Trigger finger is one of the most common problems presenting to hand clinics in the UK. Traumatic and compressive forces created through digital movement leads to thickening of the flexor tendon sheath. The most successful methods used to treat trigger finger are corticosteroid injection and surgical release. The ring, thumb and middle finger are the most frequently affected digits. The incidence of multiple digits being affected is between 20% and 24%, with a higher incidence in Diabetes Mellitus sufferers. We report a case of failed injection therapy in a patient with multiple trigger digits, review the literature and advocate the use of surgical release as a first line treatment option in those patients with multiply involved digits.

Cervical spine collars are applied in trauma situations to immobilise patients' cervical spines. Whilst movement of the cervical spine following the application of a collar has been well documented, the movement in the cervical spine during the application of a collar has not been. There is universal agreement that C-spine collars should be applied to patients involved in high speed trauma, but there is no consensus as to the best method of application.

The clinical authors have been shown two different techniques on how to apply the C-spine collars in their Advanced Life Support Training (ATLS). One technique is the same as that recommended by the Laerdal Company (Laerdal Medical Ltd, Kent) that manufactures the cervical spine collar that we looked at. The other technique was refined by a Neurosurgeon with an interest in pre-hospital care. In both techniques the subjects' head is immobilised by an assistant whilst the collar is applied.

We aimed to quantify which of these techniques caused the least movement to the cervical spine. There is no evidence in the literature quantifying how much movement in any plane in the unstable cervical spine is safe. Therefore, we worked on the principle: the less movement the better.

The Qualisys Motion Capture System (Qualisys AB, Gothenburg, Sweden) was used to create an environment that would measure movement on the neck during collar application. This system consisted of cameras that were pre-positioned in a set order determined by trial and error initially. These cameras captured reflected infra-red light from markers placed on anatomically defined points on the subject's body. As the position of the cameras was fixed then as the patients moved the markers through space, a software package could deduce the relative movement of the markers to each camera with 6 degrees of freedom (6DOF).

Six healthy volunteers (3 M, 3 F; age 21-29) with no prior neck injuries acted as subjects. The collar was always applied by the same person. Each technique was used 3 times on each subject. To replicate the clinical situation another volunteer would hold the head for each test.

The movements we measured were along the x, y, and z axes, thus acting as an approximation to flexion, extension and rotation occurring at the C-spine during collar application. The average movement in each axis (x, y and z) was 8 degrees, 8 degrees and 5 degrees respectively for both techniques. No further data analysis was attempted on this small data set.

However this pilot study shows that our method enables researchers to reproducibly collect data about cervical spine movement whilst applying a cervical collar.

Recurrent shoulder instability in those with bony defects is a difficult surgical problem to resolve. Burkhart and De Beer described an unacceptably high recurrence rate for arthroscopic Bankart repair in the presence of an inverted-pear glenoid with or without an engaging Hill-Sachs lesion, with suggestions that an open modified Latarjet procedure should be recommended in such patients. The Congruent-Arc Latarjet is a modification of the Latarjet open bony stabilisation for shoulder instability developed by Burkhart and De Beer. It involves rotation of the coracoid so the curved under-surface lies congruent with the glenoid. At the Royal Derby Hospital, UK, this procedure has been adopted by our four shoulder surgeons, two of whom undertook fellowship training with De Beer, we studied the outcomes of the patients who had undergone the modified Congruent-Arc Latarjet procedure in our department.

Fifty-two consecutive patients were identified over a five-year period at the Royal Derby Hospital or Derbyshire Royal Infirmary between 2006 and 2010 inclusive. With the approval of the clinical audit department, the data was collected using theatre records and clinical coding information to identify the patient group. A review of the case notes and local PACS system was undertaken to establish pre and post-operative examination findings, radiology findings regarding Hill-Sachs defects and glenoid bone loss, re-dislocation rates and post-operative function with return to normal activity. The endpoints of this study were aimed at finding out whether patients did return to normal function, were able to continue doing activity that would have provoked dislocation prior to surgery, and how many of the cases re-dislocated.

No surgeon consultant had a patient who re-dislocated after this procedure. The follow-up period was from 1 year to 6 years post-operatively. The complications of this procedure were found to be the dislodgement of bone anchors in 2 patients, who required further arthroscopy to remove the suture anchor from the gleno-humeral joint. One patient had prolonged functionally limiting loss of external rotation, which resolved after intensive physiotherapy at 7 months follow up. We will provide graphical representation of the pre and post operative functional scores.

We have demonstrated that the Congruent-Arc Latarjet is a reproducible procedure in the hands of surgeons other than the original authors, particularly when comparing our current 0% re-dislocation rate with the published literature, which suggests that 3.9% of patients undergoing this procedure with greater than 25% bone loss of the glenoid or an engaging Hill-Sachs will re-dislocate post-operatively, and this is better than the 6% re-dislocation rate of the standard Bristow-Latarjet procedure.

We present the 12 month data on the relatively novel drug Dabigatran Etexilate (Pradaxa), a new oral anticoagulant which was introduced to combat the risk of post operative venous-thromboembolic disease (VTED) in orthopaedic surgery. This drug was introduced at our hospital in March 2010 and we present our modified protocol of: using 5000u subcutaneous Dalteparin whilst in hospital and giving Dabigatran only on discharge, and at a lower dose (150mg compared to 220mg).

We carried out a retrospective analysis of the notes and imaging of every patient who underwent elective hip and knee arthroplasty over 12 months since the drug was introduced. We evaluated the rate of VTED complications and the rate of transfusion and bleeding post operatively.

The case series of 370 patients showed a 1% risk of deep vein thrombosis with no pulmonary emboli and 1 death due to an unrelated cause. There was a transfusion rate of 11% with 0.5% patients taken back to theatre for evacuation of haematomas. There were no reported adverse effects of Dabigatran.

We argue that our modified protocol for this novel drug should be followed as it is both safe and effective for postoperative anticoagulation.

An anaesthetist recently remarked that orthopaedic surgeons are ‘twice as strong as an ox but half as smart’. We set out to ascertain if this had any evidence basis by conducting an observational study.

We compared 36 male orthopaedic surgeons to 40 male anaesthetists across 3 hospitals to ascertain if there was a significant difference between the two groups in terms of Intelligence Quotient (IQ) and strength. We tested the IQ of each doctor using an official MENSA IQ test. We assessed the strength as reflected by the grip strength using a hand-grip dynamometer. Un-paired t-tests were used to assess statistical significance.

Orthopaedic surgeons had a significantly greater mean grip strength 47.25Kg (SD=6.95) compared to anaesthetists 43.83Kg (SD=7.57) (p=0.04). The mean IQ of orthopaedic surgeons was also significantly greater at 105.19 (SD=10.85) than anaesthetists at 98.38 (SD=14.45) (p=0.02). Furthermore, the IQ of orthopaedic surgeons seems to increase with increasing age and seniority (an IQ jump of 5 IQ points from Registrar to Consultant).

We have concluded that this proverb should be revised to orthopaedic surgeons are as strong as an ox and twice as smart, although further studies are advocated to ascertain the IQ of Ox.

