAT-1 expression may vary with anatomical location and pathology. Activation of these receptors and transporters by the increased synovial fluid concentrations of glutamate that occur in arthritis may contribute to pathological changes and nociception.


P.M. Mayhew C.M. Rose K. Brown P. Bearcroft N. Loveridge J. Reeve K.E.S Poole

Introduction: Previously, 3D finite element models of the midfemoral neck (MFN) predicted maximal compressive stress in the inferior cortex and trabeculae during the heel-strike of normal gait. We hypothesised that older women (compared with younger women) would have relative preservation of inferior trabecular bone, reflecting continued walking activity into old age. Recently, we identified preservation of the infero-anterior femoral neck cortex in old age despite women at 85 having 55–80% thinner superior cortices than women aged 25. Here, we examined regional trabecular bone mineral density in an extended region of interest (ROI) of the MFN, to establish age-associated differences and their likely contribution to hip fracture in a cross-sectional study of 100 women aged 20–90 years using 64-slice computed tomography (CT).

Methods: 100 healthy women were recruited by decade from age 20 to 90 (inter-quartile range 38–72). Participants consented to an extension of a routine clinical pelvic CT scan (Siemens 64-slice CT) using a fixed threshold of 450mg/cm3 and Mindways Software (BIT-2) to analyse both hips (1mm slice thickness, 0.59 mm voxel size). The starting position for cross sections was a 1mm thick MFN slice where the femoral neck height to width ratio was 1.4, since this location along the neck axis has been shown to be highly reproducible and unaffected by age (mean 51%, SE 0.016%). 5 parallel 1mm thick slices were evaluated towards the midline. Age effects on trabecular BMD (tbBMD mg/cm3.) were evaluated using linear regression (by anatomical quadrant).

Results: Trabecular BMD was significantly lower at 85 than at 25 years old amounting to over 50% difference in 3 out of 4 quadrants: Supero-posterior tbBMD difference between 25–85 years by modelling −146mg.cm3., (absolute %) −53%, r 2 (age) 0.61, p < 0.0001; Infero-anterior −25mg.cm3., −24%, r 2 0.094, p < 0.002. In the infero-anterior quadrants (that receive maximal stress at the heel strike in normal gait) there was relative preservation (r squared only 0.094) and only a 24% difference between 85 and 25. Body weight had no association with tbBMD in any quadrant (unlike cortical thickness).

Conclusion: Trabecular bone was better preserved in the infero-anterior quadrant in elderly women than in the other 3 quadrants. Since tbBMD also makes a small but significant contribution to the reduction of the risk of failure of femoral necks ex-vivo, increasing trabecular bone in the remaining quadrants should be included in strategies to prevent hip fracture, alongside efforts to strengthen the cortex.


C.H. Lee R. Rajan H.I. Roach

Osteoarthritis (OA) is a common degenerative disease associated with aging thatas yet has no cure. Glucosamine (Gln) is a naturally produced amino sugar that forms part of the cartilage matrix and is taken by millions of OA sufferers in the hope of alleviating their symptoms. Apart from alleviating pain, there is evidence in the literature that Gln may also be a chondroprotective drug in OA and some clinical trials have shown reduced joint space narrowing in patients taking 1mg Gln per day. However, the mechanisms by which Gln might have its beneficial effects are still uncertain.

We wanted to determine whether Gln has any influence on the aberrant gene expression that takes place in OA chondrocytes. To this end, we cultured healthy articular chondrocytes and induced aberrant gene expression with TNF-α /OSM. Healthy human chondrocytes were isolated from the cartilage of the femoral head obtained after hemiarthroplasty from four patients who had fractured the neck of their femur. Each sample was divided in to 4 groups prior the monolayer culture:

Control culture,

Gln only,

treated with TNF-α/OSM,

treated with TNF-α /OSM and Gln.

At confluency (~ 2 weeks) RNA was extracted for analysis of mRNA expression by RT-PCR. The impact of Gln on the expression if the inflammatory cytokine IL-1b and the protease MMP-13 was determined by conventional RT-PCR.

No expression of IL-1b was found in control cultures and Gln on its own did not induce expression. As expected, TNF-a/OSM induced the expression of IL-1b in all four patients. When Gln was present together with TNF-a/OSM, IL-1b expression was prevented in two patients and considerably reduced in the other two patients. With respect to MMP-13, expression was present in 3/4 cultured controls and Gln did not influence this expression. TNF-α /OSM increased expression of IL-1b, and the cytokine-induced expression was slightly reduced by Gln in 2/4 patients.

These results suggest that Gln prevents the TNF-α /OSM-induced expression of IL-1b, but has limited direct influence on MMP-13 expression, at least in vitro. If the data are applicable to the in vivo situations, the results support the proposed chondroprotective effect of glucosamine at the cellular level.


A Getgood R Brooks L Fortier N Rushton

Introduction: Platelet rich plasma (PRP) has been hypothesised to be of potential benefit to articular cartilage tissue engineering, through its release of autologous growth factors. The aim of this study was to ascertain whether the addition of thrombin is required to achieve platelet activation and sustained growth factor release in-vitro, when PRP is applied to a collagen based osteochondral scaffold.

Methods: Collagen/glycosaminoglycan scaffolds were fashioned, to which equal combined volumes of test substances were added (n=3): 500μl PRP; 375μl PRP + 125μl autologous thrombin (3:1); 455μl PRP + 45μl bovine thrombin (10:1). One ml of DMEM/F12 medium was added to each scaffold and changed completely at 12/24 hours, and 3/10 days, following which release of TGF-β1, PDGF-AB and bFGF were measured using ELISA. Secondly, equal sized collagen/glycosaminogly-can and polylactide co-glycolide scaffolds were fashioned to which 500μl of PRP were added (n=3). Similar conditions were followed as previously except that only PDGF-AB was assayed.

Results: A similar cumulative release profile of all growth factors was found over the 10 day period. An increase in growth factor release was seen in the PRP only group at all time points with PDGF-AB in particular reaching statistical significance at all time points (p< 0.006). These findings remained apparent when a correction for volume was made (p< 0.028) suggesting a particular role of the collagen in platelet activation. This was shown in the second experiment, in which a significantly increased cumulative volume of PDGF-AB was released from the collagen/glycosaminoglycan scaffold without thrombin activation (p< 0.04).

Discussion: This study shows that collagen is a potent activator of platelets, requiring no further additive to achieve satisfactory growth factor release when applied clinically. These results suggest that if PRP is combined with polymer scaffolds, it should be activated with thrombin to achieve optimum growth factor release.


R. Rout S.M. Mcdonnell S. Snelling X. Xia N. Bottomley P. Hulley A.J. Price

Introduction: Anteromedial gonarthrosis (AMG) is a distinct phenotype of osteoarthritis (OA), with a specific pattern of disease. There is full thickness cartilage loss anteromedially, progressing to an area of damaged cartilage, and then to an area of macroscopically and histologically normal cartilage posteriorly. It can be considered to be a spatial model of OA progression. Apoptosis, or chondrocyte cell death, has been shown to be a feature of OA cartilage, however the triggers are poorly understood; similarly, reactive oxygen species (ROS) have been implicated in OA. They have never been studied in a replicable topographical model of OA. This study characterises the regional levels of cell death and implicated ROS in AMG using a number of immunohistochemical studies.

Method: Ten tibial resection specimens were obtained from patients undergoing unicompartmental knee arthroplasty. Eight above knee amputations (from patients with peripheral vascular disease) were used as age matched controls. Cross sections taken through all regions were paraffin embedded. Routine histology was performed and immunohistochemical studies were conducted for Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL), Active Caspase 3, Cytochrome C, Active Bax, Bim, 3-Nitrotyrosine and Forkhead Box O3A (FOXO 3A).

Results: Cell death, as detected by TUNEL appeared predominantly in the surface layer of chondrocytes of damaged cartilage (p< 0.001). Median values were 23% in superficial cartilage (range 0 – 51) compared to 0% in deeper cartilage (range 0 – 15). There was a significant difference in TUNEL staining between regions (p=0.001). This ranged from 26% (most damaged) to 4% (undamaged). There was a good correlation with degree of cartilage damage (ρ=0.66, p< 0.001) asdefined by histological grade and TUNEL was significantly higher (p< 0.001) in AMG compared to the control samples which showed an average of 2% TUNEL overall. Upstream markers of apoptosis (Active Caspase 3, Cytochrome C, Active Bax), assessed qualitatively, were present in a similar distribution to that of TUNEL staining. 3-Nitrotyrosine was also shown to be a predominantly surface phenomenon. There was a significant difference (p< 0.001) between regions, ranging from 58% (most damaged) to 10% (undamaged). Again, this was significantly higher that the control samples (p< 0.001). In line with indicators of ROS mediated damage, Bim and FOXO3A were also detected.

Discussion: The mechanism of apoptosis in OA cartilage has not been studied in depth, and understanding the biochemical and molecular responses of ‘stressed’ chondrocytes may provide invaluable information about the specific causes of cell death. Such cellular responses may provide targets for disease modification, thus delaying or preventing the need for joint arthroplasty. We conclude that AMG is a phenotype demonstrating cartilage at progressive stages of disease. Apoptosis involves the intrinsic mitochondrial pathway and ROS appear to be implicated. Further work is needed to provide evidence of what lies further upstream of markers demonstrated in this study.


U. Ahmed N. Rabbani M.L. Costa R. Watts P.J. Thornalley

Background: Osteoarthritis (OA) is a progressive degenerative condition that causes pain and impairs the mobility of more than 10% of the UK population. Over 50,000 total knee replacements (TKR) are carried out each year for patients with the most severe symptoms. The aim of this study was to assess if markers of protein damage in the synovial fluid and plasma of patients with OA increase with severity of symptoms. These markers may then be of use in assessing disease presence and progression to assist with subsequent management. Proteins damaged by glycation (modified by sugars) and oxidation undergo cellular proteolysis. The proteolytic debris thereby formed - called glycation and oxidation free adducts (glycated and oxidised amino acids) - is released into the synovium and plasma for urinary excretion. In this study the concentrations of the glycation free adducts, Nε-carboxymethyl-lysine (CML) and methylglyoxal-derived hydroimidazolone (MG-H1), and the oxidation free adduct methionine sulfoxide (MetSO) were measured in the synovial fluid and plasma of patients with severe OA (sOA) and early-stage OA (eOA).

Methods: Patients were recruited from those attending the Rheumatology clinics at Ipswich Hospital, Ipswich and the Orthopaedic clinics at University Hospital, Coventry. Volunteer subjects were recruited to the normal healthy control group. The age (years; mean ± SD) for patient and control subject groups was: controls 45 ± 6 (n = 8), sOA 70 ± 12 (n = 8), eOA 50 ± 14 (n = 6). Patients found to have eOA changes (Outerbridge grade I/II) during routine arthroscopy were recruited to the eOA group. Synovial fluid and venous blood samples were taken with informed consent. All synovial fluid samples were taken from the knee joint. The concentrations of glycation and oxidation free adducts were assayed by stable isotopic dilution analysis liquid chromatography with tandem mass spectrometric detection (LC-MS/MS) in ultrafiltrate of synovial fluid and plasma. Significance of difference between study groups was assessed by ANOVA and Student’s t-test.

Results: The concentrations (nM; mean ± SD) of MetSO, CML and MG-H1 in synovial fluid were all markedly increased in OA patients with more severe disease. MetSO free adduct: eOA 459 ± 107 and sOA 2889 ± 1064 (p< 0.001). CML free adduct: eOA 77 ± 24 and 224 ± 51 (p< 0.001). MG-H1 free adduct: eOA 387 ± 182 and sOA 674 ±199 (p< 0.05). Analysis of plasma of these patients also showed increases in the concentrations of corresponding glycation and oxidation free adducts compared to those of normal healthy controls.

Discussion: The concentration of glycation and oxidation free adducts increased with severity of symptoms in the synovial fluid of patients with OA. This probably occurs by down regulation of protective gene expression in OA. Measurement of plasma protein glycation and oxidation free adducts may be useful in assessing progression and severity of OA. In the future, these markers may guide non-operative management and facilitate earlier joint-preserving surgery.


A Getgood R Brooks A Lynn T Simon H Aberman N Rushton

Introduction: Current treatment options for small, contained articular cartilage defects include microfracture, osteochondral autograft plugs or newer synthetic plugs. Chondromimetic is a novel biphasic biological scaffold composed of collagen and glycosaminoglycan. The addition of brushite provides the scaffold with a regionally specific component mimicking both phases of the osteochondral unit. The aim of this study was to show the efficacy of Chondromimetic in repairing a surgically created osteochondral defect in a caprine model.

Methods: Osteochondral defects were made in the lateral trochlear sulcus (LTS) and medial femoral condyle (MFC) of nine goats. Chondromimetic scaffolds (6x6mm) were inserted into each defect (n=6), while three controls had defects left empty (n=3). All animals were sacrificed at 26 weeks postoperatively. Macroscopic evaluations and quantitative stiffness properties were assessed. Histological sections were taken at approximately the centre of the defect, stained with Safrinin O/Fast Green and scored using a validated quantitative assessment tool.

