Hip resurfacing arthroplasty (HRA) in patients with a varus deformity of the femoral neck-shaft angle (NSA) has been cited in the literature as contributory factor towards a poorer outcome. Our experience has not reflected this. We examined the outcomes of patients with varus hips against a normal cohort.

Measurement of the femoral neck-shaft angle was undertaken from standard antero-posterior radiographs pre-operatively. The mean NSA was 128.5 degrees (SD 6.3). Patients less than 122.2 were deemed varus and those above 134.8 valgus. These parameters were consistent with the published literature.

The varus cohort consisted of 23 patients, mean NSA 118.7 (range 113.6-121.5), mean follow-up 49 months (range 13-74), mean OHS & HHS, 16 & 93.5 respectively. Complications included 2 cases of trochanteric non-union; no femoral neck fractures or revisions. The normal cohort consisted of 125 patients, mean NSA 128 degrees, mean follow-up 41 months (range 6-76), mean OHS & HSS, 18.8 & 88.9 respectively. Complications included 5 cases of trochanteric non-union and 1 revision. Statistical analysis demonstrated no difference between the cohorts OHS (p=0.583) or HHS (p=0.139).

Our experience in patients with a varus femoral neck has been positive. Our analysis has demonstrated no difference in outcomes between the cohorts.

We investigated the role of Plasma Viscosity (PV), C-reactive protein (CRP) and Frozen Section (FS) in diagnosing prosthetic joint infection. We compared these results with microbiological diagnosis of infection of the tissue samples (three or more samples grown same organisms in culture).

53 patients, average age 67 years (37 – 89) underwent joint revision surgery. 34 patients had hip and 19 patients had knee joint revision arthroplasty, this includes single and multiple stage revision surgeries and excision arthroplasty. Nine (17%) patients had microbiologically proven joint infection. PV had sensitivity of 100%, specificity of 43% and negative predictive value of 100%. CRP had sensitivity of 89 %, specificity of 75% and negative predictive value of 97%. FS (presence of infection being more than 5 neutrophils/hpf) had sensitivity of 56% and specificity of 84%.

We recommend PV and CRP to be used in the investigation of prosthetic joint infection. If both CRP and PV are normal the chance of infection is very low (negative predictive value of 100%). In our series an elevated PV and CRP represented a 50% chance of having a joint infection. The role of frozen section does not appear to be beneficial in the diagnosis of joint

Soft tissue reactions following metal-on-metal arthroplasty of the hip have been under discussion in recent times. The phenomenon has been observed since the advent of arthroplasty, but the particular nature of metal-on-metal (MoM) resurfacing or total hip arthroplasty (THA), and the associated shedding of metal particles in high wear states, appears to excite a more aggressive response. Recent reports suggest involvement of muscle groups on a wide scale, and some cases of neurovascular involvement. It is not known which reactions require widespread muscle excision, and which cases may be adequately addressed by bearing exchange alone. We report three cases of soft tissue reaction (pseudotumour) following MoM hip resurfacing all managed with revision to ceramic-on-ceramic (CoC) THA with minimal soft tissue excision. All patients were female with ages at original operation of 49, 52 and 58 years. Time to revision surgery was 85, 28 and 66 months respectively.

Prosthesis revision resulted in progressive and satisfactory resolution of the pseudotumour. We propose that in the early stages, pseudotumour following MoM hip resurfacing can be adequately managed with revision to ceramic-bearing THA with minimal soft tissue excision, rather than revision with extensive soft tissue debridement that has been recently described.

Treatment of osteoarthritis is evolving, allowing surgical treatment options at an earlier stage. The interpositional knee device is a recently developed patient specific implant used for the treatment of mild to moderate uni-compartmental osteoarthritis. The benefits over traditional methods of surgical management are: it's less invasive, can be a day procedure and does not limit future options. Young Adults with early uni-compartmental arthritis are suitable. A MRI scan of the patient's knee is reviewed by radiologists to decide if the patient is suitable. A bespoke implant is produced. Prior to insertion an arthroscopy is undertaken to allow proper positioning.

We treated 27 patients with the iForma Conformis interpositional knee implant in South Wales at the Princess of Wales Hospital, Bridgend and the Royal Glamorgan Hospital, Llantrisant since November 2007. The pre- and post-operative WOMAC scores were recorded. The average age was 54.7 years, BMI 32; 10 females and 20 males. The average pre-operative WOMAC score was 42.2 improving to 62.9 post-operatively. 35 implants were used. 7 patients experienced post-operative problems. No dislocations were reported. Average follow-up was 12.6 months.

Our early experience suggests patient selection plays a role in the outcome following surgery. It indicates that this device is a viable and safe alternative to a uni-compartmental knee replacement.