Patients with hip fracture are at high risk of venous thromboembolism (VTE). Chemical thromboprophylaxis with low molecular weight heparin (LMWH) is associated with a risk of major bleeding in certain patient groups, such as those with renal failure. In these patients, unfractionated heparin should be used. Our aim was to determine the practice of VTE risk assessment in patients admitted with hip fracture against the national guidance, which states that all should have VTE risk assessment on admission. We also assessed the impact of introducing the VTE risk assessment form on prescribing practice of chemical thromboprophylaxis in patients with renal failure.

Prospective audit of patients of 50 patients admitted with hip fracture from 4/8/10 with re-audit of 50 patients admitted from 17/2/2011 after introducing the VTE risk assessment form into the hip fracture admissions proforma. Retrospective analysis was undertaken to determine chemical thromboprophylaxis prescribing in patients with eGFR <30ml/min/1.73m².

Patient demographics were comparable in both audit loops, with the mean age being equal (84 years) and an equal majority of female patients (76%). There were similar numbers of patients with eGFR <30ml/min/1.73m² in both audit loops with 8% (n=4) in the initial audit, and 10% (n=5) in the re-audit. Frequency of VTE risk assessment significantly increased from 16% to 86% after including the VTE risk assessment form in the hip fracture proforma (p<0.0001). Despite this, there was no significant reduction in prescribing of LMWH in patients with renal failure with eGFR <30ml/min/1.73m², (P=0.52).

Documentation of VTE risk assessment in patients admitted with hip fracture can be improved by simple measures such as inclusion of the VTE risk assessment form in the admissions proforma. However, this did not result in a reduction of LMWH prescribed in patients with significant renal failure and risk of major bleeding.

Cognitive impairment is common in patients with hip fracture both on admission and may develop later on. Reduced cognitive function is a risk factor for development of delirium, correlates with poor rehabilitation, and is an independent predictor of increased mortality. Despite its commonplace and potential for serious morbidity, cognitive dysfunction is often poorly assessed & diagnosed.

Our aims were to 1) assess the practice of cognitive assessment on admission for hip fracture patients according to local guidelines and 2) ascertain whether it can be improved by the formal introduction of Abbreviated Mental Test Score (AMTS) & Clock Drawing Test (CDT) in the hip fracture admission proforma.

A prospective audit was undertaken of cognitive assessment by either AMTS or CDT for 50 consecutive patients admitted with hip fracture from 4/8/2010. Subsequently, the hip fracture admission proforma was amended to include both the AMTS & CDT. A re-audit was performed on 50 consecutive patients admitted from 17/2/2011 to determine the change in practice.

Patient demographics were comparable in both audit loops, with the mean age being equal (84 years) and an equal majority of female patients (76%). Cognitive assessment by either AMTS or CDT significant increased from 28% (n=14) to 86% (n=43) in the re-audit (p<0.0001). All AMTS were completed in accordance with instructions, whereas almost half of CDTs were incompletely or incorrectly filled out (45%).

The assessment of cognitive function can be greatly improved by inclusion of both the AMTS & CDT to the hip fracture admission proforma, allowing the most appropriate multi-disciplinary care to be planned for the patient. Whilst both CDT and AMTS are good screening tools for cognitive impairment, many are unfamiliar with CDT & more training is needed.

Femoral component fracture is a rarely reported but devastating complication of total knee arthroplasty. It has occurred most frequently with Whiteside Ortholoc II replacements uncemented knee replacements. Presentation may be with acute pain, progressive pain or returning deformity. It occurs more commonly in the medial condyle of the femoral component. It is rarely seen in cemented replacements.

All currently available literature describing fractures of condylar replacements, both cemented and uncemented. Predisposing factors include varus deformity either pre or post operatively. The mechanism of failure is thought to be failure of the infiltration of bone into the replacement. This is often due to polyethylene wear or metallosis causing abnormal tissue reaction with or without osteolysis.

We present the case of a fractured Press Fit Condylar (PFC) cemented implant (DePuy, Johnson&Johnson, Raynham, Massachusettes, USA) affecting the medial condyle. To our knowledge this is only the third reported case of fracture in a PFC implant, and the first in a cemented PFC implant.

Our patient was a 64 year old male who presented with unresolving knee pain post total knee arthroplasty, caused by fatigue fracture of the medial condyle of the femoral component. This was identified as loosening on plain radiographs and replaced with a revision prosthesis with a good post operative result. Given our aging population and with the increase of joint arthroplasty, this case sheds light on a potentially under recognised and increasingly important cause of knee pain following arthroplasty.

The administration of prophylactic antibiotics is essential in the prevention of surgical site infection, particularly when metalwork is implanted. Intravenous Cefuroxime has been the antibiotic of choice for prophylaxis in our unit over the last few years. Unfortunately this has been linked to an increased rate of Clostridium Difficile infection. Our departmental antibiotic prophylaxis guidelines, based on the Scottish Intercollegiate Guidelines Network (SIGN), were therefore revised, such that intravenous Flucloxacillin and Gentamicin became the first line agents.

We primarily aimed to assess whether prophylactic antibiotics were being administered according to our revised local guidelines. Steps were then taken to improve adherence to the guidelines, and the audit repeated.

Data was collected prospectively between 1^st November 2010 and 28^th November 2010 (cycle 1). Demographic data, type of surgery, details of choice, dose and timing of antibiotic administration were compiled. The quality of documentation was also reviewed. Interventions to improve adherence to the guidelines were commenced between 1^st January 2011 and 28^th February 2011. This included a departmental presentation, supplementary distribution of the guidelines and email communication to all orthopaedic surgeons and anaesthetists to increase awareness. A repeat audit cycle was performed between 1^st March 2011 and 28^th March 2011 (cycle 2). All data was stored and statistically analysed using SPSS for Windows 17.0.

A total of 130 patients were included, with 65 patients in each cycle. Demographic data and type of surgery were reasonably similar in both cycles. Intravenous antibiotics, when required, were administered within 30 minutes of the surgical incision in most cases in both cycles of the audit. In the first cycle of the audit only 9 out of 65 patients (14%) received the correct antibiotics as suggested by our updated guidelines. This improved significantly to 46 out of 57 patients (81%) in the second cycle. Documentation of antibiotic prescribing in the anaesthetic record, operation note and drug charts also improved in the second cycle.

We observed poor initial adherence to our updated guidelines as most patients received incorrect antibiotic prophylaxis. However, following our audit interventions to increase awareness of the new guidelines, we witnessed a significant improvement in compliance. Our next step will be to ensure that the new policy of using intravenous Flucloxacillin and Gentamicin does indeed reduce the rate of Clostridium Difficile infection while maintaining a low rate of deep and superficial wound infection.

Pre-operative templating has become an essential aspect of pre-operative preparation for elective total hip replacement. The techniques involved have evolved from acetates used with analogue radiographs to digital processes. This study audits the accuracy of the TraumaCad software in total hip replacement since its introduction at two centres in the same trust.

The pre and post-operative radiographs of 40 patients undergoing total hip replacement by a single surgeon at a district general hospital were retrospectively reviewed. Patients that had templating of their digital Picture Archiving and Communications Systems (PACS) pelvic images using the TraumaCad software programme (Orthocrat Ltd, Petach-Tikva, Israel) were included. The templated acetabular component and femoral stem was compared to the actual size of acetabular and femoral prostheses inserted at surgery.