Results: Macroscopically, the repair tissue scored higher in the MFC and LTS (p< 0.05) compared to controls. In all defects, the mechanical stiffness was found to be within one standard deviation of native cartilage, except that of the LTS controls. Histologically, the predominant tissue in the cartilage layer was deemed to be hyaline-like in three of six MFC defects, and five of six LTS defects according to the modified Sellers score. This was compared to one in three and zero of three in the MFC and LTS controls respectively.

Discussion: These results represent the early findings from an ongoing in-vivo study in which a further group of animals will be sacrificed at one year. At six months, the histology and mechanical properties are encouraging and should continue to improve with time. These results show that Chondromimetic may represent an acceptable alternative to marrow stimulation in the treatment of osteochondral defects.


Ehab Kheir Thomas Stapleton David Shaw Zhongmin Jin Eileen Ingham John Fisher

Introduction: The aim of this study was to develop a technique to decellularise a porcine cartilagebone construct with a view to using this as a biological scaffold for transplantation into human osteochondral defect as a cartilage substitute.

Methods: Decellularisation was based on a modification of the technique of Booth et al (2002). Cartilage bone matrix (n=9) were decellularised by exposing the tissue to 2 cycles of dry freeze-thaw followed 2 more cycles with the addition of hypotonic (10mM tris-HCl, pH8.0) buffer. Samples were then cycled through hypotonic buffer, followed by ionic detergent (0.1% [w/v] sodium dodecyl sulphate [SDS]) in the presence of protease inhibitors (aprotinin 10 KIU/ml) and 0.1% (w/v) ethylene diamine tetraacetic acid (EDTA). This was followed by washes in PBS with aprotinin and incubation in nuclease solution containing DNase (50U/ml) and RNase (1U/ml). Decontamination using 0.1% (v/v) peracetic acid in PBS was then incorporated to achieve disinfection of the tissue samples. Finally, samples were washed in PBS. Three decellularisation protocols were used depending on the number of hypotonic/SDS cycles: this was either done once, three or six times referred to as DC1, DC3 and DC6 respectively. Fresh & decellularised cartilage were compared histologically using haematoxylin and eosin staining, to visualize cellular content, sirius red, to visualise collagen fibres & alcian blue, to visualise glycosaminoglycans (GAG). Immunohistochemistry staining for galactose-α-1,3-galactose (α-gal), collagen I, II & VI was performed for fresh and decellularised samples. DNA assay: Genomic DNA was extracted using a DNA isolation kit for tissues (Roche Applied Sciences). Collagen and DMB sulphated sugar assay, as described by Stapleton et al. (2008), were performed to measure collagen and GAG content. The biphasic property of fresh and decellularised cartilage was determined using a pin on plate indentation test.

Results: H& E staining revealed the absence of visible whole cells. Sirius red stain gave evidence of the retention of collagen following decellularisation. In contrast, the acellular matrix showed evidence of loss of GAGs. There was no evidence of the expression of α-gal in the acellular scaffold. DNA analysis revealed the absence of genomic DNA in comparison to fresh tissues (ANOVA, p< 0.05). The decellularisation process had minimal effect on the collagen content of the cartilage. Nevertheless there was a significant difference in the sulphated sugar content of the fresh tissue when compared to the decellularised tissue (ANOVA, p< 0.05), indicating loss of 92% GAG. Biomechanical testing of decellularised tissues showed a significant change (ANOVA, p< 0.05) in comparison to the fresh cartilage.

Discussion: In conclusion this study has generated data on the production of an acellular cartilage bone matrix scaffold for use in osteochondral defect repair. To our knowledge, this is the first study that has successfully removed whole cells and α-gal from xenogeneic cartilage and bone tissue. Future studies are required to investigate methods to recellularise the acellular matrix using an appropriate cell type and mechanical conditioning and to investigate replenishing GAG loss following decellularisation.


S. Saha* J. Kirkham D.J. Wood S. Curran X.B. Yang

Introduction: Articular cartilage has limited capacity for regeneration. Tissue engineering strategies offer future hope for cartilage replacement and repair. In an attempt to mimic functional native cartilage for tissue repair, current research focuses on construct/implant designs that simulate an embryonic like microenvironment to promote cellular differentiation along a chondrogenic lineage. The aim of the present study was, for the first time, to illustrate the differences between human neonatal and adult chondrocytes along with bone marrow stromal cells (HBMSCs) to differentiate the factors that promote chondrogenesis and maintain functional homeostasis.

Material and Methods: Adult chondrocytes, neonatal chondrocytes and HBMSCs were cultured in monolayers for 1, 2 and 3 weeks in basal or chondrogenic media. Expression of transcription factor Sox9, Aggrecan (ACAN) and Collagen type II (COL2A)was compared via real time polymerase chain reaction (q-PCR). Alternatively, cells were seeded onto 3D PLGA scaffolds and cultured in vitro for 3 and 6 weeks in basal or chondrogenic media. Paraffin sections of the constructs were stained with Alcian blue/ Sirius red and expression of Collagen type II and Aggrecan was visualised via immunohistochemistry.

Results: For monolayer cultures of all three cell types, at week 1, expression of all three genes was down regulated in basal medium compared to levels in chondrogenic medium. By week 2, q-PCR revealed an increased expression of Col2A in chondroinduced neonatal chondrocytes compared to adult chondrocytes and HBMSCs. A steady increase in SOX9 expression was observed with time in all three cell types in chondrogenic medium. However, SOX9 expression in week 2 was higher for each cell type in basal medium compared with chondrogenic medium. ACAN expression by HBMSCs was greatly enhanced compared with that of neonatal and adult chondrocytes after 2 weeks in chondrogenic medium. By week 3, basal cultures of all cell types showed an overall lower level of gene expression compared with chondroinduced cells. 3D constructs revealed the formation of cartilage like tissue for all three cell types with the presence of a prominent superficial layer and middle zone in the chondroinduced constructs. A superficial layer was also observed in constructs cultured in basal media but there was no evidence of any other characteristic zones. A fibrous capsule had formed around the chondroinduced tissue by week 6. Thinnest capsules were observed for constructs seeded with neonatal cells, with thickest capsules in constructs seeded with HBMSCs. Immunohistochemistry revealed a greater presence of aggrecan and type II collagen in the chondroinduced constructs compared to those cultures in basal media.

Conclusion: This comparative study indicates a major difference between the microenvironment of human neonatal chondrocytes, adult chondrocytes and HBMSCs. The expression of high amounts of COL2A and ACAN (considered to be middle to late markers in chondrogenesis) in week 1 in neonatal chondrocytes indicates a difference in temporal gene expression during chondrogenesis or in maintaining cartilage homeostasis. The study provides potentially useful information to inform cell-based therapies for cartilage regeneration.


W.S.A. Khan S.R. Tew A.B. Adesida J.G. Andrew T.E. Hardingham

Bone marrow derived mesenchymal stem cells are a potential source of cells for the repair of articular cartilage defects. Hypoxia has been shown to improve chondrogenesis in adult stem cells. In this study we characterised bone marrow derived stem cells and investigated the effects of hypoxia on gene expression changes and chondrogenesis.

Adherent colony forming cells were isolated and cultured from the stromal component of bone marrow. The cells at passage 2 were characterised for stem cell surface epitopes, and then cultured as cell aggregates in chondrogenic medium under normoxic (20% oxygen) or hypoxic (5% oxygen) conditions for 14 days. Gene expression analysis, glycosoaminoglycan and DNA assays, and immunohistochemical staining were determined to assess chondrogenesis.

Bone marrow derived adherent colony forming cells stained strongly for markers of adult mesenchymal stem cells including CD44, CD90 and CD105, and they were negative for the haematopoietic cell marker CD34 and for the neural and myogenic cell marker CD56. Interestingly, a high number of cells were also positive for the pericyte marker 3G5. Cell aggregates showed a chondrogenic response and in lowered oxygen there was increased matrix accumulation of proteoglycan, but less cell proliferation, which resulted in 3.2-fold more glycosoaminoglycan per DNA after 14 days of culture. In hypoxia there was increased expression of key transcription factor SOX6, and the expression of collagens II and XI, and aggrecan was also increased.

Pericytes are a candidate stem cell in many tissue and our results show that bone marrow derived mesenchymal stem cells express the pericyte marker 3G5. The response to chondrogenic culture in these cells was enhanced by lowered oxygen tension, which up-regulated SOX6 and increased the synthesis and assembly of matrix during chondrogenesis. This has important implications for tissue engineering applications of bone marrow derived stem cells.


Siyuan Li Clare Hughes James Melrose Susan M. Smith Christopher B. Little Bruce Caterson Anthony J. Hayes

Introduction: In a previous study (Hayes et al., 2007)we reported that novel chondroitin sulphate (CS) sulphation motifs on cell-associated proteoglycans (PGs) may be putative biomarkers of progenitor/stem cell sub-populations resident within the superficial zone of articular cartilage (Dowthwaite et al., 2005). In this study, using the same panel of antibodies, we examine the distribution of novel CS sulphation epitopes in a more clinically relevant model – the developing human knee joint.

Methods: Twelve-14 week human foetal knee joint rudiments were processed into paraffin wax then de-waxed and immunoperoxidase-stained with mAbs 3B3(−), 7D4 and 4C3 using the Vector Universal Elite kit with Nova Red, Mayers Haematoxylin, mounted under coverslips and then photographed.

Results: All three CS sulphation motif epitopes localised prominently at sites of incipient articular cartilage formation at a stage before there was any histological evidence of secondary ossification at the epiphysis. Interestingly, these CS epitopes were also detectable in very defined regions within the perichondrium; growth plate; the fibrocartilage of both meniscus and enthesis; vasculature; and at sites of capillary invasion, with subtle differences in their distribution; for example, 3B3(−) identified the cellular lining of cartilage canals within the epiphyses, whereas 7D4 labelled more their cellular contents.

Discussion: The results of this study show that novel CS sulphation motifs on cell and matrix PGs play important and diverse roles in the development of a wide range of musculoskeletal connective tissues, including articular cartilage. We hypothesize that the unique sulphation sequences on CS-containing PGs are involved in regulating cell proliferation and differentiation events, through interaction with soluble signalling molecules (e.g. growth factors) in the extracellular milieu. These antibodies show considerable promise for uses in tissue engineering applications for identifying and sorting stem/progenitor cells for regeneration of musculoskeletal tissues.


S. Tarsuslugil C. Hanlon R. O’Hara N. Dunne F. Buchanan J. Orr D. Barton R. Wilcox

Introduction: Computational modelling of the spine offers a particularly difficult challenge to analysts due to its complex structure and high level of functionality. Previous studies [Wijayathunga, 2008; Jones, 2007] have shown that finite element (FE) predictions of vertebral stiffness are highly sensitive to the applied boundary conditions and therefore validation requires careful matching between the experimental and simulated situation. The aim of this study was to develop and experimentally validate specimen specific FE models of porcine vertebrae in order to accurately predict the stiffness of single vertebra specimens.

METHOD: Nine single vertebra specimens were excised from the thoracolumbar region of two porcine spines. The specimens were mounted between two parallel PMMA housings and each specimen was imaged using a micro computed tomography (μCT) system (μCT80; Scanco Medical, Switzerland). In order to accurately match the experimental conditions, a radio-opaque marker was positioned on the specimen housing at the point of load application. The vertebrae were separated into two groups: a development set (set 1) consisting of three specimens and a validation set (set 2) of six specimens. Specimens from set 1 were used to establish the optimum method of conversion from image greyscale, to element material properties. The models in set 2 were used to assess the accuracy of the stiffness predictions for each model. The vertebrae were tested in a materials testing machine (AGS-10kNG; Shimadzu Corp., Japan) under axial compression and the stiffness for each specimen was calculated. The μCT data was imported into an image processing package (Scan IP, Simpleware, UK). The software enabled the images to be segmented and the vertebra, cement housings and position of load application to be identified. The segmented images were down-sampled to 1mm voxels, enabling a FE mesh to be generated (Scan FE; Simpleware, UK) based on direct voxel to element conversion. The Young’s modulus of each bone element was assigned, based on the greyscale of the corresponding image voxel. The PMMA housing plates were assigned homogeneous material properties (E = 2.45 GPa). Abaqus CAE 6.8 (Simula, Providence, Rhode Island, USA) was used for the processing and post-processing of all the models.

Results: The mean experimental stiffness was 4321 N/ mm (standard deviation = 415 N/mm). The optimum conversion factor was calculated for set 1, which yielded a root mean squared (RMS) percentage error of 7.5% when compared with the experimental stiffness. Using this optimised scale factor, FE models of specimens from set 2 were created. The predicted stiffnesses for set 2 were compared to the corresponding experimental values and yielded an RMS error of 10.1%.

Conclusion: The results indicate that specimen specific models can provide good agreement with the corresponding experimental specimen stiffness. In addition, the method employed in this study proved robust enough to be applied to vertebral tissue obtained from different animals of the same species. This method will now be developed to assess treatments for traumatic spinal injuries.