The Oxford unicompartmental knee replacement (UKR) was introduced in 1976 with good results. Mobile bearings in the lateral compartment have been associated with unacceptably high bearing dislocation rates, due to greater movement between the lateral femoral condyle and tibia, and the lateral collateral ligament's laxity in flexion. The new domed implant is designed to counter this with a convex tibial prosthesis and a fully-congruent, bi-concave mobile bearing allowing a full range-of-movement (ROM), minimising dislocation risk and bearing wear.

We present complication rates and clinical outcomes for a consecutive series of our first 20 patients undergoing Oxford domed lateral UKR, between June 2006 and August 2009, with minimum 6-month follow-up. There was one unrelated death (31 months post-UKR) and one postop MI. We had no bearing dislocations, infections or loosening nor other complications. All patients had post-op Oxford Knee Scores; eleven had pre-op scores and demonstrated a significant improvement – mean pre-op 22.75 to post-op 35.45 (p=0.01). All achieved full extension with average ROM 116°, mean change in ROM was –2.6°(p=0.6).

This study adds to previous work in confirming a low level of complications with this new procedure (including the early learning curve), particularly bearing dislocation and demonstrates excellent functional outcomes.

We analysed the clinical data of 858 consecutive primary total hip and knee replacement patients to establish how age, ASA grade, body mass index and a simplified cognitive score correlate with the length of hospital stay and early complication rates. We further used statistical regression analysis to study how hospital stay and complication rates correlate with different pre-operative grading systems based on combinations of age, ASA grade, body mass index and a cognitive score.

The results indicate that age and ASA grade correlate significantly with both length of hospital stay and complication rates, while body mass index correlated poorly with both. A grading system based on a combination of age and ASA grade (the AA Grade) correlated significantly with both length of hospital stay and complication rates. Adding body mass index or a cognitive score did not significantly add to the correlation.

We discuss the relevance of this simple grading system and how it might contribute to pre-operative risk assessment and peri-operative planning.

At the Peninsula NHS Treatment Centre in Plymouth some of the surgeons are UK trained and some trained elsewhere in Europe.

This paper examines the outcomes of a large series of joint replacements from 2006 to 2008 at a minimum of one year follow up to determine whether the place of orthopaedic specialist training makes any difference to the outcome. The same implants were used by all surgeons and the anaesthetic technique and post-operative management was identical.

1700 patients were interviewed by a structured telephone questionnaire with over 92% follow-up and the results entered into a joint replacement database. Additional data about length of stay and blood transfusion was added.

Results will be presented about length of stay, transfusion requirements, any further treatment or hospital attendance relating to the new joint, reoperation, deep or superficial infection, hip dislocation, VTE and patient satisfaction.

The surgeon's place of orthopaedic training was found to make no difference to the surgical outcome.

Long-term prospective RCT comparing hemiarthroplasty (HEMI) and total hip arthroplasty (THA) for the treatment of intracapsular neck of femur fracture.

81 previously mobile, independent, orientated patients were randomised to receive THA or HEMI after sustaining a displaced neck of femur fracture. Patients were followed up with radiographs, Oxford hip score (OHS), SF-36 scores and their walking distance.

At a mean follow up of 8.7 years, overall mortality following THA was 32.5% compared to 51.2% following HEMI (p=0.09). Following THA, patients died after a mean of 63.6 months compared to 45 months following HEMI (p=0.093). Patients with THA walked further and had better physical function. No HEMIs dislocated but three (7.5%) THAs did. Four (9.8%) HEMI patients were revised to THA, but only one (2.5%) THA required revision. All surviving HEMI patients had acetabular erosion and all surviving THA patients had wear of the cemented polyethylene cup.

Patients with THA have better function in the medium-term and survive longer.

It costs the NHS £2billion/year to treat 70000 hip fractures. Following hemiarthroplasty a departmental x-ray is standard practice.

During 2009 217 hemiarthroplasties were performed in our unit. 210 had postoperative radiographs (148 departmental, 62 in theatre). All patient demographics were considered and hospital costs accounted for.

Mean patient age was 83 (55-100) years. Mean theatre times were 120 (51-213) minutes in the departmental x-ray group and 128 (74-187) minutes in the theatre imaging group. Hospital stay was decreased from 12.8 (3-41) days in the departmental x-ray group to 11.8 (3-32) days in the theatre imaging group. Orthopaedic beds cost £136/day. Departmental x-rays give a radiation dose of ∼12mGy and costs £48.30, theatre imaging gives ∼0.26mGy with no additional cost given the radiographers previous allocation to the list.

Changing our practice to intra-theatre imaging has improved patient safety, reduced the average inpatient stay and saves our trust approximately £40,000 annually.

An osteoporosis screening service for patients presenting to the fracture clinic in Derriford Hospital Plymouth was established in February 2009. We report on the findings of the first year of patients referred for dual energy X-ray absorptiometry (DEXA) screening.