The acetabulum was accurately templated in 38.9% of the hips and within ± 1 size in a further 44.4% (total 83.3%). The femoral stem size was accurate in 27.8% of the hips and within ± 1 size in a further 52.8% of the hips (total 80.6%). Such a variation is likely due to the variable positioning of the calibration ball.

TraumaCad is a useful tool in the pre-operative templating of hips successfully predicting the prosthesis components within ± 1 size in the majority of hips studied. However, it should not be relied upon as an absolute measurement of the size of prosthesis to be used, rather be used as a suitable guide to intra-operative stages such as the femoral neck cut position.

Full-thickness burns around the knee can involve the extensor mechanism. The gastrocnemius flap is well described for soft tissue reconstruction around the knee. We describe a method where a Whichita Fusion Nail¯ knee arthrodesis, combined with a medial gastrocnemius muscle flap was used to salvage the knee and preserve the lower leg following a full-thickness contact burn.

The gastrocnemius flap for wound coverage of an open knee joint was originally described in 1970 and remains the workhorse for soft tissue knee reconstruction. There are a number of local alternatives including the vastus lateralis, medialis and sartorius flap; and perforator flaps such as the medial sural artery perforator island flap and islanded posterior calf perforator flap, however many of these are unsuitable for larger defects.

Full-thickness burns around the knee can put the extensor mechanism at risk and subsequent rupture is a possible consequence. The gastrocnemius flap has been used to cover a medial knee defect with exposed joint cavity following a burn and also been used in post burn contracture release around the knee.

The primary indication for Wichita fusion nail is a failed total knee replacement. It allows intramedullary stabilization with compression at the arthrodesis site to stimulate bone union. With fusion rates reported up to 100% and low complication rates as compared to other methods of fusion, the technique has a useful role in limb salvage type procedures.

While use of the gastrocnemius flap in knee burns has been described before we believe this is the first time that this combination of techniques, namely knee arthrodesis with soft tissue reconstruction using a gastrocnemius flap, has been reported. Combining these procedures with a multidisciplinary approach provides a useful alternative leading to limb salvage and avoiding the need for an above knee amputation when extensor reconstruction is not possible.

The main purpose of preoperative blood tests is to provide information to reduce the possible harm or increase the benefit to patients by altering their clinical management if necessary. This information may help clinicians assess the risk to the patient, predict postoperative complications and establish a baseline measurement for later reference.

National Institute of Clinical Excellence (NICE) has issued guidelines around the need for pre-operative blood tests related to the age of the patient, comorbidities and the complexity of the procedure they will undergo.

We decided to retrospectively review the pre-operative blood requests for patients under the age of 65 who were admitted at our institution over a 2 month period for open reduction and internal fixation of the ankle or tibial plateau and manipulation under anaesthesia of the lower limb. Patients were divided into 2 groups, under the age of 40 and between 40-65 years old. Patients under the age of 18 were excluded. These surgical procedures were classified as ‘intermediate complexity’.

Admission clerkings of our 63 patient cohort were reviewed to ascertain if any patients had a significant co-morbidity or past medical history. The pre operative blood tests requested for each patient were audited against the NICE recommendations.

None of the patients under the age of 40 had any significant comorbidites, whilst 8 patients above the age of 40 suffered with hypertension.

95% of patients had at least one blood test carried out. All patients over the age of 40 had at least one blood test. Tests requested included full blood count (91%), urea and electrolytes (91%), coagulation (66%), liver function tests (67%), group and save (69%), CRP (70%), ESR (2%), thyroid function tests (5%) and CK (2%). Only 5 patients (5%) followed the guidelines correctly.

The clinical value of testing healthy individuals before an operation is debatable. The possible benefits of routine preoperative investigations include identification of unsuspected conditions that may require treatment before surgery or a change in surgical or anaesthetic management. The American Society of Anaesthesiologists has stated that ‘routine preoperative tests (i.e. tests intended to discover a disease or disorder in an asymptomatic patient) do not make an important contribution to the process of perioperative assessment and management of the patient by the anaesthesiologist.’

The overzealous requesting of preoperative blood tests also has a financial burden upon individual institutions. Our study also showed that some blood tests, such as inflammatory markers and thyroid function tests, were inappropriately requested. Adherence to the NICE guidelines would have resulted in a significant financial saving.

This review has shown that adopting the NICE guidelines may result in a decrease in the amount of unnecessary blood tests patients undergo when they attend hospital for routine, minor or intermediate surgical procedures. If these guidelines were implemented for all surgical procedures, this would undoubtedly result in a significant financial saving for the institution and the NHS as a whole. At our institution we have implemented surgical and anaesthetic team awareness and education around these guidelines in a bid to reduce the use of unnecessary testing.

Subtalar dislocation of the hindfoot is a rare injury and can be associated with poor functional outcomes. We report a case of an irreducible subtalar dislocation in an elite athlete, who returned to elite sport.

A 28 year old competitor in the world mountain bike championships was injured in a high speed fall from his mountain bike during a competitive downhill run in July 2007. He had an obvious deformity at the scene and a fracture dislocation of the ankle was suspected. The injury was closed and neuro-vascular status was intact. Radiographs revealed the ankle mortise was intact with the talus anatomical, but a subtalar dislocation was present which proved irreducible in the emergency department.

The patient was taken to the operating theatre and the dislocation was reduced through a short antero-medial arthrotomy using a blunt lever and traction. Post- reduction, the joint was stable and was supported in a below knee cast. He was kept partial weight bearing for 6 weeks and then had an intensive physiotherapy rehabilitation regime. Serial radiology showed no evidence of avascular necrosis or other skeletal abnormalities.

Our patient has since returned to elite Mountain Biking and won the British National Championships in 2008 and the World Championships in Canberra in 2009.

Through the paediatric LCP Hip plating system (Synthes GmBH Eimattstrasse 3 CH- 4436 Oberdorff), the highly successful technique of the locking compression plate used in adult surgery, has been incorporated in a system dedicated to pediatrics. We are presenting the outcome of the paediatric LCP hip plating system used for a variety of indications in our institution.

We retrospectively reviewed the notes and radiographs of all those children who have had Paediatric LCP Plate for the fixation of proximal femoral osteotomy and proximal femur fractures in our institution, between October 2007 and July 2010, for their clinical progress, mobilization status, radiological healing and any complications.

Forty-three Paediatric LCP hip plates were used in forty patients (24 males and 13 females) for the fixation of proximal femoral osteotomies (n=40) and proximal femur fractures (n=3). The osteotomies were performed for a variety of indications including Perthes disease, developmental dysplasia of hip, Cerebral Palsy, Down's syndrome, coxa vara, Leg length discrepancy and previous failed treatment of Slipped Upper Femoral Epiphysis.

Twenty-five children were allowed touch to full weight bearing post operatively. Two were kept non-weight bearing for 6 weeks. The remaining 13 children were treated in hip spica due to simultaneous pelvic osteotomy or multilevel surgery for cerebral palsy.

All osteotomies and fractures radiologically healed within 6 months (majority [n=40] within 3 months). There was no statistically significant difference (p= 0.45) in the neck shaft angle between the immediately postoperative and final x-rays after completion of bone healing.