M. Glaysher H.I. Roach

Osteoarthritis (OA) is characterised by the progressive destruction of articular cartilage by matrix-degrading enzymes. Although initially produced by synovial fibroblasts, these enzymes are derived from OA chondrocytes as the disease progresses. Inflammatory cytokines (IL-1beta, TNF-alpha, oncostatin M) are known to induce the aberrant expression of the proteases and IL-1beta in vitro. We wanted to investigate whether the transcription factor NF-kB, which is frequently involved in signal transduction, is a mediator of the effects of inflammatory cytokines. Hence we determined the effects of NF-kB inhibition on the expression of IL-1beta, MMP-13 and MMP-3, which was induced in healthy chondrocytes by culturing with TNF-alpha/OsM.

Chondrocytes were isolated from the healthy cartilage of femoral heads obtained from patients after hemiarthroplasty following a femoral neck fracture (n=4). The chondrocytes from each patient were divided into four experimental groups: untreated control culture; culture with TNF-alpha/OsM; culture with TNF-alpha/OsM in presence of an NF-kB inhibitor; and culture with TNF-alpha/OsM treated + control peptide. Two inhibitors of NF-kB nuclear translocation were employed: an NF-kB p65 (ser276) inhibitory peptide (Imgenex) and (E)-2-Fluoro-4′-methoxystilbene, an analogue of resveratol (Merck). Cells were grown in monolayer culture for two weeks and received two rounds of treatment. Once confluent, cells were harvested and total RNA was extracted, using a Qiagen kit. RNA was reverse transcribed into cDNA and the expression of IL-1beta, MMP-3 and MMP-13 was analysed by conventional RT-PCR.

No expression of IL-1beta was found in control cultures but expression was induced, as expected, following treatment with TNF-alpha/OsM. Presence of the NF-kB inhibitor reduced IL-1beta expression, but did not abolish it completely, as suggested by reduced intensity of the PCR band. This was seen in all four samples. Similarly, NF-kB inhibition attenuated MMP-13 expression in three patients, but in one patient MMP-13 was already expressed in control cultures and no change was observed in the treated groups. MMP-3 was uniformly expressed across all experimental groups and was unaffected by NF-kB inhibition.

NF-kB is the generic name for a family of transcription factors, of which the p65-p50 heterodimer is the most prevalent. NF-kB is normally sequestered within the cytoplasm in an inactive form by binding to inhibitory kB (IkB) proteins. Activation involves degradation of IkB and nuclear translocation of NF-kB. The present results show that the cytokine-induced expression of IL-1beta and MMP-13 in healthy chondrocytes involves nuclear translocation of NF-kB.


N. KALSON Z. KAPACEE D.F. HOLMES S. AL-YOUHA F. CONTI-RAMSDEN Y. LU K.E. KADLER

Embryonic chick tenocytes cultured in fixed-length three-dimensional fibrin gels synthesise a taught collagen fibril-rich extracellular matrix that closely resembles embryonic tendon (Kapacee et al., Matrix Biology, 27: 371–375, 2008). Importantly, the cells replace fibrin with parallel arrays of collagen fibrils that are able to resist pulling forces. Regenerative medicine strategies for musculoskeletal applications require the development of tissue with mechanical strength comparable to that of native tissues. How the cells generate tension is not understood and the mechanical properties and the cellular behaviour of this culture system have not been described. This project aimed to describe the morphology of cells in the tendon-like constructs and to quantitate the mechanical properties of the constructs.

Multiphoton imaging (MPI) can image deep into objects with reduced phototoxicity, allowing live-cell applications. MPI of the tendon constructs revealed that cells under tension were aligned longitudinally with the matrix. However, when tension was released the cells became rounded. The results suggested that embryonic tendon cells align along lines of force. Mechanical testing of newly-formed tendon constructs (T0), then at weekly intervals to six weeks (T7 to T42) was performed using an INSTRON® failure-testing machine. An initial increase in ultimate tensile strength (UTS) was seen from T0 to T7 (1.023±0.031N to 1.150±1.150N, p=0.006), followed by a gradual decline at T35 to 0.350±0.043N, after which there was no further decrease. The UTS of the constructs was comparable with embryonic day 14 chick tendon. The initial increase in strength between T0 and T7 was cell dependent; constructs immersed in Triton-X 100 to remove cells were weaker than cellular constructs (1.277±0.096 versus 0.508±0.099, p< 0.001). Stress-strain plots demonstrated toe, heel, linear and failure regions that are classically observed in tendon.

The results show that embryonic tendon cells synthesise an extracellular matrix of collagen fibrils that are tensioned by the cells, and that the tendon constructs have mechanical strength comparable to in vivo generated tissue.

The research is generously supported by grants from The Wellcome Trust.


N.J. Bottomley E.G. McNally S. Ostlere B.J.L. Kendrick D.W. Murray C.A.F. Dodd D.J. Beard A.J. Price

Introduction: This study explores whether modern magnetic resonance imaging (MRI) with improved cartilage sequencing is able to show a more detailed view of antero-medial osteoarthritis of the knee (AMOA) than previously, so enabling a radiographic description of this common phenotype of disease. Modern MRI technology allows us to visualize in great detail the structures and cartilage within the knee, providing a better understanding of the pathoanatomy of AMOA. This description of the end stage of disease is useful as a baseline when investigating the progression of arthritis through the knee. Preoperative assessment of patients and selection of intervention is very important and preoperative imaging forms an integral part of this. This will also be useful in preoperative assessment and surgical management of patients.

Methods: 50 patients with a radiographic diagnosis of anteromedial osteoarthritis of the knee and had been listed for unicompartmental knee arthroplasty (UKA) had MRI as part of their pre-op workup. At operation all were deemed suitable for UKA using the current Oxford indications. The image sequences were coronal, axial and sagittal with a predetermined cartilage protocol. The state of the ACL, cartilage wear degree and location, presence and pattern of osteophytes, meniscal anatomy and subchondral high signal were assessed.

Results: All the ACLs were visualized and in continuity, however 40% showed intrasubstance high signal. 100% of medial compartments showed full thickness anteromedial loss with preservation of the posteromedial cartilage. When present, the meniscus was extruded in 75% of cases.

90% of lateral compartments were normal and none had full thickness cartilage loss. However 10% showed high signal in the tibial plateau. There was a highly reproducible pattern of osteophyte formation; 94% posteromedial and posterolateral aspect of medial femoral condyle; 90% medial tibial; 80% medial femoral and 84% lateral intercondylar notch.

Discussion: This study maps the pattern of anteromedial osteoarthritis using modern MRI techniques. This creates a baseline description of disease which is useful when investigating disease progression. This also has importance in determining preoperative indications (preservation of ACL and posteromedial cartilage); surgical technique (determine pattern of osteophytes requiring resection) and potentially important for long-term outcome (early lateral compartment changes).


AC Gray PJ Duffy JN Powell S Belenke C Meek J Mitchell

Aims: There are concerns over the physiological effects of intramedullary femoral fracture stabilisation in patients with pulmonary injury. This large animal study used invasive monitoring to obtain sensitive cardiopulmonary measurements and compared the responses of ‘Early Total Care’ (intramedullary fracture fixation) and ‘Damage Control’ (external fixation), after the induction of lung injury.

Methods: Acute lung injury (PaO2/FiO2 < 200 mmHg) was induced in 12 invasively monitored and terminally anaesthetised sheep via oleic acid infusion into the right atrium. Each animal underwent surgical femoral osteotomy and fixation with either reamed intramedullary (n=6) or external fixation (n=6). Haemodynamic and arterial blood-gas measurements were recorded at baseline, 5, 30 and 60 minutes after fracture stabilisation.

Results: The mean (+/− S.E.) PaO2/FiO2 fell significantly (p< 0.05) from 401 (+/− 39) to 103 (+/− 35) and 425 (+/− 27) to 122 (+/− 21) in the externally fixated and intramedullary nailed groups respectively after acute lung injury. The further combined effect of surgical osteotomy and fracture fixation produced a mean (+/− S.E.) PaO2/FiO2 of 98 (+/− 21) and 114 (+/− 18), in the externally fixated and intramedullary nailed groups immediately after surgery. This was not significantly different within or between groups. Similarly the pulmonary vascular resistance (PVR) measured at 5.8 (+/− 0.8) and 4.8 (+/− 0.7) after lung injury in the externally fixated and intramedullary nailed groups changed to 5.7 (+/− 0.5) and 4.0 (+/− 0.7) after surgical osteotomy and fracture fixation (no significant difference within or between groups). The PaO2/FiO2 or PVR was not significantly different at the monitored 5, 30 and 60 minute intervals after fracture stabilisation.

Conclusion: Against a background of standardised acute lung injury, there was no further deterioration produced by the method of isolated femoral fracture fixation in sensitive physiological parameters commonly used during intensive care monitoring.


Yan Wang Ming Ni Pei-Fu Tang Gang Li

Introduction: This study tested the hypothesis that the use of biomaterials in distraction osteogenesis (DO) would reduce the treatment time and enhance bone formation in bone defect management.

Methods: A 1.0cm tibial shaft was removed in the left tibia of 36 rabbits. Rabbits were divided into three groups: Group A, the defect gap was reduced with the tibia shortened for 1.0-cm; Group B, the defect gap was filled with 1.0-cm porous hydroxyapatite/tri-calcium phosphates cylindrical block (HA/TCP block, diameter 0.5-cm); Group C, The 1.0-cm defect gap was reduced 0.5cm and the remaining 0.5-cm defect gap was filled with 0.5-cm HA/TCP block. The tibia was then fixed with unilateral lengthener; for groups A and C, lengthening started 7 days after surgery at a rate of 1.0 mm/day, in two steps. Group A received lengthening for 10 days and Group C for 5 days, there was no lengthening for Group B. All animals were terminated at day 37 following surgery. The excised bone specimens were subject to micro-CT, mechanical testing and histological examinations.

Results: Bone mineral density and content and tissue mineral density and content, as well as the mechanical properties of the regenerates were significantly higher in Group C compared to Groups A and B. Micro CT and histological examinations also confirmed that the regenerates in Group C had most advanced bone formation, consolidation and remodeling compared to other groups.

Conclusion: The combined use of biomaterials and DO technique can reduce the treatment time and enhance bone consolidation in bone defect management.


A. Dawoodi S. L. Evans

Introduction: Acrylic bone cement (ABC) manufacturers vary their products by using different proportions of the principle ingredients to optimise handling time or mechanical properties. Surprisingly, there is limited research showing the effect of varying monomer/polymer and initiator/activator ratios (independent from other constituents) on thermal and mechanical properties of ABC.

Materials and Methods: The formula for CMW (DePuy) was reproduced using original ingredients obtained from different suppliers. The commercially available CMW monomer/polymer ratio is approximately (0.6 ml/gm). Six variants of CMW bone cement were prepared by varying the monomer/polymer ratio (0.4–1 ml/gm) and eight variants were prepared by varying the initiator/activator BPO/DMPT ratio (1.71–11.25). Specimens were stored in an incubator for 7 days at 37 °C. Thermal characteristics of the polymerisation reaction such as maximum polymerisation reaction temperature (Tmax) and setting time (Ts) were recorded using a thermocouple and Picolog digital data recorder. Compressive mechanical properties were measured using Zwick Roell All Round Testing System implementing ISO5833 recommendations. SPSS software was used to perform ANOVA and calculate Pearson correlation coefficient.

Results: Increasing monomer/polymer ratio resulted in prolongation of setting time (5.3–11.3 minutes) displaying a significant (p= 0.000) correlation (r=0.988); however, there was no significant correlation with Tmax (r=−0.123, p=0.792). Increasing the monomer/polymer ratio resulted in a significant reduction in yielding compressive strength (F=110.97, p=0.000) and modulus (F=16.1, p=0.000). Pearson correlation test showed that monomer/polymer ratio had a significant correlation with yielding compressive strength (r= −0.930, p=0.002) and a significant correlation with the corresponding modulus of elasticity (r= −0.827, p=0.022). An increase in the BPO/DMPT ratio did not display a significant (p= 0.172) correlation (r=−0.535) with Tmax; however, the setting time was prolonged by increasing the BPO/ DMPT ratio with a significant (p=0.002) strong positive correlation (r=0.903). Compression tests showed a significant (F=13.45, p=0.000) reduction in yielding compressive strength with a significant (p=0.04) inverse (r=−0.729) correlation with the BPO/DMPT ratio. Modulus of elasticity followed a similar pattern to a lesser degree displaying a significant (F=5.123, p=0.001) reduction in values which was moderately correlated (r=−0.619), though insignificant (p= 0.101) with BPO/ DMPT ratio.

Discussion and Conclusions: Varying the monomer/ polymer ratio independently from other constituents in acrylic bone cement significantly affects setting time and compressive mechanical properties. Setting time can be prolonged to increase handling time; however this will occur at the expense of a reduction in compressive stiffness and strength. Similarly, varying the BPO/DMPT ratio may result in optimised handling time; however, this will also cause a reduction in compressive strength and stiffness. These finding are paramount in clinical applications where compressive strength is essential e.g. percutaneous vertebroplasty.


