Rivaroxaban was introduced for thromboprophylaxis at the Royal Cornwall Hospital for hip and knee arthroplasty surgery in October 2009. We identified 140 patients from theatre logbooks who underwent elective joint replacement between October 2009 and March 2010. Patient notes, computer and DVT clinic records and WebPacs data were collected to determine the uptake of the new drug and the incidence of wound problems, DVTs and any other post-operative complications. In our sample 55.7% [78/140] patients received rivaroxaban. 10.3% [8/78] of patients on rivaroxaban suffered wound complications compared with 6.6% [4/62] of patients on alternative anticoagulation. Three patients suffered DVT's, 1 of whom was taking rivaroxaban. There were a further 6 patients, 4 on rivaroxaban, with leg swelling severe enough to merit investigation, all of whom had negative doppler scans. Bleeding events included 4 patients with postoperative haematemesis of which 2 were taking rivaroxaban. Five patients, all under different surgical operators of which 3 had taken rivaroxaban, developed stiff total knee replacements and were offered MUA or physiotherapy.

Wound ooze is common following Total Knee Arthroplasty and persistent wound ooze is a risk factor for infection, increased length and cost of hospitalisation. We undertook a prospective study to assess the effect of tourniquet time, periarticular local anaesthesia and surgical approach on wound oozing after TKA. The medial parapatellar approach was used in 59 patients (77%) and subvastus in 18 patients (23%). Periarticular local anaesthesia (0.25% Bupivacaine with 1:1000000 adrenalin) was used in 34 patients (44%). The mean tourniquet time was 83 minutes (range 38 to 125 minutes). We found a significant association between cessation of oozing and periarticular local anaesthesia (P = 0.003), length of the tourniquet time (P = 0.03) and the subvastus approach (P = 0.01). Periarticular local anaesthesia, the subvastus approach and shorter tourniquet time were all associated with less wound oozing after total knee arthroplasty.

Magnetic resonance imaging (MRI) scans are widely used in the assessment of knees, often prior to arthroscopic procedures. The reporting of chondral damage on MRI scans can be variable. The correlation between MRI reports of chondral damage and that found at arthroscopy is often inconsistent. The aim of this study was to identify how well MRI reports correlated with the extent of chondral damage found at arthroscopy. A retrospective case-note review of a single-surgeon series of 175 arthroscopic procedures was performed. 83 patients were included in the study. The remainder were excluded if an MRI scan had not been performed, or had been performed more than 3 months prior to surgery. The condition of the articular cartilage demonstrated by MRI was compared to that found at arthroscopy. Data was analysed for presence and extent of chondral damage. Comparison between MRI and arthroscopy findings showed high Specificity (90%) and Negative Predictive Values (89%) for chondral damage, but low Sensitivity (46%). Cohen's kappa values < 0.2 revealed very poor correlation for the extent of damage. This study demonstrates that MRI is good at describing whether articular damage is present but does not reliably describe the extent of the damage.

Treatment of syndesmotic injuries is a subject of ongoing controversy. Locking plates have been shown to provide both angular and axial stability and therefore could potentially control both shear forces and resist widening of the syndesmosis. The aim of this study is to determine whether a two-hole locking plate has biomechanical advantages over conventional screw stabilisation of the syndesmosis in this pattern of injury. Six pairs of fresh-frozen human cadaver lower legs were prepared to simulate an unstable Maisonneuve fracture. The limbs were then mounted on a servo-hydraulic testing rig and axially loaded to a peak load of 800N for 12000 cycles. Each limb was compared with its pair; one receiving stabilisation of the syndesmosis with two 4.5mm quadricortical cortical screws, the other a two-hole locking plate with 3.2mm locking screws (Smith and Nephew). Each limb was then externally rotated until failure occurred. Failure was defined as fracture of bone or metalwork, syndesmotic widening or axial migration >2mm. Both constructs effectively stabilised the syndesmosis during the cyclical loading within 1mm of movement. However the locking plate group demonstrated superior resistance to torque compared to quadricortical screw fixation (40.6Nm vs 21.2Nm respectively, p value <0.03).