Among the children treated without hip spica, 1 child suffered a periprosthetic fracture. Of the children treated in hip spica, 2 had pressure sores, 3 had osteoporotic distal femur fractures and 2 had posterior subluxations requiring further intervention.

There were no implant related complications.

The Paediatric LCP Hip Plate provides a stable and reliable fixation of the proximal femoral osteotomy performed for a variety of paediatric orthopaedic conditions.

Treatment of acute Achilles tendon rupture is based on obtaining and maintaining apposition of the ruptured tendon ends. Surgical treatment utilises direct suture repair to produce this objective, while conservative or non-surgical management achieves the same effect of closing the tendon gap by immobilisation of the ankle joint in a plantar flexed position within a plaster cast or POP. There is still variability in the conservative treatment practices and protocols of acute Achilles tendon ruptures. The purpose of this study is to examine the current practice trends in the treatment of Achilles tendon ruptures amongst orthopaedic surgeons in the UK.

A postal questionnaire was sent to 221 orthopaedic consultants in 25 NHS hospitals in the Greater London area in June 2010. Type and duration of immobilisation were considered along with the specifics of the regime used.

Ninety questionnaires were returned giving a 41% response rate. Conservative treatment methods were used by 72% of respondents. A below knee plaster was the top choice of immobilisation (83%) within this group. The mean period of immobilisation was 9.2 weeks (Range 4-36). Weight bearing was allowed at a mean of 5.3 weeks (range 0-12)

The specific regime used by consultants was quite heterogeneous across the group, however the most used immobilisation regimen was a below knee plaster in equinus with 3 weekly serial plaster changes to a neutral position, for a total of nine weeks. A heel raise after plaster removal was favoured by 73% of respondents used for a mean period of 6.4 weeks (Range 2-36). In response to ultrasound use as a diagnostic tool, 42.4% of respondents would never use it, 7.6% would use it routinely, while 50% would use it only according to the clinical situation. Comparison of foot and ankle specialists with non-specialists did not reveal a significant difference in practice in duration of immobilisation or time to bearing weight.

Conservative management remains a widely practice option in the treatment of Achilles tendon ruptures. Although there are available a number of modern walking aids, the concept of functional brace immobilisation is not as widely used as below knee plaster cast immobilisation, which remains a popular choice amongst orthopaedic surgeons today. There is still no consensus on the ideal immobilisation regimen although a below knee plaster in equinus with serial changes for a total of nine weeks is the most frequently used choice. Further randomised controlled trials are required to establish the optimal treatment strategy for conservative management of Achilles tendon rupture.

Hip resurfacing arthroplasty is emerging as an increasingly popular, conservative option for the treatment of end-stage osteoarthritis in the young and active patient. Despite the encouraging clinical results of hip resurfacing, aseptic loosening and femoral neck fracture remains concerns for the success of this procedure.

This study used finite element analysis (FEA) to analyse the stresses within proximal femoral bone resulting from implantation with a conservative hip prosthesis. FEA is a computational method used to analyse the performance of real-world structures through the development of simplified computational models using essential features.

The aim of this study was to examine the correlation between the orientation of the femoral component of a hip resurfacing prosthesis (using the Birmingham Hip Resurfacing as a model) and outcomes during both walking and stair climbing. The outcomes of interest were stresses in the femoral neck predisposing to fracture, and bone remodelling within the proximal femur.

Multiple three-dimensional finite element models of a resurfaced femur were generated, with stem-shaft angles representing anatomic (135°), valgus (145°), and varus (125°) angulations. Applied loading conditions included normal walking and stair climbing. Bone remodelling was assessed in both the medial and lateral cortices.

Analyses revealed that amongst all orientations, valgus positioning produced the most physiological stress patterns within these regions, thereby encouraging bone growth. Stress concentration was observed in cortical and cancellous bone regions adjacent to the rim of the prosthesis. As one would expect, stair climbing produced consistently higher stress than walking. The highest stress values occurred in the varus-orientated femur during both walking and stair climbing, whilst anatomic angulation resulted in the lowest stress values of all implanted femurs in comparison to the intact femur.

This study has shown through the use of FEA that optimising the stem-shaft angle towards a valgus orientation is recommended when implanting a hip resurfacing arthroplasty. This positioning produces physiological stress patterns within the proximal femur that are conducive to bone growth, thus reducing the risk of femoral neck fracture associated with conservative hip arthroplasty.

The treatment of chronic osteomyelitis involves a debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead space management is practised with antibiotic impregnated cement. These depots of local antibiotics are variable in elution properties and need removal. We review the use of bioabsorbable synthetic calcium sulphate as a carrier of gentamicin and as an adjunct in treating intramedullary osteomyelitis.

A retrospective review of cases treated consecutively from 2006 to 2010 in the Royal Liverpool University Hospital was undertaken. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology and microbiology. The Cierney-Mader system was used to classify. Treatment involved removal of implants (if any), intramedullary debridement and local resection (if needed), lavage and instillation of the gentamicin carrier, supplemented with systemic antibiotics. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip) and general health outcome (SF36).

There were 31 patients (22 male, 9 female). The mean age was 47 years (20-67). Twenty-five cases were post-surgery (6 open fractures) and 6 were haematogenous in origin. The median duration of osteomyelitis was 1.6yrs. The bones affected were 42% femur, 45% tibia, 3% radius and 10% humerus. 11 cases had diffuse as well as intramedullary involvement. 9 cases underwent segment resection and bone transport. We identified Staphylococcus Aureus in 16 and Coagulase Negative Staphylococcus in 6 cases. The median follow-up was 1.7 years (0.5-5.6). The median scores attained were: AOFAS-78, DASH-32, IOWA-71, Oxford-32. There were two recurrences.

Dead space management of intramedullary infections is difficult. We describe a method for delivery of local antibiotics and provide early evidence to its efficacy. The treatment success to date is 93%.

Bioabsorbable carriers of antibiotics are efficacious adjuncts to surgical treatment of intramedullary osteomyelitis.

Displaced fractures of the neck of femur are routinely treated in the elderly by either cemented hemiarthoplasty, in the fit, or uncemented hemiarthroplasty, in the less fit. In Scotland the Scottish Intercollegiate Guidelines Network (SIGN) guidelines are followed to identify which patients should have a cemented prosthesis. This is based on cardiovascular status, and the age and fragility of the patient. An uncemented prosthesis should be a final operation. A peri-prosthetic fracture is considered a failure of treatment as the patient then has to undergo an operation with a far greater surgical insult.

We looked at all neck of femur fractures over a period of Jan 2007 to June 2010. The number of the peri-prosthetic fractures for uncemented hip hemiarthroplasties was established and a case note review was carried out.

There was 1397 neck of femur fractures. 546 hemiarthroplasties were carried out, of which 183 were cemented, and 363 uncemented. 14 patients (4% of uncemented hemiarthoplasties) had peri-prosthetic fractures. The case notes of these patients were analysed.

We found there was a common link of significant cardiovascular risk, lack of falls assessment (only 14% of patients had a completed falls assessment and 35% sustained their fracture during an admission to hospital) and confusion (43% had a degree of dementia that caused significant confusion).