L. Richards C.L. Bladen J. Fisher E. Ingham J.L. Tipper

Introduction: Nanometre sized UHMWPE particles have recently been isolated from periprosthetic tissues and hip simulator lubricants [1,2]. The biological response to UHMWPE particles of 0.1 μm and above has been well characterised, with particles in the 0.1–1.0 μm size range having the highest biological activity [3]. The purpose of the study was to determine the biological activity of nanometre-sized particles in terms of osteolytic cytokine release from primary human monocytes.

Methods: Monocytes were isolated from peripheral blood from 5 healthy donors by density gradient centrifugation over Lymphoprep. Cells were cultured using the agarose gel technique [3] at particle volume (μm3):cell number ratios of 10:1 and 100:1. The particles used were:

1 Polystyrene FITC-conjugated FluoSpheres (FS; Invitrogen) in 20 nm, 40 nm, 0.2 μm and 1.0 μm sizes.

2a Complete Ceridust® 3615 (CD), a low MW polyethylene powder (size range 15 nm – 53 μm).

2b Nanometresized Ceridust® (fractionated by filtration using 10, 1, 0.1, 0.05 & 0.015 μm filters).

3 Clinically relevant GUR 1120 UHMWPE debris produced aseptically using a multidirectional wear rig.

All particles were tested for the presence of endotoxin prior to culture with cells. Cells without particles were used as a negative control and 200 ng/ml LPS was used as a positive control. Cell viability was assessed using the ATP Lite assay (Perkin Elmer) and ELISA was used to determine TNF-alpha, IL-1beta, IL-6 and IL-8 release at 3, 6, 12 and 24 h.

Results: FluoSpheres and CD had no effect on cell viability at 10 or 100:1. Clinically relevant UHMWPE particles had no effect on cell viability at 10:1, however, at 100:1 significant differences (P< 0.05) were seen at 3, 12 and 24 h for Donors 1 and 3. The 40 nm, 0.2μm and 1.0 μm FS caused significant elevation of TNF-α release at the 12 and 24 h time points at 100:1. There was no significant increase in TNF-α release for the 20 nm FS (3/5 donors). Particle volume and particle size showed correlation with cellular response, with the 20 nm FS showing the lowest biological activity. Clinically relevant UHMWPE particles and nanometre sized CD produced significantly higher quantities of TNF-alpha at 100:1. Release of interleukins IL-1beta, IL-6 and IL-8 followed a similar trend to TNF-alpha release.

Discussion: This study found that all nanometre-sized particles had the potential to provoke inflammatory cytokine release from macrophages. Particle volume and particle size played critical roles in initiating cellular responses. There was a lower particle size limit, with the 20 nm FS showing the lowest activity. Nanometre-sized polyethylene particles (CD) caused elevated TNF-α release, and since it has been shown that nanometre-sized UHMWPE particles are produced in large numbers in vivo [2], the relative contribution of these particles to osteolysis should be considered. The biological response to nanometre-sized clinically relevant UHMWPE particles is currently under investigation.


S. Teramura S. Russell C.L. Bladen J. Fisher E. Ingam N. Tomita J.L. Tipper

Introduction: UHMWPE wear particles induce osteolysis and loosening of total joint replacements. Much effort has been directed at reducing the wear volume of UHMWPE, such as crosslinking treatments [1]. Recently, interest in UHMWPE with vitamin E (VE) has increased due to its improved wear resistance in knee prostheses [2], as well as improved mechanical properties. The aim of this study was to culture human peripheral blood mononuclear cells (PBMNCs) with known volumes of clinically relevant wear debris from UHMWPE with and without VE in order to quantify and compare their respective biological activities.

Methods: For UHMWPE with VE, GUR1050 UHMWPE powder was mixed with VE at 0.3% (w/w) and 3% (w/w) using a screw cone mixer. The wear rates were evaluated using a six-station multidirectional pin on plate wear simulator against a smooth CoCr plate (Ra 0.01–0.03 micrometres), in 25% bovine serum, under a load of 160N and a frequency of 1 Hz. Endotoxin-free clinically relevant wear debris was generated aseptically for cell culture studies, using a single-station multidirectional pin on plate wear rig housed in a class II safety cabinet. PBMNCs were isolated from blood collected from three healthy donors then cultured with debris at particle volume (μm3) to cell number ratios of 100:1 using the agarose gel technique [3]. Cells without particles were used as the negative control, and LPS at 200 ng/ml was the positive control. Cell viability was assessed by ATP-Lite assay, and TNF-alpha, interleukin (IL)-1beta, IL-6 and IL-8 were measured by ELISA at 12 and 24 h.

Results: The 3% VE UHMWPE was found to have a higher wear rate than both the Virgin and the 0.3% VE UHMWPE, although there were no significant differences. Particle size and volume distributions were similar for all materials, with the mode of the frequency distributions being in the 0.1–1 micron size range. Cell viability was not adversely affected by any of the treatments. Cells cultured with virgin UHMWPE debris secreted significantly higher quantities (P< 0.05) of TNF-alpha compared to debris from both the 0.3% and the 3% VE UHMWPE, which released comparable levels of TNF-alpha to the cell only control group. The results for the other cytokines, IL-1beta, IL-6 and IL-8, and for the two additional donors showed similar trends as the results for TNF-alpha.

Discussion: The biological response to wear particles is strongly influenced by particle size and volume [3]. Cells cultured with wear debris of UHMWPE containing VE released very low levels of cytokines in comparison with virgin UHMWPE, even there were no significant differences in particle size. Differences in the chemical composition of the particles or different rates of protein adsorption may explain these differences. VE has anti-inflammatory properties, which may act by free radical scavenging. VE has been shown to reduce production of reactive oxygen species and pro-inflammatory cytokines such as TNF-alpha and IL-1beta from monocytes [4]. The anti-inflammatory effects of UHMWPE particles containing VE are currently being investigated.


T Warrener P El-Dalil A Abudu MDe Souza

Introduction: Limb preserving surgery in children with bone sarcoma remains a significant challenge as most are expected to survive their disease and put significant functional loads on their reconstructed limbs. The most common reconstructions used for children with lower limb sarcomas are endoprosthetic replacements and rotationplasty. This study aimed to investigate and compare differences in the complications and functional outcomes between these two methods of reconstruction.

Methods: This is a retrospective case control study of 12 rotationplasty patients and 12 patients who received EPR. Patients were selected at random from records provided by both centres and matched according to age at diagnosis, sex, site of disease and date of surgery. The Musculoskeletal Tumour Society (MSTS) score was used to evaluate functional outcome, and surgical complications were assessed qualitatively.

Results: Five patients (42%) treated with endoprostheses experienced some form of post-operative surgical complication compared to three patients (25%) treated with rotationplasty and one patient from each group required an amputation to treat the complications. The average MSTS score was 22.7 in the EPR cohort and 18.9 in rotationplasty patients. This difference was statistically significant (p=0.05).

Discussion: The study showed that patients who received EPR suffered more surgical complications than rotationplasty patients. However the results demonstrated superior functional outcomes in patients who received EPR.

These results suggest that the functional benefit historically attributed to rotationplasty has been negated by modern endoprostheses, probably due to improvements in surgical experience and prosthesis technology.

Conclusion: Our experience shows that patients with EPR are more likely to suffer more surgical complications but have similar, if not better functional outcomes compared to rotationplasty.


K Gokaraju J Miles G W Blunn R C Pollock J A M Skinner S R Cannon T W R Briggs

Introduction: Non-invasive expandable prostheses for limb salvage tumour surgery was first used in 2002 and has now been implanted in a series of 40 skeletally immature patients.

Method: Our review of these includes 24 distal femoral replacements, 5 proximal femoral replacements, 3 total femoral replacements and 8 proximal tibial replacements. These were used to treat 31 osteosarcomas, 7 Ewing’s sarcomas, 1 chondrosarcoma and 1 aneurysmal bone cyst. Patients had a mean age of 11.7 years (7–16). Follow-up extended to 88 months with a mean of 26.3 months.

Results: There has been 1 failure of the prosthesis gearbox which required revision surgery. 4 of the prostheses reached their maximum length and were successfully re-operated to exchange components of the prosthesis and resume lengthening. 3 patients had disseminated meta-static disease (1 being present before primary surgery) and another developed infection of the prosthesis that required an above-knee amputation. There have been 233 lengthenings overall with 1 patient requiring reversal on one occasion due to intractable pain; this pain rescinded 30 minutes after lengthening was reduced by 10mm. Otherwise lengthening was well tolerated despite the significant growth of the limbs: mean 21.2mm (0.5–84mm). At latest follow-up the mean Musculoskeletal Tumour Society score was 75% (26–93%).

Discussion: The results achieved are equivalent to our series of minimally invasive growers which require repeated surgery. Our non-invasive growing prostheses remain reliable and negate the need for recurrent operations, thus resulting in low infection rates. Our results remain encouraging up to 7 years after first use, maintaining leg-length equality and function.


M T R Parratt J Miles K Gokaraju B G I Spiegelberg R C Pollock J A Skinner S R Cannon T W R Briggs G W Blunn

Introduction: Intramedullary cementless fixation of massive tumor prostheses was developed to combat the high incidence of aseptic loosening in a young population of tumor patients. Its use has also expanded to include reconstruction of failed major knee arthroplasty. Our system uses a hydroxyapatite coated titanium stem in conjunction with a hydroxyapatite collar to obtain fixation.

Methods: We present a series of 72 patients (34 females, 38 males) with a mean follow-up of six years (2 months – 14 years). The mean age at the time of surgery was 17 (5 – 77). Within this group, 51 patients had osteosarcomas, 10 had giant cell tumors, eight had Ewing’s sarcoma and one each had malignant fibrous histiocytoma, spindle cell sarcoma and failed total knee arthroplasty. Non-invasive and minimally invasive growing prostheses were used in 33 patients.

Results: Nine patients required revision of the prosthesis at a mean of 5.2 years; 5 for aseptic loosening and four for infection. Twelve patients died at a mean of 20 months (1 – 84) post-operatively. Radiological evidence demonstrated remodelling around both the stem and the collar. There was gap closure to the hydroxyapatite coated collar in cases where seating was not complete. Consistent loss of cortical bone around the mid-stem was noted in the first 12 months but remained stable beyond this time frame.

Discussion: This study highlights our experience with cementless distal femoral endosprostheses. We demonstrate good results with regard to revision rate, gap closure and osseointegration.


N E Fisher R J Grimer L Jeys A Abudu S Carter

Endoprosthetic replacement of the pelvis is one of the most challenging types of limb salvage surgery with a high rate of complications. In order to try and decrease the high risk of complications and to allow greater versatility in the reconstruction options, a new concept of pelvic endoprosthesis was developed in 2003. Since then 20 of these ice cream cone pelvic prostheses have been inserted at our centre incorporating antibiotic laden cement around the prosthesis to minimize infection risk.

Aim: To review the outcomes of the ice cream cone prostheses and to learn lessons from this.

Method: retrospective review of records and Xrays of patients having an ice cream cone type prosthesis at our centre.

Results: 20 ice cream cone prostheses were inserted in the past 5 years. Six of the implants were inserted following failure of a previous pelvic reconstruction (one for hydatid disease, one following a excision arthroplasty for chondrosarcoma, three following failed pelvic EPRs). Of the primary tumours, there were 9 chondrosarcomas, 2 Ewings, one each of osteosarcoma, epithelioid sarcoma and GCT. All of the patients had at the least had a P2+P3 resection with most having resection of the ilium above the sciatic notch. The average age of patients at operation was 50.5yrs [range 13–81yrs]. Ten patients (50%) had one or more complication following surgery, of which dislocation was the most common, affecting 5 patients (25%), of whom two have permanent dislocations. Four patients (20%) developed a deep infection of the prosthesis but all had this controlled with early intervention. Two patients (15%) developed a local recurrence, both at the time of widespread metastases. Only one patient has had the prosthesis removed, for severe pain. There were six deaths, four due to metastatic disease and two from cardiovascular complications. The complication was significantly lower for Surgeon A (who did 15 of the 20 procedures).

Conclusion: This method of treatment is still associated with high morbidity but early results are promising. Complications are much lower with increasing experience.


B Rose S Macmull S Heaton R Pollock J Skinner T Briggs S Cannon

Introduction: The aim of the study was to review the long-term survival and outcome of 49 consecutive endoprosthetic lower limb diaphyseal replacements undertaken for neoplastic conditions.

Methods: A retrospective review of all femoral and tibial diaphyseal replacements performed between 1990 and 2009 at our specialist bone and soft tissue tumour unit was performed. Minimum follow-up was one year. Joint sparing prostheses were excluded.

Results: 49 femoral (31) and tibial (18) diaphyseal replacements were implanted into 46 patients (31 male, 15 female). Mean age at surgery was 47 years (range 9–79). Surgery was performed for malignancy in 46 cases (97%), of which 41 (89%) were primary bone and soft tissue sarcomas. The predominant pathologies were osteosarcoma (24%), malignant fibrous histiocytoma (14%) and chondrosarcoma (14%). Mean follow-up was 81 months (range 12–221 months). Survival within the follow-up group was 96% at 1 year, 79% at 5 years, and 69% at 10 years. In surviving patients, using revision, recurrence and amputation as endpoints, prosthesis survival was 91% at 1 year, 58% at 5 years, and 33% at 10 years. In total, 13 prostheses underwent revision surgery and there were 3 amputations following diaphyseal replacement. Of these 16 cases, 75% were for aseptic loosening or prosthetic failure, 13% for tumour recurrence, and 13% for infection.