Patients between 50 and 75 years of age, who sustained a fracture as a result of a fall from standing height or less, who had not previously had a DEXA scan within the last two years, were referred. Patients outside these age limits with other risk factors for osteoporosis were scanned at the discretion of the fracture clinic consultant. Of those patients who were referred, 96% subsequently attended for a scan timed to coincide with their scheduled fracture clinic follow-up appointment.

402 patients were scanned in total, of which 351 were female and 51 were male. The mean patient age was 65. The results for women were as follows: 21% normal, 45% osteopenic, 34% osteoporotic. The results for men were: 19% normal, 43% osteopenic, 38% osteoporotic. The scan results were forwarded to the patient's general practitioner for action as deemed necessary.

These findings support the establishment of this screening service for both men and women.

Controversy exists whether a single proximal lateral tibia (PLT) locked plate is adequate for bicondylar fractures and whether the use of integral raft screws makes the use of bone graft less important.

57 consecutive patients who underwent reconstruction with a locked PLT plate were retrospectively reviewed. Radiographs were examined for operative reduction and subsequent loss of reduction.

55 patients were followed-up for an average of 27 weeks. Fractures were divided into unicondylar (Group 1, n=33) and bicondylar (Group 2, n=22). Union occurred in all patients, with no revisions or removal of metalwork at final follow-up. In 50 patients (88%), the fracture was reduced to within 2mm of anatomical. Articular surface collapse of >2mm occurred in three patients. Nine patients underwent bone grafting with no difference in outcome. A supplementary medial plate was used in three patients with a separate posteromedial fragment.

Except for a separate posteromedial fragment, the use of a single locked PLT plate for bicondylar fractures allows union to occur without failure. With the use of integral raft screws, the need for bone graft is questionable. The short-term radiological results and complication rate of PLT locked plating is excellent.

Manipulation under anaesthetic (MUA) for the treatment of frozen shoulder is well established and effective however timing of surgery remains controversial. Intervention before 9 months has previously been shown to be associated with improved outcome. We test this theory by measuring Oxford Shoulder Score (OSS), re-MUA and subsequent surgery rate.

A retrospective review of a prospectively collected, single surgeon, consecutive patient series revealed 244 primary frozen shoulders treated by MUA within 4 weeks of presentation. The mean duration of antecedent symptoms was 28 weeks (95% CI 4-44 weeks) and time to follow up was 26 days (95% CI 11-41 days). The mean OSS improved by 16 points (2-tailed t test p< 0.001) with a mean follow up OSS of 43 (95% CI 38-48). 195 shoulders were manipulated before 38 weeks (9 months) and had the same mean change in OSS (16) as the 49 shoulders manipulated after 38 weeks. 48 shoulders, including 15 diabetic shoulders required further MUA. 8 shoulders had subsequent surgery. These events were also independent of antecedent symptom duration.

Early MUA does not appear to produce improved outcomes when compared to later intervention but we note does result in an earlier return to function.

The addition of Extended Scope Practitioner (ESP) clinics was proposed to review new Foot and Ankle referrals, to reduce time consultants spend in clinic and free them up for theatre. There would be a cost benefit to the Primary Care Trusts (PCT), a clinic appointment with the consultants cost's around £140 and ESPs around £70.

We prospectively collected data from the ESP clinics for two months in 2009. We looked at the number of patients referred on to the consultants and how many of these needed surgery.

During this period one hundred and forty one patients were booked into ESP clinics, forty three were referred to the consultants, ninety one were managed by the ESPs and seven patients failed to attend. The estimated saving to the PCT during the 2 month period was £6860 which would be £41,160 over a year. Twenty nine of the patients referred to the consultants required surgery giving a 74% conversion rate.

The use of ESPs in Foot and Ankle Clinic reduces the number of new referrals seen by consultants, therefore being cost effective to the PCTs. This also increased the consultant's surgical conversion rate producing a more efficient service.

Lower limb mal-alignment due to deformity is a significant cause of early degenerative change and dysfunction. Standard techniques are available to determine the centre of rotation of angulation (CORA) and extent of the deformities. However, distal femoral deformity is difficult to assess because of the difference between anatomic and mechanical axes. We describe a novel technique which accurately determines the CORA and extent of distal femoral deformity.

Using standard leg alignment views of the normal femur, the distal femoral metaphysis and joint line are stylised as a block. A line bisecting the anatomical axis of the proximal femur is then extended distally to intersect the joint. The angle (?) between the joint and the proximal femoral axis, and the position (p) where the extended proximal femoral axis intersects the joint line are calculated. These measurements can then be reproduced on the abnormal distal femur in order to calculate the CORA and extent of deformity, permitting accurate correction.

We examined the utility and reproducibility of the new method using 100 normal femora. We found this technique to be universally robust in a variety of distal femoral deformities.