Cemented implants should be considered in those who have failed falls assessment, or are confused; even if the cardiovascular risk is significant. This decision should be made in conjunction with a senior anaesthetist. This is being implemented in our unit and a prospective audit is being carried out over the same time period (July 2010 to Dec 2013) to assess the benefit.

The femur is a common site for skeletal metastases. The Gamma2 nail has proved effective in relieving pain and restoring function. Little data exists on the use of the Gamma3 Long Nail (GLN) in this condition. Improved instrumentation is suggested to reduce operative time and facilitate minimally invasive surgery. This study reports a series of patients treated in a District General Hospital.

A retrospective casenote review was performed of all patients treated with the GLN for femoral metastatic disease over a five year period. Patients were followed-up for a minimum of one year. Functional level was assessed using the Parker Mobility Score (PMS).

12 patients underwent 15 nailings. Mean age was 75.4 years (median 75.7, range 61-92). In bilateral cases, the operations were performed during the same hospital admission. There were seven prophylactic nailings for impending fracture from proximal femoral lesions, seven procedures for actual fractures distal to the intertrochanteric line, and one basicervical fracture associated with multiple femoral metastases. Primaries were four prostate, two breast, two lung, one bowel, one bladder, one renal, and one myeloma.

Average anaesthetic time for all procedures was 134 mins (median 125, range 90-210). Average peri-operative drop in serum haemoglobin was 2.3g/dL (median 2.1, range 0.6-4.8). Five patients with actual fracture and one patient with impending fracture required blood transfusion, receiving 2.2 units on average.

In-hospital mortality rate was 0.83%, with only one patient not surviving to discharge. One year mortality was 83.3%. Only two patients were alive one year post-operation. Of the remaining patients, average survival was 3.2 months (median 3, range 1-6). Patients spent an average of 17 days on an acute orthopaedic unit (median 14, range 4-80). Two patients required further convalescence in a rehabilitation unit.

There were three surgical complications. Two impending fractures became complete, One intra-operatively and one post-operatively. In the case of basi-cervical fracture, the proximal screw cut out of the femoral head, requiring revision to a long-stem bipolar hemiarthroplasty. This was the only re-operation required in this series.

Average pre-operative PMS was 5.2 (median 4, range 2-9). Average peri-operative drop in PMS was two points (median 1.5, range 0-6). Of the 11 patients who survived to discharge, 10 were independently mobile and returned to their pre-operation residence. Nine required a change in walking aids. Only one patient reported post-operative pain.

This small patient series suggests that the Gamma3 Long Nail is a suitable treatment option for impending and actual metastatic femoral fractures in the District General setting. Length of stay, in-hospital mortality and re-operation rates compare favourably with published data on the Gamma2. There was a significant drop in Parker Mobility Score but all patients bar one were independently mobile and returned to their home. Anaesthetic time was not lower than with the Gamma2, suggesting little tangible benefit of the new instrumentation.

3D printing an additive manufacturing technique, allowing for rapid prototyping in many industries. To date, medical applications have generally been within a research or industry environment, as the costs (expertise, software and equipment) have been prohibitive.

We have established a means by which 3D printing of bones can be achieved quickly, cost-effectively and accurately from standard computer tomography (CT) digital imaging and communications in medicine (DICOM) data.

CT DICOM data of a malunited forearm fracture were manipulated using open-source software (no cost) and a 3D model was produced by selective-laser-sintering. The entire process took 7 days (total cost £77). This process and the resultant model were then assessed for overall accuracy.

This sequential methodology provides ready and economical access to a technology that is valuable for preoperative templating/rehearsal in complex 3D reconstructive cases.

Rapid prototyping (RP), especially useful in surgical specialities involving critical three-dimensional relationships, has recently become cheaper to access both in terms of file processing and commercially available printing resources.

One potential problem has been the accuracy of models generated. We performed computed tomography on a cadaveric human patella followed by data conversion using open source software through to selective-laser-sintering of a polyamide model, to allow comparative morphometric measurements (bone v. model) using vernier calipers. Statistical testing was with Student's t-test.

No significant differences in the dimensional measurements could be demonstrated. These data provide us with optimism as to the accuracy of the technology, and the feasibility of using RP cheaply to generate appropriate models for operative rehearsal of intricate orthopaedic procedures.

Dupuytren's contracture is a common condition affecting 25% of men over the age of 65. With less advanced disease or with patients not suitable for a general or regional anaesthetic needle fasciotomy is the surgical option of choice.

The aim of this audit is to see whether the Department of Trauma and Orthopaedic surgery at Wirral University Teaching Hospital NHS Foundation Trust comply with the NICE guidelines.

All patients who underwent needle fasciotomy for Dupuytren's contracture at Wirral University Teaching Hospital NHS Foundation Trust from December 2008 and November 2010 were identified. The case notes of these patients were reviewed.

In a 23 month period 9 patients (13 fingers), underwent needle fasciotomy. There were 6 female and 3 male patients. The mean age at the time of surgery was 70 years (61-84 years). Of the 13 MCPJ contractures 12 had a full correction. At the PIPJ 5 of the 8 had a full correction. Of the one contracture affecting the DIPJ, this was fully corrected.

None of the patients undergoing needle fasciotomy had any complications recorded. At a minimum follow up 4 months and a mean follow up of 14 months, none of our patients have returned to the unit with recurrence of disease.

In our unit needle fasciotomy is a safe and effective in correcting deformity. To date we have no complications or recurrence. None of these patients have returned for further surgery. We are compliant with the NICE guidelines.

In order to achieve a true AP and lateral radiograph of the wrist, there must be no movement at the radio-ulnar joint. Projections taken with only pronation and supination at the wrist provide two views of the radius but a single view of the ulna. True radiographs are achieved by rotating the humerus through 90 degrees and extending at the elbow between the two views. Our aim was to look at whether true lateral and AP radiographs are taken by our radiology department.

Between April 2009 to November 2010, we identified all patients with ulna shortening osteotomies. This was because the plate and screws placed only in ulna making it easy to identify if two projections of the ulna have been achieved. Radiograph at first follow up were reviewed using PACS.

Of the 29 patients identified, 5 patients were excluded. Only 6 out of 24 patients had TRUE wrist projections

Most radiographs taken were inadequate and this has to be communicated with the radiology department. Two different views are needed to accurately comment on radiographs. Patients have to be sent back to radiology department. This causes an increase in clinic time, radiation to the patient and inconvenience.

Stem geometry is known to influence the outcome in THA; however it is unknown whether the material properties, stiffness in particular can influence the stem stability and outcome. The aim of this study was to measure the influence of stem material properties on micromotion and migration using Roentgen Stereophotogrammetric Analysis (RSA) system.

41 patients were implanted with a collarless polished tapered (CPT) femoral stem (Zimmer, Warsaw, Indiana), which was made of either cobalt-chromium (CoCr) (n=21) or stainless steel (n=20). RSA was used to measure dynamically inducible micromotion (DIMM: difference in stem position in going from double-leg stance (DLS) to single leg stance (SLS)), prosthesis bending (difference in the head-tip distance when going from DLS to SLS), and mean migration of the head, tip and the cement restrictor. DIMM and bending were measured at 3 months, migration at 6, 12 and 24 months. All analyses were carried out using SPSS for windows (v.15.0.0, Chicago. IL, USA). Results were reported as mean ± 95% confidence interval (CI) and regarded as significant when p < 0.05.