Discussion: Lower limb diaphyseal endoprosthetic replacements are a useful surgical treatment method for patients with malignant neoplastic diaphyseal bone lesions requiring excision and reconstruction. This is both limb salvage and joint-sparing reconstructive surgery.


R J Grimer S R Carter R M Tillman A Abudu L Jeys P Unwin

Aim: To investigate the effectiveness of silver coated titanium prostheses in preventing periprosthetic infection in a group of very high risk patients.

Methods: Periprosthetic infection is one of the main problems in limb salvage surgery, especially for tibial and pelvic prostheses or following revision surgery, particularly if it has been done for a previous infection. We have used silver coated prostheses in 21 cases on a named patient basis and have now assessed the results.

Results: Between July 2006 and June 2008 21 patients had a silver coated prosthesis inserted. 11 patients were having a second stage revision after a previous infection, 6 were having a pelvic prosthesis inserted, 3 were having a primary tibial replacement and one a one stage proximal tibial revision. Three patients developed a postoperative infection, two of the pelvic replacements and one infected revision (a total femur replacement). Of these only one patient required removal of the prosthesis (for overwhelming coliform infection in a pelvic replacement) whilst the other two infections both settled with antibiotics and washout.

Discussion: The anticipated risk of infection in this high risk group would have been around 20%. The actual infection rate was 14% but two of the infections completely resolved with relatively modest treatment. This suggests that the silver coating may not only have a role in preventing infection but also enhancing control of infection should it arise. There were no other side effects and we believe that these preliminary results are encouraging and should lead to a further evaluation of silver for preventing infection around prostheses.


F Sinnaeve R J Grimer S R Carter R M Tillman A Abudu L Jeys

Aim: To review our experience of managing patients with aneurysmal bone cysts (ABC)

Method: We reviewed the medical records and radiographs of all patienst with aneurismal bone cyst treated at our unit over a 25 year period. During that time the policy of the unit was to treat ABCs with biopsy/curettage without use of adjuvants or bone grafting. Patients were followed up with regular Xrays until healing had taken place. Local recurrences were again treated with curettage, occasionally supplemented with embolisation or bone grafting.

Results: 237 patients (128 female, 109 male), with a median age of 14 yrs (range 1 to 76) received treatment. The cyst size varied from 1 to 20 cm and the median duration of symptoms was 16 weeks (range 0 to 8 yrs). The most common sites were the tibia (55) followed by the femur (41) then the pelvis (29) and humerus (27). 35 (15%) of the patients presented with a pathological fracture. Primary treatment was by curettage alone in 195, curettage and bone grafting in 7, aspiration and injection of steroids or bone marrow in 7, excision in 5 and observation alone in 17. The rate of local recurrence requiring further surgery was 12% with all local recurrences (bar one) arising within 18 months. Local recurrence was not related to site, age, sex or whether the patient had previous treatment or not. Local recurrences were managed with curettage alone in 19 of the 23 cases, with one having embolisation, one excision and 2 curettage and bone grafting. This was successful in all but 3 cases who were controlled with a third procedure.

Conclusion: The local control rate of ABCs with simple curettage is 88% which is as good as those published for any other technique. We recommend biopsy in all cases and limited curettage at the same time, many ABCs will heal with this simple procedure. Full curettage is needed for those showing no signs of healing within 4 weeks. Local recurrence is very unusual after 18 months.


C L M H Gibbons F Jones R Taylor H Knowles P Hogendoorn J A H Wass M Balke P Picci C Gebert N A Athanasou

Introduction: Giant cell tumour of bone (GCTB) is an expansile osteolytic tumour of bone which contains numerous osteoclast-like giant cells. GCTB is a locally aggressive tumour which can cause extensive bone destruction that can be difficult to control surgically, up to 35% of cases recurring after simple curettage. Bisphosphonates are anti-resorptive agents that have proved effective in the treatment of a number of osteolytic conditions.

Methods: This study reports results from four European centres where bisphosphonates are being used to treat problematic GCTBs. Details of treatment with bisphosphonates of 25 cases of primary, recurrent and metastatic GCTBs was assessed clinically and radiologically.

Results: Most primary/recurrent tumours did not exhibit progressive enlargement and, in some cases, both primary and metastatic GCTBs showed a degree of radiological improvement following treatment. Some patients also noted relief of pain following treatment. In a few cases, no apparent treatment effect was noted and there was disease progression. Several inoperable large spinal/pelvic GCTBs remained stable in size following treatment.

Discussion: Our findings provide preliminary evidence for the use of bisphosphonates to inhibit the progressive osteolysis associated with GCTB. These agents had a beneficial clinical and/or radiological effect in most cases. This study reports results from four European centres and highlights the fact that these centres are all employing different clinical indications and different regimes of bisphosphonate treatment. Bisphosphonates have significant side effects and indications for treatment and standardisation of drug type and dosage regimes (and measurement of agreed outcome measures to determine treatment efficacy) should be established for the use of these agents to control GCTB tumour growth and osteolysis.


G S J Chuter T W Barwick S A Murray C H Gerrand

Introduction: The workload of a bone and soft tissue tumour (BSTT) multidisciplinary team (MDT) is varied. Only a proportion of the workload attracts specific funding from the National Commissioning Group (NCG) but many patients who do not have primary malignant bone tumours are also seen and treated. We analysed the workload of our supra-regional BSTT MDT to determine the variety of conditions seen, the proportion that does not attract specific funding and the expertise required to run the service.

Methods: A prospective database was used to identify all new patients discussed at our weekly BSTT MDT meetings between 2004 and 2008 inclusively. Patients were divided by diagnosis into eight categories and further identified as to whether or not they attracted funding under NCG regulations.

Results: 1743 new patients were identified of which 83 were excluded. Of the remaining 1660, 65% were non-sarcoma and 50% were benign. 31% of the malignant workload was non-sarcoma. Only 11% of patients were eligible for NCG funding. Of those requiring surgery, the orthopaedic team managed 93% of benign and 77% of malignant cases; general, plastic, or thoracic surgical teams managed the remainder.

Discussion: NCG funds the management of all malignant primary bone tumours and the investigation and/or treatment of other selected conditions; the majority of our workload does not qualify. Despite fluctuations in the total workload, the ratio of benign to malignant cases remains relatively constant. Considerable expertise across many different specialties is essential for an effective and efficient MDT.


B Rose G Tamvakopoulos K Dulay R Pollock A Flanagan J A Skinner T W R Briggs S R Cannon

Introduction: Low-grade fibromyxoid sarcoma (LGFMS) is a rare soft tissue neoplasm most commonly presenting in young to middle-aged adults. LGFMS is an indolent tumour with a deceptively benign histological appearance. Local recurrences are not uncommon and tumours can metastasise. The FUS-CREB3L2 gene translocation has been shown to occur commonly in cases of LGFMS. The literature suggests that the FUS-CREB3L2 fusion-gene is a specific marker for LGFMS.

Methods: We report the cytogenetic analysis of 29 LGFMS cases, and clinical outcomes of 21 patients treated surgically between 1998 and 2008 at our regional bone and soft-tissue tumour centre.

Results: The mean age was 45.4 years and mean follow-up 30.1 months. The most common tumour location was the lower limb. There were no cases of local recurrence or metastasis. Fifteen patients (52.2%) were FUS-CREB3L2 translocation-positive, suggesting either that translocation incidence in our series is lower than other studies, or that reverse-transcriptase polymerase chain reaction (PCR) is less sensitive than the literature suggests. Patients testing positive presented at a younger age (38.2 years, compared to 45.6 years), and had larger tumours than their negative counterparts (mean diameter 97.6mm, compared to 65.2mm), although there was no difference in clinical outcome.

Discussion: We conclude that PCR testing for the FUS-CREB3L2 translocation is a useful tool for confirming the diagnosis of LGFMS, but has no role in predicting short-term clinical outcome. It is not necessary to perform wide excision, and marginal margins are adequate. Longer-term follow-up is required to elucidate differences in the long-term clinical outcome between translocation-positive and negative patients.


R Jennings N D Riley B Rose R Rossi A Saifuddin J A Skinner S R Cannon T W R Briggs R Pollock

Introduction: Chondrosarcoma is the second most common primary malignant bone tumour. Distinguishing between grades is not necessarily straightforward and may alter the management of the disease. We evaluated the correlation between the pre-operative needle biopsy and excision biopsy histological grading of chondrosarcoma of the femur, tibia and humerus.

Methods: A consecutive retrospective series of 100 patients with a histological diagnosis of chondrosarcoma made at a supra-regional bone tumour unit was reviewed. Twenty-one patients were excluded because 20 had only excision biopsy, due to radiological confidence in the diagnosis, and one had only the pre-operative biopsy on record, thus this series included 79 available cases. The remaining patients underwent a pre-operative needle biopsy.

Results: In 11 instances, there was a discrepancy in histological grade. Therefore, there was an 86% (68 out of 79) accuracy rate for pre-operative histological grading of chondrosarcoma, based on needle biopsy. However, the accuracy of the diagnostic biopsy to distinguish low-grade from high-grade was 90% (71 out of 79).

Discussion: From this series we conclude that accurate image-guided biopsy is a very useful adjunct in determining histological grade of chondrosarcoma and the subsequent treatment plan. At present, a multidisciplinary approach, comprising experienced Orthopaedic Surgeons, Radiologists and Pathologists offers the most reliable means of accurately diagnosing and grading chondrosarcoma of long bones.


A Puri A Gulia M G Agarwal C H Srinivas

Objectives: To analyse functional outcome of giant cell tumor (GCT) distal radius treated with en bloc excision and reconstruction with ulnar translocation and wrist arthrodesis.

Methods: Between June 2005 and March 2008 fourteen patients of Campanacci grade 3 GCT distal radius treated with en bloc excision were reconstructed with ulnar translocation (radial transposition of ulna) and wrist arthrodesis. Seven (50%) patients had recurrent disease. Average resection length was 7.9 cm (range 5.5cm–15 cm). Twelve cases were fixed with a plate and in 2 an intramedullary nail was used. Union at both junctions was evaluated and functional assessment done using MSTS score.

Results: All 14 patients had followed up till bony union. Eleven patients were available at time of final review with an average follow up of 24.5 months (range 13–48 months). Average time for union at ulnocarpal junction was 4 months and ulnoradial junction was 5 months. No case required any additional procedure to augment union. Three cases had a soft tissue recurrence and one had pulmonary metastasis. Average range of prono supination was 80 degrees, one patient with synostosis had complete restriction of prono supination. Average MSTS Score at last follow up was 26 (86.6%).

Conclusions: Ulnar translocation provides a local vascularised bone graft to bridge the defect after excision of distal end radius tumors without the need for microvascular procedures. Unlike centralization of the ulna it retains prono supination while maintaining good hand function.


G S Tamvakopoulos B Rose K De-Silva S Shankar A Flanagan A Saifuddin J Skinner T Briggs S Cannon R Pollock

Introduction: The Musculoskeletal Tumour Society recommends that patients with musculoskeletal tumours are treated in specialist centres. Core needle biopsy is an effective method of obtaining tissue diagnosis but a dilemma arises when the material is non-diagnostic. Our aim was to evaluate the management of non-diagnostic biopsies.

Method: We retrospectively reviewed all core needle biopsies performed between 2003 and 2009 in our regional centre. Non-diagnostic biopsies were identified and management reviewed.

Results: 4,520 core needle-biopsies were performed of which 120 (2.6%) were non-diagnostic. Of these 85 (70%) were treated definitively on the basis of existing imaging, 8 (7%) required further imaging before treatment and 27 (23%) had a repeat biopsy.

Of the 27 repeat biopsies a positive histological diagnosis was obtained in 22 patients. The remaining 5 were again non-diagnostic giving a total of 98 patients being treated definitively without a tissue diagnosis.

Of these 98 cases, 39 (40%) were treated non-operatively, 37 (38%) had curettage and 22 (22%) underwent wide excision.

In the curettage group 33 out of 37 patients had a benign tumour on final histology. Four patients turned out to have intermediate/high grade tumours and subsequently underwent wide excision.

In the wide excision group, 17 out of 22 patients had an intermediate/high grade tumour on final histology. Five patients underwent an unnecessarily wide excision of a benign lesion.

None of the patients treated non-operatively turned out to have a tumour.

Conclusion: After non-diagnostic core-needle biopsy, the patient can safely be managed without tissue diagnosis, with low error rate, provided they have been subjected to a multidisciplinary discussion.


C R Chandrasekar R J Grimer S R Carter R M Tillman A T Abudu L M Jeys

Background: And Aims Pathological fractures of the proximal femur due to primary bone sarcomas are difficult to treat. The aim of the study was to assess the factors determining the outcomes following pathological fractures of the proximal femur due to primary bone sarcomas.

Methods: 93 patients with a pathological fracture of the proximal femur due to primary bone sarcomas were studied. The patient, tumour and treatment factors in relation to overall survival were analysed.