There is controversy regarding the optimum method of stabilising traumatic anterior pelvic ring injuries. This study aimed to evaluate the role of pubic symphysis plating.

Softcast is an attractive alternative to POP for unstable forearm fractures, providing a comfortable, water-resistant splint that can be removed without a plaster saw. Unreinforced Softcast has, however, only been recommended for buckle fractures. A laboratory study was undertaken to compare standardised POP, Softcast and reinforced Softcast splints at clinically relevant endpoints. The load at clinical failure of a 6-wrap Softcast forearm splint was 504N in bending, 202N in kinking, and 11Nm in torsion (equalling 30.4%, 26% and 42.2% of the equivalent values for a circumferential 4-wrap POP). Softcast was however stronger in all modes than a fibreglass-reinforced Softcast splint, such has been recommended for acute fractures. Furthermore, the load to failure in all modes exceeds that which can be exerted by body weight in many paediatric patients. Softcast demonstrated complete recovery of its original shape on unloading, and was 4% lighter than POP. A 6-wrap Softcast splint provides adequate mechanical stability and protection for paediatric patients up to 20kg, not engaged in high-risk activities. The primary risk is not of fracture angulation and loss of position, but temporary indentation of the splint, causing discomfort or pain. Considering its ease of removal, Softcast may be preferable for younger paediatric patients.

Optimal utilisation of operating theatres has a significant impact on the ability of an institution to deliver productive, value for money surgical services. With the recent introduction of the national ‘Productive Theatres’ programme and in the current economic climate it is receiving increasing attention. In addition, it improves patient satisfaction and outcomes, reduces adverse events and has positive influences on staff morale. The aim of this study was to highlight factors influencing trauma theatre utilisation in general, whilst also addressing any problems identified with a view to improving trauma services locally. We conducted a prospective analysis of activity in the trauma theatre at our institution over 1 month. Direct observation was performed by a single independent observer. In the absence of any published guidelines, all theatre lists were assessed against pre-determined standards for each component of the theatre pathway. Overall end utilisation (combined time utilised for anaesthesia and surgery) was found to be low at 65%. A number of factors were found to contribute to inefficiencies including delay in sending for patients (mean 42mins, range 0-105), prolonged patient transit times to theatre (mean 22% of all sessions), late starts to lists (mean 43 mins, range 15-105 mins) waiting for x-ray availability (mean 21mins, range 10-45) and knock on delay from previous lists. Surgeons and anaesthetists were found to be, overall, arriving on time or early for all lists. Strategies for maximising trauma theatre productivity are essential. This study has identified common issues, of potential benefit to numerous institutions when planning trauma services.

Scaphoid injuries remain a challenge in both diagnosis and subsequent management. Untreated scaphoid non-union leads to inevitable osteoarthritis. Non-unions are picked up via an established management pathway in out trust and treated surgically with a standardised technique of non-vascularised bone grafting and retrograde screw fixation. Patients that underwent primary screw fixation and grafting for scaphoid non-union between 2004-2008 were reviewed. These patients were followed up clinically and radiologically. They were assessed for time to union, complications, DASH score, patient satisfaction and return to work. In addition comparison was made between the use of Herbert screw and Twinfix screw fixation and between tricortical iliac crest graft and corticocancellous distal radial bone graft. Forty-two consecutive patients underwent surgery of which 35 (83%) were available for follow up. Mean follow up was 39 months (range 13-72). 31 (89%) patients had gone on to radiological union. Of those united the mean DASH score was 11. Mean time to union was 4.4 months (range 2-15 95% CI 3.3 – 5.5). 95% of patients were satisfied with their operation and would recommend it to a friend in the same situation. No significant difference in outcomes were identified between Herbert screw and Twinfix screw fixation or between iliac crest or distal radial bone grafting techniques. This study has shown encouraging results for an established protocol for management of scaphoid non-union. Outcomes are as a good as any published comparable series in the literature and provide further support to the use of this technique.