Preliminary analysis showed that total head DIMM was significantly (p = 0.02) greater for CoCr (0.97mm ± 0.6mm) than stainless steel (0.27mm ± 0.6mm). The mean stem bending for CoCr was 0.08mm (± 0.06mm) and for stainless steel 0.15mm (± 0.06mm) (p =0.77). Both implants heads migrated posteriorly, medially and distally. The mean subsidence for the cobalt-chromium and stainless steel stems was 1.02mm (± 0.19mm) (p < 0.001) and 1.12mm (± 0.34mm) (p=0.001) (p= 0.07) at 24 months.

It was interesting to note that the dynamically induced micromotion was greater for the stiffer stem, however there were no differences in terms of overall migration, indicating that survival (in terms of loosening) should be the similar for both steel and CoCr versions of this implant.

Orthopaedic problems are common in patients with Ehlers-Danlos Syndrome (EDS). Articular hypermobility can be particularly disabling leading to instability in the appendicular skeleton. We present a case of an EDS patient presenting with knee pain and instability. It highlights important lessons to be learned when considering joint replacement in this patient group.

A 51 year old lady with EDS underwent a posterior cruciate retaining total knee replacement for pain and instability. She dislocated her knee replacement three months post-operatively after a fall. Her knee was reduced at her local emergency department causing injury to the popliteal artery. She required urgent popliteal artery repair and fasciotomies. The common peroneal nerve was also irreversibly damaged by the dislocation. She has since had one further dislocation and is now awaiting revision surgery. When considering total knee replacement (TKR) in EDS, the patient must be warned of the inferior results compared to TKR for other causes. The increased risk of complications must be explained and a more constrained TKR design considered to address the inherent joint laxity. The potential consequences of a dislocated TKR can be disastrous and therefore relocation must be performed in a controlled environment in the operating theatre.

Skeletal Cryptococcosis although rare has been reported in immunodeficient individuals and in particular those with HIV. We present a case in a HIV- negative patient who presented to the London Sarcoma service masquerading as a primary bone tumour and review the relevant literature.

A 71 year old lady presented with a three month history of right submammary pain associated with a new lump. Chest radiographs showed an osteolytic lesion in the right 6^th rib. CT scans demonstrated mediastinal lymphadenopathy and numerous lung nodules. Differential diagnosis of the lesion included TB abscess, myeloma, lymphoma or as a primary lung tumour presenting with hilar lymphadenopathy and necrotic skeletal metastasis. CT guided biopsy was performed with histology showing necrotising granulomatous inflammation with numerous yeast like organisms in keeping with Cryptococcus fungal infection. She was treated successfully with a six week course of voriconazole.

Cryptococcal skeletal infections can cause significant morbidity and mortality and should be considered as a rare cause of lytic osseous lesions.

Anterior cruciate ligament (ACL) reconstruction is a commonly performed operation. A variety of graft options are used with the most popular being bone-patellar-tendon-bone and hamstring autograft. There has been an increase in the popularity of hamstring autograft over the past decade.

The aim of the study was to assess the ten year subjective knee function and activity level following four-strand semitendinosis and gracilis (STG) anterior cruciate ligament reconstruction.

86 patients underwent anterior cruciate reconstruction by two knee surgeons over a 12 month period (January 1999 to December 1999). 80 patients meet the inclusion criteria of arthroscopic ACL reconstruction. The same surgical technique was used by both surgeons involving four-strand STG autograft, single femoral and tibial tunnels and aperture graft fixation with the Round headed Cannulated Interference (RCI) screw. Patient evaluation was by completion of a Lysholm Knee Score and Tegner Activity Level Scale at a minimum of ten years from reconstructive surgery. This was by initial postal questionnaire and subsequent telephone follow-up.

80 patients underwent anterior cruciate reconstruction with average age 30.9 years (15 to 58 years). There was a 77.5% (62 patients) response at ten years to the questionnaire.

The median Lysholm Knee Score at ten years was 94 (52 to 100). The median activity level had decreased from 9 to 5 at ten years according to the Tegner Activity Scale. 73% of patients reported a good or excellent outcome on the Lysholm score. The group of patients was further divided into those that required meniscal surgery and those that did not. The patients that did not require meniscal surgery had a median Lysholm score of 94 and those that required meniscal surgery had a similar median Lysholm score of 92.5. However it was noted that 8 patients required medial and lateral partial menisectomies at the time of original reconstruction. This group of patients had a median Lysholm Knee Score of 83.5 and Tegner Activity Scale of 4 at ten years following reconstruction. 17 of the 62 patients (27.4%) required re-operation because of further knee symptoms, with 4 patients requiring revision of the anterior cruciate following re-rupture.

In conclusion anterior cruciate ligament reconstruction with four-strand STG hamstring autograft provides a reliable method of restoring knee function, with a 6% revision rate for re-rupture at ten years. Combined partial medial and lateral menisectomy at the time of the initial reconstruction is a poor prognostic indicator of function at ten years.

Adverse weather conditions during the winter months put increased pressure on orthopaedic trauma departments across the country. The increased incidence of injuries has resulted in a strain on resources at a local level and a situation can arise whereby cases need to be prioritised according to clinical need and fitness of the patient. Ankle fractures, frequently caused by slipping in adverse weather conditions, tend to be an injury where a high proportion of patients are young and active and can therefore cope better physiologically waiting several days for their operation. It is well documented that there is a window of opportunity when operating on ankle fractures, during which the swelling will permit fixation. We aimed to establish whether a link exists between delay to surgery for ankle fractures, the length of post-op hospital stay and the rate of complications.

We included all patients who underwent surgical fixation of an ankle fracture over a three month period between 1.1.10 and 31.01.11. Data was obtained through theatre records, discharge and clinic letters and from the local PACS X-ray system. Basic patient data, admission, theatre and discharge dates were collected along with details regarding mechanism of injury, type of fracture, fixation and documented complications. Patients were subdivided into two groups: those who underwent surgery within 48 hours of injury and those who waited longer than 48 hours. Many of the patients in the delayed surgery group remained inpatient until after their surgery whilst those more capable of mobilising with crutches were allowed home to elevate.

64 patients underwent fixation of an acute ankle fracture during the three month study period. 28 patients (44%) had a documented fall on ice or snow. 29 patients were operated upon within 48 hours. 35 patients surgery was delayed by a mean of 9 days (3-28). The mean length of post op hospital stay for the early surgery group was 3.00 days. In the delayed surgery group the mean length of stay was 4.28 days (p=0147). There were 4 complications in the early group (14%) compared with 7 in the delayed group (20%).

Delaying surgery for ankle fractures more than 48 hours suggests a trend towards an increased length of post-operative hospital stay and a slightly increased rate of complications but not to significant levels. A larger sample size may have provided a significant difference. Given this trend, we recommend early fixation of ankle fractures wherever possible providing soft tissue swelling allows tension free wound closure.