Results: There were 55 male and 38 female patients. The mean age was 47 years. The diagnoses were Chondrosarcoma -34, Osteosarcoma – 21, spindle cell sarcoma – 25, Ewing’s sarcoma -13. 74 patients had a pathological fracture at diagnosis and 19 patients had a fracture after the diagnosis. 17 patients had metastases at diagnosis. 24 patients had an intracapsular fracture. Limb salvage was possible in 60 patients (65%), 18 patients had an amputation and 15 patients had palliative treatment. 27% of the patients were referred after an unplanned surgery. The mean follow up was 49 months [range 0–302]. Twenty one patients [23%] had a local recurrence -10 patients had a diagnosis of chondrosarcoma, four patients had osteosarcoma and seven had spindle cell sarcoma. The overall five years survival was 37% [Ewing’s sarcoma 60%, Chondrosarcoma 57%, spindle cell sarcoma 28%, osteosarcoma 13% and dedifferentiated Chondrosarcoma 0% (p-0.002)]. Metastasis at diagnosis was a significant factor (p-0.04) affecting survival.

Conclusion: We conclude that a pathological fracture of the proximal femur due to osteosarcoma and dedifferentiated chondrosarcoma. carry a poor prognosis.


R Rossi B Rose N D Riley R Jennings A Saifuddin J A Skinner S R Cannon TWR Briggs R Pollock

Introduction: Within a study group of 102 consecutive patients diagnosed with chondrosarcoma of the femur, tibia or humerus, an association with previously treated breast cancer was noted. We researched this proposed relationship.

Methods: We retrospectively reviewed the records of all patients diagnosed histologically with chondrosarcoma of the femur, tibia or humerus over a six-year period at a supra-regional bone tumour unit. We identified those patients who had previously been treated for breast cancer.

Results: There were 58 female and 44 male patients. The study group contained six females (10%, mean age 53 years) who had previously been treated for breast cancer, a higher proportion than would be expected. They were referred following identification of a solitary area of increased activity on routine screening with isotope bone scan, presumed to be a solitary bony metastasis. Most (86%) of this breast carcinoma sub-group had developed low-grade bone chondrosarcoma (Trojani grade 0.5-I) and only one case (14%) had developed high-grade chondrosarcoma (Trojani grade II–III).

Discussion: A suspicious long bone lesion on bone scan in a patient with a past medical history of breast cancer must, therefore, not be assumed to be a metastasis without further investigation; the possibility of a chondral lesion should be considered. It is important that patients receive a full multidisciplinary team investigation prior to treatment in order to obtain the correct tissue diagnosis, as the management of these conditions is often different. Our study suggests there may be a relationship between patients previously treated for breast cancer and the development of subsequent chondrosarcoma.


R U Ashford C P Esler

Introduction: Despite the lack of good clinical evidence post operative radiotherapy is standard practice following non radical surgical treatment of skeletal metastases in long bones There is little in the literature about the size of radiation field and whether the whole bone, the nail or just the area of the metastatic deposit should be covered.

Methods: We present two cases where the metastases were treated by intramedullary nailing and were subsequently irradiated. In each case the tip of the intramedullary nail was outside the radiotherapy field.

Results: Subsequent second metastasis formation occurred at the tip of the nail compounded by pathological fracture. Salvage surgery was achieved in one case with a total femoral replacement and in the other by bi-columnar plating of the humerus with cement augmentation.

Discussion: Intramedullary nailing of a metastasis will seed the tumour to the tip of the nail. It is therefore essential that the tip of the nail be included in the radiotherapy field post-operatively as salvage surgery for subsequent pathological fracture is technically demanding. The aim of any surgery for skeletal metastases is that the reconstruction should outlast the patient. Communication between surgeon and radiation oncologist is essential.


J J Joseph A Pillai D Ritchie E McDuff A Mahendra

Introduction: Bizarre parosteal osteochondromatous proliferation(BPOP) is a benign lesion of bone originally described by Nora et al in 1983. To date there are no UK-based case series in the literature. Here we present the Scottish Bone Tumour Registry(SBTR) experience of this rare lesion.

Method: A retrospective analysis of SBTR records was performed.

Histological specimens were re-examined by a consultant musculoskeletal oncology pathologist. Radiographs were re-reported by a consultant musculoskeletal radiologist.

Results: From 1983–2009, 13 cases were identified; 6 male, 7 female. Age ranged from 13–65.

All patients presented with localised swelling. Pain was present in 5 and trauma in 2.

9 lesions affected the hand, 3 the foot, and 1 the tibial tuberosity.

12 lesions were excised and 1 curetted. There were 7 recurrences of which 6 were excised. 1 patients’ recurrence was not treated. 1 lesion recurred a second time. This was excised. There were no metastases.

Radiographs typically showed densely mineralised lesions contiguous with an uninvolved cortex. Cortical breakthrough was present in 1 case and scalloping in another.

Histology characteristically showed: hypercellular cartilage with pleomorphism and alcification/ossification without atypia; bone undergoing maturation; and a spindle-cell stroma.

Discussion: SBTR records indicate that BPOP is a rare lesion with no sex predilection that affects patients over a wide age range.

Minor antecedent trauma was present in only 2 cases. In agreement with Nora et al. we feel that trauma is unlikely to represent an aetiological factor.

Recurrence was over 50% in this series. Although this is similar to that found in other reports, it may indicate that more extensive resection is required for this aggressive lesion.

Finally, although radiological/histological findings are often bizarre there have been no reported metastases and so it is important that BPOP is not mistaken for, or treated as, a malignant process such as chondrosarcoma.


M H Arastu A Rashid S Haque S Bendall

Introduction: The rising incidence of metastatic bone disease (MBD) in the UK poses a significant management problem. Poorly defined levels of service provision have meant that improvements in patient prognosis have been mediocre at best. For that reason the British Orthopaedic Association (BOA) in conjunction with the British Orthopaedic Oncology Society (BOOS) issued guidelines in 2002 on good practice in the management of MBD. Despite the availability of these standards, there is very little robust data available for audit. The aim of this study was to conduct a regional survey of how these guidelines are being used in the management of MBD.

Methods: A questionnaire was designed with 9 multiple choice questions representing the most common MBD scenarios. This was posted to 106 Consultant Orthopaedic Surgeons in 12 NHS Trusts in the South East of England.

Results: The overall response rate to the questionnaire was 44%. There was considerable variation in the management of solitary femoral diaphyseal lesions, pathological subtrochanteric and intertrochanteric femoral neck fractures and vertebral metastases. Furthermore only 2 out of the 12 Trusts surveyed had a designated MBD lead as per the BOA/BOOS guidelines.

Discussion: Our study reflects the variation in the management of MBD throughout the region, which may in turn be linked to poorer clinical outcomes. The results demonstrate the possibility of

inappropriate initial treatment,

subsequent late tertiary referral and

poor understanding of the biomechanical basis of orthopaedic implants, with the potential for inappropriate choice of prostheses and high failure rates.

Streamlining cancer care will involve establishing regional MBD units within large centres where multidisciplinary services are available. Consequently all surrounding hospitals will need a designated MBD lead that can function as a conduit to this integrated care for selected patients.


A Puri M G Agarwal A Gulia

Objective: To assess whether hemicortical excision and biological reconstruction instead of the conventional wide resection for selected cases of malignant surface tumors, may give adequate oncologic clearance with less morbidity and better function.

Methods: From January 2000 to June 2007 a total of 29 malignant surface tumors were managed at our institute. Fifteen of these were treated with hemicortical excision and reconstruction. They consisted of 10 parosteal osteosarcomas, 1 periosteal osteosarcoma, 1 high grade surface osteosarcoma, 1 adamantinoma and 2 surface chondrosarcomas. Nine were in the distal femur, 3 in tibia, 2 in the humerus and 1 in the radius. Four of these were residual/recurrent lesions following earlier intervention. After hemicortical excision with adequate margins the bone defect was reconstructed with allograft/autograft and suitable internal fixation where indicated.

Results: Margins were reported free in all cases. There were no infections. Three of five patients who did not have fixation with a plate at index surgery sustained a subsequent fracture which was then reduced and fixed. Follow up duration was from 24 to 90 months. Two patients had isolated soft tissue recurrences. Both underwent re excision and are currently disease free at 36 and 38 months respectively after recurrence. Eleven patients had a maximum possible score of 30 (MSTS functional scoring); other four had a score of 29. None of the cases have developed distant metastasis.

Discussion: Early results indicate that in selected cases, hemicortical excision is an oncologically sound procedure. The ability to do a biological reconstruction with bone helps avoid some of the serious complications of a megaprosthetic reconstruction while permitting full active loading of the extremity and near normal function. Internal fixation at index surgery permits early mobilization and minimises the incidence of subsequent fractures.


O Zaikova R J Grimer L G Kindblom A T Abudu R M Tillman L Jeys S R Carter

Introduction: Parosteal osteosarcoma is a rare, mostly low grade tumor arising from the surface of the bone. The aim of the study was to establish risk factors for local recurrence (LR) and death.

Method: Retrospective review of a prospectively collected database with complete up-to-date follow up.

Results: 63 patients were diagnosed and treated at our centre from 1978 to 2007. The most common site was the femur (37) followed by the tibia (10) and humerus (9). The median size was 7cm (2 – 16). At the time of diagnosis 27 (43%) were low grade, 13 (21%) were low grade but had invaded the medullary canal and 8 (13%) had a high grade component; the data was missing in 15 patients (24%). All patients were operated.

LR arose in 11 patients (17.5%) at a mean of 38 months and was related to surgical margins. There were no LR in the 26 wide resections, but the risk of LR was 20% in those with a marginal and 46% in those with an intralesional excision. LR appeared as a higher grade than the primary tumor in 3 patients (27%).

9 (14.3%) patients developed metastases at a median of 22 months (6 – 123). Five patients developed both LR and metastases. Seven patients died from the tumor, 2 patients are alive with metastatic disease.

None of the patients with a low grade tumor and wide or marginal margins died of tumor, but 2 patients (18%) operated intralesional died of tumor.

Discussion: There was a statistically significant relationship between surgical margins and LR (p< 0.001). All patients with low grade parosteal osteosarcoma operated with wide margins have been cured. LR appeared often in higher grade than the primary tumor. Patients with low grade tumor and intralesional margins had 18% risk to tumor-ralated death.


E E Pakos R J Grimer S R Carter R M Tillman A Abudu L Jeys D Peake D Spooner V P Sumathi L G Kindblom

Of 3000 patients diagnosed with primary malignant bone tumours and treated at our unit over the past 25 years, 234 (7.8%) were considered to be spindle cell sarcomas of bone (ie not osteosarcoma, chondrosarcoma, Ewing’s, chordoma or adamantinoma). We have analyzed their management and outcomes.

The diagnosis of these cases varied with fluctuations in the popularity of conditions such as MFH, fibrosarcoma and leiomyosarcoma with the passage of time. Treatment was with chemotherapy and surgery whenever possible. 36 patients had metastases at diagnosis and 17 had palliative treatment only because of age or infirmity. The most common site was the femur followed by the tibia, pelvis and humerus. The mean age was 45 and the mean tumour size 10.2cm at diagnosis. 25% of patients presented with a pathological fracture. Chemotherapy was used in 70% of patients the most common regime being cisplatin and doxorubicin. 35% of patients having neoadjuvant chemotherapy had a good (> 90% necrosis) response. The amputation rate was 22% and was higher in patients presenting with a fracture and in older patients not having chemotherapy.

With a mean follow up of 8 years the overall survival was 64% at 5 yrs and 58% at 10 yrs. Adverse prognostic factors included the need for amputation, older age and poor response to chemotherapy as well as a pathological fracture at presentation. The few patients with angiosarcoma fared badly but there was no difference in outcomes between patients with other diagnoses.

We conclude that patients with spindle cell sarcomas should be treated similarly to patients with osteosarcoma and can expect comparable outcomes. The histological diagnosis does not appear to predict behaviour.


W Cheung R Grimer L Jeys A Abudu R Tillman S Carter

Patients who undergo soft tissue sarcoma excision accumulate serosanguinous fluid, potentially resulting in a seroma. This can lead to wound complications and delay post-op radiotherapy.

The purpose of this preliminary report is to assess the impact of routine application of Tisseel sealant prior to closure.

We investigated whether the sealant Tisseel is effective as a sealing agent to reduce the duration and volume of serosanguinous fluid drainage. Results were compared with individually matched controls.

Patients were split into 2 groups: those receiving 10mls sealant and those not receiving the sealant. Efficacy was evaluated by the number of days required for wound drainage, the volume of fluid drainage and the length of stay compared with matched controls.

The preliminary findings suggest that application of the sealant reduced the duration and quantity of fluid drainage after excision of the STS, allowing earlier discharge from hospital.

We present this work to suggest that the members of the British Orthopaedic Oncology Society should consider using this in a randomised controlled trial setting to evaluate its efficacy nationally.