Pedicle screw systems are now the commonest method of achieving posterior spinal fixation. Surgical planning in spinal surgery may include measuring pedicle size to guide screw size on WEBPACS. We performed a study to determine whether measuring pedicle size on CT is accurate and reproducible using the WEBPACS ruler tool.

A human cadaveric spine along with 5 geometrical shapes were scanned using a multislice spiral CT scanner with 1mm cuts. The objects and the pedicle diameters for lumbar and thoracic vertebrae in the axial plane were measured independently using the WEBPACS ruler tool by 2 observers (to the nearest 0.1mm). The geometrical shapes and pedicle size on the skeleton were then measured using Vernier callipers by an independent third observer. All measurements were repeated a week later.

The WEBPACS ruler on a CT scan is accurate to within 0.5-0.6mm of the true size of an object. The error for pedicle measurements is marginally higher (0.6-1.0mm) and this may reflect the fact that they are ill defined geometric shapes. Measuring pedicle size on CT for surgical planning may have implications for small pedicles when sizing them up for a good screw.

Last minute cancellations of operations are a major waste of NHS resources. This study identifies the number of late cancellations at our elective orthopaedic centre, the reasons for them, the costs involved, and whether they are avoidable.

Last minute cancellations of operations in a 7-month period from January to July 2009 were examined.

172 cases out of 3330 scheduled operations were cancelled at the last minute (5.2%). Significantly more cancellations occurred during the winter months due to seasonal illness.

The commonest causes for cancellation in descending order of frequency were patient unfit/unwell (n=76, 44.2%), lack of theatre time (n=32, 18.6%), patient self cancelled/DNA (n=20, 11.6%), staff unavailable or sick (n=9, 5.2%), theatre or equipment problem (n=8, 4.7%), operation no longer required (n=8, 4.7%), administrative error (n=7, 4.1%) or no bed available (n=5, 2.9%). In 7 out of the 172 cancelled cases (4.1%) no cause was identified. 59.7% of the cases were potentially avoidable.

3.2% of Patients seen in the specialist pre-operative anaesthetic clinic (POAC) were cancelled at the last minute for being unfit or unwell, compared to 2.2% seen in the routine nurse led clinic. Last minute cancellations cost the hospital over £700,000 in 7 months.

Outcome following wrist fractures is difficult to assess. There are many methods used to assess outcome following distal radius fractures, but may be that simply asking the patient for their level of satisfaction may be enough. We looked at 50 wrist fractures at 12 weeks post injury and compared their level of satisfaction with various respected outcome measures (Gartland and Verley, Sarmiento, Cooney, Patient-Rated Wrist Evaluation, Hand Function Score, and Disability of Arm Shoulder and Hand Score) to determine whether there was a correlation with their level of satisfaction. The aim was to determine which wrist scoring system best correlates with patient satisfaction and functional outcome and which individual variables predict a good outcome. Forty-five females and 5 males with a mean age of 66 years (range 19 to 93 years) were included in the study. Multivariate regression analysis was carried out using SPSS 17.

Patient satisfaction correlated best with the MacDermid, Watts and DASH scores. The variables in these scoring systems that best accounted for hand function were pain, ability to perform household chores or usual occupation, open packets and cut meat.

The McDermid, Watts and DASH scores provide a better measure of patient satisfaction than the Gartland and Verley, Sarmiento and Cooney scores, however they are all time consuming, complicated and may indeed not be necessary.

The four most important questions to ask in the clinic following wrist fractures are about severity of pain, ability to open packets, cut meat and perform household chores or usual occupation. This may provide a simple and more concise means of assessing outcome after distal radial fractures.

The treatment of nonunion is challenging providing the surgeon with a variety of different surgical options in order to encourage and achieve bone consolidation. Despite excellent results presented in 2008 of 99% union rates, Judet Osteo-Periosteal Decortication does not seem to be popular at present with bone grafting and distraction osteo-modelling being the favoured option.

Retrospective analysis was performed from December 2002 to December 2008 of 46 cases of osteoperiosteal decortication(Judet technique) for failure of fracture union.

Union was successfully achieved in 39 of the 45 patients(85%) after a mean delay of 10.7 months(range 3-39 months). Thirty patients(65%) achieved union following the decortication procedure without subsequent operations. The mean number of procedures following decortication was 0.6(range 0-4) mostly being performed for metalwork failure. Metal work failure occurred in 13 cases(28%) with the majority occurring in decortications of the femur(n=11,85%). The femur was the location of all persistent non unions in the series. The nonunion scoring system(0-100,Calori et al 2008) means were noticeably worse for the persistent nonunion group(41.67, range 34-46) compared to the union group(29, range 4-52).

Osteoperiosteal decortication remains a highly effective surgical technique in the management of failed fracture union.