The safe and effective management of orthopaedic patients out of hours requires the communication of radiographs between junior residents and their non-resident seniors. Despite stringent guidelines issued by the Caldecott Guardian on the transmission of patient sensitive data, there is no data describing actual exchanges in the literature. The objective was t describe current trends in the transmission of patient sensitive data between resident Orthopaedic juniors and their non-resident seniors out of hours.

The method was a Questionnaire survey polling Orthopaedic registrars in North London. Seventy-six (76) trainees participated in the survey. Fifty Three (53) trainees received radiographs for review off site. Forty-eight (48) reported receiving patient radiographs for review to their personal email account. 48% of these trainees reported that the images contained patient sensitive information. 40% of the trainees who received images to their personal email had a NHS mail account which was not used.

Remote access to patient radiographs improves patient management out of hours. Although there is some awareness of Caldecott guidelines for the handling of patient sensitive electronic data, compliance is extremely poor. We recommend that all trainees who routinely handle patient sensitive data remotely acquire a free NHS mail account for receiving patient radiographs

The aim of the study was to highlight the absence of an important pitfall in the Advanced Trauma Life Support protocol in application of rigid collar to patients with potentially unstable cervical spine injury.

We present a case series of two patients with ankylosed cervical spines who developed neurological complications following application of rigid collar for cervical spine injuries as per the ATLS protocol.

This has been followed up with a survey of A&E and T&O doctors who regularly apply cervical collars for suspected unstable cervical spine injuries. The survey was conducted telephonically using a standard questionnaire. 75 doctors completed the questionnaire. A&E doctors = 42, T&O = 33. Junior grade = 38, middle grade = 37. Trauma management frontline experience >1yr = 50, <1yr = 25. Of the 75 respondents 68/75 (90.6%) would follow the ATLS protocol in applying rigid collar in potentially unstable cervical spine injuries. 58/75 (77.3%) would clinically assess the patient prior to applying collar. Only 43/75 (57.3%) thought the patients relevant past medical history would influence collar application.

Respondents were asked whether they were aware of any pitfalls to rigid collar application in suspected neck injuries. 34/75 (45.3%) stated that they were NOT aware of pitfalls. The lack of awareness was even higher 17/25 (68%) amongst doctors with less that 12 months frontline experience. When directly asked whether ankylosing spondylitis should be regarded as a pitfall then only 43/75 (57.3%) answered in the affirmative.

We would like to emphasise the disastrous consequences of applying a rigid collar in patients with ankylosed cervical spine. The survey demonstrates the lack of awareness (∼ 50%) amongst A&E and T&O doctors regarding pitfalls to collar application. We recommend the ATLS manual highlight a pitfall for application of rigid collars in patients with ankylosed spines and suspected cervical spine injuries.

The need for hip and knee replacement surgery is increasing. Enhanced recovery programmes, where patients mobilise quickly and safely after surgery, have been adopted now in many hospitals. There are anecdotal reports of Primary Care Trusts raising thresholds for referral for surgery based on patients' Body Mass Index (BMI).

The aim of this study was to evaluate the early outcome of hip and knee arthroplasty in obese patients (BMI>30) enrolled in the enhanced recovery programme.

Between March 2010 and January 2011, 672 patients were enrolled in our enhanced recovery programme. 316 patients (47%) were classified as obese (BMI>30, range 30-39). There was no significant difference in the length of stay: 4.58 days in the obese patients and 4.44 days in the non-obese. There was also no difference in the rates of superficial infections or oozy wounds. Knee replacements was performed more commonly than hip replacements in the obese group

There was no significant difference in the early outcome of hip and knee replacement surgery in patients with a higher Body Mass Index when undergoing lower limb arthroplasty through the enhanced recovery programme. These patients should continue to be offered surgery when clinically indicated.

NICE technology appraisal guidance 157 suggests that the oral anticoagulation medication Dabigatran etexilate can be used for the primary prevention of venous thromboembolic events (VTE's) in adult patients who have undergone elective total hip or knee replacement surgery.

The NICE guidance reports that 13.8% of patients receiving recommended doses of Dabigatran experienced adverse bleeding events. In the pivotal hip and knee VTE trial, wound secretion only accounted for 4.9% of patients treated with Dabigatran (cf 3.0% of patients treated with Enoxaparin).

We report our wound secretion experience after Dabigatran use at Warwick Hospital from March 2009 to March 2010. Of the 788 lower-limb arthroplasties performed, 55 patients (6.9%) had oozing wounds after discharge (Mean=8 days, Range=1-39 days). This resulted in 226 extra home-visits by discharge nurses, 26 positive microbiology cultures and 5 confirmed wound infections needing antibiotic treatment and/or surgical intervention. Incidentally, there were also 2 known cases each of deep vein thrombosis and pulmonary embolus in this cohort. The number of complications was markedly increased from previous years when LMWH was the VTE prophylaxis used.

This data suggests that the use of Dabigatran in Warwick Hospital may significantly increase surgical site morbidity and resource output after lower limb arthroplasty.

Acute Kidney Injury (AKI) formerly known as “acute renal failure” results in rapid reduction in kidney function associated with a failure to maintain fluid, electrolyte and acid-base homeostasis. The UK NCEPOD published a report in 2010 on AKI that revealed many deficiencies in the care of patients with AKI. The UK Renal Association has published the final draft of Clinical Practice Guidelines for Acute Kidney Injury on the 08/01/2011. In our study we determined retrospectively the occurrence of this problem in a District General Hospital and its impact on recovery after lower limb arthroplasty.

Data was collected retrospective study over 3 months between Oct to Dec 2010 from theatre registers and the hospital database system. 359 patients were identified. Preoperative (baseline) and postoperative blood investigations included Creatinine, Urea, K+, Na+, GFR, Haemoglobin were analysed. Data collection also included type of anaesthesia, timing of operation, duration of procedure and estimated blood loss. From the hospital database system and clinic letters we collected length of stay and time required for blood results to come back to baseline.

A diagnosis of Acute Kidney Injury was based on the International Kidney Disease Improving Global Outcomes (KDIGO) staging classification as recently recommended by UK Renal Association. Stage I Creatinine increase by ≥ 26 μmol/L from baseline, Stage II Creatinine increase by 200-300% and Stage III Creatinine increase ≥ 300%.

In our study 11.97% (43/359) of patients developed acute kidney injury following lower limb Arthroplasty. 18 patients (42%) developed Stage I (Cre increase ≥ 26 μmol/L), 17(39%) developed Stage II (Cre increase 200-300%) and 8 patients (19%) developed Stage III (Cre increase ≥ 300%) AKI. Most of these patients were operated during the afternoon session. Patients with acute kidney injury stayed longer in hospital (11.7days) compared to similar age group of patients (6.35days) admitted during the same period. 25% of patients took more than a month for renal parameters to come down to normal.

AKI is a new definition and the incidence in our hospital is higher than the 1% expected nationally. Patients with AKI are often complex to treat and specialist timely referral and transfer to renal services if appropriate should be considered. The etiology of Acute Renal Injury is very complex and includes gentamicin antibiotic prophylactic, rapid blood loss in elderly frail patients, non-steroidal pain killers and preexisting cardiac and renal pathology.