T W Barwick G Chuter S Murray C Gerrand

Introduction: Well-differentiated liposarcomas have a tendency to recur locally but do not metastasise unless dedifferentiation occurs. In this study, a tumour superficial to the deep fascia of the trunk or limb is termed an atypical lipoma (AL) and one deep to fascia, a lipoma-like liposarcoma (LL) reflecting increased difficulty in wide local excision.

Methods: We prospectively collected data for 87 well-differentiated liposarcomas excised at our institution from 1998–2008. Data was recorded on a multidisciplinary team database and verification was undertaken using patient records. Any radiological investigation performed was determined retrospectively. Primary excisions performed elsewhere were excluded. The aim was to produce recommendations on the clinical and radiographical post-operative management of these common tumours.

Results: LL was seen in 74 patients and AL in 13 (mean age 58 years, mean follow up 5 years). The mean size of LL excisional biopsy was 148mm and 54mm for AL (p< 0.05). There were no AL recurrences. Five LL (7%) locally recurred within a mean of 5 years (range 2–10 years). All were deeply related to neurovascular structures (4 thigh-marginal/complete excisions and 1 upper arm-piecemeal excision). One recurrence was detected by MRI from 26 LL patients (35%), the other four being clinically suspected prior to re-scanning. During follow up, a chest radiograph was performed in 21 LL patients (27%) and no metastases were detected.

Discussion: Patients with a completely excised superficial AL need no routine follow up. Follow up of LL is determined by the patient, the tumour size and the location. The routine use of interval MRI to detect local recurrence of uncomplicated LL is not necessary. MRI provides ‘base-line’ post-operative information where a neurovascular bundle was closely related to the tumour or excision was incomplete. Chest radiographs are not indicated in screening for metastases in these tumours unless locally recurrent.


C R Chandrasekar R J Grimer S R Carter R M Tillman A T Abudu L M Jeys

Introduction: Malignant tumours of the foot and ankle are rare. The aim of the study was to document one of the largest series of malignant tumours affecting the foot and ankle and to assess the outcomes following limb salvage and amputation.

Methods: The study was a retrospective review of the patients with a malignant tumour of the foot and ankle. Demographic details, diagnosis, treatment and outcomes were retrieved from the electronic patient records containing information on over 20 000 patients seen over a 25 year period.

Results: Two hundred and twenty five patients had malignant tumours affecting the foot and ankle. It was common in the fifth decade (35 patients). The mean age was 46 years. The commonest diagnosis was synovial sarcoma (40 patients) followed by chondrosarcoma (23 patients) and Ewing’s sarcoma (21 patients). The mean tumour size was 5.6 cm (0.8 to 17.5 cm). 82 patients (37%) underwent an unplanned excision and 13% (29 patients) presented with metastases at diagnosis. Primary bone tumours were 28% (64 patients), soft tissue sarcomas were 62% and metastatic tumours were 8% while lymphoreticular malignancies were (1%). Limb salvage was possible in 71% (156 patients). 29% (65 patients) had a below knee amputation. 7% (15 patients) had a local recurrence. The 5 years survival was 63%. The 5 years survival for the patients who had limb salvage was 68% compared with 54% for the patients who had an amputation (p 0.03).

Conclusion: Though amputation can provide better local control, limb salvage surgery improves survival.


H A Branford White H Giele P Critchley D Whitwell C L M Gibbons

Introduction: Acral sarcomas present as small tumours to specialised orthopaedic services. There is a high incidence of inadequate resection compromising clinical and functional outcome.

It is advised that lumps which are greater than 5cm should be referred to a sarcoma centre for management and that small lesions cause less harm with unplanned excision.

Method: Data from the Oxford Registry was collated of all those patients with acral sarcomas who underwent surgery in a period from 1997 – 2008 at The Nuffield Orthopaedic Centre including site, size, histological subtype, of tumours, history of previous surgical excisions, staging, and functional scores.

Results: 27 patients were treated (17 foot and ankle cases, 10 hand tumours). The commonest acral lesions were synovial sarcomas (30%).

Of the hand patients 7 of the 10 patients had wide excision of the lesion with 3 an amputation. 5 of the cases were for inadequate previous excision (50%).

7 of the 17 in the foot and ankle group underwent amputation (41%) the rest wide excision. 29% of cases were for second time surgery due to inadequate previous excision.

Discussion: Our study shows that up to 50% of patients with acral tumours are undergoing further surgery due to previous inadequate excision. The belief that 5cm should be a benchmark for specialist referral should not be applied to such lesions.


T W Barwick G Chuter S Murray C H Gerrand

Introduction: The ‘Two Week Wait’ (2ww) process has been in force since the year 2000, with the subsequent implementation of 32-day diagnosis and 62-day treatment ‘rules’, as part of reforms to NHS cancer services. The aims of this study were to compile a definitive diagnostic profile of 2ww referrals, establish whether a histological diagnosis was required and consider the current 2ww impact on services in our centre.

Methods: Two hundred and nine patients were referred to the North of England Bone and Soft Tissue Tumour service and prospectively recorded on a computerised multidisciplinary tumour database from 2006–8. The data was reviewed and verified using pathology, radiology reports and patient records.

Results: Malignancy was diagnosed in 41(20%) patients (n=209). This comprised 21 soft tissue sarcomas (10%), 11 primary bone tumours (5%), and 9 metastatic bone tumours (4%).

63 (30%) benign bone or soft tissue neoplasia and 80 (38%) non-neoplastic conditions were diagnosed. No mass lesion was identifiable in 25 patients (12%). A diagnostic or therapeutic biopsy was undertaken in 108 (52%) patients.

Discussion: Fifteen percent of 2ww referrals to our centre have a primary bone or soft tissue malignancy. The 2ww caseload has increased significantly in recent years and non-malignant conditions (80%) must still be diagnosed within the 31 day rule. We utilise a ‘one-stop clinic’ approach, with access to ultrasound guided biopsy, and a weekly multidisciplinary meeting to facilitate timely investigation and treatment of all patients regardless of referral route.


R Sharma A Dramis R Tillman R Grimer S Carter A Abudu L Jeys

Introduction: Giant cell tumor (GCT) is a benign but locally aggressive tumor that primarily affects the epiphyses of long bones of young adults. Pulmonary metastases in giant cell tumor are rare. We report our experience of treating pulmonary metastatic GCT of bone over the last 24 years between 1984–2007.

Methods: A retrospective review of patients’ records and oncology database of patients with metastatic GCT

Results: We had 471 patients with GCT of bone out of which 7 patients developed pulmonary metastases (1.48%). Six patients following diagnosis and initial treatment and one with pulmonary metastases present at the diagnosis. There were 4 males and 3 females aged between 23 to 40 years (median, 27 years). All patients had GCT around the knee (distal femur/proximal tibia). All patients eventually required Endoprosthetic Replacement apart from one who was treated with curettage only. The time of pulmonary metastases from initial diagnosis was 16–92 months (median, 44.6 months). All patients who developed metastases in the postoperative period had thoracotomy for excision of the pulmonary metastases. Two patients received chemotherapy for control of the local recurrence. At an average follow up of 151 months (27–304 months), all patients were alive

Discussion: Pulmonary metastases have been reported as 1% to 9% in GCT. Because of its rarity, very little is known about the long-term outcome and the best treatment for the pulmonary lesions. The mortality rates recorded for patients with pulmonary metastatic GCT range from 0% to 37%. In our series the mortality rate was 0% and metastases 1.48%. It seems that surgical resection of pulmonary metastases gave excellent rate of survival.


B J F Dean J J Matthews D W Reed H Pandit E McNally N Athanasou C M L H Gibbons

Introduction: Hoffa’s fat pad (HFP) of the knee is affected by a variety of tumours and tumour-like conditions. HFP can be affected by diffuse or solitary, focal disease. Solitary tumours are relatively uncommon but with widespread uptake of Magnetic Resonance Imaging Scans (MRI) an increasing number of Hoffa’s fat pad tumours (HFP) are being recognized.

Methods: This paper reports a consecutive series of 20 cases of solitary symptomatic HFP tumours referred to Oxford bone and soft tissue tumour service between 1999 and 2008. The commonest presenting symptom was anterior knee pain. All patients underwent open excision after diagnostic magnetic resonance imaging (MRI).

Results: Histology revealed varied diagnoses with the commonest being pigmented villonodular synovitis (PVNS) and ganglia. American Knee Society scores improved from 76 pre-operatively to 96 post-operatively with an improvement in functional scores from 92 to 100. In one patient, MRI identified the cause of hypo-phosphataemic osteomalacia as an HFP phosphaturic mesenchyma tumour despite the lack of local symptoms.

Discussion In conclusion the majority of solitary HFP tumours are benign and may be either cystic or solid. MRI and plain radiographs are the imaging of choice. The definitive treatment of both cystic and solid tumours should be selective arthrotomy and excision biopsy. Arthroscopic resection is not advised, as complete excision is not always possible. None of the 20 patients in this series had a malignant tumour but this has been reported in the literature. Calcification on plain radiographs may indicate a malignant lesion. All patients in our series reported substantial improvement in symptoms following open tumour resection.


K Gokaraju M T R Parratt B G I Spiegelberg J Miles S R Cannon T W R Briggs G W Blunn

Introduction: Following resection of tumours in the distal femur, reconstruction with joint-sparing prostheses have shown good short-term functional outcomes. There is however limited literature on the affect of knee-sparing prostheses on function of the femoral physes in skeletally immature children.

Method: We discuss two patients, a male (11yrs) and female (10yrs) who had joint-sparing distal femoral prostheses inserted for treatment of Ewing’s sarcoma. The knee joint, along with the distal growth plate, was preserved and fixed to the distal end of the prosthesis using unicortical screws positioned distal to the physis. In the female, these screws were removed 6 months post-op due to prominence of the screws under the skin. In both patients, we assessed radiographs from immediately post-surgery and the most recent follow-up (20 and 28 months respectively). In each set, for the operated limb, we measured the height and width of the distal femoral epiphysis, the total length of the femur and the length of the proximal femoral bone segment from the femoral head to the proximal bone-prosthesis interface. In addition, post-operative assessments of leg lengths, bilaterally, were documented.

Results: In both patients, distal femoral epiphyseal height and width in the operated leg showed no significant change following endoprosthetic replacement. In the female, growth did not resume even after removal of the epiphyseal screws. In both patients, lengths of the femur and the proximal bone segment increased significantly following surgery. The patients demonstrated no clinical leg length discrepancy at the most recent follow-up.

Discussion: This study suggests that the function of the distal femoral growth plate ceases following insertion of joint-sparing distal femoral endoprostheses, probably due to trans-physeal fixation. This does not appear to resume following early removal of distal screws. The proximal growth plate, however, continues to function adequately enough to maintain symmetry in overall leg length.


S Vijayan W Bartlett R Lee P Ostler G W Blunn S R Cannon T W R Briggs

Introduction: Massive endoprostheses are widely employed in limb salvage surgery for malignant bone tumours. Whilst joint preservation rather than replacement is usually attempted, cases arise where there is insufficient bone following tumour resection to allow adequate fixation of a joint sparing prosthesis.

Method: We report a series of four patients (aged 4–12), in which irradiated autologous bone was combined with distal femoral replacement in order to preserve the native hip joint.

Results: There were three cases of Osteosarcoma and one Ewing’s sarcoma. After a mean follow-up of 53.5 months (range 9–168), all four patients are alive without evidence of local recurrence or metastases. One implant was revised after 14 years following fracture of the extending component of the growing endoprosthesis. There were no cases of loosening or peri-prosthetic fracture.

Discussion: This is the first report of a new technique utilising irradiated autologous proximal femoral bone combined with distal femoral replacement in skeletally immature patients.


K Gokaraju M T R Parratt B G I Spiegelberg R C Pollock J A Skinner S R Cannon T W R Briggs

Introduction: Alveolar soft part sarcoma (ASPS) is a soft tissue tumour found primarily in adolescents and young adults. It has an incidence of 0.5 – 1.0 % of all soft tissue sarcomas and a predilection for females. The lesion is inherently malignant and may occur throughout the body however, reports suggest they are predominantly detected in the anterior thigh. Symptoms include a painless slow-growing mass but ASPS can commonly present with brain or lung metastases due to the high vascularity of the lesion. Microscopically, cellular groups exist with centralised areas of necrosis, thus resulting in a pseudoalveolar appearance.

Methods: We identified six cases of histologically proven ASPS. The mean age was 28.5 years (21–36). Four patients were male. All patients had a primary presentation of a mass, two of which were painful. All patients, except one, presented within 8 months of the onset of symptoms (mean 3.8 months) with the other seeking medical advice only after 72 months. The location of the mass included the thigh in three patients and the triceps, soleus and retroperitoneal space in the others. Four patients underwent pre-operative diagnostic biopsies. Surgical excision was performed in all patients.

Results: The mean size of tumour was 9.4 x 9.4 x 6.3cm but there was no correlation between lesion size and duration of symptoms. The patient who presented late was found to have multiple lung metastases prior to surgery. Despite appropriate adjuvant therapy, three patients developed post-operative metastases at a mean of 5.2 months (1–24), two of which died along with the patient who presented with metastases at a mean of 2.6 years.