The need for careful postoperative observation cannot be overemphasised together with judicious blood replacement as required. Acute Kidney Injury following lower limb arthroplasty is a sensitive marker of postoperative care. A successful surgical outcome may not mean a successful renal outcome. Patients with AKI are often complex to treat the new AKI definition and staging system allows an earlier detection and management of this condition. Further prospective audit with large number of patients are required.

Trans-articular coronal shear fractures of the distal humerus pose a significant challenge to the surgeon in obtaining an anatomical reduction and rigid fixation and thereby return of good function. A variety of approaches have been described which include the extended lateral and anterolateral approaches and arthroscopically-assisted fixation for non-comminuted fractures. Fixation methods include open or percutaneous cannulated screws and headless compression screws directed either anterior to posterior or posterior to anterior. We describe an illustrated, novel approach to this fracture which is minimally invasive but enables an anatomical reduction to be achieved.

A 15 year old male presented with a Bryan and Morrey type 4 fracture as described by McKee involving the left distal humerus. He was placed in a lateral position with the elbow over a support. A posterior longitudinal incision and a 6cm triceps split from the tip of the olecranon was made. The olecranon fossa was exposed and a fenestration made with a 2.5mm drill and nibblers as in the OK (Outerbridge-Kashiwagi) procedure. A bone lever was then passed though the fenestration and used to reduce the capitellar and trochlear fracture fragments into an anatomical position with use of an image intensifier to confirm reduction. The fracture was then fixed with two headless compression screws from posterior to anterior into the capitellar and trochlear fragments (see images). Early mobilisation and rehabilitation were commenced. Follow-up clinical examination and radiographs at six weeks revealed excellent range-of-motion and function with anatomical bony union.

We believe that this novel approach to this fracture reduces the amount of soft tissue dissection associated with conventional approaches and their associated risks and also enables earlier return to function with restoration of anatomy.

Informed consent is vital for good patient-surgeon communication. It allows the patient to be given an unbiased and accurate view of the procedure as well giving an opportunity for patients to gain trust in their surgical team. The consent form is written evidence of this discussion and a poor consent form implies a sub-standard consenting process. The General Medical Council (GMC) have issued guidelines for consent in surgical procedures. These state that all common risks and rare but serious risks should be disclosed as well as all information being given in clear simple and consistent language.

Currently, the consent form for a hip fracture operation is hand written. Our hypothesis was that the quality of consenting is variable and that many important complications may not be identified.

The British Orthopaedic Association (BOA) blue book, ‘The care of patients with fragility fractures,’ has given guidance of common and serious complications associated with operative management of hip fractures. In addition to these procedure specific complications, we have identified general complications from standardised joint arthroplasty consent forms in our trust, such as deep vein thrombosis. Our standards based on GMC guidance are that the consent form should be legible, free from jargon, without abbreviations and should include the specific and general complications.

We retrospectively identified and analysed 30 consecutive consent forms of patients that underwent operative management for hip fractures between March and April 2011. Of all consent forms, 59% were completely or partly illegible, 77% had used abbreviations and medical jargon. Inclusion of general complications on the consent form varied; infection 100%, bleeding 100%, deep vein thrombosis 82%, MI 18%, pneumonia 12%, death 12% and haematoma 0%. Specific operative complications were poorly included, with no patients undergoing hemiarthroplasty being advised of the risk of prosthetic loosening, acetabular wear or periprosthetic fractures. For consent of patients undergoing fracture fixation, 67% had been informed of re-operation and 40% had been told of non-union.

This data shows that consent forms are generally poorly written and subject to great variation in complications for the same surgical procedure. This data is likely to apply to some extent to all hospitals that use blank consent forms. This has implications for patient care and safety, as well as medicolegal implications for medical professionals. In our hospital, consent forms have been standardised for joint arthroplasty, with all complication pre-printed with plain English explanations below. Our proposal is that all common operations should have pre-printed consent forms. This would standardise consenting and provide a much improved documentary evidence of the consenting process.

This data has a number of lessons that can be applied to other hospitals. Firstly, we suggest that other hospitals consider standardised consent forms. Secondly, individual trainees should be clear that consent forms remain the documentary evidence of the consenting process, long after you forget the verbal details and you should ensure that you include all complications, write clearly and without jargon or abbreviations.

Urinary catheterization in the postoperative period is known to increase the risk of deep joint infection following arthroplasty. A number of studies have attempted to elucidate the individual patient factors and surgical procedural factors which predispose patients to postoperative urinary retention.

We conducted a retrospective observational study of three hundred patients to specifically determine the effect of the anaesthetic technique on the incidence of urinary retention following elective lower limb arthroplasty. One hundred consecutive patients were surveyed in each of three groups differing by the type of the anaesthetic technique and the drug administered; 1) general anaesthesia with femoral nerve block, 2) spinal anaesthesia with intrathecal fentanyl, and 3) spinal anaesthesia with intrathecal morphine.

The incidence of urinary retention requiring catheterisation in male patients receiving intrathecal morphine was 58% compared with 10% and 6% for those who had general anaesthesia with femoral nerve block and intrathecal fentanyl, respectively. This difference was statistically significant (p<0.01). The incidence of urinary retention in females across all groups was =2%. The average residual volume of urine following catheterisation was 750ml (460-1500ml).

Our findings show that the use of intrathecal morphine greatly increases the risk of postoperative urinary retention in male patients, whereas no significant increase was found amongst female patients. This risk should be carefully considered when choosing the type of intraoperative anaesthetic/analgesic combination employed in male patients and be rationalised against the intended benefits to the patient.

The National Institute of Clinical Excellence (NICE) published guidance for reducing the risk of venous thromboembolism (VTE) in January 2010. This guidance has had a significant impact on the management of all inpatients. It is now mandatory to risk assess every inpatient and commence appropriate treatment if indicated. The guidelines specifically exclude outpatients although NICE recognises' that lower limb cast immobilisation is a risk factor for VTE. The purpose of our study was to establish the current practice for the management of outpatients treated with lower limb casts in England.

The NHS Choices website lists 166 acute hospitals in England. A telephone audit was conducted in February 2011. A member of the on call orthopaedic team was asked: 1. Are you aware of the NICE guidelines for VTE prophylaxis? 2. In your department, outpatients treated with a lower limb cast, are they risk assessed for VTE? 3. If a patient undergoes Open Reduction Internal Fixation (ORIF) for an ankle fracture and is discharged wearing a cast, are they given VTE prophylaxis? 4. If yes - for how long are they treated?

Responses were obtained from 150 eligible hospitals (1 FY1, 28 FY2, 44 ST1-ST2, 76 ST3+, 1 Consultant). 62% of responders stated that they were aware of the NICE guidance. 40% of responders stated that outpatients were routinely risk assessed for VTE. 32% of responders stated that ankle fractures treated with an ORIF and discharged wearing a cast would receive VTE prophylaxis. The duration of treatment varied from 5 days, to 6 weeks, to removal of cast.

The management of patients treated with a lower limb cast is variable and inconsistent throughout England. Although there are no national guidelines for this patient group, the routine risk assessment of outpatients was higher than anticipated by the authors. We recommend that if VTE prophylaxis is commenced as an inpatient, then it should be continued until the cast is removed.