Discussion: This series demonstrates that this tumour may present as a painful mass. Despite early detection and appropriate treatment, ASPS remains a highly malignant neoplasm with a high associated mortality rate.


W Taylor R J Grimer S R Carter R M Tillman A Abudu L Jeys

The two week wait has been established as a potential means of diagnosing malignant tumors earlier and thus hopefully leading to improvements in outcome. There remains controversy as to whether these clinic achieve this end or whether they just speed up treatment of patients already diagnosed (eg by imaging)

Aim: The aim of this study is to evaluate the diagnoses of all patient referred with a suspicious soft tissue lump to a two week wait clinic, to assess the diagnostic ‘hit rate’ and how many of these had already had imaging leading to a possible diagnosis of malignancy.

Method: Review of the diagnoses and referral criteria for all patients referred to a soft tissue sarcoma early diagnosis clinic.

Results: ** patients were referred under the 2 week wait criteria with a possible soft tissue sarcoma. ** (**%) turned out to have a malignant diagnosis. Of these, *8 were STS, ** were other soft tissue malignancies and ** were bone malignancices (** being….) Of the patients with a malignant diagnosis, only ** were referred directly to this hospital as a two week wait without previous investigation. Of the remainder *8 had undergone imag-9ing prior to referral leading to a suspicion of malignancy and ** were referred after investigation at another hospital. The average size of STS diagnosed after 2 week wait referral was ** which compared with **cm in those not referred via this route over the same time period.

Conclusion: Patients referred to a soft tissue 2 week wait clinic had a **% risk of malignancy. Of these, ** were new diagnoses suspected purely on clinical as opposed to imaging grounds.


D Bhasker

Introduction: In 2004 The Bone and Soft Tissue Tumour Service based at the Freeman Hospital gained recognition as a specialist sarcoma service. As a result, the service formed standards with auditable outcomes based on the NICE guidelines for specialist cancer services. This study aimed to explore whether the Bone and Soft Tissue Tumour Service meets the standards set. It also compares the results of the current study to the results of the last service evaluation carried out in 2005.

Methods: Four key domains identified from the current standards were explored including; face-to-face contact with healthcare professionals, access to a specialist nurse, knowledge of support services and hospital stay.

Design – retrospective questionnaire

Setting – Bone and Soft Tissue Tumour clinics, Musculoskeletal outpatients, Freeman Hospital

Subjects – 45 follow-up patients with a diagnosis of sarcoma.

Results: Of the 45 patients who participated 100% were satisfied with face-to-face consultations with healthcare professionals. This included consultations regarding the diagnosis, investigations and results.

98% were ‘satisfied’ or ‘very satisfied’ with their hospital stay.

In comparison to the previous study, access to the specialist nurse had improved by 22%. Although, not all patients currently access a specialist nurse.

Patients’ knowledge of support services (sarcoma support group and helpline) has fallen since the previous survey.

80% (36/45) of patients had no complaints about the service.

Discussion: The results of this study suggest a high rate of satisfaction with the service currently delivered. Of the key areas explored, face-to-face consultations and satisfaction with hospital stay scored highly. Improvement in patient access to a specialist nurse may subsequently improve knowledge of support services. This means patients are better emotionally supported thus, further improving overall quality of service delivered.


C Menna R J Grimer S R Carter R M Tillman A Abudu L Jeys

Low grade central osteosarcoma is a rare intramedullary bone producing tumour. It accounts for only 1–2% of all osteosarcomas. Due to the indolent nature of low grade central osteosarcoma, achieving a correct and prompt diagnosis is the real challenge both from imaging and histology, particularly as it may resemble a benign condition, i.e. Fibrous Dysplasia.

We have reviewed 15 cases of low grade central osteosarcoma with long term follow-up (2 to 22 years) to identify problems in diagnosis and treatment and to assess outcome.

There were 7 females and 8 males with a mean age of 37 yrs (range 11 to 72 years); 13 cases arose in the lower limb (8 femur, 4 tibia, 1 os calcis), 1 in the pelvis and 1 in the upper limb. The average duration of symptoms prior to presentation was over 2yrs. A primary diagnosis of low grade central osteosarcoma was achieved for only 6 cases (4 open and 2 needle biopsies), in the other 9 the primary diagnoses were GCT, cystic lesion or fibrous lesion (both benign and malignant) and all of them had undergone treatment (usually curettage with or without bone grafting for this). Definitive treatment was with surgery attempting to obtain wide margins. Marginal excision was associated with local recurrence in three cases but there were no local recurrences in patients who had a wide excision, even in those with prior treatment. Only one patient has died following the development of multiple metastases after 9 years. The survival rate is 90% at 15 years.

We present this study to show the difficulties in diagnosing this rare type of osteosarcoma and to highlight the importance of wide surgical margins to obtain local control.


J Jagadeesan J Davies A Raurell R U Ashford

Objectives: It is common for breast surgeons to excise impalpable tumours and fine-wire localisation is commonly deployed by breast radiologists to facilitate such surgery. Pre-operative localisation can be achieved using conventional ultrasound but this necessitates co-ordination with the radiology department.

Methods: We have utilised the SonoSite (SonoSite Inc, Bothell, WA) portable ultrasound system available widely in operating theatres for insertion of vascular lines and perineural catheters, for localisation of deep impalpable tumours.

Results: Two patients who had undergone mid-forearm amputations for synovial sarcoma are presented. The first presented with axillary recurrence of his tumour. MRI scanning of his stump revealed two lesions suspicious of recurrence. Both were impalpable initially. The lesions were identified using the SonoSite and excision biopsy performed. Histologically the lesions were neuromata. The second patient had imaging in keeping with neuromata and again the Sonosite was utilised to detect the lesions and facilitate removal.

Discussion: Sonosite portable ultrasound machines are readily available in the operating theatre and may be utilised to aid removal of tumours. They do not replace other imaging but can make surgery less traumatic in that smaller incisions may be used.


T Okoro R U Ashford

Introduction: Metastases in multiple myeloma are typically lytic and when non-union occurs it is usually atrophic

Methods: We report a lady of 67 years who was diagnosed with myeloma 9 years previously. She presented with a sudden onset of pain in her right forearm. Plain radiographs demonstrated a lytic lesion typical of multiple myeloma with an undisplaced pathological fracture in her right ulna. The fracture was treated in a short arm cast for 6 weeks and then by mobilisation. The underlying bone deposit was treated subsequently by external beam irradiation.

Results: Nine months later she was re-referred to the orthopaedic oncology service with marked forearm pain particularly on rotation. Radiographs demonstrated a hypertrophic non-union of the pathological fracture with a typical elephant’s hoof appearance. The fracture was stabilised using a Foresight ulnar nail (Smith and Nephew, Warwick, UK).

Discussion: Whilst non-unions in metastatic malignancy are typically atrophic, just occasionally hypertrophic non-unions can occur. Management principles remain the same with stabilisation of the entire bone and early mobilisation being appropriate.


M W Bateman B J Smith R J Grimer

Introduction: Postoperative infection rates following endoprosthetic surgery are currently around 11%. In comparison with routine orthopaedic infection rates (0.5–2.0%) this is high and warrants investigation. Antibiotic prophylaxis at the time of surgery has been proven to reduce postoperative infection rates. We are looking to see if this is being administered correctly.

Methods: We sought the records of 183 patients undergoing primary EPRs at the ROH within an 18 month period. We were unable to locate 57 (69%) leaving 126 to analyse. We recorded details of the surgeon conducting the operation, the perioperative antibiotics administered, and whether the patient developed a SSI postoperatively. We grouped the patients into three groups, those who received the correct regime as defined by the department (1.5g Cefuroxime at induction followed by 3 doses of 750mg Cefuroxime at 8, 16 and 24 hours post-op), those who received cefuroxime but in an incorrect regime and those not receiving cefuroxime. We further looked at the frequency individual surgeons were administering the correct antibiotics. Finally we applied a Chi-squared anaylsis to see if there was a significant difference in infection rates between those receiving the correct antibiotics and those not.

Results: 52 patients (41%) received cefuroxime in the correct regime, 27 (22%) received cefuroxime in an incorrect regime and 47 patients (37%) did not receive cefuroxime. The different surgeons at the hospital administered the correct regime in varying frequencies (0%–65%). Giving the correct antibiotic dose is associated with a reduction in the incidence of postoperative SSI (0.1> p> 0.05).

Discussion: A large proportion of EPRs are carried out without the recommended prophylactic antibiotic cover. The rate of correct antibiotic administration varies widely between surgeons from the same department. This lack of appropriate prescribing could be contributing to a high rate of postoperative infection and therefore needs addressing.


R Grimer S Carter R Tillman S Abudu L Jeys

Aim: To identify factors leading to the success or failure of extracorporeal irradiation and reimplantation of bone (ECIR).

Method: Review of experience of this technique since 1996 documenting successes and failures.

Results: 35 patients with a variety of malignant bone tumours underwent ECIR from 1996 up to 2007. The most common diagnosis was Ewings’ sarcoma (15) followed by osteosarcoma (9) and chondrosarcoma (5) with the most common sites being the pelvis (15) followed by the tibia (10) and humerus (3). The age range was from 7 to 66 and 8 were skeletally immature at the time of surgery. The bones were sterilised with a dose of 90Gy before reimplantation.

The overall patient survival was 69% at 5 years and 62% at 10 years. Local recurrence arose in 4 cases, 3 of whom already had metastatic disease. None of the LR arose in the irradiated bone. The rate of non union was 9% at the 58 osteotomies, the greatest risk being in the tibia. There were four graft fractures of which 3 needed fixation and all united. There is one case of convincing graft resorbtion after 12 years. Two patients developed infections but there have been none since the done was routinely immersed in antibiotics whilst being irradiated.

Conclusion: ECIR is a useful technique with very limited indications. In the majority of cases it works well. It appears particularly useful in pelvic resections and diaphyseal resections. Distal tibial reconstructions do worst. The irradiated bone needs reinforcing with either cement or a bone graft for best results.


B G I Spiegelberg S A Hanna S Tai K Gokaraju R Carrington R Pollock S R Cannon T W R Briggs

Introduction: The aim of this study is to investigate whether MoM implants result in more chromosome aberrations and increased blood metal ions post-operatively when compared to MoP implants.

Large head metal-on-metal articulating surfaces of the hip are being used in increasing numbers of patients for oncological purposes due to the increased stability and reduced dislocation rate. Recent studies have raised many concerns over possible genotoxicity of MoM implants.

Methods: This is a prospective study of patients who have undergone elective total hip replacement. Patients were randomised into two groups (MoP and MoM). Patients are reviewed pre-operatively (control group), at 3 months, 6 months, 1 year and 2 years post-operatively. On each occasion blood tests are taken to quantify metal ion levels (chromium, cobalt, titanium, nickel and vanadium) using HR-ICPMS and chromosome aberrations in T lymphocytes using 24 colour fluorescent in situ hybridisation (FISH).

Results: 24 patients had MoP prosthesis and 29 a MoM. Cobalt and chromium concentration increased during the first 6 months in both MoM and MoP groups, in the MoM group the chromium levels were twice that of MoP group and 12x that of the preoperative samples. There was no difference with the levels of titanium, nickel and vanadium. Chromosome aberrations occurred in both groups. At 6 months both the MoM and MoP groups showed increase frequency of aneuploidy aberrations with further increases after one year. Structural damage in the form of translocations occurred in the MoM group after one year, but not in the MoP group.

Discussion: Results of this study show that the levels of chromium and cobalt are significantly higher in the MoM group compared to the MoP group. This corresponds to increases in chromosome aberrations between the groups particularly in aneuploidy and translocations present in the MoM group at 1 year.


K Gokaraju B G I Spiegelberg M T R Parratt J Miles S R Cannon T W R Briggs

Introduction: There is limited literature available on the use of metal prosthetic replacements for the treatment of non-traumatic lesions of the proximal radius. This study is a medium-term follow-up of implant survivor-ship and the functional outcome following insertion of metal proximal radius endoprostheses performed at the Royal National Orthopaedic Hospital.

Method: We present a series of six patients treated with endoprosthetic reconstruction of the proximal radius following resection of non-traumatic pathologies. The patients included four females and two males, with a mean age of 39 years at the time of surgery. Their diagnoses included Ewing’s sarcoma, chondroblastoma, benign fibrous histiocytoma, radio-ulna synostosis and renal carcinoma metastases in two patients. Follow-up extended to 192 months with a mean of 76 months.

Results: During this time there were no complications with the prostheses, the most recent radiographs demonstrated secure fixation of the implants and none required revision. One patient developed posterior interosseuous nerve neuropraxia following surgery, which partially recovered, and another patient passed away as a result of disseminated metastatic renal cell carcinoma which was present pre-operatively. The patient with radio-ulna synostosis had a 25° fixed flexion deformity of the elbow post-operatively but good flexion, supination and pro-nation. All other patients had full ranges of movement at the elbow. Functional scores were assessed using the Mayo Elbow Performance Score with patients achieving a mean score of 86 (65 – 100) out of 100.

Discussion: The results of the use of proximal radial endoprostheses for treatment of non-traumatic lesions are encouraging with regards to survivorship of the implant and functional outcome of the elbow.